Coordinated Assistance for Reproductive Health Supplies (CARhs): How a phone call led to improved supply chain management

Publication date: 2014

COORDINATED ASSISTANCE FOR REPRODUCTIVE HEALTH SUPPLIES (CARHS) How a phone call led to improved supply chain management Julie Solo January 5, 2014 1 | Coordinated Assistance for Reproductive Health Supplies (CARhs) Table of Contents Executive Summary . 2 Introduction . 3 Methodology . 4 Findings . 4 History of CARhs . 4 Purpose and Achievements . 8 What is CARhs? . 8 Has CARhs Been Successful? . 10 Growth and Changes . 13 Should CARhs Do More?. 13 Should CARhs Address Broader Systems Issues? . 15 Should CARhs be Preventing as well as Reacting? . 16 Should CARhs Have its Own Resources? . 17 Should CARhs Change its Approach to Country Engagement? . 18 Conclusions . 20 Appendix 2. Question Guide for Key Informants . 23 Appendix 3. Data Provider Survey . 24 2 | Coordinated Assistance for Reproductive Health Supplies (CARhs) Executive Summary In 2004, a group of donors came together to collaborate and better coordinate their efforts to address contraceptive stockouts around the world. Initially known as the Countries at Risk (CAR) and later renamed Coordinated Assistance for Reproductive Health Supplies (CARhs), this group has worked together effectively for close to ten years. Now facing a number of questions and challenges, the CARhs group is undertaking a strategic planning process to plan for its future. This report summarizes information from three sources: 1) review of documents, including annual progress reports and notes from CARhs calls; 2) interviews with 11 key informants; and 3) a survey of data providers (14 responses). The findings will complement other information sources and will inform a strategic planning meeting to be held in February 2014. HISTORY OF CARHS The CARhs group was established in December 2004, and its first meeting took place in January 2005. CARhs was intended to meet monthly as a forum where key global-level partners involved in the funding and procurement of contraceptives and condoms—UNFPA, USAID, World Bank, KfW, and others—would share information to identify countries on the verge of or in supply shortages, to better understand the causes of these shortages, to identify solutions, and to coordinate the implementation of solutions. The focus of CARhs has been largely, though not exclusively, on contraceptives. The role of the group has evolved, largely as a response to improvements in data available to the CARhs. Initially the group relied primarily on anecdotal reports, but this changed in October 2007 when USAID, through the USAID | DELIVER PROJECT, created the monthly “Procurement Planning and Monitoring Report” (PPMR) to capture the stock status and other issues pertinent to contraceptive security. This led to the fairly informal group becoming somewhat more structured and formalized. The PPMR has grown from one country—Bangladesh—in 2007 to 13 countries in September 2008 and currently includes data from over 30 countries. The PPMR evolved from an Adobe PDF document produced by a closed database to an online, interactive database allowing data providers, CARhs members, and external users to have much greater data access and analytical tools. The new database also enables CARhs to automate some of its agenda preparation and record meeting notes online. This also allows CARhs participants to see the lists of issues and work to resolve problems even outside of the monthly call. PURPOSE AND ACHIEVEMENTS What is CARhs? In defining CARhs, the most common themes were the idea of addressing stockouts, having a group working together collaboratively, and increasing visibility around what was happening at the country level. But beyond these common themes, there were differences in emphases and lack of agreement about how much of an entity of its own CARhs should be, a common issue for coordinating groups. Developing and communicating an agreed-upon definition would be useful. Has CARhs been successful?CARhs has achieved a number of successes, not only in expediting or transferring shipments but also in providing useful information. There is a need, though, for better communication about its accomplishments. This will help to ensure continued participation and support and will also help clarify what the group does as a way to align expectations and reality. 2 | Coordinated Assistance for Reproductive Health Supplies (CARhs) GROWTH AND CHANGES: FIVE STRATEGIC QUESTIONS 1. Should CARhs do more? There has consistently been interest in adding more countries, an indication of the usefulness of CARhs. Most people feel that the focus should remain on contraceptives but that groups working on other commodities could learn from CARhs. Many respondents expressed interest in capturing more of the complete supply chain picture, including forecasting information. There was a good deal of interest in doing more with the data that CARhs has in order to better address supply chain issues. 2. Should CARhs be addressing broader systems issues? There was generally agreement that while this was beyond the regular mandate of CARhs, it would make sense to use the information that CARhs has to help inform broader efforts. When this was tried previously, the problem was not with the concept but with the process. Specifically, the CARhs group would need to identify the most appropriate people to whom information is channeled on broader systems issues. 3. Should CARhs be preventing as well as reacting? Many felt that stating that CARhs does not deal with preventing supply crises was a misinterpretation of what CARhs does and how it operates, calling attention again to the need to clarify and communicate what CARhs is and does. 4. Should CARhs have its own resources? There were mixed feelings about this question and also a lack of clarity about what it would mean exactly for CARhs to have resources rather than drawing upon the already existing resources of UNFPA and USAID. While there is an intuitive appeal to the idea of CARhs having an emergency fund of some kind, the reality of putting such a fund in place is complicated. This was tried in the past after an analysis showed that additional funds would have enabled CARhs to address the third of its issues that it could not resolve, but due to timing issues the money was absorbed by UNFPA and not used specifically by CARhs. An update of this kind of analysis could be helpful in providing clearer guidance. 5. Should CARhs change its approach to country engagement? There were mixed responses regarding whether there was a need to increase country engagement. In discussing this issue, several respondents emphasized the importance of building country-level capacity while still acknowledging the need for a global entity. CARhs is a successful example of the power of partnership. Addressing the questions discussed above can help it operate even more effectively and efficiently. As it moves forward, it can build upon its strengths and successes to continue to meet the important goal of reducing stockouts, thereby improving access to reproductive health commodities for women around the world. 3 | Coordinated Assistance for Reproductive Health Supplies (CARhs) Introduction It started with a phone call. There were discussions before that call, but it was the call that really started and defined Countries at Risk (CAR), which would later become known as Coordinated Assistance for Reproductive health supplies (CARhs). Recognizing the need to find coordinated ways to deal with supplies emergencies and issues, several donors came together to take action. The monthly call would enable them to more effectively and efficiently address stock issues for contraceptives in countries around the world. Since its beginning in 2004, CARhs has grown, developed a strong database with which to make decisions and take actions, and has had numerous successes. While it has grown to be much more than a phone call, that sense of communication and collaboration from the first call still guides its actions and purpose. CARhs is currently facing a number of strategic challenges that will impact the way the group operates and potentially strain the financial and human resources available to it. First, CARhs is considering expanding the number of countries and programs it seeks to assist. Second, the monitoring of implant flows in association with the new Implants Access Initiative has created a parallel coordination structure with different reporting flows, which requires additional time and resources from CARhs members. Thirdly, new challenges are emerging with other contraceptive methods, namely injectable contraception. These challenges raise a number of questions, including the following:  Should CARhs include additional countries/programs, and on what basis should those countries be selected?  What role does CARhs play in the global contraceptive supply chain?  Can/should CARhs engage countries in a more direct manner? If so, what form should this engagement take?  What is the appropriate role for the group members in terms of preventing supply issues from rising to the level of CARhs? Addressing these challenges presents an opportunity for the CARhs group to improve its operations and increase its impact in addressing supply chain issues. To date, the group has never met face-to-face, nor does it have any foundational documentation on which to base its answers to the above questions. Moreover, management of CARhs will shift for the first time in over four years to the Reproductive Health Supplies Coalition (RHSC), which is not itself a procurer. Almost ten years after that first CARHs call, and given these challenges, it is a timely moment to reflect on the purpose of CARhs, how it functions, and how it can best and most strategically move forward. To this end, CARhs has decided to undertake a strategic planning exercise. 