Countries-at-Risk Group Progress Report (CARhs): October 2007 – September 2008

Publication date: 2008

1 Countries-at-Risk Group Progress Report: October 2007 – September 2008 The Countries-at-Risk (CAR) group was established in December 2004. Its first meeting took place in January 2005. The CAR meets monthly as a forum where key global-level partners for the funding and procurement of contraceptives and condoms – UNFPA, KfW, USAID, the Reproductive Health Interchange staff, and others – share information to identify countries in, or on the verge of , reproductive health supply shortages, to better understand the causes of these shortages, to identify solutions, and to coordinate the implementation of the required actions. The CAR’s focus is largely, though not exclusively, on contraceptives. UNFPA initially assumed the lead in supporting the logistics and management of the CAR (organizing meetings, keeping notes, etc.); this role was assumed in January 2007 by the RHSC Secretariat; and in May 2008 by USAID. The role of the CAR has expanded during the period covered by this report, largely as a response to improvements in data available to the CAR. In October of 2007, USAID and the USAID | DELIVER PROJECT began to produce a monthly “Procurement Planning and Monitoring Report” (PPMR) on stock status and other issues pertinent to contraceptive security. The PPMR has grown from 1 country (Bangladesh) in the first report to 13 countries by September 2008 (Bangladesh, Ethiopia, Kenya, Malawi, Ghana, Mozambique, Rwanda, Tanzania, Uganda, Zambia, El Salvador, Nicaragua, Paraguay). While improving the CAR’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. Thus, the CAR has taken on the additional function of providing information regarding impending shipments to country officers in a more direct manner. 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 shipping system). This added function has obliged the CAR to work through electronic means as well as teleconference, for the efficient sharing of information. This report reviews the CAR’s actions for the period October 2007 through September 2008 (last progress report October 2006 to September 2007). This report uses indicators that CAR members adopted in early 2006 to monitor CAR activities. The report summarizes the CAR’s activities and accomplishments, and offers observations on issues that have come to the CAR’s attention and merit broader attention by the Reproductive Health Supplies Coalition (RHSC). A. Indicators 1. Number of meetings held: Nine (out of 12) monthly meetings were held between October 2007 and September 2008. The group has met monthly without fail since February. This translates into a meeting “rate” of 75%, a significant improvement from the 42% meeting rate in 2006-7. 2. Number of organizations/individuals participating per meeting: The “core” organizations during this period were UNFPA, USAID, KfW, RH Interchange, the USAID | DELIVER Project, and the RHSC secretariat. Other organizations participated 2 on an ad hoc basis, such as World Bank (who changed from core to ad hoc member in May 2008 at their request) and Crown Agents. Overall, there was 91% attendance of core organizations at CAR meetings. One core organization (UNFPA) missed one meeting and one (KfW) missed four meetings. Number of Organizations Participating per Meeting Number of Individuals Participating per Meeting Range: 5 – 8 Average: 5.9 Range: 5 – 10 Average: 7.8 3. Products most cited for stock outs: The table below shows number of monthly instances of stock-outs reported in the PPMR, across all countries, between the January 2008 and August 2008 reports. # of times Stocked Out Product Name 8 Combined Oral Pills 8 2/3-Month Injectable 7 Monthly Injectable 7 Female Condom 6 Male Condom 6 CT380A IUD 6 Implants 4 Progestin Only Pills 4. Causes of supply problems (listed in no particular order):  Lack of timely and (sometimes) transparent procurement planning and procurement processes by governments  Production or registration issues affecting ability of donor to provide supplies in a timely manner  Donor pullout or transition to direct budget or basket funding  Delays in arrival or customs clearance of supplies from donors/manufacturers  Lack of accurate information on in-country stock status (sometimes delayed fulfilling emergency requests)  Demand exceeding forecasts  Funds not available in a timely way for procurement, sometimes due to delay in signing a financing agreement between donor and government 5. Number of countries with re-occurring short-term crisis: Five countries came to the CAR for emergency action multiple times: Bangladesh, Ghana, Kenya, Paraguay and Uganda. Only one country was cited as experiencing re-occurring crises in the 2006-7 CAR Progress Report. The increase in number of countries where emergencies were discussed multiple times by the CAR probably represent greater visibility of country stock levels and a more proactive approach of the CAR, rather than poorer supply availability at the country level. However, several limitations in donor provision of contraceptives 3 (especially related to production and/or registration of certain contraceptive methods) may also have been a greater obstacle to sustained supply than in previous years. Specific challenges for maintain appropriate stock levels in countries were created, for example, by