Coordinated Assistance for Reproductive Health Supplies Group Progress Report: October 2009 - September 2010

Publication date: 2010

1 Coordinated Assistance for Reproductive Health Supplies Group Progress Report: October 2009 – September 2010 The Coordinated Assistance for Reproductive Health Supplies Group (CARhs, formerly “Countries-At-Risk”) group was established in December 2004. Its first meeting took place in January 2005. The CARhs meets monthly as a forum where key global-level partners for the funding and procurement of contraceptives and condoms share information to identify countries in, or on the verge of, reproductive health supply shortages. The goals of the CARhs group are to understand the causes of these shortages, to identify solutions, and to coordinate the implementation of required actions. The CARhs’s focus is on contraceptives. Since 2007, the CARhs has mainly used the monthly “Procurement Planning and Monitoring Report” (PPMR), developed and produced by USAID and the USAID | DELIVER PROJECT, as its main source of data. The PPMR provides information on contraceptive stock status, incoming supply shipments, and other issues pertinent to contraceptive security. As of September 2010, the PPMR provided data on 21 countries (ASIA: Bangladesh, Nepal; AFRICA: Ethiopia, Ghana, Kenya, Liberia, Malawi, Mali, Mozambique, Nigeria, Rwanda, Senegal, Tanzania, Uganda, Zambia, Zimbabwe; LATIN AMERICA: Dominican Republic, El Sa lvador, Haiti, Nicaragua, Paraguay). While improving the CARhs’s visibility of current or impending stock shortages, the PPMR also allows country program managers to request updated shipment information and actions directly from donors. CARhs uses several sources of shipment data, including the Reproductive Health Interchange, UNFPA’s Order Tracking System, and USAID’s “My Commodities” database. With this information, the CARhs also serves the function of providing information regarding impending shipments to country officers. This function improves local information for stock management and has helped avert stock shortages several times (e.g., when countries expect an order not in the donor’s order tracking system). This added function has obliged the CARhs to work through electronic means as well as teleconference, for the efficient sharing of information. The CARhs still encourages and responds to anecdotal reports of stock emergencies as well, to broaden its coverage across developing countries. This report reviews the CARhs’s actions for the period October 2009 through September 2010, using indicators that CARhs members revised and adopted in January 2010 to monitor CARhs activities. Therefore, some of the indicators measure the period October 2009 – September 2010, while others measure January 2010 – September 2010. The PPMR database has been modified to capture and track information on CARhs indicators for PPMR countries. This has led to a much greater capacity to quantify the impact, and lack of impact, of the CARhs. The group officially changed its name from the “Countries-At-Risk” (CAR) Group to the “Coordinated Assistance for Reproductive Health Supplies” Group (acronym: CARhs) in May 2010. The new name was chosen as it was considered to better reflect the broader mandate of the group, and because of some reports that countries don’t want to be identified as “at risk”. A. CARhs Process Indicators 1. Number of meetings held: 2 Twelve monthly meetings were held between October 2009 and September 2010. This translates into a meeting “rate” of 100%, matching the high standard set in 2008-9. The structure and format of the CARhs meetings allow efficient and effective information and problem solving, meetings are typically 60-70 minutes and deal with 5-10 stock issues (i.e., the CARhs spends less than 10 minutes per stock issue typically). 2. Number of organizations and individuals participating per meeting: Since September 2009, the “core” members of the CARhs have been UNFPA’s Commodity Management Branch, UNFPA’s Procurement Services Branch, USAID, the RH Interchange Secretariat, and the USAID | DELIVER Project. Non-core members, who participate on an ad hoc basis according to need, included the World Bank, KfW, the UN Foundation (Pledge Guarantee for Health staff), the RHSC Secretariat, and Marie Stopes International. KfW was unable to participate in any CARhs meeting which hampered CARhs effectiveness in some cases, though it did provide information for several CARhs items. Three of five core organizations attended 100% of meetings, two attended 75% of meetings; overall attendance of core organizations at CARhs meetings was 90%. This is certainly the highest attendance by core organizations in the history of the CARhs. The World Bank and the RHSC Secretariat have been particularly regular and effective non-core members. Number of Organizations Participating per Meeting Number of Individuals Participating per Meeting Range: 4 – 8 Average: 6.1 Range: 6 – 12 Average: 8.9 3. Number of country representatives (guests) participating in CARhs calls: This indicator serves to