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Contraceptive Security: Practical Experience in Improving Global, Regional, National, and Local Product Availability

Publication date: 2006

CONTRACEPTIVE SECURITY PRACTICAL EXPERIENCE IN IMPROVING GLOBAL, REGIONAL, NATIONAL, AND LOCAL PRODUCT AVAILABILITY OCTOBER 2006 This publication was produced for review by the United States Agency for International Development. It was prepared by the DELIVER project. CONTRACEPTIVE SECURITY PRACTICAL EXPERIENCE IN IMPROVING GLOBAL, REGIONAL, NATIONAL, AND LOCAL PRODUCT AVAILABILITY The authors’ views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government. DELIVER DELIVER, a six-year worldwide technical assistance support contract, is funded by the U.S. Agency for International Development (USAID). Implemented by John Snow, Inc. (JSI), (contract no. HRN-C-00-00-00010-00) and subcontractors (Manoff Group, Program for Appropriate Technology in Health [PATH], and Crown Agents Consultancy, Inc.), DELIVER strengthens the supply chains of health and family planning programs in developing countries to ensure the availability of critical health products for customers. DELIVER also provides technical management of USAID’s central contraceptive management information system. Recommended Citation Sarley, David, Raja Rao, Carolyn Hart, Leslie Patykewich, Paul Dowling, Wendy Abramson, Chris Wright, Nadia Olson, and Marie Tien. October 2006. Contraceptive Security: Practical Experience in Improving Global, Regional, National, and Local Product Availability. Arlington, Va.: DELIVER, for the U.S. Agency for International Development. Abstract At the Istanbul Conference in 2001, participants identiﬁed strategies for increasing contraceptive security to ensure that clients can chose, obtain, and use the methods they need. Particular emphasis was given to increasing donor funding for contraceptives and to ensure the government’s work with the private and nongovernmental (NGO) sectors meets the contraceptive commodity needs of their populations. Since 2001, DELIVER and other cooperating agencies have worked at the global, regional, national and sub-national, and community level to implement the strategies from the Istanbul meeting; and to develop new approaches to improving contraceptive product availability. Five years after Istanbul, this report documents the progress made in improving contraceptive security. It begins by describing the experiences of contraceptive clients in different parts of the world. It describes the experiences countries have had in learning to understand their clients’ needs and improve their contraceptive security. The report documents the lessons learned in increasing and diversifying contraceptive ﬁnance; understanding and expanding the total market; and working with the public, private, and NGO sectors to improve service delivery and product availability. It also describes different regional initiatives adopted in Latin America, Africa, and Eastern Europe; and it identiﬁes new challenges countries face around procurement and donor coordination and how these challenges have been addressed. The report describes what has been done and deﬁnes what remains to be done to improve contraceptive product availability. DELIVER John Snow, Inc. 1616 North Fort Myer Drive, 11th Floor Arlington, VA 22209 USA Phone: 703-528-7474 Fax: 703-528-7480 Email: deliver_project@jsi.com Internet: deliver.jsi.com CONTENTS Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii 1. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Ten Things You Need for Contraceptive Security. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Publication Purpose and Outline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2. Client Perspective. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Cynthia in Ghana. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Ana in El Salvador . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Lorna in the Philippines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Mariana in Romania . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 3. The Global Challenge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Contraceptive Security, 1998–2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Key Funding and Technical Assistance Partners in RHCS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Challenges and Opportunities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 4. Regional Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 LAC: Confronting Phaseout and Procurement Constraints. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Asia:Working with the Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 West Africa: Connecting a Regional Strategy to Existing Challenges. . . . . . . . . . . . . . . . . . . . . . . 30 Eastern Europe: Cross Fertilization of Regional Solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 East Africa: Building on Local Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 5. Commitment and Coordination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Commitment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Coordination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 6. Policy Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Policy Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Product-related Policy Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Supply Side Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Demand Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Issues Related to Health Sector Reform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 7. Total Market Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 What Is a Total Market Approach? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Markets Are Already Segmented . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Improving the Targeting of Free and Subsidized Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . 64 Market Segmentation Case Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Practical Strategies for Promoting a Total Market Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 CONTENTS iii 8. Financial Diversification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 The Funding Challenge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Options to Diversify . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Classifying Countries by Their Sources of Contraceptive Funding . . . . . . . . . . . . . . . . . . . . . . . . 81 Strategies to Improve Financial Diversification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Financial Diversifi cation Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 9. Procurement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 A Growing Need for Procurement Capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 We Have the Money, but Where Are the Commodities? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 What Is an Ideal Public Procurement Model?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Strengthening Procurement Planning and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Transparency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Value for Money Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Improving Quality Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Independence from Political Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Procurement Key Steps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 10. Logistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Ensuring a Supply Chain Presence at the Policy Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Goals of an Optimized Distribution System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Innovations for Improved Last Mile Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 11. Service Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Choose, Obtain, and Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Key Service Provision Influences on Product Availability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Contraceptive security and family planning Service Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 12. Next Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Focusing on the Client . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Reinforcing Global Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Reinforcing Regional Groupings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Diversifying Commodity Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Addressing Key Policy Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Making the Total Market Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Financing Contraceptive security Strategies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Addressing Procurement Capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Improving Logistics Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 In Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 iv CONTRACEPTIVE SECURITY Figures 1. Active Users of Pills from Family Planning Program and Private Sector in Romania . . . . . . . . . . 13 2. Contraceptive Prevalence Rate Compared to and Maternal Mortality in West Africa . . . . . . . . 31 3. Contraceptive Security Index Scores for East African Countries . . . . . . . . . . . . . . . . . . . . . . . . . 38 4. Policy Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 5. Percentage of Contraceptive Prevalence Rate Provided by the Public Sector . . . . . . . . . . . . . . . 61 6. Socioeconomic Profile of Public-sector Family Planning Users . . . . . . . . . . . . . . . . . . . . . . . . . . 63 7. Correlation between Equity in Contraceptive Use and Public Sector Targeting . . . . . . . . . . . . . 65 8. Correlation between Equity in Contraceptive Use and Public Sector Targeting . . . . . . . . . . . . . 66 9. Convergence in Contraceptive Prevalence Rate in Bangladesh 1993 to 2004 . . . . . . . . . . . . . . . 67 10. Contraceptive Prevalence Rate by Quintile for Women of Reproductive Age Mali, 1995–1996. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 11. Income Distribution in Mali . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 12. Ghana Market Segmentation Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 13. Contraceptive Prevalence Rate and Unmet Need by Age and Residence. . . . . . . . . . . . . . . . . . . 71 14. Percentage of Women of Reproductive Age Using Modern Methods and Source of Method Acquisition by Quintile, Paraguay 2004 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 15. Percentage of Women Using Contraceptive Methods and Women with Unmet Need in Paraguay, 1998–2004 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 16. Illustrative Financial Diversification Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 17. The Procurement Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 18. Impact of Health Sector and Economic Reforms on the Supply Chain and Commodity Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 19. Supply Chain Process Improvement Approach (DMAIC) Process . . . . . . . . . . . . . . . . . . . . . . . 105 Tables 1. Comparison of IRP and Bulk Prices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 2. Selected Family Planning Indicators for Eastern Europe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 3. Costs Associated with Transportation, Duties/Tariffs, and Value Added Tax . . . . . . . . . . . . . . . . . 50 4. Classification of the Relative Contribution of the Public and Private Sectors . . . . . . . . . . . . . . . 62 5. Estimated Annual Cost of Couple Years of Protection as a Percentage of Household Income for Poorest and Richest Deciles by Product, 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 6. Contraceptive Prevalence Rate and Unmet Need by Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 7. Estimated Contraceptive Commodity Support by Donor Agency 1990 to 2004, in Thousands $U.S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 8. Potential Sources of Funding for Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 9. Classification of Countries by Their Source of Contraceptive Funding. . . . . . . . . . . . . . . . . . . . . 82 10. Four Procurement Principles for the Public Purchase of Contraceptives . . . . . . . . . . . . . . . . . . . 93 11. Management of Contraceptive Quality Control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Boxes 1. Benefits of the West Africa Regional Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 2. Romania—a Regional Family Planning Success Story . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 3. Workshop in West Africa Links Partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 4. Typical Composition of a Contraceptive Security Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 5. Ghana MOH and Partners Develop Strategy to Ensure Long-Term Contraceptive Security. . . . 45 6. Mali Regulates Prices for Commodities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 7. Some Providers May Lack Training in Managing Side Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 8. Malawi Implements Sector Wide Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 9. Indonesia Developed Advocacy and Planning Tool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 10. Premise: How Better Coordination and Market Segmentation Can Improve CS Efficiency. . . . . 59 11. Chile’s CENABAST: Case Study in Efficient Procurement Management . . . . . . . . . . . . . . . . . . . . 95 CONTENTS v vi CONTRACEPTIVE SECURITY ACRONYMS AIDS acquired immunodeﬁ ciency syndrome ARV antiretroviral ATP ability to pay AWARE-RH Action for West Africa Region-Reproductive Health BCC behavior change communication BKKBN (Indonesian family planning coordinating agency) BLM Banja La Mtsogolo (a Marie Stopes afﬁ liate, Malawi) CA cooperating agency CAFTA Central America Free Trade Agreement CBV community-based volunteer CCSS Costa Rican Social Security Fund CDC Centers for Disease Control and Prevention CENABAST (Chile’s semi-autonomous procurement agency) CIB coordinated informed buying CIDA Canadian International Development Agency CMS central medical store CPR contraceptive prevalence rate CS contraceptive security/commodity security for contraceptives CSR contraceptive self-reliance (Philippines program) CYP couple-years of protection DFID Department for International Development (U.K.) DGFP Directorate General of Family Planning (Bangladesh) DHS Demographic and Health Survey DMAIC supply chain process improvement approach DSW German Foundation for World Population ECOWAS Economic Community of West African States EHP Essential Health Package EMEA European Medicines Agency EML essential medicines list ENDSSR (Paraguay’s national Survey of Demography and Reproductive and Sexual Health) EU European Union FBO faith-based organization ACRONYMS vii FDA U.S. Food and Drug Administration FP family planning FPLM Family Planning Logistics Management GFATM Global Fund to Fight AIDS, Tuberculosis, and Malaria GDF Global Drug Facility of the Stop TB Partnership GMP good manufacturing practice GOB Government of Bangladesh GP general practice GSMF Ghana Social Marketing Foundation HIV human immunodeﬁ ciency virus HMIS health management information system ICB international competitive bidding ICC/CS Interagency Coordination Committee for Contraceptive Security (Ghana MOH) ICPD International Conference on Population and Development IDA International Dispensary Association IEC information, education, and communication IMR infant mortality rate IPPF International Planned Parenthood Federation IPS (Paraguayan Social Security system) IRP international reference price ISO International Organization for Standardization ISP public health institute of Chile IU international unit IUD intrauterine device IWG Interim Working Group on Reproductive Health Commodity Security JICA Japan International Cooperation Agency JSI R&T John Snow Research and Training Institute, Inc. KfW Kreditanstalt für Wiederaufbau LAC Latin America and the Caribbean LAM lactational amenorrhea method LGU local government unit (Philippines) LMIS logistics management information system MDG Millennium Development Goal MERCOSUR Mercado Común del Sur MIU million international units MOF Ministry of Finance viii CONTRACEPTIVE SECURITY MMR maternal mortality rate MOH Ministry of Health MOHFW Ministry of Health and Family Welfare MWRA married women of reproductive age NORAD Norwegian Agency for Development Cooperation NGO nongovernmental organization NSU nonsurgical vasectomy NTT Nusa Tenggara Timur (Indonesian province) OB/GYN obstetrician/gynecologist OI opportunistic infection ORS oral rehydration solution PACTO ANDINO Andean Community of Nations PAHO Pan-American Health Organization PAI Population Action International PATH Program for Appropriate Technology in Health PDA personal digital assistant PHC primary health care PHRplus Partners for Health Reformplus (USAID) PMTCT preventing mother-to-child transmission PNSSR Paraguay National Reproductive and Sexual Health Plan PPAG Planned Parenthood Association of Ghana PPD Partners in Population and Development PRB Population Reference Board PRH Ofﬁce of Population and Reproductive Health (USAID) PRSP poverty reduction strategy paper PSI Population Services International PSP Private Sector Program (USAID) RCHU Reproductive and Child Health Unit (Ghana MOH) RH reproductive health RHCS reproductive health commodity security RHI Reproductive Health Interchange RHSC Reproductive Health Supplies Coalition SDA Salvadoran Demographic Association SDP service delivery point SI Supply Initiative SIDA Swedish International Development Cooperation Agency SMC Social Marketing Company ACRONYMS ix SPARHCS Strategic Pathway to Reproductive Health Commodity Security STARH Sustaining Technical Achievements in Reproductive Health and Family Planning (USAID) STG standard treatment guideline STI sexually transmitted infection SUMI Seguro Universal Materno Infantil SWAp sector wide approach TRIPS Trade-Related Aspects of Intellectual Property Rights UNDP United Nations Development Programme UNFPA United Nations Population Fund USAID U.S. Agency for International Development VAT value added tax VCT voluntary counseling and testing (HIV/AIDS) WAHO West Africa Health Organisation WHO World Health Organization WHO/AFRO World Health Organization/African Regional Ofﬁce WRA women of reproductive age WTO World Trade Organization CONTRACEPTIVE SECURITY x 1. OVERVIEW Projections prepared by the Interim Working Group on Reproductive Health Commodity Security (IWG) (Interim Working Group 2001a) in 2001 showed that donor funding would need to increase, initially by $24 million1 and then by 5.3 percent per annum, if donor-funded contraceptive supplies were to meet the projected demand in 2015. While global data are incomplete, available information suggests that over the last four years donors have largely failed to sustain the increases in funding required. Donor funding has, at best, grown at a slow rate in nominal terms, while actually decreasing in real terms for some donors. This is despite the recent resource mobilization eﬀorts by the Supply Initiative and the Unit ed Nations Population Fund (UNFPA). On closer inspection, however, the situation appears to be far more positive. Concerted and coordinated actions have taken place simultaneously at global, regional, country, district, and local levels, that have helped improve reproductive health commodity security (RHCS). While many constraints remain and much needs to be done, this practical experience shows how to attain future gains in commodity security (CS)2 for contraceptives, as well as for any other essential health commodity. TEN THINGS YOU NEED FOR CONTRACEPTIVE SECURITY The tremendous diﬀerences in regions, among countries, and even within countries, mean that there is no single or cookie-cutter approach to improving contraceptive security (CS). Nonetheless, common themes have emerged from the concrete and successful work completed in the last ﬁve years in sustaining improvements in CS. Much of this work has involved applying the Strategic Pathway to Reproductive Health Commodity Security (SPARHCS) (Hare et al. 2004) framework. This tool—which has been used to assess RHCS, strategic planning, and implementation—has increasingly been adopted and adapted in diﬀerent ways to meet diﬀerent local conditions and situations. The SPARHCS framework focuses attention on seven components that are necessary for RHCS: context, commitment, coordination, capital, capacity, client, and commodities. DELIVER’s experience in applying SPARHCS suggests that the capac ity component should be further disaggregated to focus explicitly on procurement, logistics, service deliv ery, and monitoring and evaluation. We have also recognized the importance of distinguishing between the RHCS policy environment and wider contextual issues (e.g., socioeconomic and political trends) that impact RHCS but usually cannot be addressed. Our work suggests that there are 10 areas that can be and need to be addressed if CS is to be attained and maintained: 1. Commitment of key stakeholders to CS is critical if improvements are to be sustained. 2. Favorable policies, often included in health sector reforms, need to encourage public and private provision of contraceptives. 3. Coordination among all stakeholders is required for true partnerships and information ﬂ ow to avoid duplication and address gaps. 1. All references to dollar amounts are U.S. dollars. 2. In this paper, commodity security refers to contraceptives unless otherwise indicated. OVERVIEW 1 4. Adopting a total market approach is one element of coordination to ensure all segments of the market are being reached and the role of diﬀerent public, private, and nongovernmental organiza tion (NGO) providers is understood. 5. Diversiﬁed funding mechanisms (i.e., capital) need to be adopted and coordinated among public, donor, NGO, and private sectors. 6. Eﬀective and eﬃcient commodity management needs accurate forecasting of commodity needs based on accurate consumption data and procurement capacity to ensure that the best prices and quality are obtained through transparent, eﬃcient, and timely ordering. 7. A well-functioning logistics system needs to be in place to ensure contraceptives are always avail able where they are needed. 8. Equity in and access to service delivery must be in place to ensure that clients, including under- served populations, are reached. 