Ensuring Access to Reproductive Health Supplies
Publication date: 2009
Ensuring Access to Reproductive Health Supplies Joint ACP/UNFPA/EC Programme in Conflict and Post-Conflict Countries This publication has been produced with the assistance of the European Commission. The contents of this publication are based on the Joint ACP/UNFPA/EC Programme Evaluation and do not necessarily reflect the views of the European Commission. The Joint Evaluation was conducted by two independent consultants with technical and logistical support from the UNFPA Commodity Security Branch. Responding to needs Saving lives and improving health Ensuring access to supplies Training to gain and sustain capacity Putting governments in the driver’s seat Rights, results and recommendations 3 5 7 9 11 14 Contents Pam Delargy/UNFPA. Returnee from Liberia at the Bo resettlement camp, Sierra Leone 2 ENSURING ACCESS TO REPRODUCTIVE HEALTH SUPPLIES A pregnant woman receiving a shot at a UNFPA-supported health clinic in Haiti. Reproductive health commodity security (RHCS) is achieved when all individuals can obtain and use affordable, quality reproductive health supplies of their choice whenever they need them. Each $1 million worth of reproductive health commodities can prevent: 360,000 unwanted pregnancies; 150,000 induced abortions; 800 maternal deaths; 11,000 infant deaths; and 14,000 additional deaths of children under five. Carina Wint/UNFPA. Haiti, 2007. 3JoinT AcP/unfPA/Ec PRogRAmmE in conflicT And PoST-conflicT counTRiES The price paid by women during times of armed conflict was about to go higher. Without immediate action, more mothers would die. The danger was a severe shortage of contraceptives and medical supplies in 17 conflict and post-conflict countries. The European Commission (EC) saw the urgent need and responded with close to 15 million Euros (18 million dollars) to purchase pills, condoms and supplies that make birth safer. Women and men gained access to contracep- tives; clinics gained life-saving supplies; and governments weakened by conflict gained skills, developed strategies and reduced shortfalls in essential commodities. The African, Caribbean and Pacific Group of States (ACP) selected the countries most in need of assistance. With European Commis- sion funding, UNFPA, the United Nations Population Fund, working through its coun- try offices, provided strategic and program- matic support to national governments. The programme helped countries to estimate current and future reproductive health com- modity requirements, and to buy and deliver products when and where they were needed. It increased access to supplies and boosted national capacity to meet maternal health goals, especially through family planning. RESPONDING TO NEEDS 4 ENSURING ACCESS TO REPRODUCTIVE HEALTH SUPPLIES Programme Joint ACP/UNFPA/EC programme of assistance to ACP countries more in need of achieving reproductive health commodity security (RHCS) Partners African, Caribbean and Pacific (ACP) Group of States, United Nations Population Fund (UNFPA), European Commission (EC) Summary This programme increased access to supplies for reproductive health programmes in 17 African, Caribbean and Pacific countries in conflict or post-conflict situations. The European Commission provided major funding in a partnership agreement with the ACP Group of States in the framework of the 9th European Development Fund. UNFPA was the implementing agency and junior funding partner. Participants Angola, Burundi, Central African Republic, Chad, Congo, Côte d’Ivoire, Democratic Republic of Congo, Eritrea, Ethiopia, Haiti, Guinea-Bissau, Liberia, Mozambique, Rwanda, Sierra Leone, Somalia and Sudan Duration 42 Months, from May 2006 to October 2009 (Initial 24 months, plus 18 months at no extra cost) Budget Euro € 16.4 million ($21 million) of which the EC provided Euro € 14.9 million ($18 million) and UNFPA provided Euro € 1.5 million ($1.8 million) Allocation 90 percent to procure reproductive health commodities 10 percent for capacity development This well-designed programme based on a highly participatory approach set out to: • Reduce shortfalls in contraceptives and other commodities for reproductive health • Improve their access, use, distribution and procurement • Build capacity and promote national ownership The result — a tremendous influx of re- productive health commodities, a thousand service providers trained, and a significant impact on national capacity to plan and manage their supply systems. PROGRAmmE AT A GLANCE 5JoinT AcP/unfPA/Ec PRogRAmmE in conflicT And PoST-conflicT counTRiES In times of upheaval, reproductive health services — including prenatal care, assisted delivery, emergency obstetric care and family planning services — often become unavail- able. Young people become more vulnerable to sexual exploitation and HIV infection. Many women lose access to family planning services, exposing them to unwanted preg- nancy in perilous conditions. When normalcy returns, mothers stand in line behind infra- structure projects as nations start to rebuild. Yet every country wants to save mothers’ lives. The ACP/UNFPA/EC programme aimed to: • Improve the health of women, particularly poor women by lowering the number of