CS Issues workshop Report: Aqaba, Jordan
Publication date: 2004
CS Issues workshop Report Aqaba 19-21 March 2004 Introduction: During the 1980s, Jordan experienced one of the highest population growth rates in the world, increasing by an average of 4.3 percent annually. The current annual growth rate of 3.7 percent is still high and suggests that Jordan’s population – now estimated at 5.2 million – will double in nineteen years. Analysis shows that both the need and demand for contraceptives is increasing. The number of contraceptive users is expected to increase by 64 percent in the next 13 years. The Government of Jordan’s (GOJ) ability to meet the coming challenges is constrained by competing priorities and inadequate resources. To address some of the CS challenges, Jordan initiated Contraceptive Security (CS) efforts in June 2002 at the request of Government and USAID, when POLICY organized a number of key informant interviews and stakeholders’ meetings. In these meetings, the stakeholders expressed commitment and agreed to support initiation of contraceptive security activities. More efforts followed in November 2002, as the Government of Jordan organized a stakeholders’ meeting to generate a common understanding of CS and the surrounding key issues in Jordan. In this meeting, a wide range of stakeholders attended, including representatives from the MOH, Ministry of Planning (MOP), Ministry of Finance (MOF), Ministry of Education (MOE), Jordanian Association for Family Planning and Protection (JAFPP), PHCI, and UNFPA, PHR Plus, UNRWA, USAID, WHO, and the commercial sector. During this meeting POLICY staff, along with CMS and DELIVER staff, introduced SPARHCS (Strategic Pathway to Reproductive Health Commodity Security). The objective of applying the SPARHCS framework was to support Jordan in developing a strategic commitment and funded action plan for ensuring an adequate supply and choice of quality contraceptives that will meet clients’ needs. With support from the USAID mission in Jordan, the POLICY project marked another step towards CS in Jordan on July 23rd 2003, when it launched the CS Working Group and Committee. In this meeting a diverse set of stakeholders representing the public and private sectors gathered to form a CS Committee and Working Group. The CSWG met after that in September and December to develop consensus on the SOW and to discuss the next steps needed for developing the strategic plan for achieving CS in Jordan. Issues workshop Finally on March 19-21, 2004 the CSWG participated in the CS issues workshop where key findings from the background studies on market segmentation, National Family Planning Accounts, an assessment of existing procurement mechanisms in Government and the NGO sectors, an assessment of operational barriers to achieving contraceptive security, and future commodity requirements for both Government and the entire market. In addition, to capture the wealth of information that has been generated over the last five years by myriad organizations, a briefing booklet has been prepared based on the SPARHCS framework. The booklet summarizes the data and results in a situation analysis. This information informed the issues identification and prioritization work carried out at the workshop and will ultimately serve the strategic planning process. The CS issues identified and prioritized by the CSWG can be found in Annexes 4-6. Participants Forty four participants attended the workshop including a wide range of stakeholders representing the following: Ministry of Health, Ministry of Finance, Budget Department, Jordanian Association for Family Planning and Protection, Higher Population Council, Royal Medical Services, Higher Health Council, Higher Youth Council, Circassian Charity Association, Jordanian Nurses and Midwives Association, Jordanian Physicians association, Private Hospital Association, Jordanian Association of Pharmaceutical Manufacturers, UNRWA, IMPACT , CMS, JHU, Engender Health , USAID(DC, Egypt, Jordan), DELIVER, and POLICY (DC, Egypt and Jordan). The workshop list of participants and agenda are included in Annexes 1 and 2 respectively. Day 1 The workshop started with opening remarks by Dr. Zuahir Al Kayed, the Secretary General (SG) of the Higher Population Council, who welcomed the participants and drew their attention to the importance of this workshop, and marked it as an implementation phase of the RHAP, which was approved and launched recently. The SG acknowledged the dedication of multisectoral Task Force and their efforts, and he stressed the importance of collaboration between all sectors to achieve CS as a major domain under the RHAP. Mr. David Piet / Team Leader , Population and Family Health Section, Social Sectors Office, USAID emphasized the importance of achieving contraceptive security in Jordan by developing a evidence-based strategic plan that is carefully thought through. He stressed the importance of private sector involvement in both the plan and its implementation and the need for an expanded method mix. Last, he called for the GOJ to fund needed contraceptives as USAID phases out. Mr. Piet stated that Jordan needs to start taking responsibility as soon as possible for its contraceptive needs. Update on CS activities Basma Ishaqat presented an overview of the contraceptive security strategic planning process in Jordan, during which she reminded the participants that Jordan is facing the challenge of increasing demand for contraceptives and