Decentralizing and Integrating Contraceptive Logistics Systems in Latin American and the Caribbean: Considerations for Informed Decision Making Throughout the Health Reform Process

Publication date: 2005

DECENTRALIZING AND INTEGRATING CONTRACEPTIVE LOGISTICS SYSTEMS IN LATIN AMERICA AND THE CARIBBEAN CONSIDERATIONS FOR INFORMED DECISION MAKING THROUGHOUT THE HEALTH REFORM PROCESS OCTOBER 2006 This publication was produced for review by the United States Agency for International Development. It was prepared by the DELIVER project. DECENTRALIZING AND INTEGRATING CONTRACEPTIVE LOGISTICS SYSTEMS IN LATIN AMERICA AND THE CARIBBEAN CONSIDERATIONS FOR INFORMED DECISION MAKING THROUGHOUT THE HEALTH REFORM PROCESS The authors’ views expressed in this publication do not necessarily refl ect the views of the United States Agency for International Development or the United States Government. DELIVER John Snow, Inc. 1616 North Fort Myer Drive 11th Floor Arlington, VA 22209 USA Phone: 703-528-7474 Fax: 703-528-7480 Email: deliver_project@jsi.com Internet: www.deliver.jsi.com DELIVER DELIVER, a six-year worldwide technical assistance support contract, is funded by the U.S. Agency for International Development (USAID). Implemented by John Snow, Inc. (JSI) (contract no. HRN-C-00-00-00010-00) and subcontractors (Manoff Group, Program for Appropriate Technology in Health [PATH], and Crown Agents Consultancy, Inc.), DELIVER strengthens the supply chains of health and family planning programs in developing countries to ensure the availability of critical health products for customers. DELIVER also provides technical management of USAID’s central contraceptive management information system. Recommended Citation Sánchez, Anabella, Wendy Abramson, Nadia Olson, and Nora Quesada. 2006. Decentralizing and Integrating Contraceptive Logistics Systems in Latin America and the Caribbean: Considerations for Informed Decision Making throughout the Health Reform Process. Arlington, Va.: DELIVER, for the U.S. Agency for International Development. Abstract Th is paper highlights key considerations for policymakers in ministries of health and decision makers from the international donor community for prioritizing supply chain management throughout the health reform process—primarily when decentralizing and/or integrating the public health system. From a thorough compilation of experiences in the Latin American and Caribbean region, this paper synthesizes key ideas that policymakers, family planning managers, and logistics advisors can consider when implementing the decentralization and/or integration reforms of certain or all logistics systems functions to help sustain an effi cient and continuous supply of contraceptives. Th ese lessons illustrate how various logistics functions can be negatively aff ected when they are not prioritized throughout reform processes, while some reform measures can have positive eff ects on the supply chain when given priority attention throughout the planning and implementation process. Th rough careful planning, decision makers can help maintain a well-built logistics system that guarantees the availability of contraceptives to clients when implementing decentralization and integration reforms. CONTENTS iii CONTENTS ACRONYMS . v ACKNOWLEDGMENTS . vii EXECUTIVE SUMMARY. ix INTRODUCTION . 1 Health Sector Reforms: Decentralization and Integration . 1 IN BRIEF: CONTRACEPTIVE SECURITY AND THE CONTRACEPTIVE LOGISTICS SYSTEM . 3 Logistics Cycle . 3 Logistics Functions . 4 DECENTRALIZATION AND INTEGRATION: A BRIEF OVERVIEW OF THEORY AND PRACTICE . 7 Health Sector Reform . 7 Decentralization . 7 Integration .11 KEY CONSIDERATIONS FOR DECENTRALIZATION .17 Secure and Develop Commitment for Family Planning and Contraceptive Availability at All Levels .17 Identify the Logistics Functions That Perform Better When Centralized .17 Select Strong Leaders Who Can Facilitate Change .18 Plan for Decentralization .18 Focus on Human Capacity, Roles, and Responsibilities, and Invest in Training and Supervision .18 Prepare for New Roles for Central and Local Levels.18 Support the Development of Innovative Local-level Initiatives .19 KEY CONSIDERATIONS FOR INTEGRATION .21 Plan for Successful Integration .21 Focus on Human Capacity and Defi ne Clear Roles and Responsibilities .21 Involve Family Planning Managers and Logistics Experts in all Phases of Integration. .21 Recognize That Strong Leadership Is Essential .22 Identify the Logistics Functions that Perform Better When Integrated .22 SOME FINAL WORDS .23 REFERENCES .25 iv DECENTRALIZING & INTEGRATING CONTRACEPTIVE LOGISTICS SYSTEMS IN LATIN AMERICA & THE CARIBBEAN FIGURES 1. Logistics Cycle . 3 2. Vertical Logistics System .11 3. Integrated Logistics System .12 BOXES 1. El Salvador Ensures Health Facilities Access to Affordable Commodities . 8 2. Devolution in Bolivia Results in Higher Commodity Prices Than Necessary . 9 3. After Careful Planning, Integration Leads to Benefi ts .13 4. In Ghana, Some Logistics Functions Are Integrated While Others Stay Vertical .14 5. In Mali, Integrated Efforts Cause System Breakdown .14 TABLES 1. Logistics Functions . 4 2. Examples of Advantages and Disadvantages of Decentralizing Contraceptive Logistics Functions .10 3. Integration of Logistics Systems in Nicaragua .15 APPENDICES .27 1. Summary of Decentralization Status by Country and Logistics Function .28 2. Summary of Integration Status by Country and Logistics Function .31 ACRONYMS v ACRONYMS CCSS Caja Costarricense de Seguro Social (Costa Rica Social Security Institute) CS contraceptive security DFID Department for International Development (United Kingdom) EPI Expanded Programme on Immunizations HIV/AIDS human immunodefi ciency virus/acquired immunodefi ciency syndrome HSR health sector reform IMSS Social Security Institute (Mexico) LAC Latin American and Caribbean LMIS logistics management information system MOH Ministry of Health NGO nongovernmental organization PRISMA Peruvian nongovernmental organization RH reproductive health SIBASI basic integrated health system (El Salvador) TB tuberculosis UNFPA United Nations Population Fund USAID U. S. Agency for International Development vi DECENTRALIZING & INTEGRATING CONTRACEPTIVE LOGISTICS SYSTEMS IN LATIN AMERICA & THE CARIBBEAN ACKNOWLEDGMENTS vii ACKNOWLEDGMENTS Th e authors of this document express their gratitude to the Ministry of Health counterparts and the DELIVER staff throughout the Latin American and Caribbean region for their critical input and the time they took away from their busy schedules to review country-specifi c information presented in this paper. In addition, we thank Carolyn Hart for her technical review of this document. We are grateful to the USAID Bureau for Latin America and the Caribbean, particularly to Lindsay Stewart, for supporting this work. We also want to honor the memory of Daniel Th ompson for his pioneering work and leadership in logistics and decentralization. viii DECENTRALIZING & INTEGRATING CONTRACEPTIVE LOGISTICS SYSTEMS IN LATIN AMERICA & THE CARIBBEAN EXECUTIVE SUMMARY ix EXECUTIVE SUMMARY Health sector reform (HSR) and sector-wide, health-strengthening initiatives—supported by bilateral donors, multilateral agencies, and development banks—have had an impact (in some cases, a large impact) on contracep- tive logistics systems performance in most Latin American and Caribbean countries during the last two decades. Two components of HSR in particular—decentralization of the health sector and integration of health logistics system functions—have aff ected Ministry of Health and social security supply systems throughout the region. On some occasions, they have had a positive eff ect, but in other cases reforms have created challenges to maintain- ing effi cient and well-functioning contraceptive logistics systems. Challenges may be magnifi ed by recent gradual decreases in donor contraceptive support and by a growing demand for contraceptives in the region. To help countries during the transition from external assistance to self-sustainability, this paper discusses the importance of prioritizing logistics—or supply chain management—throughout the health reform process. Logis- tics, or supply chain management, is the set of activities that moves products to people. Th e supply chain can be designed to succeed in virtually any environment as long as policymakers and program managers are committed to making and keeping products available for their clients. In all circumstances, supply chain management requires careful and detailed planning, policy-level visibility and support, suffi cient human and material resources, and a commitment to the collection and use of accurate and timely information to drive supply chain decision making. Without these, supply chains are vulnerable to disruption and waste and many of the goals of health reforms can be lost. With these conditions, however, supply chains are robust and can bring many benefi ts in terms of program impact, effi ciencies and cost savings, quality of care, and customer satisfaction—all important objectives of most health reforms. Th is paper synthesizes key considerations that policymakers, family planning managers, and logistics advisors can take into account when implementing decentralization and/or integration reforms of certain or all logistics systems functions, which will help sustain an effi cient and continuous supply of contraceptives: Before implementing decentralization and integration eff orts, a commitment to family planning and to ensur- ing contraceptive availability must be sought and developed at all levels. Early planning is crucial to guarantee that reform eff orts—namely, decentralization and integration—help sustain commodity availability at all levels. Logistics functions must be carefully analyzed during the planning phases of decentralization and integration eff orts. Strong leadership often facilitates change; natural, respected leaders must be identifi ed and included in the process to guide technical discussions on the advantages and disadvantages of decentralizing and integrating certain aspects of the supply system. Data-based planning from the outset about possible challenges to decentralizing or integrating diff erent func- tions may result in more realistic plans and, consequently, make implementation easier. Some functions may lead to better system performance when they are centralized, while others may result in better performance when they are decentralized. John Snow, Inc./DELIVER’s experience suggests that health systems should retain central capability for some logistics functions that are most likely to fail when decentral- ized, for example— • • • • • • x DECENTRALIZING & INTEGRATING CONTRACEPTIVE LOGISTICS SYSTEMS IN LATIN AMERICA & THE CARIBBEAN logistics management information systems design of inventory control systems specifi cations and enforcement of essential medicines lists product selection and essential service package specifi cations bulk procurement rationing for scarce essential products quality assurance for all products. (John Snow, Inc./DELIVER 2001) A focus on human capacity and new roles and responsibilities must be part of the planning process to ensure true ownership of logistics responsibilities. Th is will require widespread training and elimination of duplicate roles and functions. Decentralization or integration of certain contraceptive logistics functions requires a signifi - cant investment