unwanted pregnancies and sexually trans- mitted infections including HIV/AIDS • Reduce health risks associated with pregnancy and childbirth The programme did so by working together with countries to improve access to and use of reproductive health commodities through their procurement and distribution. The ultimate aim was to improve Reproduc- tive Health Commodity Security (RHCS). RHCS means that all individuals can obtain and use affordable, quality reproductive health supplies of their choice whenever they need them. SAVING LIVES AND ImPROVING HEALTH Risky birth made safer Mariama needed an emergency C-section. Reproductive health commodities procured through the ACP/UNFPA/EC programme in Sierra Leone helped to save the life of Mariama and her baby. “I am so happy he’s healthy,” she says. Far too many women are not so fortunate: the risk of a woman dying as a result of pregnancy or childbirth during her lifetime is about 1 in 8 in Sierra Leone, compared with less than 1 in 17,400 in Sweden. 6 ENSURING ACCESS TO REPRODUCTIVE HEALTH SUPPLIES 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 160,000 New Continuing A cc ep to rs 2001 2002 2003 2004 2005 2006 2007 2008 Contraceptive users in 13 Districts of Sierra Leone Source: Draft Annual Progress Report 2008, Reproductive Health Division, Ministry of Health and Sanitation, Sierra Leone, March 2008 Use of contraceptives rises with start of programme The spike in people using contraceptives shown in this chart can be attributed in part to the suc- cess of the ACP/UNFPA/EC programme, say government officials in Sierra Leone, because they became widely and easily available to existing and new users. Hospital staff in Sierra Leone assert that the ACP/UNFPA/EC programme reduced maternal deaths, increased life-saving Caesareans, and maintained a much steadier supply of contraceptives and other medicines. It made it possible for a hospital in Makeni to attract poor pregnant women with the provision of free services. Re-stocking a warehouse destroyed in war The entire government warehouse for medicines (including contraceptives) was destroyed by fire during civil conflict that erupted in Chad in February 2008. Already in operation, the ACP/UNFPA/EC programme rushed commodities to the country to alleviate the dire situation. 7JoinT AcP/unfPA/Ec PRogRAmmE in conflicT And PoST-conflicT counTRiES Without the right products, even the best health programmes can’t succeed. Access to a reliable supply of contraceptive pills, condoms and obstetric drugs and supplies is absolutely essential to reproductive health programmes. Without secure supplies, no country can ensure the right to reproductive health. Nor can they achieve the Millennium Development Goals. The ACP/UNFPA/EC programme worked to ensure access to safe, effective contra- ception enabling crisis-affected couples to manage scarce family resources more effec- tively. It also increased access to drugs such as oxytocin and magnesium sulphate that can make the difference between life and death during childbirth. The programme succeeded in reducing shortfalls of reproductive health commodities at the country level. All of the countries had previously reported serious and sometimes chronic shortfalls for contraceptives. About 90 percent of total funds were devoted to supporting the procurement and distribution of reproductive health commodities. Thanks to the programme, estimated shortfalls were reduced by: • 44 percent for male condoms • 44 percent for contraceptive pills • 13 percent for injectables This constitutes a major contribution to the reproductive health commodities that UNFPA provided to countries through a variety of funding sources. When you can plan your family, you can plan your life. “I am on line waiting for the pill. I come every month. I have six children already; my oldest just got married. Life is hard enough,” says a mother in Cote d’Ivoire. Access to free contraceptives has given her a life-changing choice to plan her pregnancies. Between 2000 and 2015, contraceptive users in developing countries are expected to increase by 40 per cent as the number of reproductive age couples grows by 23 per cent and demand for family planning becomes more widespread. ENSURING ACCESS TO HEALTH SUPPLIES Affordable, quality reproductive health supplies of their choice “Now we can space the number of children we have. Before we were having children back-to-back,” says Baywa, a mother of three who came to a clinic with her husband. The ACP/UNFPA/EC programme in Chad helps to keep costs down so Baywa can afford contraceptives. Institutionalizing training for logistics management In Côte d’Ivoire, the institute for training midwives and nurses and the faculty for pharmacists now offer courses on logistics management information systems for reproductive health commodities. More than 400 people in 10 different districts will have received training by the end of 2009. In many countries, acute shortages of health providers like this man in Chad (below) make training an ongoing priority. The programme procured and delivered: • Contraceptives to 16 participating countries; conflict prevented delivery to Somalia • Reproductive health kits to 9 countries with supplies for safe delivery in refugee situations during the acute phase of emergency • Medicines and supplies for safe delivery and emergency obstetric care to 7 countries In spite of the huge amount of reproductive health commodities procured and delivered to participating countries, needs remain enormous and shortfalls still persist, although not to the same extent as before. Training prepares the next generation of health managers and is critical to recovery in conflict and post-conflict countries. Acute shortages of qualified personnel in public health existed in all 17 countries participat- ing in the ACP/UNFPA/EC programme. 