encourage the CARhs to invite country level representatives (‘guests’) to participate in regular or ad hoc CARhs calls. The country representatives will be invited to address recurrent or extended stock crises where the CARhs is unable to identify solutions. Inviting country representatives is also expected to raise awareness of the CARhs and broaden participation in the Coalition. Two guests were invited to participate in the CARhs, and both accepted the invitation: Mike Mushi, of USAID/Tanzania, and Tim Manchester of USAID/Tanzania. Both discussed significant contraceptive financing issues facing the government of Tanzania. CARhs has not yet developed a process or strategy for identifying when to invite country-level guests and who to invite. Thus far, invitations have been opportunistic. This explains the poor representation of countries and organizations as guests of CARhs. 4. Number of action and information items: This indicator is meant to provide information on need for the CARhs. It quantifies the number of items per month where the CARhs seeks to take action or to provide information either in response to a direct request from the country (typically communicated through the PPMR) or because a CARhs member notes a country commodity issue which may require attention. The CARhs dealt with (to conclusion) a total of 184 distinct commodity issues between October of 2009 and September of 2010, of which approximately 103 required CARhs action 3 (the remaining requiring information). Almost all of these issues came from the countries reporting in the PPMR. As many of these issues span multiple CARhs sessions, the CARhs concluded work on an average of 9.4 issues for action and 7.4 issues for information per month. The total number of action issues concluded per month ranged from 6 to 15. B. CARhs Effectiveness Indicators 5. Number of issues resolved through CARhs action: Between January 2010 and September 2010, 102 issues requesting or requiring CARhs action were finalized (i.e., the CARhs either provided assistance or determined that it could not assist). For 28 issues, CARhs action was not needed in the end. For the remaining 74 issues, the CARhs took action which helped resolve the specific problem in 47 cases (64%). In 16 cases, the CARhs was unable to assist. In 9 cases, the CARhs provided relevant information but was unable to take action to resolve the stock situation. A full breakdown of CARhs action, by situation, is provided below. Most action issues facing the CARhs were for averting future stockouts (meaning the issue came to CARhs’ attention and was concluded when stock levels were below minimum levels but not stocked out). For these cases, CARhs successfully took action in 26 of 40 issues (65%) requiring action. When stockouts occurred, CARhs was only able to take beneficial action in 6 out of 14 cases (43%). CARhs is most successful at taking action to deal with existing overstocks (11 of 16 cases, 69%; typically delaying or cancelling future shipments). Action outcomes Existing Stockouts Avert Future Stockouts Existing Overstocks Other (stocks btw max/min) Action Outcome Totals CARhs action not needed 4 15 8 1 28 CARhs unable to act 2 9 5 0 16 CARhs only able to provide info 6 3 0 0 9 CARhs took action that did not add value 0 2 0 0 2 CARhs took action that added value 6 26 11 4 47 Issue Type Totals 18 55 24 5 102 6. Modes of CARhs Action The CARhs can take various different kinds of actions to assist countries maintain appropriate stock levels. Most of these are related to modifying existing shipments (expediting, postponing or canceling), but CARhs can also identify funding for new shipments and can provide policy advice or technical assistance. The below table shows that the value that CARhs most often implements to assist countries is creating new shipments or expediting existing shipments. The ability of CARhs to identify new funds for additional shipment is a positive sign for an area that has been a challenge for the CARhs in previous years. 4 7. Number of issues where CARhs provided relevant information: Between January 2010 and September 2010, 80 issues requested or required shipping or commodity information from the CARhs (an average of 8.8 cases per month). In 78 of these cases, the CARhs provided some relevant information. In only 2 cases was the CARhs unable to provide relevant information. Information Outcomes Existing Stockouts Avert Future Stockouts Existing Overstocks Other (stocks btw max/min) Information Outcome Totals CARhs provided valuable information 25 41 2 10 78 CARhs information not needed 0 0 0 0 0 CARhs unable to provide valuable info 0 2 0 0 2 Issue Type Totals 25 43 2 10 80 8. Number of months taken to avert short-term crisis: Of the 49 issues between January 2010 and September 2010 where CARhs action helped to resolve a short-term crisis, the average duration until resolution was 2 months, with a range from 1 to 7. Duration until resolution is reached tends to be longer when the crisis requires identifying or facilitating funds for new shipments of commodities. CARhs action tends to be quick when the crisis merely requires canceling, delaying, or expediting existing shipments. 