in human capacity development, information systems, and logistics training at diff erent levels; without this training, the result may be less eff ective supply system performance. Th e time and eff ort required to reorient staff and provide logistics and supervisory training is often underestimated. A pilot test approach can help ensure smooth implementation of, for example, an integrated logistics informa- tion system that, subsequently, will be instituted on a larger, national scale. Th roughout the planning stage, family planning and logistics experts must be included for advice and analy- sis of the eff ects of decentralizing and integrating the contraceptive logistics system. Th is will help protect the family planning program and its positive eff ects on maternal and child health and will ensure contraceptive availability at all levels. For countries that are just beginning to plan for decentralization or integration and for those that are already in the implementation stage, it is important to proceed cautiously. Other countries’ experiences have shown that unanticipated problems may occur when supply chain management has not been considered a priority throughout the reform process. A lack of careful planning can seriously degrade the logistics system, interrupting the effi cient fl ow of commodities to the client, which is an essential component of any eff ective health program. – – – – – – – • • • INTRODUCTION 1 INTRODUCTION Traditionally, international donors have partially or completely supplied contraceptives to the Latin American and Caribbean (LAC) region. As a result, in-country ministries of health (MOHs) and social security institutes have set up, fi nanced, and managed vertical contraceptive logistics systems that function separately from essen- tial medicine and other specialized (also vertical) supply systems, such as vaccine, HIV/AIDS, tuberculosis (TB), and malaria supply chains.1 In recent years, however, donor support for contraceptives has started to decline worldwide. In the early 1990s, Latin America was the fi rst region to begin experiencing a decline in contracep- tive donations from the U.S. Agency for International Development (USAID) and other donors. Mexico, Chile, and Colombia were the fi rst to become completely donor independent, assuming total fi nancial and managerial responsibility for contraceptive procurement and distribution. Brazil and Costa Rica soon followed when donor contraceptive support ceased. In the LAC region, nine countries are beginning various stages of planning for the phaseout of external donations and/or technical assistance: Bolivia, Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Nicaragua, Paraguay, and Peru. Because of these shifts in donor support, MOHs have begun developing and strengthening their own national contraceptive security plans, including implementation of policy, procurement, fi nancing, service delivery, logistics, and market segmentation strategies. To help countries during the transition as they move from external assistance to self-sustainability, this paper discusses the importance of prioritizing logistics throughout the health reform process. Logistics—or supply chain management—is the set of activities that moves products to people. Th e following analysis illustrates that the supply chain can be designed to succeed in almost any environment, as long as policymakers and program managers are committed to making and keeping products available to their clients. In all circumstances, supply chain management requires careful and detailed planning, policy-level visibility and support, suffi cient human and material resources, and a commitment to the collection and use of accurate and timely information to drive supply chain decision making. Without these, supply chains are vulnerable to disruption and waste, and many of the goals of health reforms can be lost. With these conditions, however, supply chains are robust and bring enormous benefi ts in terms of program impact, effi ciencies and cost savings, quality of care, and customer satisfaction—all important objectives of most health reform initiatives. HEALTH SECTOR REFORMS: DECENTRALIZATION AND INTEGRATION During the past two decades, health sector reforms (HSRs)—supported by bilateral donors, multilateral agencies, and international fi nancing institutions—have, in one form or another, impacted contraceptive logistics systems in most LAC countries. Two HSR strategies in particular—decentralization of the health sector and integration of health logistics system functions—have created both positive eff ects, as well as challenges for public-sector contra- ceptive supply systems throughout the region. Integration can be defi ned as the merging of vertically managed health services and management activities—for example, the development of a consolidated logistics system for all essential medicines. Th e impending phaseout of contraceptive donations is frequently a justifi cation for integrating the contraceptive supply system into the overall logistics system for all essential medicines or vice versa. Decen- tralization in health systems typically pushes varying degrees of responsibility for management functions from the central to the regional or district level, or sometimes to the municipal or facility level. Degrees of decentralization 1. The term supply chain refers to the entire chain of storage facilities and transportation links through which supplies move from manufacturer to con- sumer, including port facilities, the central warehouse, regional warehouses, district warehouses, all service delivery points, and transport vehicles. 2 DECENTRALIZING & INTEGRATING CONTRACEPTIVE LOGISTICS SYSTEMS IN LATIN AMERICA & THE CARIBBEAN vary between functions and between countries, and discrepancies exist between policy and practice. While integration and decentralization can be benefi cial to ensuring that commodities get to the customers who need them, these reforms can pose signifi cant challenges to the integrity of the logistics system, particularly when supply chain management has not been prioritized throughout the reform process. Th e key fi ndings from this report about decentralization and integration of contraceptive supply systems can assist health managers and deci- sion makers prioritize supply chain management when considering or implementing HSR. IN BRIEF: CONTRACEPTIVE SECURITY AND THE CONTRACEPTIVE LOGISTICS SYSTEM 3 To achieve contraceptive security (CS), MOHs and others must know their commodity requirements, have or be able to coordinate the resources required to meet commodity requirements for the medium- to long-term, and eff ectively procure and distribute supplies (or have them procured and distributed) to clients. Understanding the logistics cycle (see fi gure 1), designing an eff ective logistics system, and effi ciently performing logistics functions provide the foundation essen- tial to attaining CS in any country. LOGISTICS CYCLE Supply chain management includes several components that must be in place and functioning eff ectively to move products effi ciently through the supply chain. Th e core focus of the logistics cycle is the consumer or customer of medicines and contraceptives. Each component of the logistics cycle must be in place and functioning eff ectively to move products through the diff erent levels of the logistics system and to ultimately deliver them to the custom- ers who need them (see fi gure 1). Figure 1. Logistics Cycle IN BRIEF: CONTRACEPTIVE SECURITY AND THE CONTRACEPTIVE LOGISTICS SYSTEM Contraceptive security has been achieved when individuals have the ability to choose, obtain, and use quality contraceptives and condoms whenever they need them. Qu alit y M onit oring Quali ty M onit ori ng Quality Monitoring Quality Monitoring Product Selection Serving Customers Inventory Management Logistics Information Money People Forecasting & Procurement 4 DECENTRALIZING & INTEGRATING CONTRACEPTIVE LOGISTICS SYSTEMS IN LATIN AMERICA & THE CARIBBEAN Th e essential components of the logistics cycle are— Product selection. Th is ensures that the right product is selected to meet the needs of the customers. Criteria for the selection of the right products must be clear and based on quality, eff ectiveness, and aff ordability. Data-based forecasting and procurement. Forecasting relies on historical consumption information as well as demo- graphic, morbidity, and program planning data to generate short- and medium-term projections that will deter- mine procurement needs and inform fi nancing options. Th e next step is to quantify the actual amounts to be procured, taking into account quantities in stock and on order, additional quantities needed to ensure adequate stock levels and buff er stocks, and available fi nanc¬ing. Commodities are then procured to ensure the timely deliv- ery of shipments, clearance of products through customs, and fi nal quality control checks. Inventory management. Th is includes the design and implementation of inventory control systems and entails correct warehousing, reliable transportation, and effi cient distribution of commodities throughout the supply chain. Logistics management information systems (LMISs). Th ese systems are critical to sound decision making. An LMIS collects data on the quantities of stock available at each distribution level, rates of consumption, and losses and adjustments. Streamlined management of this component (either run manually or through an automated system) is essential for eff ective overall system performance. An LMIS that has accurate, timely, and complete data allows managers to facilitate stock movements to ensure product availability, provide accountability to funders and poli- cymakers, help minimize waste, and ensure increased transparency. Political leadership and adequate fi nancing. Both of these help support the effi cient functioning of the logistics system. Th e logistics cycle must be supported by an eff ective policy and legal framework, which is addressed at the national level. Program managers, technical assistance providers, and donors must understand and articulate how each component in the cycle aff ects health service delivery and specifi c objectives that policymakers care about: health reform, cost recovery, commodity security, and program expansion. Political leadership is a necessary instru- ment to establish a legal and regulatory framework that supports commodity avail¬ability, including aff ordable prices, adequate fi nancing, and sound supply chain management. Quality monitoring. Th is should take place during all stages of the cycle. (Rao, Mellon, and Sarley 2006) LOGISTICS FUNCTIONS Understanding and examining the essential logistics functions, which are part of the logistics cycle described above, are funda- mental when prioritizing supply chain management throughout the reform process. Table 1 lists the essential logistics functions that must be effi ciently carried out throughout the logistics cycle to ensure commodity availability for the client. As mentioned above, the logistics system can be customized to any setting as long as international donors and agencies, as well as national policymakers, in close coordination with MOH family planning and logistics staff , carefully analyze the eff ects of health reforms on each function of the logistic cycle and on the logistics system as a whole, and then determine the most eff ective way to proceed with