Countries-at-Risk Group Progress Report (CARhs): October 2008 – September 2009

Publication date: 2009

1 Countries-at-Risk Group Progress Report: October 2008 – September 2009 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 share information to identify countries in, or on the verge of, reproductive health supply shortages. The goals of the CAR group are to understand the causes of these shortages, to identify solutions, and to coordinate the implementation of required actions. The CAR’s focus is on contraceptives. Since 2007, the CAR has 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 2009, the PPMR provided data on 16 countries (ASIA: Bangladesh, AFRICA: Ethiopia, Ghana, Kenya, Malawi, Mozambique, Nigeria, Rwanda, Sierra Leone, Tanzania, Uganda, Zambia, LATIN AMERICA: Dominican Republic, 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 now 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 CAR to work through electronic means as well as teleconference, for the efficient sharing of information. The CAR still encourages and responds to anecdotal reports of stock emergencies as well, to broaden its coverage across developing countries. This report reviews the CAR’s actions for the period October 2008 through September 2009, using indicators that CAR members revised and adopted in January 2009 to monitor CAR activities. The PPMR database has been modified to capture and track information on CAR indicators for PPMR countries. This has led to a much greater capacity to quantify the impact, and lack of impact, of the CAR. Also worthy of note is that the CAR group revised the CAR norms in September 2009. The previous norms, dating from February 2007, were updated to reflect current procedures and to clarify membership rules and member responsibilities. A. CAR Process Indicators 1. Number of meetings held: Twelve monthly meetings were held between October 2008 and September 2009. This translates into a meeting “rate” of 100%, a significant improvement over the 75% meeting rate in 2007-8 and 42% meeting rate in 2006-7. 2. Number of organizations and individuals participating per meeting: 2 As of September 2009, the “core” members of the CAR were UNFPA’s Commodity Management Branch, UNFPA’s Procurement Services Branch, USAID, the RH Interchange Secretariat, the USAID | DELIVER Project, and the RHSC Secretariat. Non-core members, who participate on an ad hoc basis according to need, included the World Bank, KfW, Marie Stopes International, and Crown Agents. KfW was unable to participate in any CAR meeting which hampered CAR effectiveness in some cases, though it did provide information for several CAR items. Overall, there was 83% attendance of core organizations at CAR meetings. Four of the six core members attended all twelve meetings. Number of Organizations Participating per Meeting Number of Individuals Participating per Meeting Range: 4 – 8 Average: 5.6 Range: 6 – 12 Average: 9.1 3. Number of country representatives (guests) participating in CAR calls: This indicator serves to encourage the CAR to invite country level representatives (‘guests’) to participate in regular or ad hoc CAR calls. The country representatives will be invited to address recurrent or extended stock crises where the CAR is unable to identify solutions. Inviting country representatives is also expected to raise awareness of the CAR and broaden participation in the Coaltion. Two guests were invited to participate in the CAR, and both accepted the invitation: Alice Micheni, of USAID/Kenya, to discuss the recurrent stock issues that plagued Kenya especially during the first half of the reporting year, and Martyn Smith, from Marie Stopes Sierra Leone, who shared information on emergency stock issues in Sierra Leone. Both guests provided information which strengthened the CAR’s ability to respond to these stock crises. Nonetheless, the CAR has not developed a process or strategy for identifying when to invite country-level guests and who to invite. Thus far, invitations have been opportunistic. 4. Number of action and information items: This indicator is meant to provide information on need for the CAR. It quantifies the number of items per month where the CAR 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 CAR member notes a country commodity issue which may require attention. The CAR dealt with a total of 106 distinct commodity issues between May and September of 2009, of which approximately 35 required CAR action (the remaining requiring information). Almost all of these issues came from the ~16 countries reporting in the PPMR. As many of these issues span multiple CAR sessions, the CAR considered an average of 13.9 issues for action and 13.6 issues for information per month. The total number of issues considered per month ranged from 13 to 44. B. CAR Effectiveness Indicators 5. Number of issues resolved through CAR action: 3 Between May and September 2009, 29 issues requesting or requiring CAR action were finalized (i.e., the CAR either provided assistance or determined that it could not assist). For 16 of these issues, the CAR took action which helped resolve the specific problem. In 8 cases, the CAR was unable to assist. In 1 case, the CAR provided relevant information but was unable to take action to resolve the stock situation. A full breakdown of CAR action, by situation, is provided below. Situation Outcome Existing Stockout Avert Future Stockout Existing Overstock Avert Future Overstock Other (stocks between max/min) Action Outcome Totals CAR action led to resolution 2 6 3 2 3 16 CAR unable to act 1 4 2 0 1 8 CAR only provided info 0 0 0 0 1 1 Totals 1 4 2 0 2 9 6. Number of issues where CAR provided relevant information: Between May and September 2009, 76 issues requested or required shipping or commodity information from the CAR. In 74 of these cases, the CAR provided some relevant information. In only 2 cases was the CAR unable to provide relevant information. Situation Outcome Existing Stockout Avert Future Stockout Existing Overstock Avert Future Overstock Other (stocks between max/min) Information Outcome Totals CAR provided relevant info 26 40 0 0 8 74 CAR not able to provide relevant info 2 0 0 0 0 2 Totals 28 40 0 0 8 7. Number of months taken to avert short-term crisis: Of the 16 issues between May and September 2009 where CAR action helped to resolve a short-term crisis, the average duration until resolution was 1.8 months, with a range from 1 to 4. Duration until resolution is reached tends to be longer when the crisis requires identifying or facilitating funds for new shipments of commodities. CAR action tends to be quick when the crisis merely requires canceling, delaying, or expediting existing shipments. 