4 | Coordinated Assistance for Reproductive Health Supplies (CARhs) Methodology In order to inform the strategic planning process, a consultant undertook a review of CARhs. Sources of data included: 1) review of documents, including annual progress reports 1 and minutes and notes from CARhs calls; 2) interviews with 11 key informants (Appendix 1) following a question guide (Appendix 2); 3) a survey of data providers (14 responses out of 32) 2 (Appendix 3); and 4) consultant participation in a CARhs call to better understand the process. The review of documents provided a foundation of how CARhs started and how it evolved, while interviews with key stakeholders and data providers offer insight and perspectives about where to go in the future. This report will complement other efforts in the strategic planning process, which will culminate in a strategic planning meeting in February 2014. Findings are presented as a synthesis of the multiple data sources, while also noting any differences between the responses of data providers and other key informants. The findings begin with a discussion of the history and evolution of CARhs. This sets the stage and provides lessons and context for addressing the questions that CARhs needs to address in its strategic planning process in order to move forward most effectively. Findings HISTORY OF CARHS In order to understand how best to move forward, it is important to first look back at the history and evolution of CARhs. The CARhs 3 group was established in December 2004, and its first meeting took place in January 2005. The CARhs was intended to meet monthly as a forum where key global-level partners for the funding and procurement of contraceptives and condoms—UNFPA, USAID, World Bank, KfW, and others—would share information to identify countries on the verge of or in supply shortages, to better understand the causes of these shortages, to identify solutions, and to coordinate the implementation of solutions. The idea arose when members of the Systems Strengthening Working Group (SSWG) of the Reproductive Health Supplies Coalition (RHSC) became concerned about stockouts and thought that if they all sat together, they could identify and figure out a coordinated response. As one donor stated, “There were too many emergency requests, and these were expensive—we were always on our back foot and reacting. So we wanted to do a better job in setting up an early warning system and get greater visibility into what was happening in countries.” The CARhs focus has been largely, though not exclusively, on contraceptives. The role of the group has evolved, largely as a response to improvements in data available to CARhs. Initially, the group relied primarily on anecdotal reports, but this changed in October 2007 when USAID, through the USAID | DELIVER PROJECT, created the monthly “Procurement Planning and Monitoring Report” (PPMR) to capture the stock status and other issues pertinent to contraceptive security. This led to the fairly informal group becoming somewhat more structured and formalized. The PPMR has grown to include data from one country (Bangladesh) in 2007 to 13 countries by September 2008; 16 countries by September 2009; 21 countries by September 2010; to currently over 30 countries. 1 These annual monitoring reports were instituted in 2005 and structured around standardized evaluation criteria that were established in 2005/6. 2 All countries reporting in the PPMR received the survey: Afghanistan, Bangladesh, Benin, Burkina Faso, Cameroon, Cape Verde, Chad, Cote d’Ivoire, Democratic Republic of Congo (DRC), Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea Bissau, Haiti, Kenya, Liberia, Mauritania, Mozambique, Niger, Nigeria, Pakistan, Rwanda, Sao Tome & Principe, Senegal, Sierra Leone, Tanzania, Togo, Uganda, Zambia, and Zimbabwe. 3 The group was initially called Countries at Risk (CAR). Due to some sensitivity by countries at being called ‘at-risk,’ the name was changed in 2010 to CARhs, keeping roughly the same acronym. Throughout this report, we will use the current name for consistency. 5 | Coordinated Assistance for Reproductive Health Supplies (CARhs) From its beginnings as an informal collaborative effort, leadership for the group has passed between UNFPA, USAID, and the RHSC, with each coordinator assuming the lead in supporting the logistics and management of CARhs, including organizing meetings and keeping notes. Over time, the monthly phone calls became truly monthly events. For the first three years, calls were held less than half of the time; this increased to three-quarters of the time in 2007 and 2008, while in the following years, calls were held every month. Early progress reports noted that the frequency of meetings has not met expectations, falling short by more than half, and that the group would benefit from more regular meetings, as well as improved information gathering and follow-up. This was clearly acted on and improved over time. A strength of CARhs which was noted in all of the progress reports was the consistent participation of key organizations, as well as the openness of discussions. The fact that meetings were held consistently and that participation remained fairly stable indicates that those involved found it to be useful. Table 1: CARhs Meetings and Participants, 2005-2011 4 2005 2006 2006-07 2007-08 2008-09 2009-10 2010-11 Meetings 42% (5/12) 44% (4/9) 42% (5/12) 75% (9/12) 100% (12/12) 100% (12/12) 100% (12/12) Number of organizations participating 5 4 (2-5) 3 (2-4) 6 (5-8) 5.9 (5-8) 5.6 (4-8) 6.1 (4-8) 5 (3-7) Number of individuals participating 7 (3-10) 3 (2-4) 8 (6-11) 7.8 (5-10) 9.1 (6- 12) 8.9 (6- 12) 7.2 (5-8) There have been significant changes over the years in how results are defined and how information is presented. Use of the PPMR has allowed for a more structured and efficient approach. The PPMR evolved from an Adobe PDF document produced by a closed database to an online, interactive database allowing data providers, CARhs members, and external users to have much greater data access and analytical tools. The new database also enables CARhs to automate some of its agenda preparation and record meeting notes online in real time. CARhs participants can see the lists of issues and work to resolve problems even outside of the call. The CARhs progress reports 6 noted the causes of supply problems. Not surprisingly, the same types of problems occur each year. Among the most frequently cited causes were: funds not available in a timely way; demand exceeding forecast; donor pullout or delays in donor- government coordination; poor procurement planning; lack of accurate information; and production issues. Specific causes can be linked to specific countries to better help with country- level planning and addressing system-level problems, an idea which is discussed in greater detail later in the report. 4 The first annual report covered the calendar year of 2005 and the first nine months of 2006, while later reports used the fiscal year from October 1- September 30. 5 This table presents the average number of organizations and individuals participating, followed by the range in parentheses 6 The most recent progress report available covered the period 2011 to12. 6 | Coordinated Assistance for Reproductive Health Supplies (CARhs) Table 2: Causes of Supply Problems Identified in Progress Reports 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11  Donor pullout  Lack of accurate information on in-country stock status  Imposition of new post- shipment testing requirements  Demand exceeding forecasting  Funds not available in timely way  Lack of funding  Re- registration of product needed  Donor pullout  Lack of accurate information on in-country stock status  Demand exceeding forecasting  Funds not available in timely way  Lack of timely, transparent procurement planning by governments  Donor pullout  Lack of accurate information on in-country stock status  Demand exceeding forecasting  Funds not available in timely way  Lack of timely, transparent procurement planning  Production issues  Delays in arrival or customs clearance  Failures or delays in national tendering processes  Delays due to donor- government coordination for donor- funded procurement  Poor procurement planning  Production issues  Delays in arrival or customs clearance  Demand exceeding forecasting  Funds not available in a timely way  Failures or delays in national tendering processes  Delays due to donor- government coordination for donor- funded procurement  Lack of procurement planning and monitoring  Production issues  Shipment delays  Demand exceeding forecasting  Funds not available in a timely way  Failures or delays in national tendering processes  Delays due to donor- government coordination for donor- funded procurement  Lack of procurement planning and monitoring  Production issues  Shipment delays  Demand exceeding forecasts  Funds not available in a timely way The progress reports noted areas for improvement for CARhs. In the first two years, this was just a list, while from the 2007-08 report until the last report, areas were reported under the following categories: 1) Expand available supplies data; 2) Improve ability to act; 3) Improve understanding of reasons for stockout; and 4) Streamline processes. Many of these issues also arose and are addressed in the survey and interviews, and these remain important categories for CARhs to consider improving for the future. Below is a list of the main issues under each of these four categories with comments on if and how these issues have been addressed. Some remain questions to this day, a fact which will be addressed in later sections of the report. Interestingly, the idea of addressing broader systems issues arose in the earliest progress reports—maintain the CARhs’ focus on “firefighting” and develop a systematic approach that links short-term crises to addressing broader systemic issues. This can include regular communications to the Coalition on the broader issues that come to the CARhs’ attention.” 