health reforms. More specifi cally, before program managers and policymakers begin to decentral- TABLE 1. LOGISTICS FUNCTIONS Functions of the Logistics System 1. Treatment protocols 2. Product selection 3. Forecasting and needs quantifi cation 4. Budgeting 5. Procurement 6. Inventory control 7. Transportation 8. Human resources/Personnel 9. Training and supervision 10. Monitoring and evaluation/Quality assurance 11. Logistics management information system 12. Warehousing and distribution 13. Organizational support IN BRIEF: CONTRACEPTIVE SECURITY AND THE CONTRACEPTIVE LOGISTICS SYSTEM 5 ize or integrate, they need to understand and examine each logistics function to determine the extent to which that function is currently eff ective, who manages and performs the function, and the resources required to ensure that each function is correctly carried out. After these determinations are made, steps can be taken to ensure that resources, functionalities, and effi ciencies are preserved, and possibly even improved upon, while reforms are carried out throughout the health sector. By preserving and deepening logistics function performance, policymak- ers and program managers can help guarantee a successful health reform process. Sustained commodity availability is a key component of any successful health program (Bossert et al. 2003). Th e following section provides lessons learned from various health reforms, which were carried out primarily in the LAC region. Th ese lessons illustrate how various logistics functions can be negatively aff ected when they are not prioritized throughout reform processes, while some reform measures can have positive eff ects on the supply chain when given priority attention throughout the planning and implementation process. 6 DECENTRALIZING & INTEGRATING CONTRACEPTIVE LOGISTICS SYSTEMS IN LATIN AMERICA & THE CARIBBEAN DECENTRALIZATION AND INTEGRATION: A BRIEF OVERVIEW OF THEORY AND PRACTICE 7 DECENTRALIZATION AND INTEGRATION: A BRIEF OVERVIEW OF THEORY AND PRACTICE HEALTH SECTOR REFORM Health sector reform (HSR) emerged as a major focus in the 1990s. Although its antecedents go back many decades, HSR measures were initially introduced by the World Bank in its World Development Report 1993: Invest- ing in Health (World Bank 1993). Th e goals of HSR include improving the quality, equity, and fi nancial sustain- ability of services as well as increasing access to these services. HSR is rooted in the desire of governments and lenders to provide expanded health care within limited budgets and resources. During the past two decades, HSR and sector-wide, health-strengthening initiatives—supported by bilateral donors, multilateral agencies, and development banks—have had an impact on contraceptive logistics systems in most LAC countries. Two components of HSR in particular—decentralization of the health sector and integra- tion of health logistics system functions—have created both positive eff ects as well as disruptions in the MOH and social security supply systems throughout the region. On some occasions, they have had a positive impact, but in other cases, reforms have created challenges to maintaining intact logistics systems. In addition, the phaseout of contraceptive donations is usually another justifi cation for integrating contraceptive supplies into the logistics system for distributing essential medicines or vice versa. DECENTRALIZATION Decentralization in health systems typically pushes varying degrees of responsibility for management functions from the central to the regional or district level or even the municipal or facility level. Degrees of decentraliza- tion vary between functions and between countries, and discrepancies exist between policy and practice. While decentralization can be benefi cial, it poses signifi cant challenges, particularly where capacity is minimal. In some respects, decentralization runs counter to many global trends in state-of-the-art logistics management, which obtains greater effi ciencies by centralizing decision making—for example, in areas such as procurement and information systems management. Most LAC countries have adopted or are planning to adopt varying models of decentralization reform in coming years. Degrees or levels of decentralization can be understood as follows: Deconcentration is the most limited and most common level of decentralization, under which authority, func- tions, and/or resources are transferred to regional and local fi eld offi ces of the central government. Delegation transfers authority, functions, and/or resources to an autonomous private, semipublic, or public institution. Devolution cedes autonomy and authority to autonomous local governments (usually municipalities), which, at least to some degree, take responsibility for service delivery, administration, and fi nancing of the health system. IN PRACTICE: SOME COUNTRY EXAMPLES Health sector reform has introduced many changes in policies that have aff ected health care delivery and the contraceptive logistics system on which health care depends. Done in the right way, these changes can help • • • 8 DECENTRALIZING & INTEGRATING CONTRACEPTIVE LOGISTICS SYSTEMS IN LATIN AMERICA & THE CARIBBEAN maintain family planning health gains and ensure effi cient distribution of contraceptives throughout the supply system. For example, the El Salvador case presented in box 1 illustrates how bulk price negotiations were preserved throughout the decentralization process, thus ensuring health facilities access to aff ordable commodities. While, in many cases, health and economic reforms have helped improve health service delivery, there have been examples of unintended adverse eff ects on the operation of family planning and other public health commodity supply chains. Th ese negative results have largely occurred because the implications of change on family planning and health commod- ity logistics systems were not considered during the planning and program design stage. Th ese outcomes have also occurred because staff at the local level needed to develop capacity to successfully carry out change and to take on new roles and respon- sibilities before reforms were implemented. Health sector decentralization frequently takes place under broader national decentraliza- tion eff orts that are supported by donors and international banks. Unfortunately, decentralization of health care systems is not always the result of thorough planning. Consequently, contra- ceptive logistics management functions that have usually worked effi ciently in a centralized and vertical system have often been disrupted by decentralization trends. In Bolivia, for example, after devolution of management functions to the municipal level, standardized norms and procedures for inventory control, and effi cient and transparent procurement management of health commodi- ties, have suff ered. As a result of devolution, bulk price negotiations are not carried out and commodity prices are higher than necessary (see box 2). Also, in Brazil, authority was devolved to municipalities without proper local capacity building or suffi cient communication about the implications of these changes over time. As a result, prod- uct availability was undermined due to a lack of capacity to effi ciently forecast, manage inventory, and procure commodities. In response, the family planning supply chain was recentralized to help rectify capacity constraints (DELIVER 2006). Several country- and function-specifi c examples of the diff erent types of decentralization are provided below. Deconcentration of procurement in Guatemala In Guatemala, procurement responsibility has been deconcentrated to the local health area level. At this time, deconcentration of the procurement function applies only to essential medicines but not to contraceptives. Annu- ally, a central-level committee negotiates price conditions with vendors for essential medicines on the basis of the BOX 1. EL SALVADOR ENSURES HEALTH FACILITIES ACCESS TO AFFORDABLE COMMODITIES In El Salvador, the MOH health system is currently deconcentrated into fi ve regions, which are, in turn, partially devolved into 27 basic integrated health care systems (SIBASIs). Each SIBASI receives and manages its own budget, including the provision of essential medicines. Although each SIBASI may independently forecast the need for essential medi- cines and contraceptives, the central MOH Essential Drugs Unit has successfully implemented a mechanism for consolidating forecasts to help lock-in bulk prices for essential medicines. This process includes tallying up product needs for each SIBASI and negotiating bulk procurements with vendors. Financial resources are then pooled from each SIBASI for a one-time procurement contract and pay- ment action. For contraceptives, the forecasting process as well as the funding mechanism is similar to that of essential medicines and supplies. The only differ- ence is that essential medicines are procured locally, whereas contraceptives are procured through the United Nations Population Fund (UNFPA). This system has resulted in numerous benefi ts, including substantial savings of limited government resources; more transparent, simplifi ed, and effi cient procurement processes; and stronger procurement capacity at the local level. This type of innovative strategy for ensuring centralized procurement under a decentralized system illustrates the MOH’s capacity to ensure cost-effective procurement while devolving decision making strategies to the local level. DECENTRALIZATION AND INTEGRATION: A BRIEF OVERVIEW OF THEORY AND PRACTICE 9 consolidated needs of the entire public health system. Th en, each health area plac- es its order directly with vendors at the pre-negotiated prices. Currently, contra- ceptives are not included in these negotia- tions because the contraceptive supply chain is still managed vertically, through collaboration with the United Nations Population Fund (UNFPA). When all donations of contraceptive commodities are completely phased out, procurement responsibility for contraceptives may also be deconcentrated to the local level. Th e challenge ahead will be to evaluate procurement options, both centralized and decentralized, that will help guarantee adequate availability of contraceptives at the lowest possible price and of the best quality (Abramson, Sánchez, and Olson 2006). Deconcentration of storage in Mexico To reduce costs and storage space requirements, Mexico’s Social Security Institute (IMSS) eliminated its central warehouse. IMSS’s suppliers now ship products directly to each of 37 delegation (state) stores. Elimination of the central warehouse reduces the need for storage space and warehouse staff , shortens the pipeline, and thus reduces costs. Th is action resulted in savings at the central level and signifi cantly reduced the transit time of the supplies by placing them closer to health facilities for the same price (Quesada and Reynoso 2002). Delegation of all functions in Costa Rica In the early 1990s, as part of HSR, Costa Rica’s MOH delegated all responsibility for health care provision (including family planning) to the Costa Rica Social Security Institute (CCSS). Th e MOH retained only a norma- tive function. In 2002, 88 percent of the population was offi cially registered with the CCSS, and the organization served as a safety net for the remainder of the population. (Health care facilities are required by law to provide care even to those