delay in the registration of USAID’s new IUD brand, and delays in the production of Norigynon. The table below reflects reports of countries where there were re-occurring crises for specific products. The table includes cases reported in the PPMR between March and August of 2008, which fit the following two criteria: 1) more than one instance of stock levels at or below 2 months of stock; and 2) CAR action or information was requested, in the PPMRs between March and August 2008. Country Name Product Name # of Months where Actual Stock <= 2 MOS Ghana Micronor 4 Rwanda Microgynon 4 El Salvador Noristerat 3 Uganda CT380A IUD 3 Kenya Female Condom 2 Nicaragua Lo-Femenal 2 Rwanda Condom-No Logo 2 Rwanda Jadelle 2 6. Number of months taken to avert short-term crisis: Many issues were resolved within a month, especially those merely requiring expedition of existing orders. However, issues which require identifying new shipments/procurements, and thus funds, to resolve stock crises tended to take several months to resolve, and often were not within the CAR’s power to resolve. 7. Number of countries where a commodity security policy discussion initiated as a result of the crisis: At least two. Bangladesh: As stocks of NORPLANT in the public health system in were dwindling, the CAR group gathered from PPMR data that the Government of Bangladesh was intending to continue procuring NORPLANT as its implant method. The CAR group determined that NORPLANT was no longer available for procurement, and informed the GOB through the local USAID | DELIVER office. This encouraged the National Technical Commission to expedite its approval of Implanon for use in the public sector. Kenya: Attention from the CAR and PPMR on dwindling stocks of several commodities in the Kenya public sector system seemed to stimulate, in part, revitalization of the Family Planning Logistics Group, a local RHCS coordinating committee, which had become dormant. CAR attention may also have catalyzed attention to delayed procurements of female condoms. B. Examples of CAR Action 4 Each month the CAR becomes aware of a wide variety of distinct commodity issues, in different countries, for different products, and of varying levels of complexity. In all cases, the CAR attempts to respond. In many cases, it does so successfully. However, various limitations to CAR responsiveness (see “Potential Areas for Improvement” below) prevent complete success. Below are a selection of issues addressed by the CAR, with accompanying outcomes. These examples were selected to indicate the range of success, and are not intended to be quantitatively representative of all CAR actions. Improving Country-Level Information on Incoming Shipments  UNFPA, USAID and KfW responded to over 100 requests for information on shipping dates and other shipment-related information. Responding to Urgent Country Stockouts  In July 2008, the PPMR indicated that the Paraguay MOH needed donor assistance to procure IUD insertion kits, as well as funds for IUD insertion training. As a result of a subsequent CAR discussion, UNFPA/Procurement Service Branch requested its local Paraguay office to consult with the MOH about their needs. In November 2008, UNFPA/Paraguay bought 180 kits for the MOH and, next year, UNFPA will coordinate with the MOH regarding the IUD insertion training needs.  In March 2008, the CAR learned that Rwanda had stocked out of IUDs in their central warehouse. Though redistribution was planned to relieve the situation temporarily, new shipments were needed and no donor had been identified. As Mozambique had an overstock of IUDs (40 MOS), USAID decided to transship 5,000 IUDs from Mozambique to Rwanda. The governments agreed, and the transshipment occurred in May. Stockout of IUDs in the Rwanda central warehouse was thus limited to two months. Modifying Shipments to Improve Inventory Control  In January 2008, the PPMR indicated that Ghana had only 5 months of stock (MOS) of Lo-Femenal in the central stores, with no shipments expected until a USAID shipment in May. USAID expedited this shipment, which arrived to the country in April and to the warehouse in May – just after the central level stockout occurred. Increasing consumption meant that this stock would only last until September, whereas the next shipment was planned for October. USAID again expedited its Lo-Femenal shipment, and by August 5 the Ghana central stores had their max level of MOS – 12 months.  In July 2008, the CAR learned that Malawi had 23 MOS of Lo-Femenal at their regional warehouses – 9 months more than the maximum level. USAID postponed shipments planned for September 2008 until October 2009 to allow the overstock situation to be relieved and not over-burden the warehouse. Challenges in Responding to Country Needs  In July 2008, the PPMR reported that Uganda had stocked out of IUDs at the central level. UNFPA planned a shipment of 6,300 IUDs to ship by air on Sept. 5. While the shipment arrived in country on time, undefined delays meant that the stock had still not reached the national medical stores as of Oct 30 2008, and the central warehouse did stock-out.  