8. Countries where a commodity security policy discussion initiated as a result of CAR action: The number of policy discussions initiated as a result of CAR action is difficult to track, however there is at least one major improvement in commodity security policy resulting from CAR action. 4 As a result of CAR monitoring of contraceptive stockout situations in Kenya, and regular discussions with in-country counterparts, stakeholders in Kenya came to recognize and acknowledge the significant problems they faced for ensuring contraceptive security. National stakeholders have since made extensive efforts to revitalize contraceptive security - restarting national coordination groups, conducting quantification exercises, and making advance commitments for contraceptive financing needs for 2010. The CAR and in-country donors took emergency actions to address contraceptive stockouts, while the Government of Kenya and donor procurements have been refilling pipelines. The significant, and hopefully continuing, improvements to contraceptive security in Kenya owe a great deal to constant CAR monitoring and discussions with country representatives for over 1 year. C. Vulnerable Product and Country Indicators 9. 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 2008 and September 2009. As shown in the figure, emergency contraceptive pills and female condoms were most prone to stockout, where as male condoms and IUDs were least likely to stockout. Product Name # of Product- Months with Stockout Total # of Records for Product As % of All Records for this Product Emergency Contraceptive Pill 17 30 57% Female Condom 15 47 32% Progestin-Only Pills 15 70 21% Combined Oral Pills 22 132 17% Injectables 30 181 17% Implants 10 71 14% IUD 13 134 10% Male Condom 11 144 8% 10. Causes of supply problems (listed in no particular order):  Failures or delays in national tendering processes;  Delays due to donor-government coordination for donor-funded procurement;  Poor procurement planning and insufficient lead time for procurements;  Production issues affecting ability of donor to provide supplies in a timely manner;  Delays in arrival or customs clearance of supplies from donors/manufacturers;  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. 11. 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 5 2008 and September of 2009, and where CAR action or information was requested or required for those issues. In both Kenya and Ghana, most of the contraceptive methods provided by the public sector faced multiple or recurrent stock crises. In Kenya, many items were at dangerously low stock levels for 6 or 7 months (i.e., most of the year), whereas in Ghana the vulnerable products were generally at risk for fewer months. In Nicaragua and the Dominican Republic, two products faced stock crises for multiple months, though in Nicaragua the crises did not last more than two months. For other countries reporting in the PPMR, no more than one product faced recurrent stock shortages. Country Name Product Name # of Months where stocks <= 2 MOS Bangladesh All Implants 6 DR All Combined Oral Pills 6 DR Depo-Provera 2 Ethiopia Male Condom-No Logo 2 Ghana CT380A IUD 3 Ghana Female Condom 4 Ghana Male Condom-No Logo 2 Ghana Micronor 3 Ghana Norigynon 4 Kenya All Combined Oral Pills 2 Kenya All Implants 2 Kenya All Injectables 6 Kenya CT380A IUD 6 Kenya Female Condom 5 Kenya Postinor-2 7 Kenya Progestin-only Pills 7 Malawi Jadelle 3 Mozambique Microgynon 2 Nicaragua All Combined Oral Pills 2 Nicaragua Norigynon 2 Paraguay Postinor-2 4 Tanzania Implanon 2 Uganda All Combined Oral Pills 2 Zambia Noristerat 2 Mode # Recurring Months with <=2 MOS 2 Average # Recurring Months with <= 2 MOS 3.6 Country with Most Occurences Kenya (35 months total for 7 products) Product with Most Occurences Combined Oral Pills and Injectables (5) Product with Most Recurring Months <=2 MOS Injectables (16) D. Additional Observations  The UNFPA Commodity Management Branch has again become a regular participant of the CAR. This has added great value to the CAR. UNFPA/CMB brings both important information to the CAR and the capacity to provide funding for needed shipments.  The CAR group has continued to upgrade the CAR notes and the CAR database to improve the CAR’s ability to track individual issues over time, to monitor the outcomes 6 of CAR actions, and to provide improved data on countries/products requiring CAR actions.  The PPMR has been revised in two significant ways to increase its utility to the CAR. It now reports Average Monthly Consumption (AMC) for all products in all programs, and countries are now encouraged to report stock levels down to the lowest levels of the health system possible.  As reported previously, a strength of the CAR is the consistent participation of key organizations, as well as the openness of CAR discussions. E. 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. The PPMR now has up to 18 countries per month and seems to be reaching the maximum capacity for both the USAID | DELIVER PROJECT and CAR can handle.  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 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. 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. While UNFPA Commodity Management Branch participation in the CAR adds great value to the CAR in terms of responding to emerging issues, the lack of other donors as regular CAR participants means that the CAR is still limited to provide additional product/shipments for issues where USAID or UNFPA can respond. The World Bank is also a regular participant and provide useful 7 information to the CAR, although it is typically not able to schedule new shipments to countries. Other donors are absent from the CAR. 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.

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