not offi cially registered.) In 2005, the CCSS provided services to more than 72 percent of family planning users (Cisek and Olson 2006). Delegation of forecasting, procurement, and distribution in Peru Since the early 1990s, PRISMA, a Peruvian NGO contracted by USAID, was responsible for the MOH’s contra- ceptive forecasting, procurement, and warehousing and distribution in Peru. Th e NGO managed the national warehousing information system; supported a central warehouse where contraceptives were stored; coordinated and funded a quarterly distribution of contraceptives to 184 points in the country; and provided training and technical support to MOH staff . However, the system has now changed, and PRISMA is transferring some of this responsibility to SISMED, the national public-sector essential medicines system. (For more information, a Peru case study is available in [Beith et al. 2006]). Th e impact of this transfer remains to be seen as the MOH takes on this additional role under a highly decentralized and integrated system. BOX 2. DEVOLUTION IN BOLIVIA RESULTS IN HIGHER COMMODITY PRICES THAN NECESSARY In Bolivia, the central government transferred authority for all aspects of administering the family planning program to local governments at the district level. Municipalities are now responsible for managing all aspects of family planning, including securing adequate funding for purchasing contraceptives and managing forecasting and procure- ment. Because contraceptives are still donated, municipalities have not included a budget to purchase these supplies despite the fact that under the Universal Insurance for Mother and Child Law each municipality should provide contraception to all women of repro- ductive age who want this service. In addition, one of the greatest barriers to achieving economies of scale and low prices for commodities is the fact that each municipal- ity has autonomy to procure essential medicines and contraceptives separately and locally—in some cases even from nearby pharmacies. Because bulk price negotiations do not take place, the country does not benefi t from the economies of scale achieved when purchasing higher volumes of commodities. 10 DECENTRALIZING & INTEGRATING CONTRACEPTIVE LOGISTICS SYSTEMS IN LATIN AMERICA & THE CARIBBEAN ADVANTAGES AND DISADVANTAGES OF DECENTRALIZING CONTRACEPTIVE LOGISTICS FUNCTIONS Th e decentralization eff ort is a continuing process that requires fl exibility to help adapt to new roles and respon- sibilities at lower levels. It also requires thorough knowledge about the reality of local-level needs and capacities and the extent to which such constraints must be addressed before reform measures are put in place. Experience in various countries in Latin America demonstrates that, even when the political mandate is to decentralize all the logistics functions, these cannot be delegated all at once or without careful planning. A streamlined and eff ective reform process requires comprehensive and detailed planning and analysis of the advantages and disadvantages of decentralizing each logistics function (see table 2). TABLE 2. EXAMPLES OF ADVANTAGES AND DISADVANTAGES OF DECENTRALIZING CONTRACEPTIVE LOGISTICS FUNCTIONS Function Advantages Disadvantages Treatment protocols Service delivery based on local needs. Reduced control over prescribing practices. Product selection Selection based on local needs. Reduced infl uence on— treatment guidelines products for priority essential services priority of preventive products like contraceptives. • • • Forecasting and needs quantifi cation, budgeting, and procurement Quantifi cation based on local requirements. Local ownership of commodity requirements and commitment to ensure product availability. Visibility and accountability at local level for forecasting and budgeting mistakes and procurement irregularities. Greatly increased prices. Increased— forecasting labor forecasting error inadequacies in local fi nancial budgets procurement complexity without basic guidelines for procurement procedures. Commodity quality control diffi cult if procurement is decentralized If staffs are not trained properly, wastage can occur. • • • • Inventory control, transportation Local control over reordering decisions. Local control of shipping schedules and transportation means. Lack of standardized guidelines and procedures that enhance accountability and transparency Impossible to rationally allocate scarce products. Local resources (staff and transport) may be unavailable. Logistics management Information system Experience has demonstrated that this function performs effi ciently only if it remains centralized. LMIS may be lost or folded into the health management information system. Lack of standardized forms, guidelines, and fl ow of information As a feedback mechanism, information no longer fl ows from the lower to the central level. Human resources management/personnel, training and supervision If leadership is exercised, resources are available, and local capacity is institutionalized, local levels have demonstrated good judgment to resolve human resources gaps to carry out logistics functions. In most cases, local trained staff may be absent or lacking necessary skills. Quality assurance Experience has demonstrated that this function performs effi ciently only if it remains centralized. Often, local levels do not have the skills or specialized equipment to perform formal quality assurance measures. Commodity quality control is diffi cult to manage if procurement is decentralized. Source: (JSI/DELIVER 2001) DECENTRALIZATION AND INTEGRATION: A BRIEF OVERVIEW OF THEORY AND PRACTICE 11 Human resources management and the proper clarifi cation of new roles and responsibilities of local-level staff in times of health reform and decentralization are of the utmost importance for the proper functioning of the logistics system. During the decentralization process, health managers need to work closely with both the human resources directorate at the central level and staff at the local levels to ensure that logistics functions, responsi- bilities, and authority are explicitly delegated. Th is can help develop an enabling environment for local staff s to perform their new roles and responsibilities. Often, oversight of this undertaking limits the performance of local staff that are expected to eff ectively manage one of the most important public health budget line items: health commodities.2 INTEGRATION For many decades, family planning and vaccine supplies have been managed independently from other essential medicine supply chains. Th is is primarily because vertical programs, such as family planning and immunizations, have also received a signifi cant level of donor support. Moreover, the immunization programs have benefi ted from strong political will to make vaccines available throughout the entire public health system. Th e result has often been the implementation of well-run commodity management systems and improved product availability. Recently, however, the rise in the essential medicines movement led by the World Health Organization, and the Expanded Programme on Immunizations (EPI) in the LAC region, have highlighted the need to deal with drug management issues across programs; in general, vertical logistics systems have shifted to integrated logistics systems that manage and supply health commodities for several or all health programs at once. Integration is best defi ned as the merging of vertically managed health services and management activities. Figures 2 and 3 provide a very basic illustration of the diff erences in how vertical and integrated systems operate. Figure 2. Vertical Logistics System 2. This section (Decentralization) is based on the following materials: (Bates et al. 2000), (Bossert n.d.), and (JSI/DELIVER 2001). 12 DECENTRALIZING & INTEGRATING CONTRACEPTIVE LOGISTICS SYSTEMS IN LATIN AMERICA & THE CARIBBEAN Figure 3. Integrated Logistics System While these fi gures depict a general illustration of vertical and integrated logistics systems, it is important to scruti- nize every logistics function and how its performance will be aff ected by integration eff orts. Field experience has demonstrated that some functions may lead to better system performance when they are vertical, while others may result in better performance when they are integrated. Th us, health policymakers and family planning and logistics experts must carefully analyze each function and determine whether to maintain vertical or integrated manage- ment of this aspect of the logistics system. Overlooking this careful examination will hinder the correct function- ing of the contraceptive logistics system. Some experts believe that vertical systems are less desirable because commodities are forced to compete for the same scarce resources: budgetary allocations, facilities, equipment, and trained personnel working in logistics management. Other experts believe that it is important to maintain a few select vertical programs to ensure that these programs are given priority attention and support, protect public health gains ensured by these special programs, and provide essential health and logistics data for local and central levels. In fact, successful programs, such as the IMSS in Mexico and the MOH in Chile, have maintained vertical family planning programs in spite of the deconcentration of most family planning responsibilities and functions. INTEGRATION OF CONTRACEPTIVE SUPPLY CHAINS WITH ESSENTIAL MEDICINES Th e integration of vertical contraceptive supply chains with larger essential drug systems continues in many countries. Integration can have both positive and negative impacts on the contraceptive logistics system. While investing in the management of a vertical program can produce superb results for indicators such as commod- ity availability, a focus on the management of a vertical program does not necessarily ensure the most effi cient use of available public-sector funds. For example, capitalizing on overall supply chain improvements, rather than investing in each supply chain separately, can help countries stretch limited resources and make improvements to all supply chains at one time. However, such broad attention may negatively impact certain priority programs by diff using oversight throughout a much larger and cumbersome system. As with decentralization, integration is a gradual and continuous process that should consider, after a careful analysis, one or two functions at a time. In DECENTRALIZATION AND INTEGRATION: A BRIEF OVERVIEW OF THEORY AND PRACTICE 13 addition, program managers and policymakers can consider mixed systems in which certain supply chain func- tions are integrated while other functions—or aspects of the same functions—maintain some degree of vertical oversight. For instance, the integration of physical processes, such as storage and transportation, can be accompa- nied by a degree of vertical program oversight and management to ensure product availability. Th e process of integration also requires good preparation and planning to ensure success. Over the long term, integration can support contraceptive security objectives as investments that will strengthen national supply chains for all commodities. However, over the short term, if not planned carefully, it can create problems: the process of integration can disrupt existing roles and management structures, and staff must prepare for and be trained in new