9. A monitoring and evaluation capacity is needed to Since independence, Bangladesh make necessary adjustments as new constraints emerge has had a strong commitment or outcomes do not meet work plan targets. to family planning, marked 10. A focus on the client and an understanding of the by a national family planning broader context that inﬂuences whether clients do or policy and strong public service do not access services is essential to understanding the provision. Contraceptive reasons for unmet need. security (CS) gains are, however, being undermined by a lack of Commitment is necessary at the highest political level and commitment to work with the among family planning (FP) advocates at all levels of the private and NGO sectors, and public, NGO, and private sector. National leaders need to talk a failure to create a cross-sector about the importance of the relationship between increased task force to coordinate on CS contraceptive prevalence and the reduction of maternal mortal- issues. ity rates (MMRs) and between increased birth spacing and decreased infant mortality rates (IMRs). FP targets should be in national policy documents, such as poverty reduction strategic papers (PRSPs) and sector-wide workplans; these must be linked to CS strategic plans. There must be— • recognition that plans need to be implemented and individu als held accountable in attaining national FP objectives While countries are • a willingness to address complex issues around partnerships increasingly including with the private sector and NGOs family planning • a commitment to discuss emerging issues with diﬀ erent stake- commodities in their holders on a regular basis so that emerging problems can be funded EMLs, the overcome. need for full supply of contraceptives requires A commitment to family planning should be reﬂected in a policy envi- close attention to making ronment that encourages and enhances the provision of services by suﬃ cient dedicated funds both the public and private sectors. Many policies impact FP service available. delivery: restrictions on who is qualiﬁed to dispense commodities 2 CONTRACEPTIVE SECURITY and provide services, regulation of private and NGO clinics, value added taxes (VATs) and import tariﬀ s, restrictions on advertising, and inclusion of FP products in essential medicines lists (EMLs), and insur ance drug beneﬁ ts. The policy environment needs to strike a clear balance between quality assurance and expanding access for both the public and private sector. To create and sustain CS improvements, active coordination is continually required among all FP stake holders. A multisector working group or committee should be established under the leadership of the Ministry of Health (MOH), and it should be clearly connected to the decision-making structure of the government and donors. Existing forums can be used if their mandate overlaps suﬃciently with CS. Strong leadership is essential and must reﬂect commitment. Regular meetings facilitate true partnership and information ﬂow, and permit monitoring of funding and commodity availability. Smaller technical teams can be tasked to address speciﬁc issues and report back to the committee. Adopting a total market approach is one crucial area of coordination. This requires recognition of the contributions diﬀerent public, NGO, and private suppliers can make in meeting client needs; and that populations may have a diﬀerent willingness and ability to pay (ATP) for their FP methods. An under standing of the contribution made by diﬀerent sources of funds can be gained from reproductive health accounts. An analysis of the contraceptive market by diﬀerent segments, deﬁned by the diﬀ erent socio economic and geographic characteristics of FP users, can help policymakers better serve the entire popula tion. Market segmentation can help ensure that free public FP methods are targeted at the poorest segments of society, while people who are able to can purchase products from the private sector. Armed with market segmentation analysis, policymakers must be willing to work with the private and NGO sectors to ensure they are enabled and encouraged to provide contraceptives to clients who can aﬀord to pay. Historically, developing countries have relied on one or two donor sources for their public contraceptives. While Market segmentation analysis in donors such as the U.S. Agency for International Devel- Paraguay highlighted the tremendous opment (USAID) and UNFPA continue to be important success both the public and private sources of supply, individual donor commitments have sector have had in expanding the failed to keep up with expanding demand. Governments availability of a wide variety and have to rely on new diversiﬁed sources of funding. Basket balanced mix of methods. Some 65 funding arrangements, in which the World Bank and percent of free public services are bilateral donors pool their funding to give governments reaching the poorest 40 percent of the greater responsibility, oﬀer important opportunities for population, while private providers governments to expand the resource pool for contracep- account for 69 percent of total CPR. tives. In addition, governments are increasingly provid- Nonetheless, scope still exists for both ing budget lines for contraceptives, funded by their own the public and private sectors to do tax revenues. Careful coordination between donors and more, particularly in providing longer- government is essential but it is sometimes constrained term methods in rural areas. by the diﬀerent demands donors continue to have for committing their funds, and for placing and managing orders. Diversiﬁed sources of funding have placed an increased burden on in-country procurement capacity. Basket funding, often under sector wide approach (SWAp) arrangements, requires government agencies to follow World Bank procurement guidelines, which are designed to ensure the best value for the money and to promote transparency in the use of public funds. To obtain the best price and quality combination, eﬀective procurement management requires— OVERVIEW 3 • specialized knowledge of the technical speciﬁcations of contraceptives so the right product is ordered and the product quality diﬀerences of bids can be distinguished • an ability to manage the procurement process from prequaliﬁcation through tendering, evalua tion, selection, and postcontract award monitoring • a regulatory framework that enables competitive bidding through access to domestic and interna tional suppliers to obtain the best prices. Procurement planning needs to include accurate consumption-based forecasts, driven by an eﬀ ective logistics management information system (LMIS) as part of a well-functioning, in-country logistics system. Getting products to users at service delivery points (SDPs) requires good warehouse facilities at central and decentralized levels, well organized transportation to service delivery points, an LMIS that tracks dispensed-to-user (consumption) data and months of stock on hand, and an analytical capacity that can compare these to maximum and minimum stock levels to identify and address shortfalls and over stocks. Strengthening the public-sector logistics system includes examining ways to work with private and NGO organizations to contract out parts of supply chain management, including transportation services and warehouse management. Service delivery must be addressed through an equity perspective if underserved populations are to be reached and access increased. In Malawi, recognizing Research by DELIVER has shown a strong correlation between the important role that reduced disparity in access between the lowest and highest wealth NGOs play in providing FP quintile and increasing contraceptive prevalence rates (CPRs). services, the public sector Market segmentation analysis can help identify who beneﬁ ts from is looking at community- public services and who has access to private-sector services. Why based voucher schemes that do poorer rural women in Paraguay use oral pills more often, give women greater access and long-term and permanent methods less often, than do richer to services. Th e MOH women? Whether access is deﬁned geographically or by socioeco- would reimburse NGO nomic criteria, public services should be designed to reach under- and private providers for served and vulnerable groups. This can include contracting NGO approved services provided and private providers as well as targeting public services in areas to poorer women. underserved by the private sector. While a focus on commodities is important, the capacity and availability of trained staﬀ and essential supplies and equipment should not be overlooked. Contraceptive security is not an objective that remains static once it is obtained. Rather, it is a dynamic process that evolves over time, requiring coordinated eﬀorts, even as progress is attained. Th e complex factors that inﬂuence it can include political changes, changes in key staﬀ in the public sector, changes in donor funding commitments, increasing demand as populations of reproductive age expand, changes in the procurement and manufacturing cycle, and the emergence of new contraceptive methods. Countries need an ability to monitor and evaluate their CS and program performance and make necessary adjust ments if new constraints emerge or outcomes do not meet workplan targets. This function should be the responsibility of a CS committee or working group, which must routinely monitor stock status reports, procurement pipeline status, existing funding and future commitments, and the quality and reach of service delivery. Developing annual forecasts, examining demographic and health survey (DHS) data, conducting market segmentation analysis, and constructing reproductive health accounts can all provide important information to identify gaps and evaluate impact. 4 CONTRACEPTIVE SECURITY Finally, we should not lose sight of the client. We need to understand both the clients’ needs and the context in which they make their contraceptive choices. In addition to ensuring availability of a balanced method mix and access to services, a broad array of other factors must be considered: girls’ education, women’s employment, religious beliefs, and other social and cultural dynamics. The impact of health sector reform and competing demands on health and social resources should also be considered. DHS data have shown that, in many countries, there is a signiﬁcant unmet need for modern methods of contraception. Understanding the reasons for this unmet need is crucial to addressing it. Unmet need can be caused by many things: distance to rural FP clinics; a lack of commodities or trained service provid ers after clients reach a clinic; or lack of access to alternative, aﬀordable NGO or private-sector services. Addressing all the other inﬂuences on CS will make little diﬀerence if the client is not considered. While no two countries face the same CS situation, signiﬁcant similarities across countries suggest that lessons can be learned and solutions duplicated from one context to another. Adopting the SPARHCS tool—whether designing and conducting an assessment, organizing a key informant workshop, or moni toring and evaluating an ongoing program—can help provide a strategic vision and framework needed to address CS. Regional initiatives that provide countries an opportunity to share experiences and lessons learned in addressing CS can also help strengthen commitment to increasing access to FP services. PUBLICATION PURPOSE AND OUTLINE This publication reﬂects the ﬁndings of much of the contraceptive security work undertaken by DELIV ER and funded by the U.S. Agency for International Development (USAID) over the last six years. It provides in a single document both a record of work completed and the lessons learned during the process. Given the investment in CS, we have documented and evaluated outcomes to help determine what really has worked and what has not. The potential audience for this publication is diverse. It includes DELIVER staﬀ and ﬁeld teams, USAID staﬀ in Washington and in the ﬁeld, counterparts from partner countries, other donors, and other cooperating agencies (CAs). It provides both a strategic overview of what has and has not worked in CS, details of what countries and stakeholders should consider doing, and, to a limited extent, some guidance on how to plan and implement CS activities. More detailed analysis and guidelines and tools can be found in various DELIVER publications at www.deliver.jsi.com; they are cited speciﬁcally throughout this document. The nature of DELIVER’s work—practical and in response to demands from the ﬁ eld—requires results- oriented outcomes that contribute to improving contraceptive commodity availability. While DELIVER has a well-developed and robust moni toring and evaluation function, we do not always have the scope to return to a project to evaluate objectively all of the earlier interventions undertaken. For example, how successful was the very ﬁ rst SPARHCS ﬁeld test in improving aware ness of and commitment to contraceptive security in Nigeria? Some of the questions raised in the following sections demand further analysis and review. Furthermore, the timing of the production of this paper means that much has been written before key elements of applied research into CS Bangladesh: Field worker gives client birth control pills. OVERVIEW 5 are complete. Now that the Contraceptive Security Index 2003 (John Snow, Inc./DELIVER and Futures Group/POLICY 2003) is updated Contraceptive Security Index 2006 and other research products are completed, we will update the contents of this report. While DELIVER has often played a leading role, much of this work has been undertaken in collaboration with other cooperating agencies and MOH agen cies. We acknowledge and cite their work, as appropriate. The remainder of this document addresses the 10 components described earlier in this chapter, adding additional country examples and a regional and global dimension. • Chapter 2 presents the perspective of the client and some of the contextual constraints aﬀ ecting demand and product availability. • Chapter 3 looks at the global perspective to identify how multilateral and bilateral agencies work ing with new and diversiﬁed donors and interest groups are tackling product availability. • Chapter 4 summarizes some of the diﬀ erent regional and subregional initiatives that have been undertaken in Latin America, Africa, and Eastern Europe to improve product availability, often in the context of diﬃcult political environments and competing health agendas. • Chapter 5 provides a more detailed explanation of the importance of commitment, coordination, strategic planning, and implementation at the country level. • Chapter 6 addresses regulatory and policy constraints on improving CS. • Chapter 7 provides practical examples of the total market approach and how it can be used to improve coordination with the private sector and expand contraceptive availability and use. • Chapter 8 elaborates on how strategies programs may be used to take advantage of diversiﬁ ed ﬁ nancing sources; linking options at the global, regional, national, and local level. • Chapter 9 provides an outline of the steps required to strengthen procurement capacity and some of the challenges that countries are facing. • Chapter 10 describes the importance of and challenges to establishing and maintaining a func tioning and eﬃcient logistics system to ensure CS. • Chapter 11 considers some of the CS issues surrounding service delivery and product availability. • Chapter 12 summarizes emerging issues and next steps. 6 CONTRACEPTIVE SECURITY 2. CLIENT PERSPECTIVE Contraceptive security (CS) is experienced one client at a time. Therefore, the client must be the central focus of any CS strategy. But, because there are so many components that must be considered, and so many systemic, ﬁnancial, and policy issues that must be addressed, it is easy for policymakers and program managers to lose sight of the ultimate beneﬁciaries—the people who use or want to use modern contraceptives. It is their voices that must be heard if their needs are to be met. With that thought, we present stories of real clients in four countries—Ghana, El Salvador, the Philippines, and Romania—to illustrate the intersection of the 10 CS components and the impact they have on the lives of these women. CYNTHIA IN GHANA Ghana has been grappling with contraceptive security since 2002 when it developed a national strategy to ensure that clients would have access to the contraceptives of their choice regardless of where they lived, where they went for family planning services, or how much money they had. In Ghana, the use of modern contraceptives among married women was just over 18 percent in 2003, the second highest in West Africa, and a considerable improvement over 1988, when it was just 4 percent. About 23 percent of married women have an unmet need for contraception, which contributes to a total fertility rate of nearly 4.5 children for each married woman. Almost half of all clients (47 percent) get their contraceptives from the public sector; therefore, the increasing contraceptive prevalence rate (CPR), combined with continued growth in the general population, means that demand for contraceptives is going to grow and the govern ment must ensure that it has the resources to meet that demand. Since launching the national strategy in 2002, the government has started using its own funds to ﬁ nance and procure contraceptives while continuing to distribute donated contraceptives from international donors. The multiple sources for contraceptives have required close coordination among the government, donors, and nongovernmental organization (NGOs) to ensure supply needs are met and to avoid dupli cation and oversupply—or undersupply due to omission—of any particular method. The Ministry of Health (MOH) has strengthened its logistics system to make sure supplies are available at service delivery points (SDPs), and has promoted the acceptance of and demand for family planning services through mass media and community outreach campaigns. The total contraceptive market in Ghana is undergo ing changes as the public sector focuses on providing free contraceptives to the poor, and NGOs and the commercial sector work to meet the needs of clients who are able to pay either subsidized or full prices for their supplies. This policy shift has happened as traditional bilateral donors reevaluate their contraceptive commodity support; the MOH has had to rethink its funding approach for contraceptives, recognizing the need to increase funding from domestic sources. This includes increasing the government budget lines, using pooled donor sector wide approach (SWAp) basket funding, and looking at private house holds to share the cost of contraceptives. Cynthia is the type of client Ghana’s national strategy is trying to help. She is 27 and lives in a village about an hour outside Ghana’s capital city, Accra. Cynthia has had to overcome many obstacles that could easily have deterred her from the consistent use of contraceptives. But, for Cynthia, the security of plan ning her family is too important to neglect (Supply Initiative 2005). CLIENT PERSPECTIVE 7 In her ﬁrst serious relationship, Cynthia became pregnant with her son, now ﬁve years old, and she and her boyfriend married. When her son was a toddler, Cynthia, who had seen advertisements about family planning on television, decided to visit the government-run clinic in her village. They provided her with regular three-month contraceptive injections. However, she developed painful side eﬀects and was unable to ﬁnd relief at the government clinic. Rather than ending her use of contraception, Cynthia began making the hour’s trip to Accra in a tro-tro (shared taxi) to visit a clinic run by Planned Parenthood Association of Ghana (PPAG), which is Ghana’s largest private provider of reproductive health services. Despite the transportation costs, she found the environment at PPAG more welcoming than the government-run clinic. “They told me about all the methods, how the drugs work, what the beneﬁts and side eﬀects are. I chose the one-month injections and they told me that if I have any problems, I can come in right away,” Cynthia explains. Fortunately, because she switched to the monthly injections, the side eﬀects have subsided. Cynthia and her husband would like to eventually have three children but plan to delay the birth of their second child for another year. Birth spacing for health and economic reasons is very important to Cynthia. “Now I can choose when to get pregnant. Also, it allows me to work,” Cynthia says. “I’ve set up my own shop selling drinks. There is nothing about family planning that I don’t like.” ANA IN EL SALVADOR Contraception is a critical part of the public health picture in El Salvador. Although political and reli gious trends tended to limit family planning eﬀorts through the late 1990’s, today 67 percent of married women use contraceptives (CDC 2003). Th is ﬁgure is largely dominated by female sterilization (about one-half of all users), followed by injectables (18 percent) and oral contraceptives (6 percent). Roughly 47 percent of Salvadoran contraceptive users receive free or subsidized family planning commodities from the government. They obtain supplies at public hospitals, clinics, and smaller health centers. Health promot ers also visit homes to deliver needed contraceptives. A fundamental aspect of attaining contraceptive security is providing clients with a choice of family plan ning methods. However, program planners in many resource-poor countries face tough budgetary deci sions, and often consider limiting the range of products they make available to users. In addition, there is the constant need to ensure that choices are informed by fact, not ﬁction. El Salvador confronted these challenges as it prepared for the phaseout of contraceptive donations from USAID in 2005. Ana is a 23-year-old woman living in the town of Cojutepeque in central El Salvador. She and her husband are among many people who had to rebuild their houses following a devastating earthquake in 2001. Ana’s only child, a vibrant 18-month-old girl, is always in her arms when she goes to the public hospital for her free quarterly dose of the injectable contraceptive, Depo-Provera. “I chose Depo because it’s much easier than keeping track of daily pills,” Ana explains. “The hospital has always been able to give it to me, but if they weren’t, I’d look for another place to get it; even if it meant ﬁguring out a way to pay for it.” Ana and other Depo-Provera users represent 18 percent of all contraceptive users in El Salvador, but every user’s reason for choosing the method varies greatly. In San Ramon, only 10 miles from Cojutepeque, Dr. Fátima de Calderón refers to her consumption records, which show that injectables are nearly the only form of modern contraception used by her clients. “Here we live in a traditional environment in which a woman who wants to use contraception must often hide it from her husband,” she says. “Many men are CONTRACEPTIVE SECURITY 8 against contraceptive use in the home because they believe that it provides an opportunity for their wives to cheat on them.” For its low frequency and low visibility, Depo-Provera is an excellent option. In using the same thinking, it would seem that intrauterine devices (IUDs) are an even better solution. Inserted just once and eﬀ ec tive for as long as 10 years, the device oﬀers the type of easy maintenance that Ana is looking for and the discretion that Dr. de Calderón’s clients require. But misconceptions that IUDs cause cancer are common, as are fears that the device will become dislodged and insert itself into the body of the fetus whose concep tion it was supposed to prevent. “When counseling new users of family planning options, we obviously try to dispel urban legends of this type. It ultimately comes down to them making a choice that they can use with conﬁdence over the long term,” suggests Cojutepeque family planning advisor, Rosa Catalina Burgos de Hernández. Dispelling misinformation and educating the public are also important tasks for service providers, but they need accurate information. Profamilia clinics are a network of health facilities and pharmacies geared toward lower-middle-class clients and run by the Salvadoran Demographic Association (SDA), an aﬃliate of the International Planned Parenthood Foundation. These clinics do not carry Depo-Provera because Profamilia doctors originally compared the strength of the product to horse medicine. Th at decision resulted in the loss of a number of Profamilia clients. Injectables are the most expensive contraceptives on the market. A year’s dosage can cost nearly four times the price for the same duration of protection from oral contraceptives. Nonetheless, in 2005, El Salvador’s budget for contraceptive procurement put Depo-Provera right at the top of the list for funding, helping secure Ana’s method of choice for another year. A signiﬁcant amount of technical assistance has supported El Salvador’s contraceptive security eﬀ orts. MOH staﬀ now has the capacity to accurately forecast their needs based on information from a function ing logistics system. Policies have been implemented to expand peoples’ access to contraceptives, particu larly through community-based distribution. This has taken place within the context of El Salvador’s graduation from USAID’s contraceptive donations. This graduation has required close coordination between the MOH, USAID, and UNFPA as the procurement agent, and the Salvadoran Demographic Association, which has also been receiving donated contraceptives from USAID. As a result, El Salvador has taken ownership of the country’s contraceptive security, with both the government and SDA ﬁ nancing and procuring contraceptives. This demonstrates political commitment at the highest levels in the coun try. Dr. Herberth Betancourt, the former Minister of Health and a pediatrician explains, “We are not only binding ourselves to an agreement with USAID to procure contraceptives independently, but also to a social contract with the people of this country to meet their demand for reproductive health supplies.” LORNA IN THE PHILIPPINES The Philippines health system is largely decentralized to the level of the local government unit (LGU)— province and municipality—and, therefore, most of the country’s contraceptive security work has been focused at this level. USAID has been phasing out its contraceptive donations, which are due to cease in 2008. At the national level, the government has decided not to procure contraceptives to replace USAID’s donation; they left that decision to the LGUs. Pangasinan, a province of 2.5 million people in northern Luzon Island, has long been a success story in family planning. The CPR for the province is 55 percent, compared to a national CPR of 49 percent CLIENT PERSPECTIVE 9 (Philippines National Family Planning Survey 2005) among married women of reproductive age (MWRA). Starting in 2005, with the phaseout of USAID-donated contraceptives, the province began procuring its own supply of pills and injectables, and it has budgeted three million pesos ($57,500) for procurement in 2006. In addition, 29 of the 477 municipalities in the province also have contraceptive budgets and procurement systems in place. This is part of Pangasinan’s contraceptive self-reliance (CSR) program, as Filipinos refer to contraceptive security. Lorna is 42 years old and has ﬁve children, ranging in age from 8 to 16 years old. She lives with her husband and children in the small rural village of Inlambo, in the municipality of Mangaldan in Panga sinan. She has been a family planning client of the Inlambo Rural Health Unit since the birth of her last child. Lorna was married when she was 26, and she soon became pregnant. She had a baby every two years until the birth of her youngest daughter. “My husband told me when we got married, ‘let’s have ﬁ ve children, then let’s start family planning’,” says Lorna. “I’m happy with ﬁve—we never wanted fewer.” But ﬁve children are a lot of mouths to feed and bodies to clothe and minds to educate. “Life is diﬃ cult,” she explains. “It’s diﬃcult to send so many children to school, and if they get sick, instead of buying food, we buy medicine.” Still, Lorna wasn’t sure she was ready to stop having babies. “I wanted one more child. But my children are saying ‘mama, that’s enough, we are too many.’ My oldest daughter (she’s 14) says when she gets married, she only wants three children.” Lorna has been using three-month inject ables for the last eight years and is very happy with the method. When asked whether she has considered a long-term or permanent method—both of which are readily available in Pangasinan—she smiles and says she’s happy with the injec tions. She is particularly glad that she and her neighbors receive them free of charge, because few people in rural villages can aﬀord to buy their contraceptives. However, a few of her neighbors said that if they weren’t able to get them for free, or if they were stocked out, as happened in 2004 because of distribution delays from the central level, they would ﬁnd a way to purchase their contraceptives. Th at would require traveling by tricycle (a motorcycle with sidecar for passengers) to the pharmacy in Mangaldan town. But stockouts are not a problem now that the province and the municipality are procuring pills and injectables out of their own budgets. This support is critical, and the result of strong commitment by both the provincial governor and the mayor of Mangaldan, Herminio Romero. “I believe one of the causes of our poverty is overpopulation,” says Mayor Romero. “Uncontrolled population growth is hindering our development, and much is being spent on services for all these people.” The 2006 budget for the municipality includes a budget line for contraceptive procurement of about $4,000, as well as $2,400 for training community-based volun teers (CBVs) who form the backbone of the rural distribution and data collection system. While not a large sum, this ﬁnancial support is a signiﬁcant commitment for the municipality. The province’s logis- Philippines: Lorna receives regular counseling and contraceptive injections from her midwife. 10 CONTRACEPTIVE SECURITY tics management information system has been adapted to capture data on supplies that municipalities procure, providing a complete picture of the provincial stock status and allowing the province’s policy- makers to allocate their resources rationally. One positive step that Pangasinan has taken is to work with pharmacies throughout the province to ensure that they stock a range of products. This total market approach is a ﬁrst step in encouraging a better segmentation of the contraceptive market. “Almost all pharmacies in Pangasinan now carry a good selection of methods, including pills, injectables, and condoms, of course,” says Luz Muego, the Provincial Population Oﬃ cer. Th is eﬀort to provides better access to people who can aﬀord to buy their own contra ceptives and, therefore, improve market segmentation. While no speciﬁc socioeconomic eligibility criteri on names the recipients of free-of-charge contraceptives, the province is encouraging local governments to focus their resources on serving the poor. To facilitate the process, the province is using CBVs to conduct regular household surveys, and is using the living standard indicators to help municipalities develop lists of speciﬁc families and speciﬁc MWRAs, in particular, who should receive free-of-charge contraceptives. “We’re reforming a three-decades-old system,” explains Governor Victor Agbayani, who has been a champion of family planning and CSR, both in his province and nationally. “There are things that don’t work…Free commodities are accessed by both the poor and nonpoor, so the poor have to compete with others who can aﬀord to pay,” he notes. “About half of those who now use [free contraceptives] can pay for contraceptives. So, with limited resources, how do you say ‘you cannot access [free contraceptives] because you can aﬀord to buy them at the pharmacy’?” The answer lies in the market segmentation: the living standards data will provide municipalities with the information they need to make informed policy decisions about targeting available resources to the neediest people. And the province will support this by issuing identity cards to people who meet the eligibility criteria.” Pangasinan’s CSR strategy is a model that the governor is happy to share with his peers, because he recog nizes that his province is in the forefront of CSR in the Philippines. “Other provinces are just focusing on replacing donations [from USAID],” he observes. “That’s a simple solution, but doesn’t solve it all.” MARIANA IN ROMANIA In Eastern Europe and Eurasia, most countries are experiencing population decreases due, in part, to low total fertility rates. Couples prefer a small family size, but health systems have relied on abortion to meet couples’ desire to limit their number of children. It is only since the mid-1990’s that this situation has begun to change. Romania posed one of the greatest challenges in the region due to a legacy of pro-natalist policies of the former communist regime, that virtually banned any form of contraception and abortion. Th is changed in 1989 when both abortion and contraceptives were legalized. But, providers had little knowledge about modern contraceptive technology and were biased against hormonal methods. Family planning services could only be provided by urban-based obstetricians and gynecologists (OB/GYNs), who had ﬁ nancial incentives to provide abortions rather than oﬀer contraceptives to their clients. During the 1990’s, the emerging private sector began oﬀering contraceptives, but their market was primarily in urban areas. Donors, such as UNFPA and USAID, provided limited quantities of contraceptives for the public sector; these were provided free to certain eligible clients through 210 family planning cabinets in urban poly clinics. However, access for poor and vulnerable people, particularly in rural areas, remained poor. By 2004, this situation had changed dramatically as family planning was integrated into primary health care (PHC) services. A large cohort of rural family doctors was trained, and access to both services and CLIENT PERSPECTIVE 11 contraceptives expanded tenfold. As of January 2006, more than 2,000 of the 2,690 rural communities have PHC units, with trained providers who can oﬀer services and free contraceptives to eligible clients. As a result, Romania has seen a remarkable increase in modern methods CPR, from 14 percent in 1993 to over 38 percent in 2004, and a dramatic decrease in the abortion rate from 3.4 per women (during their reproductive years) in 1993 to 0.84 in 2004 (Ministry of Health et al. 2005). Mariana and her family are among the many beneﬁciaries of the changes in Romania. She is 29 and lives with her husband, son, and daughter in Prundu Bârgâului, a rural community of about 6,000 people in northern Romania. She is a client of the local primary health center, which is staﬀed by three family doctors who, since 2004, have been providing Mariana and her neighbors with family planning services. Mariana’s son, who is six, was born with signiﬁcant physical disabilities. “My child can’t walk, doesn’t speak, mentally he is OK, but not physically,” she says. “After giving birth to my ﬁrst child, who is physi cally impaired, I was not exactly sure whether I wanted to have a second one.” But Mariana didn’t have many options after the birth of her son. “My husband was careful enough, also [we used] condoms and abortion. After the abortion, I found out that free contraceptives were available…[but] I didn’t take any before my second pregnancy. I was afraid I might become overweight.” One of the eligibility criteria for receiving free contraceptives was if women had had a recent abortion. However, there was insuﬃcient counseling to address Mariana’s concerns about gaining weight. And, the contraceptives were only available at the polyclinic in the city of Bistriţa, which is 45 minutes away by car. The next time Mariana got pregnant, she and her husband decided to have the baby. “When I found out I was pregnant, I had to make a decision: whether to keep the baby or have an abortion. I yearned for the crying of a normal baby and for the steps of a normal baby.” Mariana got what she’d hoped for—she gave birth to a healthy daughter four years ago. But Mariana came to a decision. “I didn’t want any more babies,” she explained. Because 90 percent of Romania’s poor live in rural areas, in 2003 policy changes were made that expanded the eligibility for free contraceptives to all rural clients, and family planning services were included in the basic package of services funded by the national health insurance scheme. At the same time, family doctors were being trained to provide family planning services at primary health care centers. When her local primary health clinic began oﬀering free contraceptives, Mariana decided to visit. “I started taking pills, but there was one day during the month when I forgot to take them,” she says. “At ﬁrst I was a little bit afraid to take them because some of my colleagues had grown fat.” Mariana decided to switch to Depo-Provera. “It’s much more convenient to do it by injections. It really made a diﬀ erence.” Mariana works full time caring for her children. Her family receives a small monthly allowance from the government to help cover the cost of her son’s care and support, but her husband was recently laid oﬀ Romania: Mariana (right) receives counseling on injectable contraceptives from her family doctor,Viorica Bonia. 12 CONTRACEPTIVE SECURITY from his job at a factory in Bistriţa, so money is tight. “It’s my dream to go to work, but I can’t, because my children—at least the older one—needs all my care.” Mariana is particularly grateful that she can get contraceptives for free. “It is a great idea to provide them for free, because otherwise…I wouldn’t be able to buy them. I can’t give up our daily bread for them, they are too expensive.” While the provision of free contraceptives was a critically important aspect of the Romania program, no negative impact was felt by the growing private-sector contraceptive market. In fact, as the use of free contraceptives has expanded, so has the private market for contraceptives (see ﬁgure 1). This consideration of the total market was vital for the sustainability of the program in Romania. While the government is striving to meet the needs of the poor, it cannot aﬀord to become a majority supplier of free contracep tives. A middle-income country like Romania must ensure that the private sector provides the majority of contraceptives. FIGURE 1. ACTIVE USERS OF PILLS FROM FAMILY PLANNING PROGRAM AND PRIVATE SECTOR IN ROMANIA 22 3, 07 7 24 1, 53 8 26 0, 39 2 28 5, 92 0 25 3, 24 2 26 4, 04 7 29 2, 19 3 27 2, 18 7 27 5, 56 1 32 8, 18 1 34 1, 87 5 37 3, 04 7 34 1, 59 5 36 1, 08 1 8, 33 4 20 ,0 10 33 ,5 23 46 ,5 75 64 ,3 05 74 ,7 32 74 ,0 03 73 ,0 26 68 ,5 42 79 ,9 44 82 ,4 80 90 ,3 92 99 ,7 42 10 8, 35 7 10 3, 57 6 0 100, 00 0 200, 00 0 300, 00 0 400, 00 0 P i l l s (c y c l e s) P r i v ate s e ctor and soci al m a rketi ng pi l l users N a tional FP pro g ram p ill users 22 3, 07 7 24 1, 53 8 26 0, 39 2 28 5, 92 0 25 3, 24 2 26 4, 04 7 29 2, 19 3 27 2, 18 7 27 5, 56 1 32 8, 18 1 34 1, 87 5 37 3, 04 7 34 1, 59 5 36 1, 08 1 8, 33 4 20 ,0 10 33 ,5 23 46 ,5 75 64 ,3 05 74 ,7 32 74 ,0 03 73 ,0 26 68 ,5 42 79 ,9 44 82 ,4 80 90 ,3 92 99 ,7 42 10 8, 35 7 10 3, 57 6 0 100,000 200,000 300,000 400,000 Pi lls (c yc le s) 2002 2003 2004 2005 2002 2003 2004 2005 Year (by quarter) Year (by quarter) Romania’s success resulted from a number of changes in policies, ﬁnances, and systems, all of which impact contraceptive security. New policies were implemented that allowed family doctors to provide family planning services and to dispense free-of-charge contraceptives to eligible clients. Services were expanded and improved by providing training to family doctors in modern contraceptive methods and client-centered counseling, and by including family planning in the basic package of services covered by the national health insurance scheme. New ﬁnancing was secured through the national government to procure contraceptives that are provided free to poor and vulnerable populations, especially in rural areas. A new logistics system was created to make sure those contraceptives are always available at the clinics when clients needed them. Behavior change and service promotion campaigns, with simple-to-understand information and education materials, built demand in rural communities for family planning services. The program expanded quickly thanks to close coordination between public, private, and NGO stake holders at both the national and local levels. All this occurred within the context of signiﬁcant health CLIENT PERSPECTIVE 13 sector reform that introduced primary health care services and national health insurance, the general population’s continuing desire for small family size, and a history of over-reliance on specialists for services and on abortion for fertility control. CONCLUSION As each of these stories illustrate, contraceptive security is experienced one client at a time. Each country is strengthening their contraceptive security in unique ways, reﬂecting their distinct contexts and indi vidual challenges. But, the overall strategies touch on some or all of the 10 components that determine whether people like Cynthia, Ana, Lorna, and Mariana will be able to choose, obtain, and use quality contraceptives whenever they need them. 14 CONTRACEPTIVE SECURITY 3.THE GLOBAL CHALLENGE CONTRACEPTIVE SECURITY, 1998–2006 As a concept, contraceptive security is a vision similar in breadth to the old Health for All rallying cry, or to the current universal access demands for acquired immunodeﬁciency syndrome (AIDS) treatment. Each is an overarching goal toward which the global health community strives to make progress; because the goal is not something that can be attained and crossed oﬀ the list, they will have to continue to strive indeﬁnitely. Like Health for All and universal access, the eﬀort has generated a new vocabulary and new ways of doing business; engaging a broader range of partners, establishing new alliances, and aligning activities toward a newly articulated common purpose. And, like those concepts, contraceptive security, to be fully realized, requires action at the individual, program, national, and global levels. Th is chapter looks at contraceptive security in the global setting, and at how multilateral and bilateral agencies working with new and diversiﬁed donors and interest groups are addressing product availability. Taking the global perspective means asking: how can systems become synchronized and how can resources be allocated most eﬀ ectively, eﬃciently, and equitably to meet growing demands worldwide? INTERIM WORKING GROUP The notion that contraceptive supplies must be available to enable individu als to plan the number and spacing of their children is, of course, not new; it has been a hallmark of family planning programs for nearly half a century. It was underscored in the Cairo Programme of Action adopted at the 1994 International Conference on Population and Development. But the concept of contraceptive security arose in the late 1990’s out of a unique partnership between John Snow, Inc.’s (JSI) health logistics program and a U.S. population advocacy organization (Population Action International), a U.S. foundation (the Wallace Global Fund), and another U.S. technical agency (PATH). In 1998, JSI was asked, “We keep hearing of anecdotal stories of clinics without supplies in developing countries. Is there a contraceptive shortage?” Our response was that, to ensure that contraceptives are available to clients, the typical situation was less one of scarcity, although funding is always a constraint, but rather one of (1) vulnerability to frequent disruptions in donor-supported supply mechanisms, (2) weak capacity in countries’ health logistics systems, (3) overall poor planning, and (4) woefully insuf ﬁcient coordination among the many systems that need to work well and work together. If only, we Samples of various contraceptives THE GLOBAL CHALLENGE 15 said, contraceptives were thought of as an essential commodity—like food or water—so that country governments, donors, and lenders would commit unequivocally to the availability of needed supplies and synchronize their ﬁnancial, program planning, and delivery systems to secure it. That is how the concept of contraceptive security was born (Hart 1998). The analogy to food security is an imperfect one; food is a basic necessity for all life, there is, of course, a high demand for food. Whereas addressing reproductive health typically meets the needs of more deﬁ ned sub-populations. But, the most useful aspects of the analogy are— • Access to life-sustaining food is universally understood to be a basic human right. At the Interna tional Conference on Population and Development (ICPD) in 1994 and ICPD+5 in 1999, the world community committed to reproductive health (RH) as a human right; and reliable access to contraceptives is a critical component of realizing that right (United Nations 1994a, 1994b). • Just as countries are obligated to their citizens to avert famine, they are obligated in the practice of public health to avert disruptions in the availability of contraceptives. • In addressing food crises, donors are aligned to step in when poor countries cannot meet their people’s needs; early warning systems have been established to track signs of inadequacy in the food supply. This synchronization of systems and the proactive use of data are possible in the realm of reproductive health as well. The Wallace Global Fund had thrown the pebble in the water, and the ripples began to spread. In 1999, Population Action International (PAI), PATH, the Wallace Global Fund, and JSI formed an alliance: the Interim Working Group on Reproductive Health Commodity Security (IWG). The IWG engaged UNFPA, USAID, Department for International Development (DFID), and other donors, and was formalized in 2000 when it secured foundation support from the Bill and Melinda Gates Foundation, the David and Lucile Packard Foundation, the William and Flora Hewlett Foundation, and the Better World Fund of the United Nations Foundation (Supply Initiative 2006). The IWG conducted research and developed materials to support a major meeting in Istanbul in May 2001 (Interim Working Group 2001b), “Meeting the Reproductive Health Challenge: Securing Contra ceptives, and Condoms for HIV/AIDS Prevention.” (All nine Istanbul papers are available online at http://www.rhsupplies.org.) USAID played a critical role in the Istanbul meeting, both by engaging enthusiastically at the highest levels of the Oﬃce of Population (as it was known then) and by sponsoring the participation of country teams, which allowed ﬁeld perspectives to be articulated in their own voices. In one of the nine pre-Istanbul papers, “Contraceptive Projections and the Donor Gap,” the Interim Working Group on Reproductive Health Commodity Security projected that even in the near future there was a large gap looming between contraceptive needs and supplies. The paper projected a shortfall of between $140 million and $210 million annually by 2015. Other IWG papers and ﬁ ndings focused on issues, including deﬁning RH supplies, country perspectives and lessons, ﬁnancing options, assessing contraceptive security, and raising awareness. Based on this research and the presentations and dialogue at the Istanbul conference, delegates concluded that a more robust response was needed from donors, coun try governments, and civil society alike. Speciﬁcally, the conference participants’ ﬁ nal recommendations identiﬁed the need to— • strengthen national capacity in areas of logistics management, analysis, and in-country donor coordination 16 CONTRACEPTIVE SECURITY • establish a web-based system of procurement • develop a list of essential reproductive health supplies to help guide policies and resource alloca tion for basic health services • revitalize donor coordination at the global level • develop a plan of action for expanding the role of the private sector • undertake an advocacy leadership campaign, backed by regional meetings on reproductive health commodity security (RHCS). A call to action was issued in the Istanbul Declaration, that concluded— The Istanbul meeting is a milestone in a dynamic process of partnerships, solidarity, and commitment to action the stakeholders pledge to