1. Expand available supplies data:  Increase information sources available to CARhs. Anecdotal reports to CARhs about stockouts seem to have decreased since the PPMR has become the primary data source. However, CARhs members should still encourage anecdotal reports, as they remain the only means of learning about and responding to stock issues in countries not reporting to the PPMR. The idea of having additional sources of regular, quantitative data—such as UNFPA Country Commodity Manager (CCM) reports—to expand the number of countries was mentioned in several reports.  Focus on the lower-level stock availability (only mentioned in 2007-08). At present, the PPMR primarily reports contraceptive stock levels at national central warehouses, because these are the data which are most often readily available in countries with weak Logistics Management Information Systems (LMIS). Thus, CARhs begins to act when it foresees central-level stockouts. However, in countries central-level stockouts are often not considered 7 | Coordinated Assistance for Reproductive Health Supplies (CARhs) urgent when stock exists lower in the pipeline—thus, country-level actors might not have a sense of urgency about some CARhs issues. To make CARhs action more aligned with local attitudes about urgency, the PPMR reports on stock availability at lower levels where high- quality data can be gathered and reported in a timely manner. What has happened: There has been a continual expansion of the number of countries included in the PPMR. When available, information of lower-level stock availability is also included, but this is not always possible. Because of this issue, a quarterly reporting schedule evolved, giving some of the data providers time to gather lower-level data. 2. Improve ability to act  Assure involvement of key stakeholders. The limited range of donors active in CARhs means that CARhs can typically only provide additional product/shipments for issues where USAID or UNFPA can respond. The World Bank had previously been a regular participant, providing useful information to CARhs, as well as assisting in facilitating the use of World Bank funds for contraceptive procurement.  Create emergency funding mechanism. One of the key factors limiting the ability of core CARhs members from resolving emergency stock issues is the inability to quickly identify funds for providing commodities to countries on the verge of a stockout. The CARhs group could consider seeking funds for procuring commodities to use at its discretion, with authorization from the local program. Such a program could leverage or be integrated into the new AccessRH or Pledge Guarantee for Health mechanisms.  Develop CARhs guidelines for emergency action. Apart from funding, the decisiveness of CARhs to resolve apparent emergency stock issues is also limited by the lack of clear guidelines or criteria for emergency action by CARhs. Developing guidelines would increase consistency in the response to stock issues and could also serve to invigorate the efforts of CARhs members to identify funds and make decisions regarding emergency shipments. What has happened: The fact that there has been a change in the landscape in this space since CARhs inception is important to note. For example, the World Bank is less active, while KfW, DFID and WAHO are much more active than when CARhs was first created. As will be discussed later in the report, there have been efforts around creating an emergency funding mechanism, but there are a number of uncertainties around this issue. 3. Improve understanding of reasons for stockout  Research causes of contraceptive stockouts. The experience of CARhs has been that contraceptive stockouts typically have multiple, inter-dependent causes that cannot easily be categorized. For this reason, the PPMR has not been designed to collect information on reasons for stockouts. However, stakeholders regularly ask CARhs for information on contraceptive stockouts, and better information may improve CARhs’ ability to respond to needs. CARhs could consider conducting research on a number of cases to determine causes of stockouts in multiple cases and possibly categorize the relative importance of different causes. What has happened: While PPMR and CARhs discussions often include looking at reasons for stockouts, there is still room for more systematic synthesis and use of this information. 4. Streamline processes  Automation of CARhs administration. The process of collecting, analyzing, and synthesizing data from PPMR, RHI, and CARhs members remains mostly manual. Significant reductions in level of effort required for managing CARhs processes would be http://www.rhsupplies.org/working_groups/systems_strengthening/global_financing_and_procurement.html 8 | Coordinated Assistance for Reproductive Health Supplies (CARhs) made by automating the creation of a draft CARhs agenda and by automating the capture of CARhs notes—all of which could be managed by an improved CARhs-PPMR database. What has happened: This has largely been addressed. As one person explained, “While we cannot have a 100% automated CARhs agenda, we have come a long way from the days when the CARhs administrator would comb through the pages of a long PDF file and cut and paste issues into Excel to create the agenda.” The Power of Partnership We also talk a great deal in the Coalition about the power of partnership. And there is no end to the examples one might draw on to demonstrate what such partnership can achieve. But I am again drawn to the one institution within the Coalition that perhaps demonstrates better than any what can be achieved by partners working together, sharing knowledge, pooling resources towards a common goal—and that is the CARhs. For those of you not familiar with it, the CARhs brings together key commodity suppliers to address short-term supply crises that periodically befall countries. This year, under the management of UNFPA, the CARhs saw on the horizon some impending—and even actual—stockouts of the injectable contraceptive Depo Provera. Together with the manufacturer Pfizer, USAID, the USAID ǀ DELIVER project, and UNFPA successfully coordinated pending orders and existing product stock and completed a transfer of 2 million units of Depo Provera, thereby allowing five sub-Saharan African countries to prevent stockouts and deliver the means to prevent 142,857 unwanted pregnancies. John Skibiak, State of the Coalition, 2013 It is important to look back in order to more effectively look forward. Having examined the past, the rest of the report now explores the present, in terms of perceptions of CARhs and its achievements, and the future, with ideas for CARhs in coming years. PURPOSE AND ACHIEVEMENTS What is CARhs? What is the purpose of CARhs? This straightforward question elicited a range of responses in interviews and the survey. It is interesting to note the similarities and different aspects that people emphasized in their definitions of CARhs’ purpose. The most common themes were the idea of addressing stockouts, having a group working together collaboratively, and increasing visibility around what was happening at the country level. An important theme was the idea of the whole being greater than the sum of its parts: “It is a classic case of bringing people together to do more than they can do on their own,” explained one respondent. Some illustrative examples are given below: “It’s there to make sure that countries have commodities when they need them. Also coordinating shipments and planning shipments so you have adequate commodities when you need them.” - Country respondent “Assisting countries to avoid or eliminate stockouts.” - USAID “It’s a group of donors and procurers who meet every month to prevent, avert, or deal with the risk of stockouts or commodities.” - RHSC “An attempt to get people to collaborate across agencies based on data—main purpose is to mitigate stockouts. And CARhs can help countries in stockout situation to get a shipment.” - UNFPA 9 | Coordinated Assistance for Reproductive Health Supplies (CARhs) “It’s a group of partners who prevent country-level stockouts of contraceptives and help countries manage supply challenges.” - Country respondent “It’s a small informal group that comes together in a nimble way to share information and solutions about short-term crises and stockouts.” - DFID One respondent from USAID highlighted the phone call when defining CARhs: “A monthly phone call by UNFPA and USAID and other stakeholders to look at data on stock levels at country level to see if there are actions that can be taken at global or country level to mitigate or avoid a stockout or change orders to prevent an overstock.” While this is still the heart of CARhs, much of the work happens outside of this call. Still, that does not diminish the importance of the calls—“Calls are basically a face-to-face meeting, and they can be more productive and efficient than exchange of emails. If it’s discussing how to do things jointly, that’s good versus just one person reporting how they are going to address something.” This calls attention to the need to make the calls efficient, which CARhs has addressed by trying to resolve as many issues as possible outside of the call. But this has implications for the structure and definition of CARhs. Data provider survey respondents also emphasized dealing with stockouts and improving contraceptive security. Several also