procedures to ensure that family planning programs are given the level of priority attention necessary to ensure contraceptive availability at all levels. IN PRACTICE: SOME COUNTRY EXAMPLES Th is segment provides brief examples of vertical and integrated logistics functions from countries in the Latin American and Caribbean region and other regions as well. Many countries, especially those graduating from donor support, see integration of contraceptive logistics as a logical step. Frequently, the contraceptive logistics system performs more effi ciently than that for other products, so integration becomes a way of capitalizing on those strengths by incorporating additional products and supplies into the system that is performing more effi ciently. Again, to maintain continuous availability of every commod- ity included in an integrated logistics system, the decision to integrate must rely on a thorough analysis of each logistics function. For instance, countries should not consider integrating the recording and information systems without planning to have an automated system. If integration occurs without automation, the system might collapse because manual capacity to process data would be insuffi cient for such a large number of products. For example, in Guatemala, the Ministry of Health decided that the logistics information system should be inte- grated right from the start; however, the contraceptive component was developed fi rst and is now being used as a model to ensure that the same improvements take place for essential medicines. Th e future challenge is to ensure that the historic gains in contraceptive availability are maintained as the contraceptive supply chain is integrated with all other essential medicines. In addition, in both Nicaragua and Bolivia, where the contraceptive logis- tics system sets the example, other drugs were integrated into this system. In Bolivia, more than 100 drugs were integrated into the Unifi ed National Supply System, including contraceptives. In Nicaragua, 11 tracer drugs were integrated into the contraceptive logistics system. Nicaragua is planning to expand and integrate a larger number of essential medicines after an automated system is fully developed and implemented. In Nicaragua, integration has led to some benefi ts for contra- ceptive supply chain management due to careful planning (see box 3). Again, the challenge, in these cases, will be to maintain the gains achieved in contraceptive availability after these supply systems are fully integrated with other essential medi- cines. Th e Ghana example describes the process of integrating some logistics functions while keeping others vertical and how, in this case, a mixed approach has proved to be most eff ective for ensuring contra- ceptive availability (see box 4). BOX 3. AFTER CAREFUL PLANNING, INTEGRATION LEADS TO BENEFITS In Nicaragua, the system was vertical until 2005, when the Essential Drugs Unit of the Ministry of Health decided to take advantage of the successes of the contraceptive logistics system and integrate essential medicines with con- traceptives. A pilot test of the new integrated system took place in 2005; the experience has been very positive. As of now, only 10 tracer drugs and four contraceptives are integrated; once the automated system for the integrated LMIS is ready, all essential medicines will be integrated. This decision will reduce the number of vertical systems from seven to one. Warehousing and distribution of supplies are now fully integrated as well. Careful planning and coordination, including prioritization of supply chain management goals, has guaranteed the smooth integration of these functions, which are expected to result in savings for the MOH, in both human and fi nancial resources. 14 DECENTRALIZING & INTEGRATING CONTRACEPTIVE LOGISTICS SYSTEMS IN LATIN AMERICA & THE CARIBBEAN In contrast, as revealed by the case of Mali, described in box 5, poorly implemented integration eff orts can result in system breakdown. As mentioned above, Nicaragua, after careful planning and a pilot test of an integrated model, has managed to keep some logistics functions vertical, including procurement and forecasting, while others have recently been integrated, such as inventory control, information systems management, distribution, and storage functions (see table 3). POSSIBLE IMPACT OF INTEGRATION ON CONTRACEPTIVE LOGISTICS Contraceptive logistics experts had previously viewed integration as having a negative impact on contraceptive supply. In recent years, however, experiences in various countries have revealed mixed impacts: integration of contraceptive and essential medicines systems may have a positive impact on some functions of the logistics system and a negative impact on others. For example— In Bolivia, integration was a disrupting factor to the contraceptive data quality of the LMIS, but at the same time, integration contributed to improved standards or norms for LMIS reporting. Th e contraceptive logistics system was the basis upon which an integrated logistics system for essential medicines and medical supplies was developed. When integration fi rst took place, some disruptions occurred and, therefore adjustments have been made, particularly in the information systems and merging of forms. As a result of these adjustments, the contraceptive system, although integrated, will be temporarily maintained parallel to other information systems • BOX 5. IN MALI, INTEGRATED EFFORTS CAUSE SYSTEM BREAKDOWN In 1998, Mali introduced some major organization re- forms in public health logistics. The government created the National Pharmacy, a new organization with com- mercial incentives for using national wholesalers, includ- ing one that held the sole contract to provide USAID contraceptives. The vertical contraceptive system was dismantled and integrated into the system managed by the National Pharmacy. However, the managers at the National Pharmacy disagreed with the idea that they should obtain contraceptives from the designated supplier and refused to do so. No mechanism existed for revers- ing this position. It was not long before stockouts began to occur, discovered mainly through site visits and most likely due to the integration effort. Health reform advo- cates had assumed that issues data provided by the new integrated LMIS would be suffi cient for forecasting needs and ensuring distribution, and that the dispensed-to-user data supplied by the old contraceptive LMIS would not be missed. Under the new system, supervisory visits that had been used to collect data from health establishments ceased—and so did the fl ow of information. BOX 4. IN GHANA, SOME LOGISTICS FUNCTIONS ARE INTEGRATED WHILE OTHERS STAY VERTICAL Until 2001, the MOH in Ghana operated more than four vertical supply chains of health commodities (including contraceptives). The family planning program was primar- ily a vertical system, with its own managers who were in charge of the forecasting, logistics information system, and inventory control. In the storage facilities, contraceptives were kept in a separate area. Later, the MOH identifi ed the need to integrate the verti- cal supply chains to make them more effi cient. The DE- LIVER project provided technical assistance to assess four logistics vertical supply chains related to contraceptives, essential medicines, non-medicine consumables, and vac- cines. As a result, today the contraceptive logistics system is integrated with essential medicines and non-medicine consumables. The warehousing, transportation, and inven- tory control management functions are integrated, while the contraceptive forecasting and procurement have been kept vertical, mainly because UNFPA is the contracep- tive procurement agent for the MOH and some of the contraceptives are provided by USAID and the Depart- ment for International Development (DFID). The logistics information system is expected to be integrated in the near future; the challenge will be to make sure contracep- tives continue to be given the priority attention they have received in the past. DECENTRALIZATION AND INTEGRATION: A BRIEF OVERVIEW OF THEORY AND PRACTICE 15 to avoid any potential loss of information during the transition from a vertical to an integrated logistics infor- mation system. Th is practice will remain until the integrated information system is fully piloted, adapted, and put in place. At the same time, integration in Bolivia has also had some favorable eff ects in that it implemented national norms and standards that health facilities and municipalities are expected to follow when managing information systems. In Nicaragua, integrating the distribution of essential medicines and contraceptives improved the availability of both types of products at the regional level, as contraceptives and essential drugs are now treated with the same level of priority; they have the same distribution schedule, which represents savings for the national program. In Zambia, before integration of stores management, the capital city maintained separate storage sites for as many as eight diff erent health programs, making transportation arrangements complicated. After integration, when supplies for all vertical programs except EPI were shifted to the Medical Stores Limited (MSL), the new system with its one-stop shopping made resupply visits to Lusaka from the districts much easier. On the other hand, integration eff orts created major logistics-related problems when policymakers moved to an integrated health management information system (HMIS) that tracked the availability of only a small number of tracer drugs: they stopped using data collection forms that provided more detailed information on consumption, stock positions, and losses at all levels of the system. Th e confusion between the functions of HMIS and LMIS stopped the fl ow of contraceptive logistics information. As a result, the central level no longer received the data it needed to estimate future contraceptive needs and lost the capacity to monitor and respond to stockouts at peripheral levels. Careful planning can help ensure that supply chain management concerns are prioritized throughout the integra- tion process and that the appropriate logistics functions, or aspects of functions, are integrated while other func- tions, or aspects of functions, continue to be managed vertically. INTEGRATION POLICIES AFFECT EVERY FUNCTION OF THE CONTRACEPTIVE LOGISTICS SYSTEM Every logistics function is aff ected by the plans and policies that a country institutes as it carries out integration measures. In some cases, the integration of the family planning program and its corresponding logistics system may lose priority when integrated if the program lacks political support throughout the reform process. For example, in 2001, Peru began to integrate the FP program into all other health programs (Beith et al. 2006). Th is integration process greatly compromised the family planning and contraceptive logistics system, particularly by a reduction in management staff and the merging of budgets because the MOH had little commitment to taking over contraceptive supply chain management from an outside entity. PRISMA, a local NGO, had previ- • • TABLE 3. INTEGRATION OF LOGISTICS SYSTEMS IN NICARAGUA Function Contraceptive Logistics System Essential Medical Supplies Logistics System Procurement Donations Budgets, loans, and donations Forecasting Consumption based Based on budgets and