continue. We know what to do about this crisis of shortfalls in reproductive health supplies, and how to do it…advocacy, national capacity building, ﬁ nancing, and donor coordination… (Interim Working Group 2001b, pp. 20–21) SUPPLY INITIATIVE After the Istanbul meeting, the members of the IWG continued to work together and continued to receive foundation support to implement parts of the Istanbul action plan. A new Reproductive Health Supply Initiative was formed, with the German Foundation for World Population (DSW) joining JSI, PAI, and PATH (see Supply Initiative website at http://www.rhsupplies.org/about.shtml?navid=1). The Supply Initiative (SI) was oﬃcially launched in 2003, and established an oﬃce in Brussels, Belgium. The SI worked until mid-2006 on four main aspects of the RH commodity security issue: • advocacy, especially to engage, educate, and mobilize European nongovernmental organizations (NGOs), bilateral donors, and the European Union around RHCS (led by PAI) • communication and support of a virtual community, which included a website, electronic and print newsletters; and several fact sheets, press releases, and other publications on various aspects of RHCS (led by DSW) • creation and operation of the Reproductive Health Interchange (RHI), which is a consolidated contraceptive procurement database for USAID, UNFPA, and IPPF (led by JSI) • establishment of a forum to develop and enhance synergy toward RH commodity security, now known as the Reproductive Health Supplies Coalition (RHSC) (led by PATH). The SI has completed its work; these major activities have been successfully launched and will continue into the future. Resources have been secured to continue and expand the RHI and RHSC; new resources are being sought for advocacy. The Bill and Melinda Gates Foundation is the main funder of this work (Population Action International 2006). THE GLOBAL CHALLENGE 17 Sample page from the RH Interchange website REPRODUCTIVE HEALTH SUPPLIES COALITION At the Istanbul meeting, a community was begun that continues to grow and mature in the way it is organized. Major players in the RHCS movement came together to form the RHSC in 2004. Th e RHSC has met ﬁve times, semi-annually, since its establishment; it was hosted by the World Bank in Washington (April and November 2004), the Gates Foundation in Seattle (May 2005), the Netherlands Ministry of Foreign Aﬀairs in the Hague (October 2005), and UNFPA in New York (April 2006). As of the last meet ing, the members of the RHSC are a diverse group of some 20 multilateral organizations, bilateral donors, private foundations, representatives of developing country governments and NGOs, technical agencies, and civil society, including the— • Bill and Melinda Gates Foundation • Department for International Development (DFID) • European Commission • German Development Cooperation (the GTZ)/KfW Development Bank • GSMF International, a Ghanaian social marketing company* • International Planned Parenthood Federation (IPPF) • Ministry of Finance, Planning & Economic Development, Uganda* • Ministry of Health, Romania* • Ministry of Health and Family Welfare, India* • Netherlands Ministry of Foreign Aﬀ airs 18 CONTRACEPTIVE SECURITY • Partners in Population and Development (PPD) • Population Services International (PSI)* • Profamilia Colombia* • Shanghai Institute of Planned Parenthood Research, China* • Supply Initiative • United Nations Foundation • United Nations Population Fund • United States Agency for International Development • World Bank • World Health Organization. (* Denotes two-year rotating membership) Th e ﬁrst chair of the RHSC was Elizabeth Lule, of the World Bank, who served from 2004 to 2005. Current co-chairs are Margret Verwijk (Netherlands Ministry of Foreign Aﬀairs) and Wolfgang Bichmann (KfW Development Bank). UNFPA and USAID are major players in the coalition, but it is a signiﬁ cant demonstration of the expanding ownership of the contraceptive security imperative that the World Bank and key European donors have stepped up to assume leadership of the RHSC in its early years. In addition to its regular meetings, the RHSC operates through three well-established working groups, each one grounded in the priorities that emerged from the Istanbul conference (RHSC 2006): • The Resource Mobilization and Awareness Raising Working Group aims to increase political and ﬁnancial commitments to RH supplies and supply systems by increasing and strengthening advo cacy at country, regional, and global levels. • The Systems Strengthening Working Group focuses on developing ﬁnancing, procurement, and distribution systems that are more data driven, better aligned, and better coordinated, so that RH supplies will be more reliably available to and within countries. An innovative, ongoing activ ity of this group is the Countries at Risk Working Group, which is made up of representatives of commodity donor/funder organizations (e.g., UNFPA, USAID, KfW, World Bank), who meet regularly by conference call to share information about the current status of contraceptive supplies in each country, raise early warnings of disruptions in the supply chain, and devise short- term solutions to meet emergency needs. • The Market Development Approaches Working Group aims to expand commercial markets for RH supplies among low- and moderate-income consumers, and to promote policies and regula tory environments that support better allocation and use of public subsidies and expanded provi sion of RH supplies by the private sector. After two initial years of operation, with SI support, the RHSC now has a dedicated secretariat, with a full-time executive director and a small technical and administrative staﬀ based in Brussels, as of August 2006. The secretariat is hosted by PATH and ﬁnancially supported by the Gates Foundation. THE GLOBAL CHALLENGE 19 As all movements and coalitions do, the RHSC should be expected to continue to evolve in the years ahead. Priorities for its evolution might include becoming even more inclusive, especially ﬁnding a way to engage Southern partners more eﬀectively; leveraging support from strategic alliances with other public health eﬀorts, such as the Global Fund; encouraging and enhancing candor, transparency, and mutual accountability; and keeping itself refreshed and focused on the ultimate objective—ensuring that women and men everywhere can always choose, obtain, and use the reproductive health products they desire. KEY FUNDING AND TECHNICAL ASSISTANCE PARTNERS IN RHCS There is not space in this publication to catalog the complete range of contraceptive security–related activities of even the major global agencies active in the ﬁeld. In the last ﬁve years, there has been a great deal of attention and productive eﬀort made in this area. The following is a very brief synopsis of key part ners’ roles. UNFPA: As a United Nations organization, UNFPA plays an unparalleled leadership role in RHCS—and has always done so—with a truly global mandate and global reach. UNFPA’s leadership role in commod ity security was internally embraced in 1999 as a follow-up to the ﬁve-year review of ICPD. A UNFPA RHCS strategy was developed soon after. UNFPA has elevated RHCS to be a strategic priority and has embodied that in organizational changes and hiring. To meet shortfalls in its own budget, UNFPA has successfully used RHCS to secure extraordinary funding from major donors, including the British, Dutch, Canadian, and European Union (EU) aid agencies. As a supplier of contraceptives, UNFPA’s procurement service is always either the ﬁrst- or second-largest donor (USAID is the other), providing in excess of $42 million worth of products, on average, annually (1990–2002). UNFPA’s procurement service has been used increasingly by ministries of health as a cost-eﬀective way to access low international prices, particularly in the face of local procurement capacity and policy constraints. UNFPA also produces useful annual data on donor spending on contraceptives and condoms, which are especially helpful for supporting advocacy and eﬀorts to operationalize RHCS (UNFPA 2005 and UNFPA n.d.). UNFPA was a co-sponsor, with USAID, in the development of SPARHCS. Finally, UNFPA is in the process of developing a new “Global Programme to Enhance RHCS,” which will be a major global initia tive, for which they are now seeking funding. U.S. Agency for International Development (USAID): USAID is the single largest bilateral donor of repro ductive health supplies (contraceptives and condoms), and in some years, even exceeds UNFPA. Since 2003, USAID has donated, on average, $70.3 million of contraceptive commodities each year. Not long after Istanbul, USAID established contraceptive security as one of the strategic priorities of the agency’s Oﬃce of Population and Reproductive Health (PRH). USAID established a contraceptive security team of advisors within PRH, and allocated special funds to support a wide array of cooperating agencies’ contraceptive security activities. USAID operates country-speciﬁc and global PRH projects using grants and contracts with cooperating agencies in all the major aspects of contraceptive security; including logistics and supply chain management, policy development, private-sector mobilization, health system strengthening, family planning service delivery, and contraceptive research and development. By sustain ing long-term relationships with trusted partners, USAID has developed its cooperating agencies (a large and diverse collection of academic and technical assistance organizations—Abt Associates, Engender- Health, Family Health International, the Futures Group, John Snow, Inc., Johns Hopkins University, Management Sciences for Health, Pathﬁnder, the University of North Carolina, etc.)—into a critically important resource for global RHCS, to which other donors are increasingly turning for expertise. 20 CONTRACEPTIVE SECURITY U.K. Department for International Development (DFID): DFID is a major supporter of UNFPA and RHCS, having been an early force behind UNFPA’s joint donor working group on commodities and logistics throughout the 1990’s. On average, during the past decade, DFID has been the fourth largest funder of contraceptive supplies. Recently, DFID partnered with the Netherlands Ministry of Foreign Aﬀairs to commission several new country studies of RHCS (Druce 2006). DFID has also led, partici pated in, or sponsored other contraceptive security–related work, recently on aid architecture and ﬁ nance, aid eﬀectiveness, HIV/AIDS, and so on (e.g., Schwanenﬂugel 2005). DFID also pays special attention to the prospects for RHCS in countries with basket funding and/or sector wide approaches (SWAps) for health. European Union (EU): Thanks to targeted advocacy conducted by UNFPA, PAI, DSW, the Supply Initia tive, and several European population/sexual and reproductive health NGOs (EuroNGOs), the EU is now a much more active and integrated participant in the RHCS movement. International Planned Parenthood Federation (IPPF): The outgoing secretary general of IPPF, Steve Sind ing, has been an eﬀective, eloquent, and persistent advocate for RHCS globally. IPPF’s network of member associations (country aﬃliates) is currently an underutilized resource for RHCS. With new foundation funding, that situation is likely to change; the country-level power of the IPPF global federa tion can be harnessed more eﬀectively for long-term RHCS. With UNFPA and USAID, IPPF was one of the founding participants in the RHInterchange, consolidating its contraceptive procurement information with UNFPA’s and USAID’s in order to foster better coordination and ease the management burden on country programs. Kreditanstalt für Wiederaufbau (KfW): The German funding agency for international development (KfW) has been the third major funder of contraceptive supplies after USAID and UNFPA. KfW’s long-time, generous support of social marketing programs makes it a major voice in eﬀorts to develop new contra ceptive markets and engage the commercial sector. KfW currently co-chairs the RHSC with the Nether lands Ministry of Foreign Aﬀ airs. Millennium Development Goals (MDG): Koﬁ Annan said, “The Millennium Development Goals were adopted ﬁve years ago by the world’s Governments as a blueprint for building a better world in the 21st century” (http://www.undp.org/mdg/). Three of the eight MDGs are explicitly about health (reduce child mortality; improve maternal health; and combat HIV/AIDS, malaria, and other diseases), and the rest are inextricably connected with health, as they deal with poverty, hunger, education, gender issues, the environment, and development partnerships. Remarkedly, though, there is no MDG target for reproduc tive health. Nevertheless, UN agencies, the World Bank, the UN Millennium Project, the Supply Initia tive, and others have all steadfastly researched and documented the importance of reproductive health to the ultimate attainment of the MDGs. RHCS has been inserted into this dialogue as an example of a quick win; we know what to do now, and how to do it, and doing it will help jumpstart large-scale progress on the broader array of MDGs. As stated in the ﬁnal paper of the UN Millennium Project, the RHCS- related quick win would be to “expand access to sexual and reproductive health information and service, including family planning and contraceptive information and services, and close existing funding gaps for supplies and logistics.” (italics added to quote) (UN Millennium Project 2005). Th e Netherlands: The Dutch Ministry of Foreign Aﬀairs is another leading bilateral donor in the ﬁ eld of RH supplies, and like DFID, one that strongly supports the role of UNFPA. The Dutch have also been instrumental, with DFID and KfW, in securing increased attention to this issue by the EU. Indeed, during the six-month Dutch presidency of the EU in 2004, RH supplies were a focal point of the THE GLOBAL CHALLENGE 21 development dialogue. Further indicating their support, the Netherlands Ministry of Foreign Aﬀ airs currently co-chairs the RHSC. World Bank: As a lender and grant maker to developing country governments, the World Bank plays a potentially major role in RHCS, but to date it has not articulated an agency vision to do so explicitly. Nevertheless, the World Bank supplied the inaugural chairmanship of the RHSC, providing engaged, visible leadership during the coalition’s critical ﬁrst two years. Additional evidence of the bank’s serious ness about strengthening its role with respect to RH supplies is that it has welcomed the secondment of a reproductive health logistics advisor for the past four years (supported by USAID, the United Nations Foundation, and the Gates Foundation). It is imperative that country recipients of World Bank health funding and their technical assistance partners fully understand the latest priorities and strategies, and its project development, funding, and review cycles, so that they can utilize every opportunity to include RH supplies and system strengthening into World Bank–ﬁ nanced instruments. World Health Organization (WHO): Both the Reproductive Health and Research, and the Medicines Poli cies and Standards, departments of the WHO, have become actively engaged in RHCS, especially around the creation of The Interagency List of Essential Medicines for Reproductive Health (WHO 2006). WHO is also engaged with PATH and JSI in RH commodity pricing studies and, on a larger scale, working with PATH and the Gates Foundation on the quality assurance of RH supplies and procurement harmoniza tion and strengthening. Foundations: U.S. private foundations, both small and large, have been instrumental in developing, guiding, and supporting the global RHCS community. The principal foundations have been the Wallace Global Fund, which no longer works on this issue, however; the Bill and Melinda Gates Foundation, which is expanding its support of the issue as part of its commitment to women’s and reproductive health; the David and Lucile Packard Foundation, and the William and Flora Hewlett Foundation, whose indi vidual funding for RHCS has declined, but whose commitment to reproductive health remains strong; and the United Nations Foundation, which only supports work with, by, and for UN agencies. In the past, the foundations sought to co-fund RHCS initiatives, or at least to collaborate closely; as of this writ ing, the foundations’ future emphases and preferred collaborative arrangements are not clear. CHALLENGES AND OPPORTUNITIES Th e ﬁnal report of the Supply Initiative states: In 1996, two years after Cairo, a handful of bilateral and multilateral donors were providing $172 million worth of contraceptive supplies to the developing world. Despite rising need for contraceptives, by 1999, that number had dropped to $154 million. In 2001, an historic meeting in Istanbul on the issue marked a turning point for the global community and set into motion eﬀorts to raise awareness, increase support, and seek solutions to the crisis in supplies. By 2004 (the year of most recent available data), bilateral and multilateral donor support for contracep tives had increased to $203 million and the issue is now ﬁrmly on the global agenda (PAI 2006). But, despite demonstrable progress, because contraceptive security comprises many components and involves many actors, there remain plenty of challenges inherent in the quest. Th ose challenges—and many proven solutions—are detailed throughout the following chapters in this publication. 22 CONTRACEPTIVE SECURITY Globally, some of the most prominent challenges and opportunities ahead include— • Applicability of the concept to and adoption by other health product categories It is a measure of the power of the contraceptive security concept that it has now been adopted and adapted to address other health commodities, such as HIV/AIDS drugs and diagnostic materials, TB drugs, and malaria treatment and prevention supplies. Commodity security is now a phrase that is often used in global public health. The concept is indeed beneﬁcial for other categories of health products, but that phenomenon enhances the real or perceived competi tion for the scarce resources for health. Keeping the focus on a narrow product category, such as contraceptives, is helpful; one understands intuitively that there cannot be security for all drugs and other health supplies in poor (or even rich) countries, and that successful advocacy requires focused messages targeted to speciﬁc audiences. But, this challenge also presents opportunities for mutually beneﬁcial linkages as new resources are mobilized and new ﬁnancing structures are orga nized (e.g., the Global Fund, the airline ticket tax). • Making and measuring progress Some of the biggest challenges for contraceptive security are establishing a baseline, measur ing progress, and attributing impact to the variety of interventions that are often undertaken together. How do we know we’re getting there, and how do we know what worked and what did not? USAID projects—DELIVER, POLICY, PHRplus, and PSP—have developed tools to track contraceptive security. USAID, UNFPA, DFID, and the EU have all conducted a wide variety of assessments, but there are no broad community standards. There is a real opportunity here for the RHSC to provide international leadership. • Sustaining interest When speaking of the need to expand and sustain family planning services and program success, Thailand’s famed Mechai Viravaidya commented on the inherently increasing diﬃ culty of doing so, using the expression “the baby gets heavier every year” (Cantlay [Hart] 1984). Every year, thanks to population growth and rising prevalence, the world’s demand for contraceptives grows. Sustaining governments’ and donors’ interest in meeting a never-ending, ever-growing need is certainly challenging. New vocabulary, new paradigms, new partnerships and alliances all help, and opportunities for creativity must be exploited. • “Addressing big tent” versus tight group Another challenge for the RHCS movement is to strike the right balance between welcoming all interested parties to join in (i.e., erecting a big tent) and ﬁnding ways to stay focused, action- oriented, transparent, and accountable. This will be a major point of deliberation and policy setting for the RHSC in 2006–2007. There may be opportunities to create sub- and/or supra- organizations to complement the RHSC, and to engage all interested stakeholders meaningfully in appropriate roles that maximize comparative advantages. CONCLUSION The next ﬁve years will be critical ones for global RHCS eﬀorts. Competition for health resources has never been greater, but by the same token, within the community the consensus around RHCS as funda mental to reproductive health appears to be stronger than ever. The newly formalized and more gener ously funded RHSC will be at the center of future developments in this ﬁeld, as will UNFPA, the Bill and THE GLOBAL CHALLENGE 23 Melinda Gates Foundation, key European donors, and USAID and its cooperating agencies. The keys to successful activities at the global level remain communication, coordination, synchronization of systems, transparency, and candor. 