In September 2008, the CAR learned that Malawi’s central warehouse only had 2 MOS of implants at the regional warehouse level. USAID moved up its next shipment of Jadelle, 5 to ship in November. However, because of production issue the expedited shipment was not accomplished and the central warehouse did stock out of Jadelle. C. Additional Observations  The CAR continues to be limited in its ability to respond to true emergencies – when country stock is running low and no donor shipments are planned for the country that can be expedited. The inability to respond derives from many factors – complacency among MOH officials, complacency among local donor representatives, balancing the ‘full supply’ goal of donors with their desire to ensure local decision-making and accountability, and inability of donors involved in the CAR to identify funds and take decisions needed for emergency procurement/shipping.  Inability to accurately track CAR actions across countries, months and organizations remains an obstacle to CAR effectiveness. CAR does not currently have the capacity to track every product issue from recognition until resolution (shipment arriving in the central warehouse), however some problems that the CAR ‘solves’ actually are not resolved adequately due to later delays not clear to CAR.  As reported in the previous CAR progress report, there is 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.  As reported previously, a strength of the CAR is the consistent participation of key organizations, as well as the openness of CAR discussions. D. Potential Areas for Improvement Expand Available Supplies Data  Focus Countries. Identify priority countries for the CAR for which we have limited visibility, and determine a mechanism for receiving data on contraceptive stocks – such as the PPMR.  Expand PPMR to Include Additional Countries. The PPMR is functioning well as a tool for monitoring stock information for the 13 countries included. However, the CAR’s visibility of stock issues in other countries remains limited. The PPMR should be expanded to include additional countries of concern to CAR members. CAR members should facilitate developing mechanisms for reporting data from their priority countries to JSI for inclusion in the PPMR.  Increase Information Sources Available to the CAR. Anecdotal reports about stockouts to the CAR seem to have decreased since the PPMR has become the primary data source. However, CAR members should still encourage anecdotal reports as, currently, the only means of learning about and responding to stock issues in countries 6 not in the PPMR. Additional sources of regular, quantitative data – such as UNFP 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.  Focus on the Lower Level Stock Availability. At present, the PPMR primarily reports contraceptive stock levels at national central warehouses. Best practices in stock management require constant availability of full supply commodities, such as contraceptives, at central warehouses. Thus, the CAR begins to act when it foresees central-level stock outs. However, in country central level stockouts are often not considered urgent when stock exists lower in the pipeline – thus, country level actors are often not responsive to CAR concerns. To make CAR action more aligned with local attitudes about urgency, the PPMR should report on stock availability at lower levels where quality data can be gathered and reported in a timely manner. Improve Ability to Act  Create Emergency Funding Mechanism. One of the key factors limiting the ability of core CAR members from resolving emergency stock issues is inability to quickly identify funds for providing commodities to countries on the verge of a stockout. The CAR should 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 CAR Guidelines for Emergency Action. Apart from funding, the decisiveness of CAR to resolve apparent emergency stock issues is also limited by the lack of clear guidelines or criteria for emergency action by the CAR. Developing guidelines would increase consistency in the CAR’s response to stock issues, and could also serve to invigorate CAR member efforts to identify funds and make decisions regarding emergency shipments.  Assure Involvement of Key Stakeholders. CAR responsiveness is also limited in some cases by the technical areas of focus of organizational participants in CAR calls. For example, UNFPA’s Commodity Management Branch (CMB) was not a participant of any CAR meeting during the reporting period; since only CMB can make funding decisions regarding emergency shipments, UNFPA’s ability to commit to resolving issues during the calls is limited. In addition, KfW is typically represented by individuals whose area of geographical coverage is limited, meaning that the organization is unable to respond to or fully participate in discussions about issues in other countries. In future CAR calls, organizational representatives should be briefed on all relevant areas for the CAR call in advance, so that CAR decision making is streamlined. Streamline Processes  Automation of CAR Administration. Link CAR notes to the PPMR database to streamline CAR data collection and availability, and development of the CAR agenda.  Improved PPRM Information. PPMR data could be more useful to the CAR if it includes data on actual stock (total # of each item) or average monthly consumption, so the CAR can estimate what quantities are needed to resolve stock emergencies. http://www.rhsupplies.org/working_groups/systems_strengthening/global_financing_and_procurement.html

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