declining donor support. To meet this challenge, the GOJ, in collaboration with POLICY, CMS and DELIVER, initiated the process of developing a long-term strategy that will move Jordan toward contraceptive security under the leadership of the government of Jordan. The process is based on the SPARHCS framework and involves a number of activities: Conducting key informant interviews Organizing Stakeholder meeting Forming the CS working group Conducting policy analysis and mobilizing information for decision making Prioritizing issues Developing a strategy Conducting a strategic planning workshop And advocating for the approval of strategy The final product will be a funded long term strategic plan for achieving contraceptive security. She also clarified that Jordan is fortunate because it has the opportunity to benefit from lessons learned in other counties. Perhaps most important among those lessons is the benefit of starting the CS planning process early, prior to imminent donor phase-out. As a result, Jordan has enough time to carefully plan and formulate a contraceptive security strategy under local leadership that will result in a sustainable accessibility to contraceptives. This was followed by presenting key findings and issues identified in the background studies conducted by POLICY Project. Current and Projected Utilization and Demand Creation Dr. Issa Almasarweh delivered the first presentation on Family Planning Projections in Jordan. He highlighted the NPS – RHAP strategic objectives and identified strategies to enable Jordan to continue to successfully reduce population growth rates. Then he clarified the uses of the DemProj and FamPlan models, and projected the resource requirements for the FP program to meet the current population goals and CPR using the DHS 2002 data, method mix, sources of methods and users. Service Delivery channels and Client Provider Interaction Dr. Suneeta Sharma delivered a presentation on the findings of the Market Segmentation Analysis using 2002 DHS data. The study revealed that there is an untapped potential for commercial products and services among users of subsidized products. A collaborative multisectoral effort is needed to maintain access to FP methods for current users, convert intenders into satisfied clients, and shift those who use traditional contraceptive methods to the more effective modern methods. Better targeting, greater coordination, and improved demand are needed for a more efficient and effective FP market. A better match must be established between current/potential users and the appropriate sources of contraceptives, taking into account the users’ location, needs, preferences, and ability to pay. Greater involvement of the commercial sector can free up donor and government resources to serve those who are the most vulnerable and who cannot afford to pay, Dr. Sharma clarified that market segmentation analysis is critical to formulating a CS strategy that takes into consideration different providers of contraceptives, different socioeconomic characteristics of clients, and the current and potential match between the two. Finance Mr. Bassam Almunair , the Financial Director at the MOH, delivered a presentation on National Family Planning Accounts. In his presentation, Mr. Almunair provided comprehensive information on sources of family planning financing; how funds are distributed and used across various components of the family planning program; and the flow of resources currently utilized for FP purposes. He also clarified that many funds do not pass directly from the source to the actual providers of services. Instead, a significant proportion passes from one organization to another before it is finally used to provide family planning services. Mr. Almunair also noted that the government of Jordan is the most important source of financing in Jordan’s family planning program. It contributes approximately 47 percent of funding followed by households 27 percent and 26 percent by donors. USAID is the main donor contributing 23 percent of funding. The study found that 82 percent of the funds are used for delivering FP services and commodities, while 10 percent is spent on training, 6 percent on BCC/IEC activities and 2 percent on research. Mr. Almunair concluded his presentation by highlighting the importance of this information to inform the strategic planning process related to Contraceptive Security, to help policy makers determine the major sources and uses of funds for FP commodities and to identify resource gaps in ensuring financial security. After each of these presentations time was given to discussions and comments, then participants were distributed to working groups and were given instruction shown in "Annex 3" to list all issues related to the presentation topics. The results of the workgroup issues identification process are found in Annex 4. Day 2 Day two started with a recap by one of the participants, Dr. Mahmood Altaher. Existing and Potential Procurement Mechanisms in the MOH, RMS, UNRWA, JUH & JAFPP Mr. Khaled Touqan presented a description and an assessment of the strengths and weaknesses of current procurement systems in both the public and NGO sectors including forecasting and distribution mechanisms. He then identified options available to the MOH for acquiring contraceptives. Mr .Touqan concluded his presentation by saying that even though all studied organizations have clear and transparent procurement systems, the systems are not