Coordinated Assistance for Reproductive Health Supplies Group Progress Report: October 2010 – September 2011

Publication date: 2011

1 Coordinated Assistance for Reproductive Health Supplies Group Progress Report: October 2010 – September 2011 The Coordinated Assistance for Reproductive Health Supplies Group (CARhs, formerly “Countries-At-Risk”) group was established in December 2004. Its first meeting took place on 16 December 2004. 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 2011, the PPMR provided data on the following countries (ASIA: Afghanistan, Bangladesh, Nepal; AFRICA: Democratic Republic of the Congo, Ethiopia, Ghana, Kenya, Liberia, Mali, Mozambique, Nigeria, Rwanda, Senegal, Tanzania, Uganda, Zambia, Zimbabwe; LATIN AMERICA: 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 2010 through September 2011, using indicators that CARhs members revised and adopted in January 2010 to monitor CARhs activities. 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: Twelve monthly meetings were held between October 2010 and September 2011. 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 2 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 Security Branch (CSB), UNFPA’s Procurement Services Branch (PSB), 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. Three of five core organizations attended 100% of meetings, one of the other core organizations attended 75% of the meetings; overall attendance of core organizations at CARhs meetings was 90%. One non-core member, the World Bank participated 50% of the time. Another non-core member, the RHSC Secretariat participated in one third of the meetings. Number of Organizations Participating per Meeting Number of Individuals Participating per Meeting Range: 3 – 7 Average: 5.0 Range: 5 – 8 Average: 7.2 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. Thus far, invitations have not been regular. 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 168 distinct commodity issues between October of 2010 and September of 2011, of which approximately 65 required CARhs action and 103 required 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 5.4 issues for action and 8.6 issues for information per month. The total number of action issues concluded per month ranged from 1 to 14. B. CARhs Effectiveness Indicators 5. Number of issues resolved through CARhs action: 3 Between October 2010 and September 2011, 65 issues requesting or requiring CARhs action were finalized (i.e., the CARhs either provided assistance or determined that it could not assist). For 24 issues, CARhs action was not needed in the end. For the remaining 41 issues, the CARhs took action which helped resolve the specific problem in 25 cases (61%). In 10 cases, the CARhs was unable to assist. In 6 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 14 of 22 issues (38 total issues less 16 “action not needed” issues) requiring action. This equates to 64%. When stockouts occurred, CARhs was only able to take beneficial action in 6 out of 13 cases (46%). CARhs is most successful at taking action to deal with existing overstocks (4 of 4cases, 100%; 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 3 16 3 2 24 CARhs unable to act 3 7 0 0 10 CARhs only able to provide info 4 1 0 1 6 CARhs took action that did not add value 0 0 0 0 0 CARhs took action that added value 6 14 4 1 25 Issue Type Totals 16 38 7 4 65 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. Possible actions that added value Total % of Total New Shipment 10 40.0% Expedited Shipment 9 36.0% Postponed Shipment 2 8.0% Canceled Shipment 2 8.0% Technical Assistance 1 4.0% Provided Policy Advice 1 4.0% Total 25 100.0% 4 7. Number of issues where CARhs provided relevant information: Between October 2010 and September 2011, 103 issues requested or required shipping or commodity information from the CARhs (an average of 8.6 cases per month). In 99 of these cases, the CARhs provided some relevant information. In only 3 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 32 59 0 8 99 CARhs information not needed 1 0 0 0 1 CARhs unable to provide valuable info 0 3 0 0 3 Issue Type Totals 33 62 0 8 103 8. Number of months taken to avert short-term crisis: Of the 25 issues between October 2010 and September 2011 where CARhs action helped to resolve a short-term crisis, the average duration until resolution was 2 months, with a range from 1 to 6. 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. 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 2010 and September 2011. As shown in the figure, female condoms were most prone to stockout, where as combined oral pills were least likely to stockout. The high rate of stockout of injectables and implants is particularly concerning because these are widely used methods, and the most popular in many countries. 5 Product Name # of Months with Stockout Total # of Records for Product As % of All Records for this Product Female Condom 17 72 24% Injectables 24 177 14% Progestin-only Pills 8 100 8% Implants 11 93 12% Male Condoms 20 159 13% CT380A IUD 12 145 8% Cycle Beads 2 28 7% All Combined Oral Pills 12 174 7% 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 2010 and September of 2011, and where CARhs action or information was requested or required for those issues. In both Kenya and Ghana, four 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 4.2 months. In five countries, two or more products faced stock crises for multiple months of the PPMR – Afghanistan, Ghana. Kenya, Liberia, and Senegal. For other countries reporting in the PPMR, no more than one product faced recurrent stock shortages. Country Name Product Name #months =/< 2 MOS Program Name Afghanistan All Combined Oral Pills 2 TechServe Afghanistan Depo-Provera 4 Afghanistan Social Marketing Organization Afghanistan Male Condom-No Logo 2 TechServe Afghanistan Progestin-only Pills 2 TechServe Ghana 3-month Injectable 4 Ministry of Health Ghana DMPA 6 EXP Social Marketing 6 Ghana Female Condom 2 Ministry of Health Ghana Jadelle 6 Ministry of Health Ghana Progestin-only Pills 3 Ministry of Health Kenya All Combined Oral Pills 4 Ministry of Health Kenya All Implants 4 Ministry of Health Kenya Female Condom 6 Ministry of Health Kenya Male Condom-No Logo 6 Ministry of Health Liberia Depo-Provera 2 Ministry of Health Liberia Female Condom 2 Ministry of Health Liberia Jadelle 4 Ministry of Health Mali CT380A IUD 2 Ministry of Health Mozambique Microlut 2 Ministry of Health Nicaragua Depo-Provera 2 Ministry of Health Nigeria Female Condom 2 Ministry of Health Senegal CT380A IUD 2 Ministry of Health Senegal Pregnon 3 Ministry of Health Tanzania Male Condom-No Logo 2 Ministry of Health Uganda Male Condom-No Logo 2 Ministry of Health D. Additional Observations ���� As of September 2011, UNFPA assumed the role of Secretariat for the CARhs. ���� As reported previously, a major strength of the CAR is the consistent participation of key organizations, as well as the openness of CAR discussions. ���� Another vital derivative of this organization is the fostering of closer cooperation in the area of commodity support between UNFPA and USAID to the countries we support. The resources of two expansive and global networks of country office staff are effectively shared by this collaboration on an almost daily basis. ���� The CARhs now has two additional sources of funds to address issues raised in the group, namely: ���� Approximately US$15 million provided by DFID ���� US$1 million plus an additional US$1 million, if needed, provided by USAID ���� There continues to be a growing need to build public sector capacities for procurement of RH commodities. This has become all the more urgent with the accelerating trend to sector-wide approaches and budget support. The transition to new assistance modalities can easily get ahead of public sector capacities to assume new/expanded responsibilities for RH commodity security, procurement being just one of many. This has led to procurement delays and the need for costly emergency shipments. • 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 7 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 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. UNFPA is in the midst of a campaign to get country offcies in Africa to update the internet-based version of CCM. 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. 8 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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