prioritized health problem areas Needs quantifi cation Yearly to twice a year ; fl exible depending on consumption and available donor budgets Annual needs estimates; little fl exibility Logistics management information system Contraceptive-specifi c information system Medical supplies—specifi c information system, but integration of contraceptives LMIS is in progress Inventory control According to established max/min levels No reserve levels Distribution Integrated: either (1) from central warehouse to regional integral health care systems (or SILAISs) or (2) from central warehouse to municipalities. In addition, in a few instances in the case of essential medicines, suppliers distribute directly to selected municipalities and hospitals. Storage Integrated: storage and control norms pertain to all products. Source: (Taylor et al. 2004) 16 DECENTRALIZING & INTEGRATING CONTRACEPTIVE LOGISTICS SYSTEMS IN LATIN AMERICA & THE CARIBBEAN ously managed the contraceptive supply system, but careful planning did not take place to ensure these functions would be smoothly absorbed by the MOH. Th ese disruptions ultimately compromised the adequate availability of contraceptives. Because of such experiences, policymakers need to analyze the effi ciency of maintaining some functions as vertical—such as management of logistics information and forecasting and/or procurement—while integrating others, such as warehousing and distribution. In addition, throughout the reform process, if a new institution is going to absorb new functions, careful planning and advocacy work must take place to make sure there is political will at all levels to transfer these responsibilities from one institution to another and to ensure the new management unit has the ability and willingness to absorb these new functions. Policymakers may also consider keeping priority programs, such as family planning and immunization, vertical to protect the important health gains assured by these programs. Even though they operate under decentralized settings, some countries—Ecuador, Mexico, and Chile, for example—have kept the family planning program and the contraceptive logistics system vertical to ensure that women have access to the contraceptives they want and need and to protect maternal and child health gains guaranteed by increased access to family planning services. Moreover, before integration policies are outlined by health policymakers, it is essential to consider the following factors when integrating health systems: Earmark funds or maintain separate budget line items for preventive programs such as vaccines and contraceptives. Donors often drive the decisions about integrating health programs or changing from integrated to vertical programs. It is important that such decisions also be based on a thorough analysis of the advantages and disad- vantages of integrating each separate logistics function before implementing integration of health programs. Unifying only products and system functions for which integration will improve the effi ciency of the logistics system is often a good approach that enables countries to derive benefi t from the advantages of both vertical and integrated systems. Remember that integration is a continuous process and the logistics system will, at certain stages, be partially integrated, with some functions working vertically while others are working in an integrated way. Integration is sometimes implemented before policy decisions and public health priorities have been clearly identifi ed and communicated at both the central and the local levels. Before communicating these policies, analyze and redesign the logistics system to operate in an integrated manner, pilot test its implementation, and trail the tracer products, including family planning commodities. Th is will avoid interferences in the fl ow of contraceptives to clients. To guarantee effi cient control and management of the system, if the information system is to be integrated, ensure that automation is part of the plan. Ensure that family planning and logistics management champions, including civil society advocates, continue to provide priority or vertical attention toward ensuring sustained contraceptive availability during, throughout, and after integration has taken place.3 • • • • • • • 3. Source for this section (Integration) is Bates et al. 2000. KEY CONSIDERATIONS FOR DECENTRALIZATION 17 KEY CONSIDERATIONS FOR DECENTRALIZATION Th e ultimate goal of health sector reform (HSR) initiatives is to improve access to and equity in health care service provision. An essential element of improving access to health care services is to ensure commodity security—to guarantee access to commodities for all individuals who need or want them. Th erefore, decisions about decentral- ization need to be made jointly by donors, ministries of health, and managers of various health programs to guar- antee improved logistics system performance and availability of all essential products (including contraceptives) for all the clients who need them. More specifi cally, if decentralization eff orts do not receive vigilant guidance from central-level leaders to ensure that national family planning policies are implemented at lower levels, there is a danger that contraceptive logistics systems will weaken and contraceptive availability will be compromised. As with other approaches to improving access to health care and commodities, there is no single or cookie-cutter approach to improving decentralization and integration of logistics systems, or to ensuring that reforms do not compromise contraceptive availability. Nonetheless, the following recommendations are based on common chal- lenges and opportunities emerging from country experiences that must be addressed if effi cient and solid logistics systems are to be attained and maintained and the contraceptive supply chain protected throughout the reform process. SECURE AND DEVELOP COMMITMENT FOR FAMILY PLANNING AND CONTRACEPTIVE AVAILABILITY AT ALL LEVELS Th e challenge in decentralized systems is to develop political support for family planning and contraceptive availability at all levels. It is extremely important that, before decentralizing the system, the central level is fully committed to family planning and to guaranteeing contraceptive availability and has placed it as a high prior- ity. Ideally, this commitment would then translate to the lower levels of the health care system. Th is begins with awareness raising about the importance of family planning and contraceptive availability among central and local health authorities, civil society leaders, and community-based groups that oversee commodity budgets and availability. Because most decentralization reforms emphasize the importance of community involvement and oversight, advocacy work at the local level with community leaders and civic groups will also help guarantee that family planning is given the priority attention necessary to guarantee contraceptive availability at all levels. IDENTIFY THE LOGISTICS FUNCTIONS THAT PERFORM BETTER WHEN CENTRALIZED Studies undertaken in Ghana and Guatemala suggest that higher system performance may result from keeping certain logistics management functions centralized while decentralizing others (Bossert et al. 2003, Bossert et al. 2004). Specifi cally, the studies indicate that the design of the inventory control system, logistics information system management, and product selection functions require enforced and standardized central guidelines and procedures. At the same time, decentralization of planning and budgeting may be associated with higher perfor- mance. Based on fi eld experience, health managers are advised to retain central authority for the logistics functions that are most likely to fail if the functions are decentralized, including— logistics management information systems• 18 DECENTRALIZING & INTEGRATING CONTRACEPTIVE LOGISTICS SYSTEMS IN LATIN AMERICA & THE CARIBBEAN design of the inventory control system specifi cations and enforcement of essential medicines lists product selection and essential service package specifi cations bulk procurement rationing for scarce essential products quality assurance for all products. (John Snow, Inc./DELIVER 2001) SELECT STRONG LEADERS WHO CAN FACILITATE CHANGE A strong leader can help bring about eff ective change. Where strong local leaders are identifi ed, it is wise to allow them to have a prominent role in guiding the decentralization reform process, building up local buy-in, and ensur- ing that the family planning program and supply chain management are given the priority attention they require. PLAN FOR DECENTRALIZATION Some of the disruptions that decentralization can cause in logistics systems performance can be avoided with good planning and careful analysis of all the logistics functions. During the planning phase, it is important not to underestimate the funding required, the technical complexity of the work needed to ensure continuity of a well-functioning logistics system, organizational constraints, and the time required to implement change. Simulta- neously, it is also important not to overestimate the availability and skills of personnel at the local level to take on new roles and responsibilities. Moreover, decision making should be decentralized only if local managers have the necessary resources, training and skills, and authority to execute those decisions. FOCUS ON HUMAN CAPACITY, ROLES, AND RESPONSIBILITIES, AND INVEST IN TRAINING AND SUPERVISION Health managers must work closely with the human resources directorate at the central level and staff from local health establishments to ensure that logistics functions, responsibilities, and authority are explicitly delegated and fully funded. Th is can help develop an enabling environment for local staff to perform their new roles and respon- sibilities. Often, overlooking this undertaking limits the performance of local staff who are expected to eff ectively manage one of the most important public health budget line items—health commodities. Moreover, it is critical to strengthen and develop local-level capabilities and to invest in logistics training and supervision. PREPARE FOR NEW ROLES FOR CENTRAL AND LOCAL LEVELS Decentralization often means a dramatic change in the role of the central level as Ministries of Health move from service delivery provider to a more normative or regulatory role. Indeed, one of the basic functions of the central level is to develop regulations, norms and protocols, and procedural guidelines for the entire health system, includ- ing the logistics system. Th is role, still needed in a decentralized setting, provides basic guidelines for managers in local health establishments who, in their respective jurisdictions, assume responsibility for service provision and health outcomes. • • • • • • KEY CONSIDERATIONS FOR DECENTRALIZATION 19 SUPPORT THE DEVELOPMENT OF INNOVATIVE LOCAL-LEVEL INITIATIVES Decentralization can encourage local health establishments to develop innovative solutions to service-delivery and human-resource challenges as well as to allow civil society a more active role in oversight and provision of health care services. As a result, local concerns and needs can be better addressed in a decentralized setting, which can result in very positive eff ects on contraceptive security and increased access to family planning services. 