talked explicitly about CARhs as a source of information— not surprising given that these respondents are the providers of data. For example: “The main purpose of CARhs is to collate and disseminate contraceptive procurement, shipment, and stock status information for participating countries and organizations. Based on the PPMR reports submitted by participating countries, CARhs also works to monitor the stock status of contraceptives, suggesting ways and/or taking specific actions to maintain the desired stock levels in these countries and organizations.” - Nigeria “To enhance information flow for timely action to prevent contraceptive shortages/stockouts.” - The Gambia “Data visibility for global stakeholders so they can make better and more timely decisions.” - Ethiopia “To provide information. To identify countries with impending stockouts, stockouts, and overstocks based on PPMR data. To identify solutions to the above supply problems.” - Ghana Stepping back from the purpose of CARhs is the question of just what it is. This becomes an issue for many types of coordinating groups or alliances—just how much of an entity of its own should it become? There seemed to be mixed feelings, with some respondents feeling like many of the questions posed in the interviews indicate too much of an approach of turning CARhs into an even larger entity, while others want to see it taking on more, which is described in the following sections. A USAID key informant articulated the former perspective: “The thing that worries me about CARhs is that the people most involved seem to think and talk about CARhs as if it’s an entity—like it needs resources or makes decisions, and I think that is dangerous. The value is that it’s USAID and UNFPA and DFID and the World Bank and the Gates Foundation putting their heads together and coming up with solutions.” While there was agreement at a general level about what CARhs is, there were clearly differences in opinion about specifics and about what it should be. Clarifying its role and “USAID and UNFPA— they pick up the phone and start talking, and they solve so many problems.” UNFPA 10 | Coordinated Assistance for Reproductive Health Supplies (CARhs) functions will be important so that all partners have expectations that match the reality of what the group is trying to do. What is CARhs? In defining CARhs, the most common themes were the idea of addressing stockouts, having a group working together collaboratively, and increasing visibility about what was happening at the country level. But beyond these common themes, there were differences in emphases and lack of agreement about how much of an entity of its own CARhs should be, a common issue for coordinating groups. Developing and communicating an agreed-upon definition would be useful. Has CARhs Been Successful? There was almost universal agreement that CARhs has been successful, but many felt that they could not actually quantify its success. “Yes, it’s successful, but that answer is based more on faith than evidence,” explained one respondent. Another added that “I don’t have the ability to quantify or put a dollar value on the solutions. I also can’t put a dollar value on the cost of doing it.” To this end, it could be useful to look at costs and benefits and/or other ways to demonstrate impact to better understand and communicate about CARhs and to inform future plans. As CARhs grows and the effort to ‘run’ it becomes greater, there will be more questions about whether the extra effort is worthwhile. One challenge with determining impact is the issue of attribution; for example, in Ethiopia CARhs helped expedite a shipment, but it also knew about this issue from the country office, so one cannot determine who gave the information first. “It can be a combined effect,” explained a CARhs call participant. Notable Accomplishments of CARhs from May 2012 to April 2013 7  A transfer from Ghana to Togo of Microgynon, alleviating some overstock in Ghana and reducing the duration of a stockout in Togo.  Cancellation of shipments to Guinea Bissau, Senegal, and Sierra Leone averted potential overstocks of Microlut, Microgynon, emergency contraceptives, female condoms, and Depo- Provera. The cancellation of the Depo-Provera shipment is especially notable given the shortage of Depo generally and the need to conserve supplies for countries with shortages.  Expedited shipments to Gambia, Ghana, and Togo contributed to averting stockouts of male condoms. An expedited shipment to Kenya contributed to averting stockouts of combined orals.  New shipments created benefited Sierra Leone and Togo (17 of all 22 new shipments were for these two countries), as well as Benin, Burkina Faso, and Mali. Notably, new shipments were split across seven different methods, with Depo and IUDs being most requested (in eight of the 22 shipments, four for each of these products).  Most frequent recipients of valuable information from CARhs were Cote d’Ivoire and the Democratic Republic of Congo (10 issues each). However, 27 different countries received at least one piece of valuable information from CARhs—nearly every country reporting in the PPMR. Some respondents were more reserved in their praise. While they see usefulness in CARhs, they felt that this was limited due to a number of issues, including a lack of a complete supply chain picture. For example, some respondents were interested in including forecasting information. Many key informants talked about issues around conflicting messages and different data sources. An informant from UNFPA felt that “Because it’s focusing too much on post- 7 As identified through analysis conducted by Trisha Long from USAID | DELIVER PROJECT. “A small group of people can make a difference.” - Donor 11 | Coordinated Assistance for Reproductive Health Supplies (CARhs) shipment and the problems with IT tools, there is a feeling that it’s not worth the investment. So if this is changed—address these two issues—then it’s a completely different ballgame. Now I don’t think it can give you a complete supply chain picture of what happens.” The CARhs group should consider what is realistic in terms of how much of the picture it can feasibly include. An analysis of issues addressed by CARhs from May 2012 to April 2013 provides some quantification of the group’s achievements. 8 In this period, CARhs addressed 507 issues (Table 3). Of these, 195 were closed (136 were information issues, and 59 were action issues). In the majority of cases of closed issues (80%), CARhs was seen as bringing added value to resolving the issue. For closed action issues, the most common action with CARhs added value was creating a new shipment (Table 4). For information issues, in the vast majority of cases (116 out of 136), CARhs provided valuable information, while in 12 cases information was not needed, and in only eight cases was CARhs unable to provide information. Table 3: Descriptive Statistics for CARhs Data, May 2012 to April 2013 Total number of issues (including continued issues) 507 Of total, number of stockouts (defined as 0.5 MOS* or less)** 146 (29%) Of total, number of shortages (defined as > 0.5 MOS but < 4 MOS)** 182 (36%) Of total, number of overstocks (defined as > 24 MOS)** 23 (7%) *Months of stock (MOS), **Stockout, shortage, and overstock definitions are specific to this exercise and based on how issues are flagged for CARhs agendas, as well as approximate lead times for shipments. Table 4: Description of closed action issues Total number of closed action issues 59 Actions where CARhs added value 35 New shipment created 22 Shipment expedited 4 Product transferred 1 Shipment cancelled 6 Shipment postponed 2 Other action outcomes CARhs unable to act 5 CARhs only able to provide information 7 CARhs action not needed 12 Data providers were asked to what extent CARhs meets their expectations. On a scale of one to five (from not very much, to somewhat, to very much), the average score was 3.25, or just a little better than somewhat. This somewhat lukewarm score is likely the result of many factors, including how effective CARhs is at resolving specific issues, how involved a country is, and what people’s expectations are. This again highlights the need to clarify what CARhs is and does. Respondents were then asked specifically about how their country or organization benefits by reporting to the PPMR. They provided several specific examples, including better monitoring of stock levels, receiving emergency shipments, or providing better data to global donors so that donors have a better understanding of country situations. However, it should also be noted that a 8 Trisha Long from USAID | DELIVER PROJECT conducted this valuable analysis discussed in Tables 3 and 4. 