24 CONTRACEPTIVE SECURITY 4. REGIONAL APPROACHES A regional approach can provide many beneﬁts to country teams addressing contraceptive security (CS). Regional workshops and conferences provide venues for the exchange of ideas and lessons learned with neighbors who face similar problems. Countries that seem to have intractable problems may encoun ter suitable solutions through the experience of others. Local solutions are most likely to be successful because of historical (cultural and demographic) similarities. Bringing neighboring countries together can also engender some beneﬁcial competition as countries can compare their performance to their neigh bors. This can prove to be a powerful stimulant for change; included in this chapter are several examples of previously recalcitrant countries becoming energized after seeing their neighbors’ successes in family planning. Analysis of common contraceptive security (CS) issues can be the basis for identifying, designing, and implementing regionwide solutions that use economies of scope or opportunity, as well as economies of scale. A regional perspective can highlight opportunities for collaboration and harmonization of approaches like pooled procurement or common drug registration, ideally through existing regional mechanisms and institutions. Solutions like these work best in the context of established regional coop eration, whether it is a regional health secretariat—such as the West Africa Health Organisation (WAHO) or the Pan-American Health Organization (PAHO)—or an existing trading block—such as the Central America Free Trade Agreement (CAFTA) or the Southern Africa Development Community. Adopting a regional approach requires careful coordination, management, and collaboration. Ideally, it should involve representatives from the public and private sectors, from diﬀerent donors and representa tives from the ministries of ﬁnance, as well as ministries of health. In this chapter, we examine experiences from ﬁ ve diﬀerent regions, each initiative building on lessons learned from its predecessors. All were conducted in collaboration with several technical assistance provid ers, as well as additional support from UNFPA, the World Bank, and KfW. Most started with some type of regional workshop. This required very careful management to ensure that the event was more than a mere talking shop but was connected to subsequent action and tangible outcomes. In many cases, country teams formed at the opening workshop became the basis for a CS working group in the country. The durability of these working groups is a litmus test for the success and sustainabil ity of regional CS work. This is best shown in the Latin America and Caribbean (LAC) region where, three years after the regional CS work began, the CS committees continue to meet and implement their strategies. While experience and the approaches adopted in the diﬀerent regions have been dissimilar, several common themes are evident for the regional CS work undertaken: • The countries within each region all experienced common problems that lent themselves to cross- country analysis. • CS bottlenecks in one or more countries were often overcome in others, providing opportunities for exchanging lessons learned. REGIONAL APPROACHES 25 • While some regionwide work has been undertaken, this has been complemented and coordinated with country-speciﬁ c work. The rest of this chapter elaborates on the regional initiatives in Latin America, West Africa, Asia, Eastern Europe, and East Africa. In each case, we summarize the context, key constraints, activities undertaken, and actions and achievements completed to improve CS in each region. LAC: CONFRONTING PHASEOUT AND PROCUREMENT CONSTRAINTS In recent years, USAID has begun a gradual phaseout of contraceptive donations to all programs in the LAC region. As countries have started to prepare for impending phaseout, many governments have strug gled with similar challenges to ensure long-term product availability. National family planning programs, NGOs, and social marketing programs face major constraints to achieving sustainability in contraceptive ﬁnancing, procurement, and service provision, while dealing with the added complexity of major health reforms, usually involving the integration and/or decentralization of various aspects of the health sector. Simultaneously, as a result of increased awareness and education about family planning, countries are challenged with satisfying the rising demand for contraceptives throughout the region. In addition, although governments and donors in the LAC region have made signiﬁcant investments in family plan ning and reproductive health programs, modern contraceptive use remains low and unmet need remains high for several groups: those living in rural areas, the lowest socioeconomic groups, the young, the uneducated, and speciﬁc ethnic groups. During the early 2000’s, several key constraints aﬀected CS in the region, including— • little ﬁnancial planning and limited political commitments toward sustaining the long-term supply of contraceptives • varied capacity for the selection, forecast, and procurement of contraceptives • fairly restrictive regulatory environments surrounding the purchase of essential medicines • lack of information sharing on the varying experiences, lessons learned, and options available for countries in the regions • increasing demand for the use of contraceptives • minimal access to basic health services for the hardest to reach, poorest, and least educated segments of the population. When ﬁrst faced with donor withdrawal, the USAID-supported countries—Bolivia,3 Dominican Repub lic, Ecuador, El Salvador, Guatemala, Honduras, Nicaragua, Paraguay, and Peru—began to consider the need to implement phaseout plans. Countries hoped these plans would help programs reduce their reliance on USAID donations while diversifying funding sources and developing their capacity to procure commodities independently. Acknowledging the constraints above and systematically preparing solutions for them were essential steps to improve CS and to sustain reproductive health programs in the region. Contraceptive commodity support to Bolivia is still being considered. 26 CONTRACEPTIVE SECURITY 3 To begin tackling these constraints, Latin America and the Caribbean (LAC) Bureau of USAID, with assistance from the DELIVER and the POLICY projects, convened a meeting in Nicaragua in July 2003 that focused on the development of a CS committee and strategy for each country in the region. Partici pants included representatives from governments, donor agencies, and the commercial sector in Bolivia, Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Nicaragua, Paraguay, and Peru. At that meeting, many stakeholders recognized that a successful CS strategy must be customized country- by-country; taking local needs, priorities, constraints, and political context into account, while learn ing from regional experiences. Consequently, ﬁve countries (Peru, Bolivia, Nicaragua, Paraguay, and Honduras) agreed to do the SPARHCS assessments. Conducted jointly by DELIVER and POLICY, the assessments evaluated each country’s political environment; ﬁnancing, procurement, and service delivery capacity; and management of the contraceptive supply chain. The assessments included interviews with stakeholders both in public and private sectors, brief logistics assessments, and analyses of reproductive health demographic data. At a USAID-sponsored LAC regional CS forum in Lima, Peru, in October 2004, DELIVER and the POLICY projects presented reports of the completed assessments. Th e Regional Contraceptive Security Report for Latin America and the Caribbean (Taylor et al. 2004) summarizes the results of all the assess ments and makes recommendations for initiatives to improve the long-term availability of contracep tives in the region. The assessments have fed directly into each country’s CS strategy, and the results have encouraged various stakeholders (national and international) to take action. For instance, after attending the meeting in Peru, representatives from Ecuador, Dominican Republic, and Guatemala also recognized the importance of an in-country SPARHCS assessment to stimulate and inform the process of achieving CS. As a result, Ecuador and the Dominican Republic jointly conducted assess ments with DELIVER in 2005; Guatemala followed suit with a full assessment conducted in early 2006. Additionally, after attending the regional forum, several governments began to focus on the need to coor dinate the provision of family planning services with the private sector. In an eﬀort to determine the most eﬃcient way of coordinating services, and with DELIVER’s support, Bolivia, Nicaragua, and Paraguay conducted a market segmentation analyses that fed into the development of inclusive and coordinated CS committees, strategies, and implementation plans. The POLICY project did a market segmentation analysis for Peru. In summary, the LAC region has undertaken regional CS activities since 2003, including an initial regional workshop in Nicaragua, which stimulated in-country assessments and coordination shortly after the workshop. Next, the region shared local progress achieved at a regional forum in Peru, which provided impetus for further analysis and implementation of CS strategies country-by-country. Key outcomes have included— • establishment of multisector CS (Disponibilidad Asegurada de Anticonceptivos [DAIA] in Spanish) committees that have continued to meet and be a source of coordination, planning, and action • completion of SPARHCS assessments and market segmentation analyses that led to the develop ment of CS strategies and an increasing recognition of the need for a public- and private-sector response to meeting CS needs for the population • establishment of an increased number of funded budget lines to ﬁnance contraceptives as donor funds phase out REGIONAL APPROACHES 27 • increased use of UNFPA as a procurement agent and other procurement options to avoid identi ﬁed local procurement constraints and to obtain contraceptives at competitive international prices. Although signiﬁcant progress has been made in recent years and all nine USAID-presence countries have taken major steps to achieve CS, further progress must be made if these countries are to be successful in assuming responsibility for providing contraceptives to their citizens. Some areas for future focus include— • further strengthening the capacity in the LAC region to ﬁnance, forecast, procure, and deliver contraceptives to those who need them • maintaining a robust and eﬀective supply chain during health sector reform • developing alternative procurement options • streamlining and/or coordinating the regulatory environment in which contraceptives are currently being procured • increasing information sharing to obtain better prices from qualiﬁ ed suppliers • ensuring adequate and sustainable ﬁnancing for the purchase of contraceptives, including the establishment of budget lines • developing the capacity of governments to put quality assurance measures in place • implementing creative strategies for reaching the least accessible, poorest. and less educated segments of the population. The collaborative process in the LAC region has shown that by comparing challenges, solutions, and successes among countries, representatives have been encouraged, inspired, and at times, embarrassed into returning home to develop customized strategies and implementation plans based on local realities and regional experiences. ASIA: WORKING WITH THE MEDIA In Asia, the focus was on working with the local media to promote positive CS messages. A regional workshop funded by USAID led to a ﬂurry of reporting and the formation of several local media groups, which have done follow-up work in their countries and made progress in addressing CS at the national and local levels. Media Advocacy for Contraceptive Security: An Asia Regional Workshop brought together key stakeholders from Bangladesh, Indonesia, Nepal, Pakistan, and the Philippines. Delegations from each country—including representatives from government agen cies, NGOs, the private sector, and the media—worked together to identify obstacles, opportunities, and key messages and players for working with the media to advocate for CS. Th e conference produced country-speciﬁc action plans to partner with the media in support of country-led CS goals. Nepal:Woman receives a birth control injection. 28 CONTRACEPTIVE SECURITY The results were immediate. Reporters with the Philippine country team ﬁled news articles and commen taries directly from the conference and conducted live radio interviews with participants. Within a month after the workshop, more than 15 newspaper and Web articles had been published in the ﬁ ve countries. A participating journalist from Nepal conducted a seminar to raise awareness among his peers about the issue. Indonesia launched a new “Coalition for Healthy Indonesia” website, which features CS information. The real success of the conference was the increased understanding between government and NGOs about how to partner with the media in pursuing CS—or any national health strategy. Mutual suspicions about the motives of both reporters and government oﬃcials were discussed candidly; this helped the two sides begin to understand each other and laid the groundwork for closer cooperation. Reporters met champions of CS (and family planning programs in general) from NGOs and even the private sector, resulting in greater public exposure for the champions and their cause, and new sources of reliable information for the reporters about national health issues. The conference was a model for raising awareness about CS in Bangladesh, which was at the forefront of discussions when the countries focused on CS. In 2004–2005, a series of district-level workshops were held to engage the district health oﬃcers in talking about CS. Th e workshops also helped raise awareness among local news reporters about the decreased use of long-term and permanent contraceptive methods, and the importance of targeting free public-sector family planning services and supplies to the people who most need them. Both issues were identiﬁed as key factors aﬀ ect ing CS in Bangladesh in a 2002 national CS launch. In Indonesia, the conference helped convince the Indonesian family planning coordinating agency (BKKBN), of the necessity to develop a CS plan to help the country cope with a sweeping decentraliza tion of government services to the district level, including family planning. Local governments were empowered to make decisions about resource allocation and local priorities, but they lacked the informa tion, experience, and tools needed to make informed decisions. The result was that Indonesia’s successful family planning program, widely regarded as a global model, was suddenly in danger of falling apart. BKKBN, with the assistance of the USAID-funded Sustaining Technical Achievements in Reproductive Health and Family Planning (STARH) project, developed a CS strategy that enabled districts to assess their own CS status and take action to improve CS through local, and often very innovative, means. Districts have allocated signiﬁcant funds for contraceptive procurement, licensed new pharmacies in rural areas to broaden access to contraceptives through the private market, and improved the targeting of free contraceptives provided through public clinics. In the Philippines, where CS is referred to as contraceptive self reliance (CSR), conference participants returned re-energized to tackle the issue at the provincial and local government levels, where responsibility for health services rests. The national government has been reluctant to commit its own ﬁ nancial resources toward the procurement of contraceptives, even though donations from USAID will end in 2008. Currently, approximately 75 percent of users rely on the free contraceptives provided by USAID. Th ere- fore, journalists and business leaders are now championing the need for self-reliance by supporting eﬀ orts to target free public supplies provided through the local government units (LGUs) to the 20 percent of users unwilling or unable to pay for them, and by encouraging an expansion of the commercial market through private-sector sources such as private midwives and pharmacies. The Employers Confederation of the Philippines is advocating support for contraceptive provision through employer-supported health plans and clinics. REGIONAL APPROACHES 29 WEST AFRICA: CONNECTING A REGIONAL STRATEGY TO EXISTING CHALLENGES Since 2003, DELIVER has been working with the WAHO and the health secretariat of the Economic Community of West African States (ECOWAS) to develop a regional RHCS strategy and to design and implement a coordinated informed buying (CIB) procurement information system. Th ese eﬀ orts have been actively supported by regional partners (e.g., WHO/AFRO, the Association Africaine des Centrales d’Achats de Médicaments Essentiels [ACAME], and the Centre d’Etudes et de Recherche sur la Population pour le Developpement [CERPOD]), and donors, including UNFPA, KfW, and the World Bank. Th e process began with an analysis of common challenges among the 16 ECOWAS countries4 and the presentation of options and solutions to annual meetings of the region’s ministers of health. The challenges facing the region are substantial and include— • limited access to quality reproductive health commodities and services • weak national logistics systems for managing RH commodities • insuﬃ cient ﬁnancing for RH commodities and services from all sources (household, community, national governments, multilateral and bilateral donors, and funders) • lack of coordination mechanisms between partners in the subregion • multiplicity of poorly coordinated activities in countries, leading to unnecessary redundancies and an ineﬃcient use of the limited resources available for RH • substantial national and operational policy barriers to RHCS. Together, these challenges have resulted in poor reproductive health outcomes throughout the subregion. For every 100,000 live births in West Africa, there are 880 maternal deaths and more than 10,000 infant deaths (PRB 2005). The percentage of married women using modern methods of contraception in the region stands at 8 percent—which is near the bottom worldwide for contraceptive use. The United Nations’ Millennium Development Goals (MDGs) include among its indicators improving maternal and infant health outcomes and reducing the spread of HIV/AIDS, all of which depend on the consistent availability and use of RH commodities. Figure 2 illustrates the relationship between high maternal mortality ratios (MMRs) and low contraceptive prevalence rates (CPRs). 4. Benin, Burkina Faso, Cape Verde, Côte d’Ivoire, Gambia, Ghana, Guinea, Guinea-Bissau, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal, Sierra Leone, and Togo. 30 CONTRACEPTIVE SECURITY 1100 1600 2,000 1000 760 740 1200 850 690 800 1,000 570 540 690 540 150 880 1020 24 330 190 0 10 20 30 40 50 60 70 G uinea Bissau N iger Sierra Leone M auritania Liberia G uinea M ali Benin C ôte d’Ivoire N igeria Burkina Faso Togo G am bia Senegal G hana C ape Verde W estern Africa Eastern Africa Europe Asia L.Am er./C aribbean % M W R A us in g m od er n co nt ra c 0 500 1000 1500 2000 2500 m at er na l d ea th s pe r 1 00 ,0 00 liv e CPR Maternal deaths 1100 1600 2,000 1000 760 740 1200 850 690 800 1,000 570 540 690 540 150 880 1020 24 330 190 0 10 20 30 40 50 60 70 G uinea Bissau N iger Sierra Leone M auritania Liberia G uinea M ali Benin C ôte d’Ivoire N igeria Burkina Faso Togo G am bia Senegal G hana C ape Verde W estern Africa Eastern Africa Europe Asia L.Am er./C aribbean % M W R A us in g m od er n co nt ra c 0 500 1000 1500 2000 2500 m at er na l d ea th s pe r 1 00 ,0 00 liv e CPR Maternal deaths FIGURE 2. CONTRACEPTIVE PREVALENCE RATE COMPAREDTOAND MATERNAL MORTALITY INWEST AFRICA -- 1100 1600 2,000 1000 760 740 1200 850 690 800 1,000 570 540 690 540 150 880 1020 24 330 190 0 10 20 30 40 50 60 70 G uinea-Bissau N iger Sierra Leone M auritania Liberia G uinea M ali Benin C ôte d’Ivoire N igeria Burkina Faso Togo G am bia Senegal G hana C ape Verde W estern Africa Eastern Africa Europe Asia L.Am er./C aribbean 0 500 1000 1500 2000 2500 m at er na l d ea th s pe r 1 00 ,0 00 liv e CPR Maternal deaths % M W R A us in g m od er n co nt ra ce pt io n Sources: MMR: PRB 2005 Women of Our World CPR: PRB 2006 World Population Data Sheet (Liberia CPR from 1998 World Population Data Where MMR is high, for example in Sierra Leone (2,000 per 100,000 live births), CPR is 4 percent. In Ghana, CPR is 19 percent, while MMR is 540 per 100,000 live births. To address these reproductive health challenges and advance its Strategic Plan for the Reduction of Maternal and Perinatal Mortality, WAHO has identiﬁed and is systematically addressing the interdepen dence between RHCS and maternal health outcomes. At the Fifth Annual Assembly in Accra in 2004, ECOWAS health ministers recommended that WAHO and its partners develop a regional strategy for RHCS to support the maternal and perinatal strategic plan (see box 1). The health ministers subsequently endorsed a road map for that strategy, which was presented in the RHCS Concept Paper at their 2005 annual meeting in Dakar, Senegal. Three key areas have been identiﬁed where the regional strategy will add maximum value for supporting and advancing RHCS, including strengthening human and institutional system capacity (e.g., supply chain and service delivery); a harmonized regulatory and policy framework (e.g., common essential medi cine lists, standard treatment guidelines, and import tariﬀs), and establishing the CIB system to allow national procurement; and supply managers to share information on supplier price, quality, and perfor mance with their counterparts in the region. REGIONAL APPROACHES 31 BOX 1. BENEFITS OF THE WEST AFRICA REGIONAL APPROACH The West Africa regional approach— • Serves as an excellent vehicle for advocacy at the regional level and for working across coun tries (with multiple countries simultaneously) to compare, inform, and inﬂ uence public health policies. • Brings key decision makers from diﬀerent settings (countries, multilateral agencies, bilateral donors, etc.) together around a common conceptual framework, terminology, tools, and methods for assessing and addressing challenges. • Helps countries share their experiences with each other. • Stimulates countries and individuals to higher levels of performance. • Brings together individuals who should be talking to each other (but are not necessarily doing so). This gives these individuals the time and space, outside their politically charged and busy environments, to share experiences and problem solve with each other. • Attracts the attention of governments, along with multilateral organizations, bilateral donors, and other partners. • Allows for the introduction and rapid testing of new approaches and tools across countries, resulting in substantial savings for organizations and projects. Using the CIB mechanism to increase the procurement eﬃciency among ECOWAS member countries has been a major WAHO initiative. The small countries in the region are often unable individually to obtain lower prices through the bulk purchase of commodities. Recent DELIVER work has indicated that potential cost savings for RH commodities can be achieved through pooling commodity require ments among ECOWAS countries. The resulting savings could potentially be used to ﬁ nance additional procurements, and mitigate part, but not all, of the enormous RH commodity ﬁnancing burden faced by countries in the subregion. Based on the quoted unit prices for the pooled volume of RH tracer commodities for the subregion, a 14 percent average savings is possible compared to the median inter national reference price (IRP).5 While this is only an estimate provided by procurement agents, and the averages provided are unweighted,6 it indicates that bulk procurements can have an aﬀect on unit prices. As table 1 shows, the unit price reductions were most signiﬁcant for contraceptives (28 percent), while the savings in the Other category (examination and surgical gloves, and oral redehydration solution) were minimal (2 percent). The greatest price reduction was seen with the combined oral pill; reference prices indicated $0.35 per cycle. When the subregion’s projected demand was aggregated, the total projected volume amounted to nearly 26 million cycles for 2004, resulting in a $0.22 per unit quoted bulk price—a 60 percent reduction over the IRP. The RH commodity pricing analysis demonstrated that there may be a potential for savings through bulk procurement. However, such a system also requires a complex pooled 5. Management Sciences for Health issues an annual International Price Indicator Guide (http://erc.msh.org) comprising two sections. The first section lists procurement prices offered by not-for-profit suppliers to developing countries for multi-source generic procurements. The second section lists tender prices offered to procurement agencies in developing countries. For each product, a median unit price is calculated.The median price is used as the international reference price. 