9. Countries where a commodity security policy discussion initiated as a result of CARhs action: The number of policy discussions initiated as a result of CARhs action is difficult to track. The CARhs is regularly providing policy advice where donors and governments have partnerships for the financing and procurement of contraceptives (e.g., where the government or a donor does the procurement using funds from another donor). The coordination required between the funder, the country government, and (when utilized) a third party procurement agent is often sub-optimal; there is often not clarity about what steps have been undertaken, what are needed, and what remains to be done. In such cases, the CARhs regularly helps identify and share information among relevant parties through its global coordination mechanism. In at least two cases, this has helped resolve contraceptive shortages. For example, in the case of Kenya, the CARhs provided advice to country partners on needed steps to ensure release of World Bank funds and to ensure that appropriate quantities of product were procured. Possible actions that added value Total % of Total New Shipment 15 32% Expedited Shipment 17 36% Postponed Shipment 8 17% Canceled Shipment 4 9% Technical Assistance 0 0% Provided Policy Advice 3 6% Total 47 100% 5 C. Vulnerable Product and Country Indicators 10. Products most cited for stock outs: The table below shows number and frequency of monthly instances of stockouts reported in the PPMR, across all countries, between October 2009 and September 2010. As shown in the figure, female condoms and progestin-only pills were most prone to stockout, where as emergency contraception and combined oral pills were least likely to stockout. The high rate of stockout of injectables is particularly concerning because this is a widely used method, and the most popular in many countries. Product Name # of Months with Stockout Total # of Records for Product As % of All Records for this Product Female Condom 14 51 27% Injectables 25 143 17% Progestin-only Pills 9 64 14% Implants 9 77 12% Male Condoms 16 145 11% CT380A IUD 11 131 8% Cycle Beads 1 15 7% All Combined Oral Pills 4 128 3% 11. Causes of supply problems (CARhs does not systematically collect information on causes of stockouts, so these are anecdotal examples without prioritization): • Failures or delays in national tendering processes; • Delays due to donor-government coordination for donor-funded procurement; • Lack of procurement planning and monitoring, and insufficient lead time for procurements; • Production issues affecting ability of donor to provide supplies in a timely manner; • Shipment delays due to climactic conditions, shipping/route changes, or customs clearance of supplies; • Demand exceeding forecasts; • Funds not available in a timely way for procurement, sometimes due to reduced revenue (e.g., due to the financial crisis) or political disagreements. 12. Number of countries with reoccurring short-term crisis: The table below reflects reports of countries where specific products faced stock shortages (stock levels at or below 2 months of stock) in more than one PPMR, between October of 2009 and September of 2010, and where CARhs action or information was requested or required for those issues. In both Kenya and Ghana, six contraceptive methods provided by the public sector faced multiple or recurrent stock crises. In Kenya, these products were at low stock levels for an average of 5 months, whereas in Ghana the average was 3.5 months. In seven countries, two or more products faced stock crises for multiple months of the PPMR – Bangladesh, Ghana. Kenya, Liberia, Mali, Mozambique, Tanzania. For other countries reporting in the PPMR, no more than one product faced recurrent stock shortages. 6 Country Name Product Name # months </= 2 MOS Program Name Bangladesh CT380A IUD 3 Ministry of Health Bangladesh Implanon 3 Ministry of Health Dominican Republic Depo-Provera 2 Ministry of Health Ghana DMPA 5 EXP Social Marketing Ghana 3-month Injectable 3 Ministry of Health Ghana CT380A IUD 3 Ministry of Health Ghana Depo-Provera 6 Ministry of Health Ghana Jadelle 2 Ministry of Health Ghana Micronor 2 Ministry of Health Ghana Norigynon 4 Ministry of Health Kenya All Implants 4 Ministry of Health Kenya All Injectables 3 Ministry of Health Kenya CT380A IUD 5 Ministry of Health Kenya Female Condom 7 Ministry of Health Kenya Male Condom-No Logo 8 Ministry of Health Kenya Progestin-only Pills 3 Ministry of Health Liberia Depo-Provera 4 Ministry of Health Liberia Male Condom-No Logo 2 Ministry of Health Mali All Implants 2 Ministry of Health Mali CT380A IUD 2 Ministry of Health Mali Male Condom-No Logo 3 Ministry of Health Mali Neo-Sampoon 2 Ministry of Health Mozambique Microgynon 6 Ministry of Health Mozambique Microlut 2 Ministry of Health Nicaragua Depo-Provera 3 Ministry of Health Senegal Depo-Provera 2 Ministry of Health Tanzania All Injectables 2 Ministry of