8 ENSURING ACCESS TO REPRODUCTIVE HEALTH SUPPLIES TRAINING TO GAIN AND SUSTAIN CAPACITy From forecasting need to distributing product A storekeeper in Sierra Leone points to shelves stocked with reproductive health commodities. Dr. Francis Smart, Reproductive Health Programme Manager, cites the role of training in avoiding shortfalls: “Because of the training, stock-out is not happening at our facility and district level…and that is something I can smile about,” he says. “The programme is greatly contributing to improving lives.” 9JoinT AcP/unfPA/Ec PRogRAmmE in conflicT And PoST-conflicT counTRiES The need for know-how was acute. Training in LMIS, logistics management information systems, addressed questions such as ‘How to manage a steady flow of commodities? How to develop policy to support this work? How to keep this supply system going?’ Support included the provi- sion of computer software to help forecast needs and manage inventory. About LMIS training: • Three regional workshops provided training for trainers • 60 trainers then trained more than 1,000 service providers in the participating countries • Each country prepared a training plan • Three countries now include the LMIS training in their national curriculum for health education: Cote d’Ivoire, Ethiopia and Liberia, with others likely to follow their example. Despite progress, the capacity for LMIS re- mains low in all participating countries, and the high turnover among professional staff in health centres makes ongoing training a necessity. More training will be an important step towards building the skills and experi- ence required to maintain a secure supply of commodities that people can count on. 10 ENSURING ACCESS TO REPRODUCTIVE HEALTH SUPPLIES This mother and baby in Chad survived a risky birth. Safer motherhood is a goal advanced by reproductive health commodity security. Globally, every minute another woman dies in pregnancy or childbirth – almost all in developing countries. Most maternal deaths could be prevented through universal access to reproductive health, including family planning. Ensuring access to voluntary family planning could reduce maternal deaths by a third, and child deaths by as much as 20 per cent. Micah Albert/UNFPA. Chad, 2009 11JoinT AcP/unfPA/Ec PRogRAmmE in conflicT And PoST-conflicT counTRiES Governments weakened by conflict and upheaval are looking for effective and effi- cient strategies to save women’s lives — such as ensuring family planning services, skilled attendance at birth and emergency obstet- ric care. Support for reproductive health is a priority on the path to recovery for these countries. To put it in perspective, the global cost of maternal and newborn deaths is $15 billion per year in lost productivity. This is a critical time to put reproductive health commodity security on the national — and global — radar screen. The ACP/UNFPA/EC programme sought to ensure development of an operational national plan for reproductive commodity security in every country. Teams of experts carried out in-depth assessments that enabled each country to map out clearly its RHCS situation. UNFPA mobilized national pools of experts who were already in place through ongoing reproductive health programmes, which proved a valuable resource. Strate- gic plans were then developed with the full involvement of government counterparts. The plans spelled out how governments can put in place better mechanisms for procure- ment, financing and distribution to meet the ever-growing demand for reproductive health commodities and services. As a result of the programme: • 17 countries conducted detailed RHCS situation analyses • 15 countries developed RHCS operational or strategic plans • 10 countries established specific budget lines for RHCS • 16 included contraceptives in their national essential drug lists • 10 countries set up RHCS coordination mechanisms Impact was even greater on closer inspection. Some countries incorporated functions rec- ommended by the programme into already existing structures, making them stronger. Putting countries in the driver’s seat was an over-arching objective. The programme promoted active participation from the start, with extensive consultation at national level. Nations identified their own needs. Credit is due to the Ministries of Health for their strong commitment to partnership. Reproductive health commodity security is highly relevant to national goals, which is one reason that participating countries made this programme their own. PUTTING GOVERNmENTS IN THE DRIVER’S SEAT Programme objectives contributed directly to meeting national goals and