12 | Coordinated Assistance for Reproductive Health Supplies (CARhs) few respondents said that they did not see any benefit. One key informant at the country level described how she liked the online system for entering data into the PPMR as this was more efficient. However, she had experienced some problems with it and asked that the system be strengthened. “The PPMR has allowed for a better monitoring of the stock level of contraceptives at the central level. It has also allowed a better exchange of information with partners and, to a certain extent, with other countries.” - Togo “The PPMR allows countries to monitor the central level stock; the feedback contributes to strengthening knowledge in logistics.” - Burkina Faso “Primarily through enabling better access to partners, especially UNFPA, New York and Copenhagen.” - Ethiopia “It gives a chance for the global donors to understand the FP commodity situation in the country.” - Kenya “Not exactly sure how the country is benefitting. Most of the Pipeline challenges are resolved through discussion with in-country stakeholders. Some challenges (funding- related) remain unresolved even after reporting through PPMR.” - Zimbabwe 9 The survey also asked data providers to identify any specific examples of a time when CARhs helped them resolve a problem. In Nigeria, CARhs did work to ensure that UNFPA resolved issues with port clearance of contraceptives in 2009. The commodities which remained at the ports for more than a year were eventually cleared and delivered to the central contraceptives warehouse. In the Gambia, “When we almost had stockout of certain commodities, they helped us to have the commodities air-freighted.” Several respondents said they had rarely or never requested for help, and one explained that it has never been clear what CARhs does. A number of countries talked about successful provision or transfers of commodities: “The CARhs group allows the resolution of procurement problems, for example, it resolved a stockout of Jadelle in Burkina through a transfer of stock from Rwanda to Burkina in 2011. The CARhs also accelerated a shipment of Depo-Provera in 2012 from USAID, which allowed the resolution of stockouts.” - Burkina Faso “Most of the supply for Togo in 2012 relied on the CARhs. The CARhs facilitated a transfer of stock of Microgynon from Ghana to Togo in March 2012.” - Togo “From my perspective, I believe CARhs has been most effective in helping to resolve problems of supply imbalances which require provision of a platform for commodity transfers but less visible when the issue has been with challenge of aligning some shipments with country requirements. CARhs identified countries in need of a commodity we were overstocked with. As a result of the coordinated effort led by CARhs, we were able to transfer stocks to two countries who needed it.” - Ghana “The CARhs group has certainly helped us with the procurement of emergency contraception, which was stocked out due to expiry.” Senegal 9 It should be noted that Zimbabwe is in a unique situation regarding contraceptive funding. USAID cannot fund anything contraceptive and is limited to funding only condoms, which it does because these are used to prevent the spread of HIV. DFID and occasionally UNFPA provide total support for contraceptives in Zimbabwe, and because of this, CARhs is limited in how much it can act. 13 | Coordinated Assistance for Reproductive Health Supplies (CARhs) One thing that was clear in interviews is that CARhs could certainly do a better job communicating success and generally communicating about what it does. Some people mentioned occasionally hearing about CARhs in the RHSC newsletter but felt that this information had decreased in recent years. “It is a low-profile group—they have done amazing stuff and no one knows about it,” explained one respondent. When asked how this visibility could help, staff from RHSC noted that it was important to show the benefits and achievements of the RHSC. Another benefit to better external communication would be that it could facilitate data collection. A USAID key informant noted that “What is important is getting data—so advocacy with MOH, USAID, and UNFPA to give data on a regular basis is good.” A data provider mentioned the need to communicate to the benefitting countries the benefits of having CARhs. As a Burkina Faso respondent noted, “The more the CARhs group addresses the recommended actions, the more the countries will have trust in the group.” Internal communication between CARhs and data providers seems to be generally going well, with some room for improvement. Respondents to the data provider survey were asked about the clarity of communication from CARhs. On a five-point scale—ranging from poor, fair, good, very good, to excellent—respondents gave an average score of three, or good. There was higher satisfaction with the frequency of communication, with an average score of four, or somewhat satisfied. One of the providers giving a lower satisfaction score felt that sometimes communication to the country level was slow. There also seems to be minimal communication amongst countries, something that could be beneficial. For example, a key informant in Liberia mentioned how she attended a conference in Burkina Faso on PPMR and as a result was able to make arrangements with Ghana to transfer supplies, since the Liberia program had extra Microlut with expiry dates coming up and needed Microgynon. CARhs could look for more systematic ways to facilitate sharing across countries. Has CARhs been successful? CARhs has achieved a number of successes, not only in expediting or transferring shipments but also in providing useful information. There is a need, though, for better communication about its accomplishments. This will help to ensure continued participation and support and will also help clarify what the group does as a way to help align expectations and reality. GROWTH AND CHANGES Overall, there was agreement that the CARhs group needs to think strategically about growth. “It started small and has continued to grow. I’m not sure the growth has been strategic, it seems rather opportunistic,” stated a respondent at USAID. In considering ways forward, it is important to keep in mind that CARhs is not acting alone in the world to address supplies issues but is part of a whole. With this in mind, several key informants recommended that CARhs “Only do what you can do” and that the group ensures that it does not undermine its effectiveness by taking on too much and taking on issues it cannot address. A USAID key informant explained that “It was created to do one specific thing—it is not designed well to do other things. But you could replicate the model for other issues.” A representative of UNFPA cautioned fixing problems before expanding, “Before extending it, need to fix the problems. That is higher problem. If people spend 70 percent of their time getting the data right, that is a problem.” Should CARhs Do More? There has consistently been interest in having CARhs do more, an indication both of the need for it to exist and an acknowledgment of its usefulness. Any consideration of doing more—whether this be more countries, more programs, or more products—must be balanced with thoughts of what is feasible and what would be needed for CARhs to do more. It is worthwhile to look at a comment from the 2009-10 progress report: 14 | Coordinated Assistance for Reproductive Health Supplies (CARhs) “The continuing expansion of the PPMR to include more countries makes country contraceptive supply challenges ever more visible to the CARhs. The CARhs, however, is now faced with a new problem—capacity to manage all of the data. As the PPMR has doubled, so does the time required to manage CARhs processes, such as developing and synthesizing data for the agenda, providing information, and following up on issues. The requirements are now about equal to the human resources available to manage these processes. Therefore, any further expansion of the PPMR and CARhs countries will need to be strategic, until processes are automated and/or streamlined.” A USAID staff member expressed this idea: “I wish there were more countries. I wish there was more visibility into lower levels of countries supply systems. I wish there was more reporting. But you can only get what people are willing to give.” A key informant from UNFPA cautioned about getting away from the core idea of collaboration, particularly between USAID and UNFPA, an important idea to keep in mind as the RHSC has recently taken over the coordination role: “If it’s too much process-oriented, if we create a task for this and someone responsible to manage it, it misses the point that collaboration means getting people who make the decisions involved so they feel responsible for it. With all due respect to the Coalition, if they try to coordinate it, they might miss the point. I would want that someone from USAID or UNFPA take leadership, so they start to talk to each other. If it comes from somewhere else it loses focus.” Through its use of the PPMR, the number of countries included in CARhs discussions has increased. However, PPMR is seen as “a USAID tool, so it’s not the full picture.” While many seem to have this perception, the PPMR actually reports on stock brought in by all partners, not only USAID. Several respondents talked about the need to find better ways to include UNFPA data more effectively and comprehensively into CARhs. Many like the idea of adding more countries. As one country-level informant stated, “If we have more countries, there is more information on what’s going on.” Another explained that “CARhs helps us, and I believe it will help other countries if they expand.” In terms of other commodities, some people thought it would be good to include some maternal health commodities. Others pointed out that it only makes sense to have ones where the group has some control over procurement. If it is not managed by the group, it does not make sense. The majority seemed in favor of keeping a focus on contraceptives. There was a good deal of interest in developing an approach that would capture a more complete picture of the supply chain situation. A data provider from Nigeria stated that “Countries would also benefit more from CARhs if it presents a holistic picture of each country, showcasing data from all sectors managing contraceptives, including public, private, and social marketing sectors. This will enable the various sectors leverage on each others‘ stock situation.” As noted earlier, UNFPA felt that it is focusing too much on the post-ordering stage; “For UNFPA, it’s hard for us to take action post-facto—maybe include forecasting information as well as shipment information.” One donor described the ongoing high-level discussions between UNFPA and USAID looking to harmonize