20 DECENTRALIZING & INTEGRATING CONTRACEPTIVE LOGISTICS SYSTEMS IN LATIN AMERICA & THE CARIBBEAN KEY CONSIDERATIONS FOR INTEGRATION 21 KEY CONSIDERATIONS FOR INTEGRATION Several countries in the LAC region have either integrated or are preparing to integrate some functions of their contraceptive logistics system with other health program logistics systems. Many of these contraceptive logistics systems were eff ective and effi cient before these reforms were carried out; the ministries of health of Bolivia, Peru, and Nicaragua chose to adapt those existing contraceptive logistics systems to the supply chain management of all essential medicines and medical supplies. Th e recommendations presented below consider the fact that integration is a dynamic process. As such, the logistics system often operates more eff ectively with a combination of verti- cal and integrated functions. Most important, to maintain a robust logistics system that guarantees continuous product (including contraceptive) availability, managers must engage in a thorough analysis of logistics functions throughout the integration process. PLAN FOR SUCCESSFUL INTEGRATION It is vitally important to plan ahead for the integration of supply systems. Guiding principles need to be estab- lished, specifi cations developed, and detailed workplans prepared that clearly articulate the responsibilities and expectations of all partners in an integrated supply system. Before introducing an integrated system at the national level, the system must be designed and carefully tested. It is important to revise, test, and then fi nalize all policies and procedures related to human resources; information fl ows; databases; training manuals; and guidelines and tools for supervising, monitoring, and evaluating the logistics system over time. FOCUS ON HUMAN CAPACITY AND DEFINE CLEAR ROLES AND RESPONSIBILITIES When integrating logistics systems, it is easy to eliminate a specifi c responsibility for one staff position while neglecting to include the responsibility under another position. It is also easy to underestimate the eff ects that changing roles and responsibilities will have on the logistics system, or overestimate staff willingness to cooperate and move the process forward. Th ese problems can be minimized by planning extensive training in the new roles and responsibilities of all related staff and avoiding deletion or duplication of roles and functions when reforms are implemented. INVOLVE FAMILY PLANNING MANAGERS AND LOGISTICS EXPERTS IN ALL PHASES OF INTEGRATION. Involving family planning managers and logistics experts in early planning stages and throughout the reform process will improve the outcomes of integrating various logistics functions. Such expertise will help protect the family planning program and its positive eff ects on maternal and child health, as well as help maintain an effi cient supply chain. 22 DECENTRALIZING & INTEGRATING CONTRACEPTIVE LOGISTICS SYSTEMS IN LATIN AMERICA & THE CARIBBEAN RECOGNIZE THAT STRONG LEADERSHIP IS ESSENTIAL Championship is the active, personal interest of senior decision makers who have the authority to induce change and prioritize programs. Th eir interest has been shown to be essential for facilitating successful logistics reform and ensuring sustained contraceptive availability. IDENTIFY THE LOGISTICS FUNCTIONS THAT PERFORM BETTER WHEN INTEGRATED Integration makes the most sense for functions such as storage and distribution; savings in these two areas are substantial because they reduce management and transportation costs. Another function that may be integrated is the logistics management information system, in which a database may run unifi ed for all essential medicines, contraceptives, and other centrally procured medicines, while still allowing desegregation of data for individual products. Moreover, automation is essential when integrating a large number of products. SOME FINAL WORDS Health services in most Latin American countries are provided by a number of public bodies; the principal provid- ers are usually the ministry of health and the social security institute. Countries in the region should consider what options currently exist that could be coordinated among institutions to gain increased economies of scale in procurement, distribution, LMISs, and other aspects of logistics management throughout the reform process. For countries that are just beginning to plan for decentralization or integration and for those already in the implemen- tation stage, it is important to proceed cautiously. Other countries’ experiences have shown that unanticipated problems may occur when supply chain management has not been considered a priority throughout the reform process. A lack of careful planning can seriously degrade the supply system, thus interrupting the effi cient fl ow of commodities to the client, an essential component of any eff ective health program. Th e lessons presented earlier illustrate how various logistics functions can be negatively aff ected when they are not considered during health reform processes. At the same time, reforms can have a positive impact on the supply chain as long as it is given priority attention throughout the reform planning process and during the implementation phase. Political situations and priorities change, even to the extent that they might be considered political fashions. Th ey come and go with the passage of time in every society, necessitating systemic reforms and organizational adapta- tions. Decentralization and integration are two such forces currently abroad in the health sector in Latin America. Supply chains can be designed to succeed in virtually any environment as long as policymakers and program managers are committed to making and keeping products available to their clients. Under any circumstance— centralized or decentralized, vertical or integrated—supply chain management requires careful and detailed planning, policy-level visibility and support, suffi cient human and material resources, and a commitment to the collection and use of accurate and timely information to drive supply chain decision making. Without these, supply chains are vulnerable to disruption and waste. With these conditions, however, supply chains are robustly successful and bring copious benefi ts in terms of program impact, effi ciencies and cost savings, quality of care, and customer satisfaction. Our experience in Latin America with health systems that have contended with a wide variety of decentralization and integration contingencies bears this out. SOME FINAL WORDS 23 24 DECENTRALIZING & INTEGRATING CONTRACEPTIVE LOGISTICS SYSTEMS IN LATIN AMERICA & THE CARIBBEAN REFERENCES 25 REFERENCES Abramson, Wendy, Anabella Sánchez, and Nadia Olson. 2006. 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Cambridge, Mass.: Data for Decision-making Project/Harvard University of Public Health, for the U.S. Agency for International Development (USAID). Bossert, Th omas, Diana Bowser, Johnnie Amenyah, and Becky Copeland. 2003. Guatemala: Decentralization and Integration in the Health Logistics System. Arlington, Va.: John Snow Inc./DELIVER, for the U.S. Agency for International Development (USAID). Bossert, Th omas, Diana Bowser, Johnnie Amenyah, and Becky Copeland. 2004. Ghana: Decentralization and the Health Logistics Systems. Arlington, Va.: John Snow Inc./DELIVER, for the U.S. Agency for International Development (USAID). Cisek, Cindi, and Nadia Olson. 2006. Contraceptive Procurement Policies, Practices, and Lessons Learned in Costa Rica. Arlington, Va.: DELIVER, and Washington, DC: USAID | Health Policy Initiative, for the U.S. Agency for International Development. DELIVER. 2006. Contraceptive Procurement Policies, Practices, and Lessons Learned in Brazil. Arlington, Va.: DE- LIVER, for the U.S. Agency for International Development. John Snow Inc./DELIVER. 2001. Strategic Decentralization: Centralizing Logistics. Arlington, Va.: John Snow Inc/DELIVER, for the U.S. Agency for International Development. Quesada, Nora, and Angel Reynoso. 2002. Evaluaćion del Sistema Logistico de Productos Anticonceptivos del IMSS, 1999. Arlington, Va.: John Snow, Inc., DELIVER, para la Agencia de los Estado Unidos para el Dessrrollo Internacional (USAID). Rao, Raja, Peter Mellon, and David Sarley. 2006. Procurement Strategies for Health Commodities: An Examination of Options and Mechanisms within the Commodity Security Context. Arlington, Va.: DELIVER, for the U.S. Agency for International Development. Taylor, P., C. Arauz, G. Subiria, C. Cisek, J. A. Medrano, D. Fuentes, and D. Sarley. 2004. Diagnostico sobre la disponibilidad asegurada de insumos anticonceptivos (DAIA): Nicaragua. Arlington, Va.: John Snow, Inc./DE- LIVER, and Washington, DC: Futures Group/POLICY, for the U.S. Agency for International Development (USAID). World Bank. 1993. World Development Report 1993: Investing in Health. Report No. 12183. World Bank. http:// publications.worldbank.org. 26 DECENTRALIZING & INTEGRATING CONTRACEPTIVE LOGISTICS SYSTEMS IN LATIN AMERICA & THE CARIBBEAN APPENDICES 27 APPENDICES 28 DECENTRALIZING & INTEGRATING CONTRACEPTIVE LOGISTICS SYSTEMS IN LATIN AMERICA & THE CARIBBEAN C o un tr y Ty pe P ro du ct S el ec ti o n Fo re ca st in g an d N ee ds Q ua nt ifi ca ti o n P ro cu re m en t S to ra ge a nd D is tr ib ut io n L M IS In ve nt o ry C o nt ro l B ud ge ti ng / F in an ci ng H um an R es o ur ce s Q ua lit y M o ni to ri ng Bo liv ia D ev ol ut io n Pr im ar ily ce nt ra liz ed M ai nl y ce nt ra l, b ut in p ro ce ss o f b ei ng de ce nt ra liz ed C en tr al ize d be ca us e of do na tio ns . H ow ev er , s om e m un ic ip al iti es pu rc ha se s om e pr od uc ts lo ca lly . In te gr at ed s to ra ge w ith w ar eh ou se s at t he c en tr al a nd re gi on al le ve ls. Ve rt ic al d ist rib ut io n. In te gr at ed w ith e ss en tia l m ed ic in es In te gr at ed M ai nl y ce nt ra l C en tr al ize d C en tr al ize d Br az il D ec on ce nt ra tio n Pr im ar ily c en tr al . H ow ev er , s om e m un ic ip al iti es a re ab le t o in cr ea se co nt ra ce pt iv e m et ho d m ix o n th ei r ow n. M ai nl y ce nt ra l. H ow ev er , s ta te s an d m un ic ip al iti es m ay a lso fo re ca st fo r co nd om s. So m e ho sp ita ls al so m ay d o th ei r ow n fo re ca st s. C en tr al ize d sin ce 2 00 5. H ow ev er , s om e m un ic ip al iti es a nd ho sp ita ls pu rc ha se ad di tio na l co nt ra ce pt iv es . Si nc e 20 05 , ce nt ra liz ed di st rib ut io n fro m ce nt ra l w ar eh ou se to m un ic ip al w ar eh ou se s. W ar eh ou sin g an d di st rib ut io n fo r so m e co nt ra ce pt iv es a re su bc on tr ac te d to an o ut sid e fi r m . C on do m s go fr om ce nt ra l t o st at e to m un ic ip al ity le ve l. M un ic ip al iti es di st rib ut e to h ea lth po st s an d ho sp ita ls. A ll he al th p os ts h av e st or ag e fa ci lit ie s. Fo ur c en tr al -le ve l LM IS s; es se nt ia l m ed ic in es li st at r eg io na l le ve l; a nd t hr ee di ffe re nt L M IS s at m un ic ip al le ve l ( on e fo r ea ch p ro gr am : RH , H IV /A ID S, an d es se nt ia l m ed ic in es ). C en tr al le ve l re sp on sib le fo r ge ne ra l co or di na tio n of lo gi st ic s re so ur ce s, di st rib ut io n, a nd w ar eh ou sin g m an ag em en t; lo gi st ic s de pa rt m en t at re gi on al le ve l; an d su pp ly co or di na tio n at m un ic ip al le ve l. M ai nl y ce nt ra l w ith e xc ep tio n of c on do m s. M un ic ip al iti es m ay es ta bl ish b ud ge ts fo r co