efficient and effective as they often contain complicated and time consuming procedures and often have inadequate financing. He also noted that the studied organizations share the common weakness of limited financial resources that lead to stock outs of some essential drugs and then discussed the potential dangers of procuring contraceptives through these mechanisms. Logistic Systems- Forecasting, Distribution and Projected Funding Requirements Mrs. Lisa Hare from DELIVER and Mrs. Abeer Almowaswas shared a presentation on "Jordanian Contraceptive Logistics System", which is designed to manage the contraceptive in- country supply chain. The system is also used to provide data to decision makers on CYP and average stock leveling, rate of consumption, losses and adjustments. Hare and Almowaswas summarized the challenges facing the system in two points: Lack of contraceptive training on the system for the service providers Software problems. Last, they provided the participants with projected purchasing costs for contraceptives if UNFPA procurement system is used. Policy, Leadership and Environment The last presentation on the workshop agenda was presented by Dr. Carol Shepherd on "Policy, Leadership and Environment: Issues and Barriers". The assessment covered areas such as: availability of contraceptives, access to providers, and alternative financing mechanisms. Dr. Shepherd talked about the context or environment in which we work, and the policies, political will and leadership needed to move forward. She also clarified that the presentation is based on work done by Dr. Issa on identifying operational policy barriers, issues identified by the participants of the awareness raising workshop, issues that have been identified in this workshop and experience from other countries. She grouped those issues under three main categories: Environment: were she talked about the political environment, religion, per capita income, population, employment, education, and disease burden. Policy: the importance of understanding the policy environment and working to remove policy barriers to CS, or formulating new policies insuring that clients can choose, obtain and use the commodities of their choice. For example she discussed Population momentum and the need for the FP program to grow to meet the new demand; the need to include new groups such as the newly married, adolescents and unmarried youth; the need to address issues such as age at marriage, premarital exam, lost opportunities; and funding and management issues such as inadequate funding, high cost, inefficiency, pricing guidelines, inadequate health information systems, management capacity, and personnel transfer policies. Leadership issues and barriers: Currently there is no high level individual or organization that has taken an active role to ensure that stakeholder organizations involved in the FP program actually carry out their roles. The HPC is headed by the prime minister and is expected to play an important role in coordinating the implementation of the reproductive health action plan. However, the HPC secretariat is somewhat understaffed to take on this role. She also stated that even though there is political commitment and support by the royal family and the prime minister, this support is often not as visible to the general public as it might be. Dr Shepherd concluded her presentation by saying that overall the FP program, in its current form, is not sustainable in the long term. Given the fact that the donor has stated an intent to withdraw support for commodities within the next 5-10 years, FP services are currently provided for free, and approximately 31% of the upper two income quintiles who could potentially afford to pay are using the public sector, serious action should be taken to redesign the family planning program to make it sustainable over the long term. Again after each presentation time was given to discussions and comments, then participants were distributed to working groups and given instructions (shown in Annex 3). To insure that the issues identification process was thoughtful and evidence-based participants were asked to list all relevant issues related to the areas presentation topics. The results of the day two workgroups was combined with the results of day one and a Contraceptive Security Issues Voting List was developed. This is shown in Annex 5. Day 3 The day began with a summary of day 2 presented by WHO ? Participants were given a last change to discuss and or raise questions about the previous two days. The Contraceptive Security Issues Voting List was then handed out to participants. Each member chose the 6 issues that s/he thought to be the most important. The votes were then tabulated and the results announced. These 6 issues will form the basis of the strategic plan. The results of the participants voting is provided in Annex 6. While the votes were being tabulated, Dr, Hussein Abdel-Aziz Sayed, POLICY’d Country Manger in Egypt and Miss Lisa Childs, USAID Egypt summarized current contraceptive security and family planning activities in Egypt. They then discussed lessons learned and similarities between the two countries. Next steps The CSWG will meet regularly to formulate a draft strategy and activities. A strategic planning workshop will be held to bring together a wide range of local stakeholders to assess and analyze the proposed strategy and specific activities. We will organize regional level meeting for key stakeholders