approaches for forecasting and placing orders and to develop common forecasting as “Trying to smooth it out—for example, if you have limited production of a product, any order placed can stop another order from happening.” While agreeing with the importance of forecasting data, a donor said some felt that “It is less important to get the forecast right, more important to be flexible to change purchase orders to adjust.” Related to the idea of having a more complete picture is the issue of how to deal with duplication of effort, such as a parallel system looking just at implants. “Are there inefficiencies? Are they working at cross purposes? When decisions are made in isolation, they can close doors to other opportunities without even knowing it. We need to look holistically.” A UNFPA key informant articulated this issue of problems arising from having 15 | Coordinated Assistance for Reproductive Health Supplies (CARhs) different information systems, which can lead to various partners having different information due to different timing and methods of measurement: “One problem is the duplication of IT systems—everyone uses different systems. It would be great if it could be one system. Could something take the lead in coordinating one global tool and have country teams report to that. Maybe this tool could be extension of PPMR. It would be good to have forecasting and shipment information to get a more complete picture. UNFPA has CCM and also CHANNEL—all of this gives a blurry picture. The idea of CARhs is very good—the devil is in the details. One detail is that there are too many IT systems. Also, a lot of time where CARhs is spending time is correcting information—this is not where they should spend time—should be on where we can take actions. The idea of coordinating and looking at problems jointly is great. But we are struggling with many systems.” An important ‘more’ is not necessarily about having more data, more countries, or more products but in doing more with the data and information that CARhs has. As one respondent noted: “I do think it would be potentially a good investment to get an analyst, something going through a lot of the actual data to see what we can actually learn from it. What are the problems, the root causes, and recommendations for solutions going forward so we don’t keep doing the same thing? There is no standing back and learning from it. No one has time for this.” Should CARhs do more? There has consistently been interest in adding more countries, an indication of the usefulness of CARhs. Most people feel that the focus should remain on contraceptives but that groups working on other commodities could learn from CARhs. Many respondents expressed interest in capturing more of the complete supply chain picture, including forecasting information. There was a good deal of interest in doing more with the data that CARhs has in order to better address supply chain issues. Should CARhs Address Broader Systems Issues? As mentioned earlier, the idea of CARhs addressing broader systems issues arose as early as the first CARhs progress report in 2005 to 2006. This is a case of where looking back is informative. There was an effort to create a mechanism to do just this, but it did not work. However, it helps point the way toward others approaches. In November 2010, the RHSC Systems Strengthening Working Group (SSWG) recommended to the RHSC Executive Committee (EC) that the EC serve as a CARhs policy group. In discussing the need for this, it was explained that CARhs acts primarily on issues that can be resolved through management of USAID and UNFPA shipments, because of both the technical representation it includes and the processes it has developed for working. CARhs regularly becomes aware of country policy issues that negatively impact RH commodity security in country, but CARhs is poorly positioned to influence those policies. The idea was to have the CARhs group recommend such countries to the RHSC EC for action, providing clear documentation of the challenge and possible solutions. The first test case was Kenya, and a brief was prepared and given to the EC. But nothing happened. Six months later, the EC never acted on it; “It landed with a thud.” In retrospect, this was not surprising, since this is not a group that engages at the operational level. The idea is not seen as a failure, but respondents suggested some changes, particularly to whom the information was brought. “CARhs isn’t set up to do anything with systems. It’s a bunch of people managing shipments, not policy influencers. I’m not sure CARhs is the place to do that. We can identify issues and have others take action—maybe find another group to take action.” 16 | Coordinated Assistance for Reproductive Health Supplies (CARhs) The idea of having CARhs do more analysis and feed that into decision-making was mentioned by several respondents. A USAID key informant explained, “It’s clear that visibility that CARhs has from PPMR from addressing country-level problems—that experience can be extremely useful to those working on systems strengthening, for example, if there are systematic problems that result in repeat offenders.” One donor respondent even started by saying, “I don't see CARhs having a role in longer-term strategic planning—traditionally it’s dealt with short-term issues,” but then later stated that “Waving a red flag—no reason that CARhs shouldn’t bring issues to the larger community’s attention. That is worthwhile.” The question is to whom does CARhs bring that information: “The Executive Committee wasn't a systems strengthening bunch of people—there are others that do that—how do you get that knowledge to the right people? How do you bring more operational people together and show them analysis from CARhs data? CARhs could play a role in synthesizing information for systems strengthening. What this all boils down to is reducing the number of fires they have to deal with. If the fire department goes to the same building multiple times, you have to go in there and look at the wiring, whether things are up to code, etc.” - USAID A UNFPA respondent supported this idea: “Yes, it should be channeled to people dealing with whole supply management issues at country level. That piece is missing, because we get too involved in global level. It’s simply a question of getting together and having coffee.” Another specific idea that arose early on, and remains an issue today, is having CARhs help address quality assurance testing requirements. This was noted in a CARhs progress report: New post-shipment quality assurance testing requirements—sometimes imposed by countries without adequate planning, sufficient notice, or financing in place—are creating new potential chokepoints in country supply chains. To what extent can (or should) donors and funders develop a common approach to this growing trend? This also came up in the October CARhs call. Should CARhs be addressing broader systems issues? There was generally agreement that while this was beyond the regular mandate of CARhs, it would make sense to use the information that CARhs has to help inform broader efforts. When this was tried previously, the problem was not with the concept but with the process. Specifically, the CARhs group would need to identify the most appropriate people to whom to channel information on broader systems issues. Should CARhs be Preventing as well as Reacting? In both the data provider survey and the in-depth interviews with key informants, respondents were asked about the characterization of CARhs as responding to crises rather than preventing them and whether CARhs had a role to play in preventing supply issues. Interestingly, a number of people disagreed with this characterization. A USAID key informant explained: “My vision of what CARhs was supposed to do—we were looking at all countries and seeing when stock at central level was getting below certain levels—that’s when we would start to act. We weren’t exclusively looking at what stockout occurred. Because it’s presented as a way to deal with stockouts—that’s why people perceive it that way.” A data provider from Ethiopia also questioned the characterization: “Not sure I agree with the characterization—appropriate role is sharing information, making sure information is acted upon by global AND country stakeholders, increasing accountability and transparency.” This again points to the need to better clarify what CARhs is and does. 17 | Coordinated Assistance for Reproductive Health Supplies (CARhs) Other data providers gave input on the role of CARhs, emphasizing building on its strategic and stockout prevention role: “The CARhs should play a more strategic role. It should identify countries that have serious supply problems with very frequent stockouts and propose a specific contraceptive procurement support for these countries. Only countries that have temporary procurement difficulties should use the Early Warning System. It is only when countries that have insufficient contraceptive security have improved their procurement system that they should participate in the Early Warning System as it exists today. This will avoid transforming a stop gap mechanism to a routine procurement mechanism.” - Togo “The CARhs should monitor each country/ organization’s reports and using the data, help to forestall stockout situations by providing donors with information regarding the stock situation in different countries to guide their donations/ procurements.” - Nigeria “The CARhs can contribute to preventing procurement problems; it should improve its collaboration with donor country representatives in order to respect the supply plans of the countries.” - Burkina Faso “Supply issues may arise due to wrong estimations, procurement planning challenges, differences in