6. Actual savings would be more or less depending on the volume procured for individual commodities. If lower quantities were procured for items with larger price differences, the savings would be less. 32 CONTRACEPTIVE SECURITY ﬁnancing arrangement, national regulatory approval, and adequate procurement capacity. A DELIVER 2005 assessment revealed that these requirements are not all currently in place in the subregion. Options resulting from the assessment were presented to the ECOWAS health ministers, who adopted a recom mendation for WAHO to begin the implementation of the CIB system (as part of the RHCS strategy). The reasoning was that the CIB mechanism would enhance each country’s ability to share and access product, supplier, and pharmaceutical market information without committing countries to a more complex pooled procurement system at this time. TABLE 1. COMPARISON OF IRP AND BULK PRICES COMMODITIES CONTRACEPTIVES Condom Injectable IUD Implant Pill Subtotal Average STI/HIV/OI Nevirapine tabs Nevirapine syrup Benzath. pen. 2.4 MIU Co-trimoxazole 480 mg Doxycycline 100 mg Metronidazole Metronidazole tab 250 mg Subtotal Average ANTENATAL Tetanus vaccine .5 ml Iron (tabs) 65 mg folic acid 5 mg Fansidar (tabs) 500/25 mg Subtotal Average Dosage condom injection IUD rod tablet tablet syrup vial tablet tablet injection tablet injection tablet tablet tablet IRP Bulk Price Variance (%) 0.026 0.020 -31 0.893 0.850 -5 0.404 0.310 -30 26.565 23.000 -16 0.347 0.217 -60 -28 0.145 0.143 -2 2.232 0.236 0.203 -16 0.009 0.008 -9 0.008 0.008 -8 0.775 0.688 -13 0.004 0.004 -9 -9 1.020 0.952 -7 0.002 0.002 -10 0.003 0.003 -9 0.020 0.019 -7 -8 REGIONAL APPROACHES 33 TABLE 1. COMPARISON OF IRP AND BULK PRICES (CONTINUED) COMMODITIES OBSTETRICS/NEONATAL Oxytocin 10/IU Ergometrine injection Ergometrine (tabs) .2 mg Subtotal Average OTHER Gloves (examination) Gloves (surgical) ORS 1000 ml Subtotal Average TOTAL AVERAGE Dosage ampoule injection tablet piece pair sachet IRP Bulk Price Variance (%) 0.095 0.093 -2 0.158 0.140 -13 0.013 0.009 -44 -20 0.025 0.025 -1 0.160 0.153 -5 0.060 0.059 -1 -2 -14 As a next step—following the health minister’s approval in 2005 to implement the CIB mechanism and proceed with the regional strategy—DELIVER is working with WAHO to put a CIB manager in place to help develop and manage a system design workshop that involves procurement managers from West African countries. The aim of the meeting is to identify operational procedures (e.g., design of report ing format, initial product list, and dissemination schedule), which will enable the ﬂow of information between programs and a central database at WAHO. Concurrent to the CIB process, WAHO has hosted a series of three strategic planning workshops with program managers and other experts that resulted in a draft regional RHCS strategic plan to be presented for approval at the 2006 meeting of ECOWAS health ministers. EASTERN EUROPE: CROSS FERTILIZATION OF REGIONAL SOLUTIONS USAID, since the early 1990’s, has been a leading partner in promoting family planning in Eastern Europe and Eurasia. This investment has been tremendously successful as countries that formerly banned family planning have promoted access to modern methods and consequently increased their CPR (table 2). While there have been notable regional successes, much work remains to be done. The region contin ues to face ongoing challenges and constraints to expanding access to and availability of family planning commodities and services. While abortion rates have declined, they remain among the highest in the world. 34 CONTRACEPTIVE SECURITY TABLE 2. SELECTED FAMILY PLANNING INDICATORS FOR EASTERN EUROPE Country Romania Russia Azerbaijan Armenia Georgia Albania Ukraine Abortion Rate (per 1,000) Estimates 1997–2001 74 80 116 81 125 55 Unmet Modern Method Need for CPR (%) (year) Contraception (%) 38 (2004) 39 53 (1999) 33 12 (2001) 53 22 (2000) 52 20 (1999) 44 68 38 (1999) 47 Source: CDC Presentation at the Ensuring Access to Family Planning Conference Several key constraints aﬀect CS in the region: • declining populations and declining fertility rates contribute to a lack of political attention to FP as political leaders assume increased fertility is desired—FP will adversely aﬀ ect this • overuse of specialists in providing FP services—focus on pathology rather than prevention • strong provider biases about diﬀerent methods, misinformation, and a lack of independent infor mation and continuing education for providers • lack of attention to choice for consumers • regulatory and ﬁnancial constraints on the availability of contraceptives • counterproductive incentives for providers to provide abortion as a leading method of fertility control • lack of NGOs and limited tradition of public-sector provision of contraceptives • limited access for the poor, vulnerable, and rural populations, in general • limited donor commodity support. Despite these challenges, a common Semashko7 medical tradition, and the common problems of moving from centrally planned to market-driven economies provide ample opportunity for countries to learn from each other. One country in the region, Romania, had made a concerted eﬀort to increase CPR as a way to address its high abortion and MMR (see box 2). Th ese eﬀorts provided countries with practical lessons learned and strategies for tackling impediments to expanded FP use. What was needed was a way to share these within the region. 7. This tradition was characterized by a uniform model of organizing health services, which was introduced in Soviet-bloc countries after World War II and was abolished in the early 1990’s. Financing of health services was entirely through the state budget with publicly owned health care facilities and publicly provided services. REGIONAL APPROACHES 35 BOX 2. ROMANIA—A REGIONAL FAMILY PLANNING SUCCESS STORY As Romania embarked on its ambitious program of expanding family planning coverage, it faced a dilemma in trying to increase the contraceptive prevalence rate (CPR). The high level of unmet need for modern contraceptives was coupled with a considerable diﬀerence in ability to pay and access between urban and rural areas. While there was a clear need for free public-sector contraceptives, the government did not have the resources to fund the needs of the whole country. Simultaneously, higher urban income levels and willingness to pay meant that private households and suppliers in pharmacies were already meeting the growing needs of the urban population. With one of the highest abortion rates in Europe, which contributed to the high maternal mortality, this was seen as an impediment to future accession to the European Union. Market segmentation analysis by the POLICY project was interpreted by DELIVER to show that free public supplies should be targeted at rural women through their local primary health clinics. This approach required the training of a new cohort of family planning providers: the general practice (GP) physicians who staﬀ the rural clinics. In addition, a number of depressed urban centers were also targeted, leaving other urban centers to continue to be supplied by the private sector. Increased availability of commodities in rural clinics was coupled with an information, education, and communication campaign, changes in regulations to allow provision by GPs, and a training program for rural GPs. Consequently, the CPR for modern methods has continued to grow from 29.5 percent in 1999 to 38.2 percent in 2004. Free contraception has not impaired the private sector. Between the ﬁrst quarter of 2002 and third quarter of 2004, the number of oral pill users increased 44 percent from 223,000 to 322,000 in the private sector; while in the same period, users of free oral pills from the public sector increased tenfold, from 8,000 to 82,000. With donor support decreasing, public-sector contraceptives have been increasingly funded from a national budget line. The Ensuring Access to Family Planning: Europe and Eurasia Regional Conference was held in Bucharest April 11–15, 2005. The conference resulted from a convergence of interest from USAID in Washington and from eight countries in the region to share experiences and lessons learned in moving FP forward in the region. Romania was chosen as the host because of the country’s impressive performance in increasing contraceptive prevalence and reducing abortion and maternal mortality rates. USAID-supported country teams from Albania, Armenia, Azerbaijan, Georgia, Russia, and Ukraine; they were joined by one team member from the USAID team in Serbia and Montenegro. USAID is support ing FP and maternal and child health programs in each country, although there is some variation in the length of time that this support has been provided. While these countries share many policy, health, family planning, cultural, and historical factors, all have adopted individual strategies to increasing access to FP in the last decade. The conference was an opportunity for participants to showcase their approaches and achievements in expanding FP, as well as to identify problems and priorities for action. The workshop involved a mix of plenary and small group working sessions for country teams, open sessions on cross-cutting technical issues, and ﬁeld visits to sites in Romania. Each country formulated a draft action plan based on the exchange of ideas at the event. They returned home with renewed interest in applying some of the lessons learned. Subsequent to the workshop, bilateral delegations from Georgia, Russia, and Ukraine have visited Roma nia again, with an additional visit planned by a group from Kazakhstan. Because of the lessons learned 36 CONTRACEPTIVE SECURITY Ethiopia: Health worker in front of shelves stocked with contraceptives and anti-malarials. from Romania, the Georgian MOH reversed its policy of limiting FP service provision to a narrow group of specialists called reproductologists. The role of the private sector has also been highlighted, and strate gies have been developed in several countries to work with manufacturers to continue to market low cost brands of oral contraceptives rather than establish subsidized social market programs. Th e Romanian example of targeting publicly provided contraceptives to speciﬁc population groups, while the private sector supplies the rest of the contraceptive market, is also being examined in Georgia and Ukraine. USAID is supporting further exchanges and sharing of lessons learned through written case studies of activities in Romania and Russia. While it is too early to quantify the beneﬁts of this intraregional exchange of ideas, the initial regional workshop has clearly stimulated an exchange of ideas and experi ences that seems set to endure. EAST AFRICA: BUILDING ON LOCAL EXPERIENCE In November 2005, KfW, USAID, and UNFPA sponsored a regional CS workshop in East Africa. The goal of the workshop was to address the critical need of improv ing access to RH supplies and services for women and men in the region. Meeting participants represented diverse interests and needs inﬂuencing reproductive health CS. Country delegations from six East Afri can countries—Ethiopia, Kenya, Malawi, Rwanda, Tanzania, and Uganda—included representatives from the ministries of health, ministries of ﬁ nance (MOFs), social marketing organizations, NGOs, and private-sector service providers, as well as other reproductive health and family plan ning advocates. The workshop was framed around several common issues and priori ties that inﬂuence contraceptive availability in the region. Most This workshop has come notably, the high HIV prevalence is an important and unfortunate at the right time when characteristic shared by countries in East Africa. Clearly, this factor most countries are trying necessitates a signiﬁcant claim on health resources and policymakers’ to balance distributions… attention—yet it is often at the expense of family planning. between family planning and HIV/AIDS. - quote from The East African countries also have relatively low CPR and high participant unmet need. CPR among married women ranges from about 6 percent to 32 percent and unmet need from 22 to 36 percent. Th e Contraceptive Security Index 2003 (JSI/DELIVER and Futures Group/POLICY 2003) oﬀers a snapshot of the CS situation in the six East African countries, combining 17 indicators related to supply chain, ﬁnancing, health and social environ ment, access, and use issues. The six countries are all close, in the range of about 40 to 50 on a 100 point scale see (ﬁ gure 3). REGIONAL APPROACHES 37 0 10 20 30 40 50 60 FIGURE 3. CONTRACEPTIVE SECURITY INDEX SCORES FOR EAST AFRICAN COUNTRIES Ethiopia Uganda Rwanda Malawi Tanzania Kenya CS Index 2003 (per 100 points) These similarities, with other prevailing issues, such as institutional capacity and health sector reform (decentralization, integration), were the foundation for the workshop. The workshop highlighted ﬁ ve key themes associated with RHCS common in the region: • the role of RHCS in achieving health outcomes and Millennium Development Goals (MDGs) • maximizing resources through ﬁnancing and procurement • a whole market approach to achieving the public health mandate • transforming systems—how recent paradigm shifts aﬀ ect RHCS • the bottom line—clients access to knowledge, services, and products. Inherent in each were the cross-cutting themes of HIV/AIDS, human capacity issues, and logistics and supply chain management. The workshop incorporated a number of approaches to facilitate the exchange of ideas and to ensure that the event yielded results. Th e ﬁrst approach was to build on existing eﬀorts. Some of the countries had made more progress in CS than others, and had already developed plans and strategies. To avoid dupli cated eﬀorts, the workshop built on any existing CS strategies. For example, Rwanda has an active CS committee and had developed an MOH CS plan. The Rwanda team developed activities that could be implemented, and they facilitated discussions between the MOH and the social marketing sector, as well as shared their experience with a broader audience. The second approach was to allow country teams to learn from each other. Dr. Catherine Sanga, head of the reproductive and child health section at the Tanzanian MOH, shared Tanzania’s experience of using government funds to procure contraceptives. These experiences proved very timely and helpful for the other participating countries. In her presentation, Dr. Sanga showcased the MOH commitment to fund and procure a signiﬁcant amount of the country’s contraceptive requirements, a commitment that has grown from $1.5 million for injectables in 2002–2003 to $6.9 million for injectables, pills, and implants in 2005–2006. Key lessons learned by the Tanzania MOH are that (1) the annual procurement require ment and plan is a powerful tool when advocating for funds, (2) regular joint annual planning is crucial for ensuring accountability among partners, and (3) it is possible for governments to fund commodities. 38 CONTRACEPTIVE SECURITY However, Dr. Sanga also noted that ﬁnancing was not the only barrier to securing an adequate supply of contraceptives. One of the major challenges encountered by the MOH is turning cash into contraceptives, which requires improved governmental capacity for managing complex procurement procedures. The third approach was to emphasize intra- country dialogue. One of the obvious strengths Uganda faced condom shortages in 2004 of a regional workshop is that it provides an and 2005 due to concerns over the quality opportunity for the participating countries of condoms being distributed in the country. to learn and share with each other. Not only Approximately 10 million public sector condoms did this workshop provide regional sharing were withdrawn from the market because of opportunities, it also allowed for discussion their odor; part of the government’s response strengthening within each of the countries. For was to require post-shipment testing for all example, despite their similar mandates, many condoms distributed in the country. Th is meant of the country participants (social marketing, that NGOs and social marketing organizations Ministry of Finance, advocacy representatives) distributing condoms were required to carry out have few opportunities to meet and share their further testing on their products despite the fact perspectives and contributions to CS. Ensur- that they were manufactured to international ing diverse representation from each country ISO quality standards, and no suitable laboratory resulted in stronger and more comprehensive in Uganda could perform the testing. Th e country CS plans. For example, one priority result was shortages all over the country while action area identiﬁed by the Uganda country regulations were clariﬁed, and arrangements were team is the uneven distribution system below made to equip a national laboratory to carry out the district level to the service delivery points required analyses. (SDPs)—in many districts only an ad hoc system is in place. The team agreed to four interventions to improve distribution: strengthen supervision through targeted interventions; engage and empower communities to demand availability of RH supplies; improve district planning and managerial skills; and strengthen zero tolerance for stockouts at the district, health subdistrict, and SDP levels. This strategy required the input of policymakers, logisticians and service delivery representatives, and community-based organizations. The fourth and ﬁnal approach was to leverage the power of collabo ration. Coordination and partnership among the three major donors I learned that some problems was often challenging in terms of ensuring a harmonized approach were regional issues, but each to addressing CS in the region. Yet, for each challenge, there was country was at a diﬀ erent a corresponding beneﬁt to the regional approach; it was clear the stage in terms of tackling impact far outweighed any diﬃculties. Most important, the leader- the challenges. - quote from ship of these three donors in CS sent a strong message about the participant importance of RHCS to countries. The collaboration of UNFPA, KfW, and USAID supported the overall CS approach of multisectoral commitment and donor coordi nation, and resulted in beneﬁts and lessons learned at the country, regional, and global levels. In addi tion, the involvement of three donors helped extend the weight and reach of the workshop because each donor engaged a unique set of stakeholders, which ensured diversity in participation. While it was diﬃcult to engage the right people The country/Africa focus of from each of these groups and to meet their varying expectations the meeting was critical for and needs, the diversity gained through multi-donor sponsorship sharing experiences that have resulted in expanded discussions and forged new relationships. In regional relevance. - quote fact, as a result of the positive experience and results in East Africa from participant REGIONAL APPROACHES 39 and the identiﬁed need in West Africa, KfW, UNFPA, and USAID plan to sponsor a similar activity in West Africa in 2006. One of the biggest challenges of the East Africa workshop was ensuring that the momentum continued within the respective countries. Each of the country teams committed to a series of next steps within their own country. The extent of this continuation varies considerably from country to country because of diﬀerent levels of donor involvement, the existence and involvement of a CS champion, and so on. Again, this is one of the challenges of a multi-donor sponsored activity where country participants are not held accountable to one organization. Despite these challenges, countries have made measurable progress since November 2005. For example, within one month of the East Africa RHCS Workshop, the MOH Health and Technical Support Services in Malawi organized a Malawi CS workshop that brought together an expanded group of stakeholders to share ﬁndings from the regional workshop and to obtain consensus on the main issues, strategies to address those issues, and what the next steps should be to strengthen CS. Particular emphasis focused on the signiﬁcant policy changes that are predicted to impact CS in Malawi. The most signiﬁ cant is the introduction of a SWAp mechanism for funding the health sector. Malawi also faces other major challenges to ensuring CS, including a lack of capacity for supply chain functions; hiring, training, and retention of staﬀ at all levels; and an underdeveloped private sector. In part, as a result of their participation in the East Africa RHCS workshop, the Uganda team has contin ued their in-country CS strategies. Team representatives have met with and engaged the broader family planning community, and are using the regional workshop to reinvigorate their monthly CS working group meetings and action tasks. In June 2006, the RHCS group developed procedures and responsibili ties for routine information sharing, analysis, and reporting on stock status, product distribution, ship ments, facility ordering, and issues at facility level. CONCLUSION Many of these regional approaches have yielded tangible results, as countries discover that their challenges are not unique and that proven solutions do exist. One of the most important factors common to all the regional activities is that they allow for peer-to-peer exchange between experts and policymakers from the participating countries. This exchange provides international recognition for the diﬃcult work they are undertaking, on the one hand; and the motivation to address challenges that once seemed insurmount able on the other. Regional CS approaches are essential tools in building in-country support for CS and in sharing lessons learned in strengthening CS. 40 CONTRACEPTIVE SECURITY 5. COMMITMENT AND COORDINATION Sogakope, Ghana: DELIVER staff at the Meeting the Commodity Challenge, May 2002. Commitment is the foundation for all improvements in contraceptive security. It begins with the top levels of government and extends down to the lower levels, other stakehold ers, program managers, and opinion leaders. That commitment must be translated into concrete action, which must be coordinated among all stakeholders to ensure a coherent response. While commitment with out coordination will achieve some results, there will likely be wasted resources and gaps in coverage. And, coordination without commitment will result in little more than frustra tion and opportunities lost. Th ere- fore, commitment and coordination must go hand-in-hand, and in most cases, are mutually reinforcing, as strong commitment facilitates eﬀective coordination and eﬀective coordination gives rise to stronger commitment. COMMITMENT Commitment is needed not just from the highest leadership of a country, but also at other levels of the public sector and from civil society. In this respect, commitment needs to be understood as part of the broader socio cultural context in a country. Various indica tors demonstrate this through concrete actions commitment to contraceptive security (CS) and family planning. Th ese include— • strong national policies containing explicit support for the right of all people to plan their families • earmarked and protected budget line items for commodity procurement Commitment by top country leadership, when manifested through concrete actions, can ensure continued donor support. Benin faced many prob lems in ensuring commodity availability—a weak public-sector supply chain led to major stockouts of all contraceptive methods over a several years. In 2005, a new Minister of Health provided, for the ﬁrst time, budget support of about U.S.