Cognizant of the importance of building broad support for CS, we will also provide training and TA to further develop advocacy skills among stakeholders and NGOs. Local NGOs and stakeholders will advocate for the approval, funding and implementation of the CS plan. Annex 1 Contraceptive Security Issues Workshop Friday March 19 – Sunday March 21, 2004 Aqaba, Jordan Workshop Goals: Present key findings of the background studies. Identify and prioritize CS issues in Jordan. Day One – Friday March 19, 2004 8.30 AM – 9.00 AM Opening HPC and USAID 9.00 AM – 10.00 AM Update on CS Activities Identify participant to recap Presentation of CS activities to date Discussion Basma Ishaqat 10.00 AM – 10.45 AM Current and Projected Utilization and Demand Creation Presentation of FAMPLAN Discussion Issa Almasarweh 10.45 AM – 11.30 AM Service Delivery Channels and Client Provider Interaction Presentation of Market Segmentation Analysis Discussion Suneeta Sharma 11.30 AM – 3.00 PM break 3.00 AM – 3.45 PM Finance Presentation on National FP Accounts Discussion Bassam 3.45 PM – 5.30 PM Work Groups Identify demand, service delivery and finance issues CSWG POLICY & Team 5.30 PM – 5.45 PM Tea/Coffee break 5.45 PM – 7.00 PM Work Groups Identify demand, service delivery and finance issues Prioritize issues CSWG POLICY & Team 7.00 PM – 7.30 PM Group Reports Top 6 issues for each group CSWGs Day Two – Saturday March 20, 2004 8.30 AM – 9.00 AM Recap Participant 9.00 AM - 10.00 AM Procurement Study Presentation Discussions Khaled Touqan 10.00 AM - 11.00 AM Logistics System – Forecasting , Distribution and Projected Funding Requirements Presentation Discussions Abeer Mowaswas and Lisa Hare 11.00 AM -10.15 AM Tea/Coffee break 11.15 AM -12.00 PM Policy, Leadership and Environment Presentation Discussion Carol Shepherd 12.00 PM - 1.45 PM Work Groups Identify current and potential issues related to forecasting, procurement, distribution and policy CSWG POLICY & Team 1.45 PM - 2.15 AM Rich Tea/Coffee break 2.15 PM - 3.30 PM Work Groups Identify current and potential issues related to forecasting, procurement, distribution and policy Prioritize issues CSWG POLICY & Team 3.30 PM - 4.30 PM Group presentations Top 6 issues for each group CSWG Day Three – Sunday March 21, 2004 8.30 AM – 10.00 AM Group presentations: issues and priorities CSWG Groups 10.00 AM – 10.30 AM Individual prioritization Participants 10.30 AM -11.00 AM Tea/Coffee break 11.30 AM – 1.00 PM Results Individual prioritization results Discussion CSWG POLICY & Team 1.00 PM - 1.30 PM Concluding Session - Next steps Basma Ishaqat 1.30 PM Lunch break Annex 2 Participants List BASMA we need this Annex 3 Instructions: Small Working Groups The purpose of this exercise is to identify all issues relevant to the Jordanian CS situation related to the topics presented today. You should use your personal experience, the materials in your folders and the presentations to help you to identify issues. First identify a facilitator, a reporter for day 1 and day 2 and a recorder. The questions listed for each session are meant to stimulate discussion. You do not have to answer the questions directly. Instead this should be a brainstorming session where you identify anything that comes to mind that might be an issue. Next, you should examine your potential list of issues and decide which are really important to the goal of achieving contraceptive security. In the course of your discussion, you should discuss the potential issue and answer the following questions: Why do you think the issue is important? How will solving the issue make a difference? How will addressing the issue help achieve or move toward contraceptive security? Please record all issues so they can be included in the development of the strategic plan. Once your group has identified all of the relevant issues, you must prioritize or rank them, choosing the most important 6 issues. When ranking your issues, please consider the following criteria: Feasibility Is it politically feasible to address this issue? Is it technically feasible to address this issue? Is it financially feasible to address this issue? Is it culturally feasible to address this issue? Impact/importance What do you expect to happen if you address this issue? What is the size of the effect that you would expect to get if you were to solve this issue? Will this result in a long term change? Will this result help achieve the goal of attaining contraceptive security? Is it already addressed in the RHAP? Urgency How urgent is it for this issue to be solved? Will solving this issue now help move the CS agenda forward more quickly? Doability Can it be done? Easy to do (low hanging fruit) Difficult to impossible Timeframe Short term Medium term Long term At the end of day 1 and day 2, each group should reach a consensus on the most important 6 issues. Of note, if a particular issue is thoroughly addressed in the RHAP you do not need to plan for it a second time. Make a note that this was in your top six and then pick another issue. Write the issues on flip chart paper. Each reporter will have five minutes to present their group’s 6 priority issues. There will be five groups. We will eliminate duplicates. During the evening, POLICY and DELIVER will type the issues into a list. On day three, we will begin by presenting the issues identified in days one and two and then debating the merits of each. We will also identify related issues that can be grouped under a single heading, e.g. some