funding budget cycles, manufacturer challenges. I think an appropriate role for CARhs members with regards to prevention, will be to 1) increase coordination on annual orders and 2) improve coordination by continuing to advocate for increased flexibility among members to be able to adjust shipments to align with supply plans.” - Ghana Should CARhs be preventing as well as reacting? A. Many felt that stating that CARhs did not deal with preventing supply crises was a misinterpretation of what CARhs does and how it operates, calling attention again to the need to clarify and communicate what CARhs is and does. Should CARhs Have its Own Resources? Opinions from key informants were mixed regarding the idea of CARhs having its own resources. This is not a new issue for CARhs. The 2006-07 progress report noted the following: CARhs “is only partially successful in effecting short-term solutions to supply shortages. The firefighting metaphor is a useful one. Sometimes, [CARhs] is akin to firefighters arriving at a fire, only to find themselves with no water. Sometimes, the discussion is more about why the fire detectors failed, then about putting out the fire. There should be a discussion, after two year’s of experience, on whether [CARhs] should have available funding and/or supplies to better and more flexibly address shortages.” This was tried in 2011. In late 2011, DFID provided funds to CARhs, although in practical terms, this meant the money went to UNFPA. In arguing for the importance of these funds, a 2011 note stated the following: “In 2010, the CARhs successfully responded to 68 percent, or two-thirds, of the stock shortages or overstocks reported to it. The CARhs facilitated 19 new shipments to countries, totaling more than $8 million. An additional $3.5 million would have allowed the CARhs to respond to the remaining one-third of stock crises that were reported to it.” 18 | Coordinated Assistance for Reproductive Health Supplies (CARhs) In the end, the effort was seen as not successful. The money had to be spent by March 2012, so UNFPA ended up absorbing it. The mixed feelings about this issue highlight the complexity of what it would mean for CARhs to have its own resources. While there is an intuitive appeal to the idea, since it could theoretically enable CARhs to respond more efficiently to emergencies, actually making it happen would be complicated. Responses below give examples of respondents who said yes, who said no, and who said maybe. YES: “If CARhs had a storehouse, they could supply and then later UNFPA could refill— maybe we could have a warehouse.” - Country informant YES: “Core funds would be helpful, you just would need clear criteria for when to use it.” - USAID NO: “If you have resources, you have to have management capacity; do you want CARhs to have its own warehouse? You have partners who do these things, so it isn’t CARhs’ comparative advantage to do that. Don’t want a new RHSC warehouse project.” - Donor NO: “I wouldn’t have done that. CARhs doesn’t need a budget—it should work with its partners. AccessRH, which has products, ought to be able to provide commodities for emergencies because of inventory system. We need to be careful that existence of a fund doesn’t act as an incentive to not manage the stock well to avoid stockouts.” - Donor NO: “That is going beyond the principle of CARhs, and I wouldn’t support that.” - UNFPA MAYBE: “There will always be need for fire department, and they ought to have water to put out the fires, but it’s an interesting question now, because to what extent are they without water? Even if CARhs had its own funds or a warehouse full of stuff, you want the water in the hose and ready to go; if CARhs only had money, they would still have to buy product. Maybe you get money and use it to stock a warehouse, then that would all have to be managed. There are a lot of issues around that, and someone would have to take these issues on with transparency. Who are the priorities, what do you do if warehouse is empty? Lots of questions which have kept people from taking on this issue in a serious way. It needs to be talked about in larger framework—near-term and long-term, balance of global CARhs and strengthening country ownership. A global level warehouse would take money, and there would be opportunity costs.” - USAID Interestingly, the lines are somewhat blurred regarding this issue. One person talked about using CARhs funds, although when probed, this seemed to refer to UNFPA resources. Once again, this is linked to the lack of clarity about what exactly CARhs is. Should CARhs have its own resources? There were mixed feelings about this question and also a lack of clarity about what it would mean exactly for CARhs to have resources rather than drawing upon the already existing resources of UNFPA and USAID. While there is an intuitive appeal to the idea of CARhs having an emergency fund of some kind, the reality of putting such a fund in place is complicated. Should CARhs Change its Approach to Country Engagement? The issue of country engagement has been challenging for CARhs. Participants in the group spoke about how there had been some tension in the past when countries were not happy that a small group of donors were talking about them behind their backs. The idea of involving countries in CARhs calls was seen as problematic, since it might be uncomfortable for countries, 19 | Coordinated Assistance for Reproductive Health Supplies (CARhs) as well as donors, to talk openly about their situations in such a public way. Several people also pointed out that the value of CARhs comes from the fact that a limited number of donors can take action, so these are the key players to involve. In discussing this issue, many respondents talked about the ongoing need to strengthen country capacity and ownership, in order to have fewer issues reach the level of the CARhs group. A data provider from Sierra Leone suggested that CARhs strengthen country team members by intensifying periodic supportive supervision and on the job training. One donor stated, “I thought that [country engagement] was happening. One of our concerns is that when donors do procurement, countries don’t take the driver’s seat.” A key informant from USAID described the importance of balancing the need for a global entity while simultaneously strengthening country- level efforts and structures: “There will always be a need for a fire department. But to what extent is CARhs compensating for the lack of what should be effective fire-fighting at the country level? It is a global analog for a country-level coordinating committee. For the time being, things are what they are, but how do we acknowledge need for global CARhs while more deliberately transitioning that capacity in fire-fighting to the country level? Would there still be need for global CARhs? Sharing across countries—that is something that truly only global CARhs can do now and possibly forever—they have that higher-level cross-country visibility.” Data providers were asked about whether CARhs should engage decision-makers in the country more. There were mixed responses. Some called for greater engagement, while some said no, it was already satisfactory. In the case of the latter, instead such engagement should be through respective partners: “Ideally, this should work through respective partners, e.g. UNFPA on CARhs to UNFPA Ethiopia. CARHs should not engage directly with FMOH.” - Ethiopia “The present level of engagement is appropriate from my perspective. I believe that CARhs is rightly situated as a very high-level global group. My suggestion is that the CARhs members further engage their in-country representatives so that they also understand the issues better.” - Ghana “Higher-level engagement with the MOH through the in-country offices. I think the global donors need to have better communication with their in-country offices so that they can be on the same track. It seems sometimes the global donors through the CARhs know more about Kenya's supply plan than the in-country donors.” - Kenya Nigeria saw a need for increased engagement: The project has been supporting the Federal Ministry of Health to improve their data management practices as well as ownership of their data. CARhs could engage the Government of Nigeria to improve their data management skills by highlighting the benefits of data visibility. A data provider from Sierra Leone felt that the engagement should be in the form of advocacy for resource mobilization to maintain an effective supply chain Should CARhs change its approach to country engagement? There were various responses regarding whether there was a need to increase country engagement. In discussing this issue, several respondents emphasized the importance of building country-level capacity while still acknowledging the need for a global entity. “Ultimately, responsibility needs to exist at country level. In a perfect world, CARhs would not need to exist, but the world is not perfect.” - Ethiopia 20 | Coordinated Assistance for Reproductive Health Supplies (CARhs) Conclusions CARhs can greatly benefit from stepping back and taking stock as it plans for its future. Input from key informants and data providers provides useful guidance as CARhs conducts its strategic planning. It is clear from the responses that an important first step will be to:  Clarify and communicate the purpose and achievements of CARhs. While there is generally a fairly consistent idea of what CARhs is and does, there are important differences in the details. This is an opportune moment to create an agreed-upon description of CARhs and its purpose and use that to raise awareness. That will be important to ensure that expectations about what the group can do match the reality of what it aims to do. Communicating more about the success of CARhs can help in getting and maintaining donor support and can strengthen data collection efforts if CARhs is more widely seen as something worthwhile and important at the country level. Some people mentioned the idea of re-naming CARhs. With the previous name change from CAR to CARhs, there was a desire to maintain a similar sounding acronym, so it would be necessary to weigh the pros and cons of a name change. In addition there are a number of operational questions for CARhs to consider. It is interesting to see that many of these questions have arisen throughout the history of CARhs, and so it is helpful to review what has been tried, and either succeeded or failed, in the past to inform future efforts. 