nt ra ce pt iv e pr oc ur em en t. U C en tr al ize d C hi le D ev ol ut io n C en tr al ize d A c om bi na tio n of ce nt ra l a nd r eg io na l ef fo rt C en tr al ize d In te gr at ed ( bo th st or ag e an d di st rib ut io n) Ve rt ic al Ve rt ic al M ai nl y ce nt ra l M ai nl y ce nt ra l, b ut ne go tia te w ith re gi on s an d m un ic ip al iti es M ai nl y ce nt ra l C ol om bi a D ev ol ut io n A c om bi na tio n: ne go tia te d be tw ee n ce nt ra l, ot he r se rv ic e pr ov id er s, an d m un ic ip al iti es D ec en tr al ize d D ec en tr al ize d D ec en tr al ize d D ec en tr al ize d D ec en tr al ize d N eg ot ia te d be tw ee n ce nt ra l le ve l a nd s er vi ce pr ov id er s (h os pi ta ls, p riv at e cl in ic s, et c. ) D ec en tr al ize d D ec en tr al ize d C os ta R ic a D el eg at io n of c om pl et e re sp on sib ilit y fo r he al th c ar e (in cl ud in g fa m ily p la nn in g) t o th e C os ta R ic a So ci al S ec ur ity In st itu te ( C C SS ) A P P E N D IX 1 . S U M M A RY O F D E C E N T R A L IZ A T IO N S T A T U S B Y C O U N T RY A N D L O G IS T IC S F U N C T IO N (U =U N C L E A R /U N K N O W N ) APPENDICES 29 C o un tr y Ty pe P ro du ct S el ec ti o n Fo re ca st in g an d N ee ds Q ua nt ifi ca ti o n P ro cu re m en t S to ra ge a nd D is tr ib ut io n L M IS In ve nt o ry C o nt ro l B ud ge ti ng / F in an ci ng H um an R es o ur ce s Q ua lit y M o ni to ri ng D om in ic an Re pu bl ic C en tr al ize d, b ut in p ro ce ss o f de vo lu tio n C om pl et e re sp on sib ilit y of th e ce nt ra l l ev el C om pl et e re sp on sib ilit y of t he ce nt ra l l ev el , b as ed on d em og ra ph ic da ta C om pl et e re sp on sib ilit y of th e ce nt ra l l ev el Ve rt ic al D es ig n an d im pl em en ta tio n ar e th e co m pl et e re sp on sib ilit y of th e ce nt ra l l ev el , w ith s om e in pu t fro m r eg io ns . D es ig n an d im pl em en ta tio n ar e th e co m pl et e re sp on sib ilit y of th e ce nt ra l l ev el . C om pl et e re sp on sib ilit y of th e ce nt ra l l ev el C om pl et e re sp on sib ilit y of th e ce nt ra l l ev el M on ito rin g of qu al ity c on tr ol ex ec ut ed b y ce nt ra l l ev el . O th er le ve ls m us t m ee t ce rt ai n st or ag e co nd iti on s to en su re p ro du ct qu al ity . Ec ua do r D ec on ce nt ra tio n C om pl et e re sp on sib ilit y of th e di st ric t/ ar ea le ve l C om pl et e re sp on sib ilit y of t he di st ric t/ ar ea le ve l, st an da rd ize d ba se d on m or bi di ty C om pl et e re sp on sib ilit y of th e di st ric t/ ar ea le ve l; p ur ch as e pr im ar ily fr om lo ca l s up pl ie rs . C on sid er in g do in g a po ol ed pr oc ur em en t ce nt ra lly . C om pl et e re sp on sib ilit y of t he di st ric t/ ar ea le ve l C om pl et e re sp on sib ilit y of th e di st ric t/ ar ea le ve l. L M IS s ar e no t st an da rd ize d ac ro ss a re as . C om pl et e re sp on sib ilit y of th e di st ric t/ ar ea le ve l. I nv en to ry co nt ro l i s no t st an da rd ize d ac ro ss a re as . C en tr al ize d pr og ra m re im bu rs es e ac h co ns ul ta tio n re po rt ed b y ar ea s; ra te s se t at c en tr al le ve l. C om pl et e re sp on sib ilit y of th e di st ric t/ ar ea le ve l C om pl et e re sp on sib ilit y of th e di st ric t/ ar ea le ve l El S al va do r M ix o f de vo lu tio n an d de co nc en tr at io n Re sp on sib ilit y of c en tr al a nd re gi on al le ve ls (S IB A SI s) Re sp on sib ilit y of ce nt ra l a nd r eg io na l le ve ls (S IB A SI s) Re sp on sib ilit y of c en tr al a nd re gi on al le ve ls (S IB A SI s) Re sp on sib ilit y of ce nt ra l a nd r eg io na l le ve ls (S IB A SI s) Th e de sig n an d im pl em en ta tio n is re sp on sib ilit y of c en tr al a nd re gi on al le ve ls (S IB A SI s) . Re sp on sib ilit y of c en tr al a nd re gi on al le ve ls (S IB A SI s) Re sp on sib ilit y of c en tr al a nd re gi on al le ve ls (S IB A SI s) . H ow ev er , f un ds ar e po ol ed a nd re qu es te d by t he ce nt ra l l ev el . Re sp on sib ilit y of c en tr al a nd re gi on al le ve ls (S IB A SI s) Re sp on sib ilit y of c en tr al a nd re gi on al le ve ls (S IB A SI s) G ua te m al a4 D ec on ce nt ra tio n (e ss en tia l m ed ic in es b ut n ot co nt ra ce pt iv es ) C om pl et e re sp on sib ilit y of th e ce nt ra l l ev el fo r co nt ra ce pt iv es (in cl ud in g N G O s) ; fo r es se nt ia l m ed ic in es lo ca l au th or iti es (in cl ud in g M O H - co nt ra ct ed N G O s) ca n se le ct a s lo ng as p ro du ct s ar e on a na tio na l e ss en tia l m ed ic in es li st . C om pl et e re sp on sib ilit y of t he he al th a re a le ve l, w ith p ar tic ip at io n fro m t he c en tr al le ve l C om pl et e re sp on sib ilit y of th e ce nt ra l l ev el fo r co nt ra ce pt iv es (b ec au se o f do na tio ns ) an d of t he h ea lth a re a le ve l ( fo r es se nt ia l m ed ic in es ) A ll le ve ls ar e in vo lv ed in b ot h di st rib ut io n an d st or ag e fo r co nt ra ce pt iv es ; th er e is no c en tr al w ar eh ou se fo r es se nt ia l m ed ic in es . C en tr al le ve l re sp on sib le fo r LM IS g ui de lin es an d pr oc ed ur es . H ea lth a re a le ve l fo llo w c en tr al gu id el in es . C en tr al le ve l se t st an da rd pr oc ed ur es (b al an ce , re qu isi tio n, an d de liv er y of su pp lie s) w ith hi gh in vo lv em en t an d pa rt ic ip at io n fro m h ea lth a re a st af f. H ea lth a re a le ve l m an ag es it s ow n bu dg et . Re sp on sib ilit y of ce nt ra l a nd a re a le ve ls Re sp on sib ilit y of c en tr al (b ec au se o f do na tio ns ) 4. Th e M O H h as d el eg at ed t o N G O s th e pr ov isi on o f a b as ic h ea lth c ar e pa ck ag e fo r th e co ve ra ge e xt en sio n pr og ra m ( in cl ud in g FP s er vi ce s) a t th e pr im ar y he al th c ar e le ve l. M O H -c on ta ct ed N G O s re ce iv e U SA ID - do na te d co nt ra ce pt iv es . W he n do na tio ns c ea se in 2 00 7, t he p la n is to a dd N G O n ee ds t o th e M O H fo re ca st in g ne ed s at t he c en tr al le ve l. 30 DECENTRALIZING & INTEGRATING CONTRACEPTIVE LOGISTICS SYSTEMS IN LATIN AMERICA & THE CARIBBEAN C o un tr y Ty pe P ro du ct S el ec ti o n Fo re ca st in g an d N ee ds Q ua nt ifi ca ti o n P ro cu re m en t S to ra ge a nd D is tr ib ut io n L M IS In ve nt o ry C o nt ro l B ud ge ti ng / F in an ci ng H um an R es o ur ce s Q ua lit y M o ni to ri ng H on du ra s C en tr al ize d C om pl et e re sp on sib ilit y of th e ce nt ra l l ev el Fo re ca st in g is th e re sp on sib ilit y of th e ce nt ra l l ev el in co nj un ct io n w ith th e pr ov in ci al / re gi on al le ve ls, w hi ch s ub m it or de rs a nd s to re pr od uc ts e ve ry th re e m on th s, an d de liv er p ro du ct s to h ea lth fa ci lit ie s on a m on th ly ba sis .N ee ds qu an tifi c at io n tr ad iti on al ly h as be en b as ed o n hi st or ic al d at a; ho w ev er t he ne w F P st ra te gy cu rr en tly b ei ng im pl em en te d is ba se d on co ns um pt io n da ta . C om pl et e re sp on sib ilit y of th e ce nt ra l l ev el Ve rt ic al Ve rt ic al Ve rt ic al C om pl et e re sp on sib ilit y of t he c en tr al le ve l. R eg io ns a re as sig ne d bu dg et s to p ur ch as e co nt ra ce pt iv es , b ut th ey a re e xe cu te d ce nt ra lly . Re sp on sib ilit y of ce nt ra l l ev el C en tr al le ve l no rm s ex ist , m on ito rin g is in cl ud ed in al l p er io di c ev al ua tio ns a t re gi on al le ve l an d re gu la r m on ito rin g is al so o ng oi ng a t di st ric t le ve l. M ex ic o D ec on ce nt ra tio n C en tr al ize d D ec en tr al ize d D ec en tr al ize d In te gr at ed Ve rt ic al Ve rt ic al Re sp on sib ilit y of bo th c en tr al a nd st at e le ve ls Re sp on sib ilit y of st at e le ve l Re sp on sib ilit y of b ot h ce nt ra l an d st at e le ve ls. N ic ar ag ua D ec on ce nt ra tio n C om pl et e re sp on sib ilit y of th e ce nt ra l l ev el C om pl et e re sp on sib ilit y of t he ce nt ra l l ev el C om pl et e re sp on sib ilit y of th e ce nt ra l l ev el In te gr at ed In p ro ce ss o f in te gr at io n fo r se le ct ed dr ug s; ve rt ic al ; re sp on sib ilit y of th e ce nt ra l a nd re gi on al le ve ls In p ro ce ss o f in te gr at io n fo r se le ct ed d ru gs ; re sp on sib ilit y of bo th c en tr al a nd re gi on al le ve ls C om pl et e re sp on sib ilit y of th e ce nt ra l l ev el Re sp on sib ilit y of th e ce nt ra l l ev el Re sp on sib ilit y of t he c en tr al le ve l Pa ra gu ay C en tr al ize d C om pl et e re sp on sib ilit y of th e ce nt ra l l ev el C om pl et e re sp on sib ilit y of t he ce nt ra l l ev el C om pl et e re sp on sib ilit y of th e ce nt ra l l ev el Ve rt ic al Ve rt ic al Ve rt ic al C om pl et e re sp on sib ilit y of th e ce nt ra l l ev el C om pl et e re sp on sib ilit y of th e ce nt ra l l ev el C om pl et e re sp on sib ilit y of th e ce nt ra l l ev el Pe ru C en tr al ize d, b ut in p ro ce ss o f de co nc en tr at io n C en tr al ize d A c om bi ne d re sp on sib ilit y be tw ee n ce nt ra l le ve l a nd r eg io ns C en tr al ize d Ve rt ic al , b ut in p ro ce ss o f in te gr at io n In p ro ce ss o f in te gr at io n; ve rt ic al ; re sp on sib ilit y of th e ce nt ra l a nd re gi on al le ve ls In p ro ce ss o f in te gr at io n; ve rt ic al ; re sp on sib ilit y of th e ce nt ra l a nd re gi on al le ve ls C en tr al ize d Re sp on sib ilit y of th e ce nt ra l l ev el Re sp on sib ilit y of t he c en tr al le ve l APPENDICES 31 A P P E N D IX 2 S U M M A RY O F I N T E G R A T IO N S T A T U S B Y C O U N T RY A N D L O G IS T IC S F U N C T IO N (V =V E R T IC A L , I =I N T E G R A T E D , M = M IX E D , U =U N C L E A R /U N K N O W N ) C o un tr y P ro du ct S el ec ti o n an d U se Fo re ca st in g, N ee ds Q ua nt ifi ca ti o n P ro cu re m en t S to ra ge a nd D is tr i- bu ti o n L M IS In ve nt o ry C o nt ro l B ud ge ti ng / F in an ci ng H um an R es o ur ce s Q ua lit y M o ni to ri ng Bo liv ia V V V I I I I I I Br az il V a nd I Th os e pr od uc ts o n th e es se nt ia l m ed ic in es li st a re in te gr at ed fo r pr oc ur em en t an d di st rib ut io n, y et v er tic al fo r al l o th er fu nc tio ns . Th os e th at a re p ar t of t he R H “ co nt ra ce pt iv e ki ts ” pr og ra m , t he F ar m ac ia P op ul ar p ro gr am , o r th e N at io na l A ID S pr og ra m a re v er tic al . I I C hi le V V V I V V V i V C ol om bi a I I I I I I I I I C os ta R ic a I f or a ll fu nc tio ns D om in ic an Re pu bl ic V V V V V V V I V Ec ua do r I I I I I I I I I El S al va do r I I V V V V I I I G ua te m al a V V M I I 5 I V I V H on du ra s V V I V Th er e is a st or ag e sp ac e on ly fo r do na te d co nt ra ce pt iv es . V V V V V M ex ic o V V I I V V I I I N ic ar ag ua V V V I In p ro ce ss o f in te gr at io n In p ro ce ss o f in te gr at io n V I I Pa ra gu ay V V V V V V M In te gr at ed w ith de liv er y ki ts M M os tly v er tic al V Pe ru V V V I In p ro ce ss o f in te gr at io n In p ro ce ss o f in te gr at io n I I I 5. Th e M O H b eg an in 2 00 6 to o ffi ci al ly u se t he L M IS fo r al l e ss en tia l m ed ic in es , n ot o nl y fo r co nt ra ce pt iv es . 32 DECENTRALIZING & INTEGRATING CONTRACEPTIVE LOGISTICS SYSTEMS IN LATIN AMERICA & THE CARIBBEAN For more information, please visit www.deliver.jsi.com. DELIVER John Snow, Inc. 1616 North Ft. Myer Drive, 11th Floor Arlington, VA 22209 USA Phone: 703-528-7474 Fax: 703-528-7480 www.deliver.jsi.com

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