of these might be activities or sub-activities under of a specific issue. At the end of this time, a voting sheet will be handed out to each participant to vote for the most important 6 issues. POLICY and DELIVER will tabulate the votes. The six priority issues will be announced and discussed. These will form the basis of the CS Strategic Plan. This does not mean that other issues are not important or will not be addressed. However, everything cannot be completed at once. These 6 issues represent those issues that you believe must be addressed first in order for work to begin on the others. N.B. If an issue is already included in the RHAP it can be referenced but should not be part of the 6 priorities. Annex 4 Issues Finance How do we fund the family planning program including contraceptives, IEC/BCC, and research five years from now? Budget line item for contraceptives Develop a fee system that exempts poor and collected revenues are used at the clinic level. Introduce new taxes – polluters and tobacco producers Include family planning services and contraceptives in health insurance (public and private) Assess the feasibility of local production of contraceptives. How do we establish a more rational approach to market segmentation? Does the benefit from rationalizing the market out weigh the costs? Lack of awareness and information among poor regarding the availability of free services Better understand why people use different sectors. Efficient use of existing resources Integration of services and training. Utilization and Demand Creation How to reduce unmet need, discontinuation and improve access to family planning? Availability of female providers with emphasis on underserved areas Improving counseling in all sectors Ensuring privacy and confidentiality Increasing outreach Improved provider knowledge, skills and attitude How do we focus an IEC/BCC program especially on contraceptive security – a national health communication strategy? How to increase male involvement in family planning decision making? Service Delivery How to ensure sustained delivery of quality family planning services and contraceptives? Improved referral system Appointment system Including counseling in pre-service and in-service training Expanding choices of family planning methods Private Sector How can we improve private sector contribution towards contraceptive security? How to get public sector recognize the significant role of the private sector in achieving contraceptive security? Commercial sector prices are very high and increasing – a large section of population cannot afford commercial sector prices. Logistics System Keep unified logistic system Annex 5 Contraceptive Priority Issues Voting List Please select the top six priority issues from the list below. Issues Vote Finance How do we fund the family planning program including contraceptives, IEC/BCC, and research five years from now? How do we establish a more rational approach to market segmentation? Efficient use of existing resources Utilization and Demand Creation How to reduce unmet need, discontinuation and improve access to family planning? How do we focus an IEC/BCC program especially on contraceptive security – a national health communication strategy? How to increase male involvement in family planning decision making? Service Delivery How to ensure sustained delivery of quality family planning services and contraceptives? Private Sector How can we improve private sector contribution towards contraceptive security? How to get public sector recognize the significant role of the private sector in achieving contraceptive security? Commercial sector prices are very high and increasing – a large section of population cannot afford commercial sector prices. Procurement How to achieve effective procurement for all sectors Logistics System How to maintain/sustain effective logistics system? Policies, Leadership How do we improve and maintain coordination among all partners (public sector, private sector, donors) Raise awareness around contraceptive security among: parliamentarians, religious leaders, young adults, males, teachers, policy makers Address missed opportunities to raise awareness of reproductive health awareness for all life stages (adolescents and adults, premarital exams, during child immunization visits, pre-natal visits, sterilization) Policies for use of user fees (retain by point of service, keep for family planning) Other policy issues should be addressed to promote contraceptive security: taxation, regulation and reform of insurance How to address issue of high turnover among top officials Annex 6 Top priority Contraceptive Priority Issues Issues Votes received How do we fund the family planning program including contraceptives, IEC/BCC, and research five years from now? 22 How to achieve effective procurement for all sectors 21 How to reduce unmet need, discontinuation and improve access to family planning? 18 How to ensure sustained delivery of quality family planning services and contraceptives? 16 Raise awareness around contraceptive security among: parliamentarians, religious leaders, young adults, males, teachers, policy makers 13 How to maintain/sustain effective logistics system 13 How do we improve and maintain coordination among all partners (public sector, private sector, donors) 12 How do we improve and maintain coordination among all partners (public sector, private sector, donors 12
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