Health Tanzania Implanon 3 Ministry of Health Tanzania Progestin-only Pills 2 Ministry of Health Tanzania Implanon 2 Ministry of Health - Zanzibar Tanzania Progestin-only Pills 2 Ministry of Health - Zanzibar Uganda Male Condom-No Logo 3 Ministry of Health Zambia Female Condom 2 Ministry of Health D. Additional Observations • 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 (see below). • USAID has now acted as the Secretariat for CARhs since May of 2008, surpassing the two year term that is typical for CARhs Secretariat duties (UNFPA Jan 2005 - Dec 2006; RHSC Secretariat Jan 2007 - April 2008). Within the next year CARhs should start 7 identifying a new secretariat organization. Streamlining CARhs processes will be crucial to that transition as well, so that the new Secretariat agency isn’t overwhelmed by level of effort required. • In November, 2010 the RHSC SSWG recommended to the RHSC Executive Committee (EC) that the EC serve as a CARhs policy group. The CARhs acts primarily on issues that can be resolved through management of USAID and UNFPA shipments, both because of the technical representation it includes and the processes it has developed for working. The CARhs regularly becomes aware of country policy issues that negatively impact RH commodity security in country, but the CARhs is poorly positioned to influence those policies. In the future, the CARhs will recommend such countries to the RHSC Executive Committee for action, providing clear documentation of the challenge and possible solutions. • The CARhs continued this year to modify the indicators that it uses to track progress. The CARhs further defined how to classify CARhs actions as successful or not, and added a classification of the type of actions CARhs takes. USAID and JSI are documenting these processes and definitions through a series of SOWs to also add to the long term sustainability and continuity of the CARhs. • Collaboration between USAID and UNFPA in decisions on commodity support for countries continues to grow at the country level, and holds promise to improve rationality in country supply pipelines (e.g., by decreasing the possibility of overstocks that result from duplicate USAID and UNFPA shipments). • While the CARhs is having good success addressing contraceptive stock issues, this comes at significant investment of human resources from the member organizations. Recurring CARhs activities (extracting data from the PPMR to develop the agenda, collecting relevant shipment data, holding CARhs teleconferences, follow-up on CARhs items, and sharing CARhs decisions/actions/information with countries) require about 10 total person-days of effort per month. There is a need to build stronger in-country coordination units who are addressing these issues from the country level and an issue that the executive committee of the RHSC may want to potentially address. It may also be time to review the model that s being used which has been successful to date but with significant investment of the contributing core institutions. • UNFPA’s access to a commodity security fund through the Global Programme for Reproductive Health Commodity Security has enabled CARhs to be extremely successful in addressing stockouts; such a mechanism is critical to addressing stockouts. E. Potential Areas for Improvement Expand Available Supplies Data ���� Increase Information Sources Available to the CARhs. Anecdotal reports about stockouts to the CARhs seem to have decreased since the PPMR has become the primary data source. However, CARhs members should still encourage anecdotal reports as, currently, the only means of learning about and responding to stock issues in countries not in the PPMR. Additional sources of regular, quantitative data – such as UNFPA 8 Country Commodity Manager (CCM) reports – would be extremely useful as a means of expanding the number of countries covered and as a check on PPMR data. Improve Ability to Act ���� Assure Involvement of Key Stakeholders. The limited range of donors active in the CARhs means that the CARhs can typically only provide additional product/shipments for issues where USAID or UNFPA can respond. The World Bank is also a regular participant and provides useful information to the CARhs, as well as assisting in facilitating the use of World Bank funds for contraceptive procurement. Other donors are absent from the CARhs. 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. Streamline Processes ���� Automation of CARhs Administration. The process of collecting, analyzing and synthesizing data from the PPMR, RHI, and CARhs members remains mostly manual. Significant reductions in level of effort required for managing CARhs processes would be made by automating the creation of a draft CARhs agenda (e.g., gathering items from the PPMR based on certain criteria, and adding RHI information) and by automating the capture of CARhs notes – all of this could be managed by an improved CARhs-PPMR database. USAID hopes to fund some such improvements in the coming year.

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