$100,000 a year for three years for contra ceptive procurement. This galvanized donors to increase their support for procurement. Currently, UNFPA, USAID, KfW (through social market ing), and IPPF, with the Ministry of Health, are providing funds for commodities and technical assistance to strengthen the entire supply chain to ensure that commodities get to users. COMMITTMENT AND COORDINATION 41 • reference to CS and to access to family planning services in other major policy documents, such as poverty reduction strategy papers (PRSPs). It is important to remember that commitment does not end with the top levels of leadership. Advocacy eﬀorts may need to continue to ensure support for CS and family planning at all levels. Where health management is decentralized, with increasing power devolving to lower levels of government, this lower- level advocacy takes on added signiﬁcance. In many developing countries, support for family planning and CS at lower levels of government and among service providers may be, at best, lukewarm, and at worst, may even amount to opposition. In that situation, it is important to continue advocacy eﬀ orts. In Madagascar, advocacy continued after the President of the Republic had come out with public support for CS. In West Africa and Southeast Asia, DELIVER has helped facilitate eﬀorts to bring together media, parliamentarians, and program managers to discuss CS issues, and to encourage coordinated advocacy to all levels of society in their countries. In some cases, service providers and local health oﬃ cials have made a strong commitment to family planning in the face of ambivalence (Kazakhstan) or outright resistance (Philippines) toward family planning at the national level. COORDINATION Coordination is an essential element in achieving CS, and nowhere is that truer than in coordinating the sources of supply. To be eﬀective, contraceptive supply chains must include many partners working together to ensure that commodities are available to all who need them. To reduce the likelihood of waste, duplication of resources, or contradictory decisions; coordination between partners ensures eﬃ cient and optimal utilization of often limited resources. Coordination is needed at many levels, including— • the central level between the diﬀerent sources of commodities, such as ministries, UNFPA, USAID, IPPF, and social marketing organizations • internationally between donors • among the various sectors providing products and services: public, nongovernmental organiza tions (NGO), faith-based, social marketing, and private (commercial) • among various technical agencies supporting CS and family planning. For many years, DELIVER has promoted coordination through its technical assistance for supply chains (see box 3). Forecasting and quantiﬁcation for contraceptives and other commodities is typically done at a national level for all programs—not just for USAID-funded procurements. The results of quantiﬁ cation exercises are shared with all stakeholders, particularly donors and other procurers, so that procurement planning becomes a coordinated exercise. Th e PipeLine software that DELIVER uses for procurement planning contains information from as many procurers as possible to ensure coordination and avoid over- and understocks. Ministries of Health are encouraged as part of their stewardship role to oversee procure ments, consumption, and stock levels for all programs. Procurement is not the only area that needs coordination, but it is the most common reason for establishing a coordination mechanism, and often results in a regular forum that facilitates communication and information sharing between stakeholders on other relevant topics. 42 CONTRACEPTIVE SECURITY BOX 3. WORKSHOP IN WEST AFRICA LINKS PARTNERS The contraceptive security (CS) situation in many West African countries is fragile at best. Low preva lence—often less than 10 percent for modern methods, high unmet need, weak supply chains, limited ﬁnancing, low education levels (particularly for women), and lack of commitment for family planning at all levels of society called for coordinated action to increase awareness of the importance of CS. In 2005, working with Africa Consultants International (ACI), a development organization with experi ence strengthening the capacity of journalists to report on HIV/AIDS, DELIVER helped conduct a workshop that brought together news media, parliamentarians, and technical people from ﬁ ve countries in the region—Burkina Faso, Côte d’Ivoire, Mali, Mauritania, and Senegal. Th e objective was to create links between these partners and encourage the sharing of information to lead to better promotion of CS and family planning by news professionals and parliamentarians. Since that event, there have been country-speciﬁc events. For instance, in Mali, a national mass media and information, education, and communication campaign to promote family planning was facilitated by this eﬀ ort, with most national newspapers featuring articles about family planning and CS, written by journalists who had attended the regional workshop or a subsequent national follow-on event. The ultimate goal of these types of activities is to build commitment for CS and family planning at all levels of society. A key lesson learned by DELIVER in strengthening contraceptive security at the country level—or in decentralized countries, at the subnational level—is the necessity to create a CS committee to bring together stakeholders involved in contraceptive procurement or provision (see box 4). These groups have many names—CS committee, family planning technical working groups, steering committees—but all share certain similarities. They include a wide variety of stakeholders representing the various sectors, programs, and partners involved in providing family planning products or services. BOX 4.TYPICAL COMPOSITION OF A CONTRACEPTIVE SECURITY COMMITTEE Typically, a contraceptive security committee may include the following stakeholders: • Public sector: - Family planning directorate - Pharmaceutical directorate - Central medical stores (CMSs) (may be independent of the MOH) - Procurement unit (may be part of CMS) - Ministry of Finance (often not a regular attendee but presence is desirable). • International partners: - Multilateral donors: e.g., UNFPA, other UN agencies, World Bank, etc. - Bilateral donors: e.g., USAID, DFID, KfW, JICA, etc. • Technical agencies: - Social marketing organizations, other agencies involved in supply chain, service provision, etc. • Private sector: - Nongovernmental organizations - Faith-based service providers - Representatives of service provider professional associations (midwives, pharmacists, doctors) - Representatives of private wholesalers and distributors. COMMITTMENT AND COORDINATION 43 The exact composition of a committee will depend on the country context and the willingness of partners to become involved. Some structures may only need to be represented on an occasional basis; for example, the national drug registration authority may need to be present when new product registration issues are involved but, perhaps, not regularly. DELIVER’s experience with these committees has provided a number of useful lessons learned for the norms and procedures in creating and running them: 1. Committees are not necessarily formal, legal, or legislative authority. In fact, they may be better created as an informal coordinating body with the mandate to share information and achieve consensus through cooperation and agreement. The MOH will always retain decision-making authority; trying to give these committees statutory powers or status can be an extremely time- consuming process and can create the perception that they might usurp powers. A more informal body can be created quickly and is more likely to be acceptable to all stakeholders. 2. While the status of the committee may be informal, it should have formal, well-understood procedural norms. For example, it is important to have a regularly scheduled meeting (for exam ple, the ﬁrst Friday of the month); minutes should be kept and circulated in a timely manner; a secretary should be appointed and held responsible for calling meetings and circulating agendas; and the role of meeting chair should be deﬁned (although this may rotate). 3. The leadership of the committee will usually rest with the public sector, although this does not preclude other stakeholders taking an informal lead in other areas (convening meetings, for example). 4. The committee should be multisectoral, with a broad representation. 5. It may be necessary to have a smaller working committee with technical representatives that meet regularly (monthly, for example), as well as a larger committee with higher-level policymakers that may meet less often (once or twice a year) to review broader policy-level recommendations. 6. Subcommittees may be convened around speciﬁc technical areas, such as procurement and logis tics, service delivery, behavior change communication (BCC); and information, education, and communication (IEC), and so forth. 7. It should be clear that the MOH has the ﬁnal say in approving any recommendations made by the committee. The scope of the committee may be as broad or as narrow as the committee desires. The following are examples of the types of activities that have been used successfully in the countries where DELIVER works: • overseeing the CS strategic process: developing, approving, implementing, and monitoring CS plans • facilitating annual (or biannual) country forecasting and quantiﬁ cation exercises • providing a forum for stakeholders to regularly share information on procurements, consump tion, and stock levels 44 CONTRACEPTIVE SECURITY • providing technical guidance for a broad range of technical activities—for example, developing capacity at a central medical store (CMS), introducing a new product to the market, or conduct ing pricing studies. The main role of the committee is coordination (rather than executive decision making); sharing infor mation and concerns, and providing a forum for discussion and consensus building (see box 5). In some cases, it may not be necessary to create a new body because a structure may already be in place that can also consider CS issues as part of an existing mandate. BOX 5. GHANA MOH AND PARTNERS DEVELOP STRATEGY TO ENSURE LONG-TERM CONTRACEPTIVE SECURITY Ghana has seen a rapid growth in contraceptive prevalence in a situation where all commodities were provided by donors. In 2002, the MOH and partners decided to develop a strategy to address current and long-term commodity supply. As a ﬁrst step, the ministry, with USAID support, convened a workshop that brought stakeholders together, including several other ministries, donors, nongovernmental organizations, and technical agencies. In addition to raising awareness about contraceptive security in Ghana and building consensus on priority issues, the workshop created the Interagency Coordination Committee for Contraceptive Security (ICC/CS). The Family Planning Coordinator in the MOH Reproductive and Child Health Unit (RCHU) was elected to lead the ICC/CS in the full development of a national strategy, to monitor the progress of other stakeholders, and to coordinate with other relevant partners involved in the process. Membership in the ICC/CS includes individuals from the RCHU, Public Health Division, Supplies Directorate, private manufacturers and distributors, and other partners. In 2003, the ICC/CS formed a smaller technical working group among its members to complete the development of a national CS strategy. The responsibilities of this group were to carry forward the issues identiﬁed in the workshop, promote collaboration and communication, and integrate the strategy into the Ministry’s Program of Work. The group remains active today in monitoring implementation of the strategy, coordinating forecasts and quantiﬁcations, and developing a ﬁ nancial sustainability plan for contraceptives. Of course, coordination is about more than creating a CS committee. But, in most cases, the creation and operation of a committee is the essential ﬁrst step in fostering coordination and cooperation. Th e very act of providing a regular forum for partners from various sectors to come together to discuss issues of common interest can create an environment where partners work together to enhance CS and provide family planning and reproductive health products and services. Similarly, the lack of will to establish a committee can be symptomatic of broader problems of commitment or willingness to engage the wider community of stakeholders involved in CS. For example, Bangladesh’s failure to form a CS task force has undermined CS gains and resulted in tensions that continue today between the MOH and the Social Marketing Company (SMC), which is one of the largest and most eﬀective social marketing organizations in the world. In some countries, particular problems for coordination in creating linkages exist between the public and private sectors—NGO, faith-based organization (FBO), social marketing, and commercial companies. Partners on both sides may not see the need to work together, there may be mutual suspicions, and sectors COMMITTMENT AND COORDINATION 45 may see their role as competing for the same customers rather than complementing each other to satisfy the whole market. Some groups may be reluctant to share information or allow outsiders to scrutinize public- or private-sector activities. By encouraging dialogue, CS committees foster cooperation. Other concrete strategies to improve cooperation include— • encourage sharing commodities during shortages (coordinated procurement planning and use of PipeLine databases can help accomplish this) • establish common standard treatment guidelines • conduct joint training—for example, private-sector providers participating in public-sector trainings. CONCLUSION For contraceptive security to improve in any resource-constrained country, there must be commitment by leaders at many levels of government and society, and coordination among all sectors that have a stake in family planning services. With suﬃcient commitment, the poorest and most vulnerable people will have access to contraceptives, while the private sector will serve the needs of those who can aﬀord to buy their products. With eﬀective coordination, the limited resources available to national programs and NGOs will be used eﬃciently enough to consistently meet the needs of all people who rely on them for their contraceptive needs. 46 CONTRACEPTIVE SECURITY 6. POLICY CONTEXT This chapter outlines how policies impact contraceptive security (CS), and includes concrete examples from countries where DELIVER has worked. Changing policies takes time and eﬀort, and while it is important to develop initiatives to address policy change, it is also important to work within an existing policy environment. DELIVER’s work means that we are usually involved in adapting to existing policies and regulations rather than actively trying to change them. Therefore, this chapter will— • oﬀer a framework for assessing the policy environment as it impacts contraceptive security • provide practical examples of DELIVER’s policy work in developing countries • suggest ways in which programs can overcome or take advantage of policies and regulations to improve contraceptive security. POLICY FRAMEWORK We adopted a simple framework (ﬁgure 4) to organize logically the issues that need to be considered in assessing the policy environment. The framework is intended only as a guide, to help us think systemati cally about the issues. We divided the policy issues into four categories: • product (or method) • supply and provider • demand • health sector reform. FIGURE 4. POLICY FRAMEWORK Demand Product and Method Selection Supply & Providers PRODUCT-RELATED POLICY ISSUES These policy issues directly impact the types, brands, and prices of the contraceptives and other reproduc tive health commodities on the market. Standard treatment guidelines pertain to methods, rather than POLICY CONTEXT 47 speciﬁc products, but we include them here for simplicity. There are six major categories of product-relat ed policies: • product registration • product quality • presence of a product on other lists: national essential medicines list; supplier approvals, prequali ﬁcation, and so forth; and standard treatment guidelines • patents/proprietary issues • tariﬀs, duties, and other importation issues • pricing policies and regulations. PRODUCT REGISTRATION Most countries have a drug registration authority, usually a government agency responsible for regulat ing the pharmaceutical products that can be legally sold in that country. They review product registration dossiers, approve products for marketing, and monitor post-approval marketing, including post-market surveillance and changes in labeling. Many countries where DELIVER works have limited capacity to evaluate drug registration dossiers. The process can be time-consuming and slow. Demands for coun try-speciﬁc labeling can add expense and time to the process of getting a product into a market. One of the recommendations DELIVER made as part of a study to develop a regional approach for CS in West Africa (Rao, Mellon, and Sarley, 2006) was to introduce regional drug registration; given the small size of many of the contraceptive markets in the region, new manufacturers may be reluctant to register their products in those countries. The costs of registration in small markets were cited as a barrier to entry by contraceptive manufacturers participating in the East African Regional Contraceptive Security workshop in 2005. Central American countries are exploring the scope for harmonized drug registration as part of the Central American Free Trade Agreement. PRODUCT QUALITY In addition to product registration, a mechanism should be in place to ensure the quality of speciﬁ c batches of products that arrive in a country. Most countries have a National Quality Control Laboratory with the power to sample and test products for purity and potency. The capacity for countries to ensure the drug quality varies considerably from country to country; many countries either subcontract this test ing to third parties or accept manufacturer certiﬁcates of analysis. However, countries will usually reserve the right to test products at any time. Lack of clear policies in this area, or the absence of clear application of those policies, can seriously impact CS when problems arise. Products may be held for several months awaiting adjudication. Donors that provide ﬁnancing for procurement, but do not procure directly, may require assurance of product quality before allowing procurement from a particular manufacturer. Th e sourcing of generic products from new pharmaceutical manufacturers based in developing countries, for example India and China, oﬀ ers signiﬁcant potential for developing countries to cut their costs and improve ﬁnancial sustainability. The challenge is to access these cheaper products while ensuring product quality. Countries with limited capacity can consider a number of options, including accepting inter national standards such as the U.S. Food and Drug Administration (FDA) or the European Medicines Agency (EMEA), the EU’s drug regulatory authority. Manufacturers should be able to demonstrate good manufacturing practice (GMP) and International Organization for Standardization (ISO) certiﬁ cation. Inspections by international organizations, such as the International Dispensary Association (IDA), can 48 CONTRACEPTIVE SECURITY also provide some endorsement. Another option would be to consider a CIB approach involving the Internet-based exchange of information on supplier performance. ESSENTIAL MEDICINES LISTS AND DRUG BENEFITS LISTS Inclusion on essential medicines lists (EMLs) is usually a prerequisite for public procurement of pharmaceu- In Benin, the essential medicines list ticals, including contraceptives. Experience has shown (EML) list includes levonorgestrol that contraceptives are not always consistently included implants, but only a single brand, Norplant. The manufacturer of on the EML. This may be because family planning was Norplant is discontinuing the product; not seen as a priority when the EML was drawn up or if Benin wants to continue to oﬀ er because World Health Organization (WHO) best prac- implants, they will need to choosetice for rational pharmaceutical management requires the a new implant. It is not clear if any speciﬁcation of generic formulations of drugs—exclud- replacement implant, in addition to ing contraceptive brand names. Medical devices, such as obtaining product registration, would IUDs and condoms, are also frequently excluded from need to be added to the EML list as aEMLs because they are not medicines. specialty. Other lists can help determine product availability. For instance, in Malawi, there is a separate essential health package medicines list that includes the medicines that can be procured under the SWAp mechanism in that country. The most recent list (active as of the end of 2005) included no female condoms and only one implant, Norplant, which is being discontinued by its manufacturer. In Kazakhstan, four types of contraceptives are included in the EML, but they are excluded from the outpatient drug beneﬁt package, which is intended to limit free drug provision to priority interventions. This has limited the scope of local health authorities to purchase contraceptives for their vulnerable popu lations. In South America, where health insurance exists in many countries, adding contraceptives to the health insurance drug beneﬁt package is a prerequisite for enabling the mobilization of health insurance funds. Standard treatment guidelines (STGs) list the preferred drug (and nondrug) treatment regimens for a health system. Speciﬁc contraceptive methods may or may not be recommended for particular situations. In many countries, IUDs are restricted—in many cases against current WHO recommendations—based on STGs that were developed from older guidelines or incorrect information. In addition to these country lists, international donors have restrictions on the products that they can supply; these can also have implications for CS. For instance, USAID has long-term contracts with certain manufacturers, and will only supply products from that manufacturer. Normally, USAID will require manufacturers to have FDA approval; which precludes many developing world manufacturers, given the investment in time and resources needed to get that approval. UNFPA is more ﬂexible but still requires ISO 9000 certiﬁcation and sometimes site visits (Armand 2006). Countries, many from the develop ing world, wishing to procure from generic manufacturers, will often need to procure those products themselves. Many donors, for example KfW, are more ﬂexible in the products they will fund, provided programs can provide assurance of the product quality. While, currently, there is no WHO prequaliﬁcation scheme for contraceptives, the current program for HIV/AIDS commodities—primarily antiretroviral (ARV) drugs and HIV test kits—includes a number of reproductive health commodities (UNFPA 2005). This precludes the use of Global Fund and United POLICY CONTEXT 49 Nations money to procure commodities that have not been prequaliﬁ ed. The future trend is likely to be toward increased scope for prequaliﬁcation of contraceptives, although this will depend on additional funding being made available to WHO to undertake prequaliﬁ cation assessments. PATENTS AND PROPRIETARY ISSUES Currently, no signiﬁcant issues exist for most reproductive health commodities, including contracep tives. ARV drugs for preventing mother-to-child transmission (PMTCT) programs may be impacted, and countries may be required to invoke the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPs) to freely procure these commodities. TARIFFS, DUTIES,AND OTHER IMPORTATION ISSUES The costs and eﬀort involved in importing contraceptives can be substantial. They are aﬀected by import tariﬀs, other duties, port charges, and taxes, such as value added taxes (VAT). They can also be aﬀ ected by import regulations and the need for an import license. World Trade Organization (WTO) reforms have tried to reduce tariﬀ and non-tariﬀ barriers to trade, but barriers still remain. While donated commodities often get waivers from import duties, there are exceptions. In Kazakhstan, the government required that the contraceptives USAID donated had to be registered, and also required that a registered importer had to bring them into the country with an individual import license for the shipment. Future regulations will require that generic products demonstrate certiﬁcates of bioequivalence as a further precondition for importation. Table 3 summarizes the duty/tariﬀ VAT and transport costs identiﬁed in nine Latin American countries (Sarley et al. 2006). This shows that import duty varies across