1. Should CARhs do more? The CARhs group has faced this issue throughout its history and has always tried to balance the desire to do more with the need to be able to do this feasibly. Generally there is a feeling that CARhs should find ways to add more countries, but there was much less support for the idea of adding more products. There was a good deal of interest in creating a more complete picture of the commodity situation in-country, possibly by including forecasting information and by somehow unifying various data systems (e.g. PPMR and CCM). In cost-benefit calculations, CARhs should consider how to reduce costs by streamlining or by possibly providing funding to cover costs and increase benefits by increasing communication of what CARhs does and by using data to help inform larger supplies system improvement efforts. There was widespread agreement about doing more with the data at hand to inform systems strengthening efforts. 2. Should CARhs address larger systems issues? CARhs is a tremendous source of information, through both the PPMR and the knowledgeable staff involved in the group, and there are many additional ways that this can be tapped to be of more use. The group should consider identifying funding to support staff or staff time to conduct further analysis and package analysis in a user-friendly manner. This staff member could be based at UNFPA, USAID, and/or the RHSC. Most importantly, CARhs would need to identify an effective way to communicate this information and the appropriate recipients of such information. Previous efforts to channel this information through the Executive Committee of the RHSC were not fruitful, but respondents did not see this as meaning that the effort was not worthwhile— merely that it could be done in a more effective manner. 3. Should CARhs be both preventing AND reacting to problems? Seemingly, part of the perception of CARhs being purely reactive is linked to it being strongly defined as dealing with stockouts, rather than seeing its broader role in helping to monitor stock levels. This is a clear example of how clarifying what CARhs does will help address this misperception. 4. Should CARhs have its own resources? This issue raised the most diverse responses, with fairly strong opinions in each direction. It too is linked to the notion of clarifying just what CARhs is. In the end, there is an appeal to the idea of having more flexible resources to use 21 | Coordinated Assistance for Reproductive Health Supplies (CARhs) to respond to situations, but it is unclear whether there is a need for a separate budget or structure, which comes with a number of complications, or a way to work more effectively with the existing systems of UNFPA, USAID, and others. Again, this is a question that has been addressed in the past, and there was a specific effort in 2012 to obtain funding from DFID for CARhs. This was not seen as successful, in that the money had a short timeframe in which to be spent and so had to be absorbed by UNFPA, the recipient of the funding. At that time, an analysis was done that showed that additional funds could have allowed CARhs to address the unresolved issues. Conducting a similar analysis again could be worthwhile. It was interesting to note that in the interviews there was some confusion about this funding, given the blurred lines of what specifically CARhs is funding and what USAID or UNFPA are funding. In the end, there is a need for more discussion as a group about this issue. 5. Should CARhs change its approach to country engagement? There will be a need for a global CARhs group for the foreseeable future, but this should not in any way take away from building country capacity and ownership. A question to consider is what, if any, role does CARhs have in building capacity at the country level. But even if this country capacity is significantly improved, CARhs does have a unique global perspective that allows for cross- country transfers and sharing. CARhs can also help facilitate countries engaging directly with each other, as was done in a PPMR training. CARhs is a successful example of the power of partnership. Addressing the questions discussed above can help it operate even more effectively and efficiently. As it moves forward, it can build upon its strengths and successes to continue to meet the important goal of reducing stockouts and thereby improving access to reproductive health commodities for women around the world. 22 | Coordinated Assistance for Reproductive Health Supplies (CARhs) Appendix 1. List of Stakeholder Interviews Name Organization Mark Rilling USAID Alan Bornbusch USAID Kevin Pilz USAID Jagdish Upadhyay UNFPA – CSB Eric Dupont UNFPA – PSB Nel Druce DFID David Sarley Bill & Melinda Gates Foundation John Skibiak RHSC Cyrille Massamba Matumona MSH DRC Minnie Sirtor-Bowier DELIVER Liberia Woinshet Nigatu DELIVER Ethiopia 23 | Coordinated Assistance for Reproductive Health Supplies (CARhs) Appendix 2. Question Guide for Key Informants Introduction: Started in 2005, the Coordinated Assistance for Reproductive health supplies (CARhs) group brings together representatives of the world’s key commodity suppliers to address the short-term supply crises that periodically befall countries. Given the growth in CARhs membership, the evolution of its actions over time, the new global efforts underway—such as the Implants Access Initiative—and other emerging global challenges, it was decided that this was an opportune time to conduct a strategic planning exercise for CARhs. The goal of the exercise is to provide a strong strategic foundation, which addresses the key questions confronting the group and prepares it to face future challenges, to guide CARhs operations going forward. This process will include assessing internal operations as well as external positioning. Interviews with members and other stakeholders will help us understand perceptions and expectations of the CARhs within the RH supplies community, identify possible new areas of activity, and determine the strategic direction for CARhs going forward. 1. How have you been involved with CARhs? 2. What do you think is the purpose of CARhs? And from what you know of CARhs, would you say it has been successful in achieving this goal? Why/why not? 3. Do you know of any recent achievements or successes attributed to CARHs? If so, what were they and, from your perspective, why were they important? How did you learn about these achievements? 4. There is talk about CARhs doing more of what has brought it success in the past: more participants feeding in supply data, more countries benefitting, and more product stocks being tracked. Are you aware of any of these discussions and, if so, what are your thoughts? 5. What do you think are some critical problem areas in the supplies area (that broadly relate to kinds of issues the CARhs has dealt with in the past)? Do you think there is any value in having CARhs engaged in these issues? If so, how would you suggest CARhs engage in these issues? 6. CARhs neither manages nor controls any resources on its own. It operates by either advancing or reallocating supplies already purchased by the key donors on CARhs. Clearly this limits what CARhs can and cannot do. Does this arrangement fit what you feel ought to be the aims of the group? What is your view on the possibility of CARHs having resources it could utilize to address stockouts? 7. CARhs has often been characterized as reactive, rather than preventive in nature. It has been a tool to respond to crises after they have arisen rather than playing a preventive role. In your view, is that okay? Should CARhs do more to prevent crises from happening? What might it do? 8. Should CARhs engage countries in a more direct manner? If so, what form should this engagement take? 9. What other activities should CARhs be engaged in going forward? 10. What else would you like us to know? 24 | Coordinated Assistance for Reproductive Health Supplies (CARhs) Appendix 3. Data Provider Survey Procurement Planning and Monitoring Report Survey of Data Providers August 2013 1. How would you describe the purpose of CARhs? 2. To what extent does the CARhs meet your expectations? 1 2 3 4 5 Not at all Somewhat Completely 3. How would you rate the clarity of communication with the CARhs members? 1 2 3 4 5 Poor Fair Good Very good Excellent 4. How would you describe the frequency of communication with the CARhs? 1 2 3 4 5 Poor Fair Good Very good Excellent 5. How does your country or organization benefit from reporting in the PPMR? 6. What role does the CARhs play in the global contraceptive supply chain? 7. Can/should the CARhs engage in your country more? If so, what form should this engagement take? 8. What is the appropriate role for the CARhs members in terms of preventing supply issues from rising to the level of the CARhs via the PPMR? 9. Do you find the CARhs is capable of resolving your problems you request help with? Why/why not? 10. How would you improve the function of the CARhs?

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