the region: in some countries, the govern ment is exempt; in others, nonproﬁt NGOs are exempt; but in other countries, neither are exempt. Th e same is true of VAT exemptions. TABLE 3. COSTS ASSOCIATED WITH TRANSPORTATION, DUTIES/TARIFFS,AND VALUE ADDED TAX Country Bolivia Duty/Tariff (%) Value Added Tax Transport (%) NA Public Nonprofi t <15 <15 Public No Nonprofi t Yes Chile 5–10 Yes Yes 3.5 Ecuador NA NA No Yes <1.0 Paraguay <5 NA No Yes NA Peru 5–10 <5 Yes Yes 2.7* Dominican Republic <15 <15 No Yes NA El Salvador <5 5–10 Yes Yes NA Honduras NA NA No Yes 6.5** Nicaragua * public-sector * NA NA * nonprofit sector No Yes 5.4** 50 CONTRACEPTIVE SECURITY When countries apply VAT as part of their ﬁscal system, exempting contraceptives from VAT is a power ful indicator of the importance aﬀorded to family planning in national policy priorities. PRICING POLICIES AND REGULATIONS Pricing needs to be considered for all products and in all sectors. Governments sometimes control prices, not just in the public sector but also in the NGO and private (commercial) sectors. Pricing can impact both consumer access to products and their availability, as markets may not make products available if proﬁt margins are too low, or if prices are so high that there is little demand (see box 6). Pricing controls may restrict the ability to have a well-segmented market with diﬀerent price points for diﬀ erent sectors targeting diﬀerent clients. That said, the main obstacle to improving CS through increased private-sector participation, particularly in sub-Saharan Africa, is not price controls but limited purchasing power, thus making markets unattractive to commercial manufacturers. It is also important to look beyond pric ing policies to actual practices. In many countries, providers may overcharge for products or for related services such as costs for consultations, for inserting IUDS or implants, or for an injection. Often, provid ers are unaware of oﬃcial pricing guidelines; in other cases, they ignore them. BOX 6. MALI REGULATES PRICES FOR COMMODITIES To increase access to commodities, many countries keep prices low. However, if prices are too low, there may not be enough incentives for channels to distribute them. Mali regulates prices in the public and NGO/social marketing sectors. Contraceptive prices in the public sector were so low compared to other essential drugs that facilities had little ﬁnancial incentive to stock them. Margins were increased for contraceptives to overcome this problem. However, price controls on social marketing products made it diﬃcult for social marketers to diﬀerentiate their products from the public sector and provide incentives to their distribution channels. The MOH opposed price increases in the social marketing sector, arguing that it ran counter to its goal of increasing access. The social marketing sector was unable to communicate their arguments eﬀectively for increases based on the creation of a diﬀerentiated, segmented market, and perceived ability to pay. SUPPLY SIDE ISSUES We examine ﬁve supply issues that impact product availability and accessibility: • supply chain • outlets and provider registration • prescription/dispensing policies • human resources at the service delivery level • integration/referrals and family planning services. SUPPLY CHAIN ISSUES Speciﬁc technical issues that impact supply chains will be considered more completely in chapter 11 on logistics. However, speciﬁc policy issues may need to be considered, particularly for private-sector distri bution. In many developing countries, there may not be adequate distribution networks for the private POLICY CONTEXT 51 sector. Often, social marketing organizations created their own distribution channel to get their products to outlets, adding to the expense of doing business. SERVICE DELIVERY POINTS In many developing countries, the absence of outlets for contraceptives is the major obstacle to access for the clients. Many people live too far from public health centers to obtain contraceptives on a regular basis, or not enough private-sector outlets are available to allow them access to private supplies. Part of the problem may be general restrictions on private business, which can include rules and regulations on opening a private-sector clinic or pharmacy and the costs of complying with government regulations. Restrictions on who can open and operate a facility contribute to limited private-sector participation and decreased contraceptive security. In Bangladesh, government regulations on the registration of private-sector clinics were originally intended to provide some quality control. Th ey failed to do this because the regulations focused on regulating service inputs, including the size of the facility and equipment present, without focusing on the actual quality of care provided. Furthermore, opportunities for government inspectors to require unoﬃcial payments have led many private clinics to avoid oﬃcial registration (Health Economics Unit Research Note No.15 1998). Bangladesh: Customer buying condoms in a drug store. PRESCRIBING AND DISPENSING In Rwanda, public- and private-sector Most countries restrict the personnel allowed to prescribe clinics with trained medical staﬀ , and dispense most contraceptives, including hormonal but no pharmacist, are not allowed methods. These rules are intended to ensure that only to dispense oral contraceptives. properly qualiﬁed and trained staﬀ provide services but Pharmacists are not allowed to often they are unnecessarily restrictive. The acute shortage dispense injectables, and district of pharmacists and doctors in developing countries means hospitals are the lowest-level facilities that some of these rules are the greatest barriers to access. allowed to dispense or provide the This can be particularly true for private-sector practice. In whole range of family planning many cases, doctors can only prescribe and pharmacists products and services available in the can only dispense, meaning that private-sector clients face country. Th is aﬀects client access, as it extra time and cost in obtaining supplies. This issue has reduces the number of service delivery been one of the major obstacles countries have faced in points from which commodities can expanding community-based distribution of contracep be dispensed. tives. When CBD agents can only distribute condoms, their eﬀectiveness is constrained. The widespread popularity of IUDs in countries, such as the Philippines and Pakistan, may be attributed in part to the fact that trained midwives are allowed to insert them. See box 7 for more information about the eﬀects of the provider’s lack of training. 52 CONTRACEPTIVE SECURITY HUMAN RESOURCES Human resources refers to both the quantity and the qual ity of staﬀ available at the service delivery level, and includes a diverse range of issues, from training of staﬀ to regula tions on who can carry out certain procedures or dispense particular methods (see prescribing above). Policies that do not train, hire, and retain adequate professionals for FP service delivery and other technical areas, such as the supply chain, cannot achieve CS. In many countries, inadequate attention is paid to contraceptive technology in training for medical staﬀ . Eﬀorts to revitalize long-term methods, such as the IUD and implants, have identiﬁed inadequate training as a key factor in limiting the popularity of those methods. Georgia initially proposed restricting family planning service provision to specially trained reproductologists. A study tour to review Romania’s successfully expanded rural general practice- based family planning services led to a change of policy allowing Georgian general practitioners to provide family planning services. Inadequate training, resulting in poor management of side eﬀects, can negatively impact the perception of certain products. BOX 7. SOME PROVIDERS MAY LACK TRAINING IN MANAGING SIDE EFFECTS In Benin, Depo-Provera is very unpopular with public-sector providers and hence clients. Among the complaints made are that the product makes clients sterile. Yet, Noristerat, a closely related product, with a similar side eﬀ ects proﬁle, is by far the most popular product in the same country; and Depo-Provera is popular in neighboring countries. At least some of this fear can be attributed to lack of training of providers and consequent poor management of side eﬀects. Branded Depo- Provera is socially marketed in the country, and the social marketing program is concerned about the negative impact of these rumors on their sales. And, because some donors only provide Depo-Provera and not Noristerat, the public sector must procure this product themselves or rely exclusively on a single donor. INTEGRATION/REFERRALS OF FAMILY PLANNING SERVICES Access to FP products and services can be greatly increased if there is an eﬃcient system of either refer rals from other services or actual integration of those services. Signiﬁcant synergies can be gained by integrating some programs. For instance, it may be desirable for eﬀective HIV/AIDS services, such as voluntary counseling and treatment (VCT) and preventing mother-to-child transmission (PMTCT), to include information on family planning and provide products at the point of service. Some FP programs are trying to leverage the increased funding for HIV/AIDS programs by integrating family planning into these programs. Integration and referrals work in both directions and family planning customer services can be improved by referrals to other programs. DEMAND ISSUES The level of unmet need in developing countries points to a signiﬁcant problem in that people want to limit or space their families but are unable to do so. While many of the problems are supply-related, many others can be linked to a lack of awareness, lack of education, and lack of information about products or services. POLICY CONTEXT 53 Some of the major demand-related issues that create problems for contraceptive security are— • advertising of products and methods • information, education, and communication and behavior change communication (IEC/BCC). ADVERTISING Most countries restrict advertising of pharmaceutical products, including most contraceptives. Pharma ceutical companies and distributors may be reluctant to fund method-speciﬁc advertising thinking that it may help their competitors as much as themselves. Even where brand-speciﬁc advertising is allowed— condoms, for instance— governments or even donors may impose signiﬁcant restrictions on the content of the advertisements. These rules are usually unwritten and may reﬂect societal mores and standards. In some instances, advertising is required to be so vague that it is not clear what is being advertised. On the other hand, rules on brand-speciﬁc advertising may not be enforced: in many countries, social marketing organizations have advertised hormonal contraceptives without drawing censure. Addressing these issues is important where social marketing and commercial market solutions are impor tant components of contraceptive security. Working with local stakeholders, including community and private-sector leaders and local politicians, can be an eﬀective way to build support. INFORMATION, EDUCATION,AND COMMUNICATION,AND BEHAVIOR CHANGE COMMUNICATION Apart from mass media advertising, peer education and community mobilization campaigns oﬀ er messag es and communication concerning family planning and contraceptives. Restrictions—both formal and informal—may be imposed on these types of messages. One of the strongest predictors of contraceptive prevalence is girls’ educa tion. Countries where female education levels are low often have low prevalence (and high unmet need). Low female education and low female status in society lead to a lack of contraceptive security. Programs can design IEC/BCC campaigns taking into account broader socio-cultural issues; for example, many campaigns in patriarchal societies target men or other decision makers such as mothers-in-law. Ghana: Billboard in Tamale, Ghana, promotes abstinence. 54 CONTRACEPTIVE SECURITY ISSUES RELATED TO HEALTH SECTOR REFORM In the drive to reform the public sectors of devel oping countries, the health sector in particular, Tanzania integrated the supply chain for continues. The goals of reform for the health contraceptives into essential drugs between sector are to improve the quality, equity, and 1999 and 2000. While the contraceptive ﬁnancial sustainability of services and to increase supply chain was working reasonably well, access. Health sector reform creates particular the potential cost savings that could be issues for contraceptive security, to such an extent achieved through integration with a well- that, in this paper, we consider them as a sepa- functioning system for essential drugs was a rate category. Four major reforms are worthy of major motivator. By mid-2000, distribution attention: costs for contraceptives had decreased by 58 percent (Sanga 2001) over the previous year, • integration of contraceptive supply chains and contraceptive stockout rates had decreased with essential drugs and other commodi- from 27 percent in 1996 to 11 percent by the ties end of 1999. Integration improved the overall • cost recovery sustainability of the supply chain for both contraceptives and essential drugs. • sectorwide approaches to ﬁ nancing • decentralization. INTEGRATION OF CONTRACEPTIVE SUPPLY CHAINS WITH ESSENTIAL DRUGS The integration of vertical contraceptive supply chains with larger essential drug systems continues to occur in many countries. Integration can have both positive and negative impacts on CS. Long term, inte gration can improve CS as investments strengthen national supply chains for all commodities. However, short term, it can create problems, as the process of integration disrupts existing roles and management structures, and staﬀ need to learn new procedures. The Tanzania example demonstrates how integration Ghana’s contraceptive security strategy into an existing, well-functioning supply chain can identiﬁed the need for more research improve CS and reduce costs. While simply investing in on ability and willingness to pay (ATP) a vertical program could potentially produce even better for contraceptives to help set price results for indicators like product availability, it would be points. On the basis of subsequent ATP highly unlikely that it could do so more eﬃ ciently. Inte- analysis, opportunities were identiﬁ ed gration makes sense from a ﬁnancial sustainability point to increase some prices in the public of view. Of course, integration is not a ﬁxed point, but and social marketing sectors and rather a continuum. The integration of physical process- thereby enhance program sustainability. es like storage and transportation can be accompanied by a degree of vertical program oversight and management to ensure product availability. DELIVER supports the MOH to oversee contraceptive distribution—fore casting, procurement, and distribution—as part of both integrated and vertical supply chains. Th e process of integration requires good preparation and planning to ensure success. POLICY CONTEXT 55 COST RECOVERY One of the goals of the Bamako Initiative8 reforms was to increase the sustainability of health systems and cost recovery; having users pay for a portion of the goods or services they receive was one way to achieve that goal. Cost recovery in the public sector is a reality in most developing countries and it has an impact on CS. On the positive side, it can enhance sustainability, enabling facilities to improve the services they oﬀer and providing funding for procurement through revolving drug funds. On the negative side, it can decrease access to products. In most countries where DELIVER works, prices are usually set suﬃciently low to allow access for most of the population. However, low-income groups may be negatively impacted and, in most cases, waiver schemes for the poor are ineﬀ ective. This impact may be more signiﬁcant for contraceptives, often perceived as a discretionary spending item, as opposed to other medicines for acute care. Th e positive impact of cost recovery schemes are often harder to discern. Often, contraceptives are donated, which means acquisition prices are low and, therefore, so are the margins. Facilities have relatively little incentive to stock contraceptives because more proﬁt can be made on other essential drugs. Some countries collect a portion of returns on pharmaceutical sales and use that money to fund procurement. Often follow-up for these funds is insuﬃcient to ensure that they are used for their intended purpose. Many of the CS assess ments DELIVER participated in have identiﬁed the need for country-level research to identify consumer willingness and ability to pay (ATP) for contraceptives. Subsequent CS strategies have validated this need and identiﬁed partners to fund or carry out the work. The need for ﬁnancial sustainability must be balanced with concerns that price increases may negatively impact access, recognizing the many diﬃculties associated with waiver schemes. SECTOR-WIDE APPROACHES TO FINANCING Many of the countries where DELIVER works are moving from a situation in which donors earmark funding for vertical health programs to one in which they provide funding to a common basket, which is then allocated by the ministry according to predetermined priorities. In many countries, family planning and CS are strongly driven by donors, leading to concerns that they may receive reduced attention in a basket funding situation. Even where donors do not pool their funding in a SWAp basket, their funds are included in the basket planning (see box 8). The movement to SWAps provides an opportunity for advocates to increase government support for contraceptive security. The process needs to be closely managed to ensure contraceptives and family plan ning continues to receive support, particularly during the transition period, a time usually characterized by uncertainty and confusion. 8. The Bamako Initiative, launched in Bamako, Mali, in 1987 by UNICEF and WHO, sought to improve maternal and child health in Africa through more equitable access to quality health care and a more efficient use of resources. 56 CONTRACEPTIVE SECURITY BOX 8. MALAWI IMPLEMENTS SECTOR WIDE APPROACH Malawi began implementing a sector wide approach (SWAp) in 2005, and included most health sector donors—MOH, DFID, NORAD, WHO, World Bank, and UNFPA. Funding priorities are determined by the Essential Health Package (EHP), which outlines a packet of activities to be funded, with priorities and an associated list of commodities. Donors that do not pool their funds in the SWAp are included for planning purpose, e.g., USAID commitment to contraceptive procurement (part of the EHP) is included in ﬁnancial planning by the SWAp secretariat at the ministry. As part of the transition to the SWAp during 2005 and 2006, DELIVER advocated for special donor funding to ensure commodities were available during the transition period. Th is was important because part of the SWAp meant the MOH would procure its own contraceptives, something it had not done before, and, therefore, required a signiﬁcant period of time to become operational. The DELIVER oﬃce has worked closely with the SWAp secretariat, providing detailed forecasts for commodity requirements. DECENTRALIZATION The movement to devolve power to lower levels in public administration creates both opportunities and challenges for CS. Decentralization in health systems typically pushes varying degrees of responsibility for management functions from the central to the district or even facility level. The degree of decentral ization varies between functions and between countries, and signiﬁ cant diﬀerences exist between policy and practice. While decentralization can be beneﬁcial, it poses signiﬁcant challenges, particularly where capacity is low. In some respects, decentralization runs counter to many global trends for logistics systems, where greater eﬃciencies can be obtained by centralizing decision making; for example, in areas such as procurement and information systems. In some countries, procurement has been decentralized, leading to increases in commodity costs when the high-volume purchasing is lost. In decentralized environments, advocacy for CS at lower levels becomes even more critical and needs to be targeted to a larger number of decision makers. Local decision makers may not consider family plan ning a priority or may be susceptible to forces actively opposed to modern methods. On the other hand, they may prove to be active and engaged partners in CS; in the Indonesian example (see box 9), develop ment of CS strategies at the district level led to strengthened advocacy from the districts to the central level for CS. Similarly in the Philippines, local districts took active ownership of CS with decentralization and forged stronger partnerships with NGOs and the private sector at the local level. BOX 9. INDONESIA DEVELOPED ADVOCACY AND PLANNING TOOL Indonesia devolved authority for its family planning program to more than 400 districts in 2002. For the ﬁrst time, local authorities were expected to forecast, procure, and distribute contraceptives and ensure quality services. Working with the Indonesian Family Planning Coordination Board, DELIVER developed a district contraceptive security (CS) advocacy and planning tool, based on the SPARHCS framework. The authorities used the tool to assess CS in two districts and to develop strategic plans to improve CS. Among the achievements of this eﬀort were agreement of an Indonesian-speciﬁ c deﬁnition of CS, establishment and funding of local budget lines for contraceptives, better targeting of free public contraceptives, introduction of expanded fees for service public provision, expansion of private provision through more streamlined procedures for establishing pharmacies, stronger partnerships between pharmacies and private service providers, and standardization of private provider fees. POLICY CONTEXT 57 In Kazakhstan, management decision making for health budgets has been devolved to the regional and district level, subject to national health policy priorities. National procurement laws now govern the purchasing of drugs and contraceptives now being undertaken by oblast (regional) health administra tions and rayon (district) hospitals. Public procurement for hospital inpatients can only include drugs on the essential medicines list (EML). The EML includes three types of oral pills and spermicide, but no condoms or IUDs, because these are medical devices, not injectables or implants. There are, however, very few inpatient clients for contraceptives. Most maternity cases are advised to adopt the lactational amenorrhea method (LAM) as their postpartum contraceptive method. For outpatients, the outpatient drug beneﬁts list deﬁnes the commodities that can be procured and provided free of charge to clients. National priority is given to diabetes, tuberculosis, oncology, and the health of children under ﬁ ve years old. Because contraceptives are not technically included, public-sector contraceptives cannot be procured and provided free of charge to the poor and vulnerable groups. While the private sector is well developed and provides a good method mix at a wide range of prices, key groups in the population are still vulner able and cannot aﬀord to pay for their contraceptives. One advantage of decentralized decision making is that, while FP may not be seen as a national priority, it is seen as a priority in at least 8 out of the 15 regions in Kazakhstan. Several have identiﬁ ed loopholes in the national procurement regulations that allow them to procure the contrace

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