development commitments including: • Existing national roadmaps and priorities for maternal and newborn health, including family planning • Millennium Development Goals, especial- ly those on reducing maternal and child mortality, on combating HIV and AIDS and ensuring universal access to reproduc- tive health by 2015 • ICPD, International Conference on Population and Development Programme of Action • Paris Declaration on Aid Effectiveness and Accra Agenda for Action • Maputo Plan of Action for the Operation- alisation of the Continental Policy Frame- work for Sexual and Reproductive Health and Rights The programme built on advocacy efforts of the UNFPA Global Programme to Enhance Reproductive Health Commodity Secu- rity and of the UNFPA Thematic Fund for RHCS. By stimulating policy dialogue on commodity security, the programme made an enduring contribution to future action. This dialogue enhanced existing and ongoing efforts by many countries to develop policy and planning frameworks that incorporate reproductive health commodity security. In 12 ENSURING ACCESS TO REPRODUCTIVE HEALTH SUPPLIES A young mother and her baby in Mozambique. Family planning programmes create conditions that enable women to enter the labour force and enable families to devote more resources to each child, thereby improving family nutrition, education levels and living standards. Some 200 million women of childbearing age want to delay or avoid pregnancy, but 137 million use no method of contraception at all, and 64 million use less-effective traditional methods. Ken Oppranni/Norway/UNFPA. Mozambique, June 2007 13JoinT AcP/unfPA/Ec PRogRAmmE in conflicT And PoST-conflicT counTRiES the policy process, nationals gained skills for strategic planning and technical analysis. Mainstreaming elements of RHCS into national programmes is evident in several countries. Cote d’Ivoire, for example, now includes contraceptives in the distribution system of its central medical store. Chad’s central pharmacy recently agreed to procure commodities through the public health system and work with UNFPA to distribute them using the national distribution system for medicines. Chad also included reproduc- tive health commodity security principles in its national development framework, an effective step towards sustainability. These examples are also encouraging other devel- opment partners to use national systems to distribute commodities, or to join forces to improve poorly performing systems. 14 ENSURING ACCESS TO REPRODUCTIVE HEALTH SUPPLIES In the end, women such as Mariama will measure the success of the programme from her personal perspective, as a mother thank- ful for a hospital stocked with supplies for emergency surgery that saved her life. Baywa will be proud that she is taking care of her family by taking the contraceptive pill until she’s ready for another child. And a young woman in Chad will seek information on contraceptives so she can avoid another pregnancy and achieve her goal of going back to school. Each woman’s story is also a universal story of human rights. The programme made repro- ductive health commodities accessible to poor women and men and their communities. In so doing it advanced their right to health and well-being. Reproductive health commodity security is designed to provide a foundation for more equitable access to family planning, condoms for HIV prevention, emergency obstetric equipment and other essential reproductive health supplies, as it works towards ensuring that all people can exercise their fundamental human right to the highest attainable standard of health. Summary of results The joint evaluation of the programme found that the programme had achieved its outputs and made important contributions towards decreasing reproductive health commodity shortfalls at country level. RIGHTS, RESULTS AND RECOmmENDATIONS Choosing school for a brighter future “I just had a baby boy. I was not using contraception before. But I am going to try it now because I want to go to school,” says this young woman, age 21, in N’Djamena, Chad. 15JoinT AcP/unfPA/Ec PRogRAmmE in conflicT And PoST-conflicT counTRiES The ACP/UNFPA/EC programme reduced estimated shortfalls by: • 44 percent for male condoms • 44 percent for contraceptive pills • 13 percent for injectables Procured and delivered: • Contraceptives to 16 out of the 17 participating countries • Reproductive health kits to 9 countries for refugees • Medicines and supplies for safe delivery and emergency obstetric care to 7 countries Provided training in logistics management information systems: • 60 trainers were trained in three regional workshops • More than 1,000 service providers received training in logistics management • Three countries now include LMIS training in national curriculum Contributed to policy and planning: • 17 countries conducted detailed RHCS situation analyses • 15 countries developed RHCS operational or strategic plans • 10 countries established specific budget lines for RHCS • 16 included contraceptives in their national essential drug lists • 10 countries set up RHCS coordination mechanisms Recommendations for future action • Provide ongoing support for reproductive health commodity security to countries in conflict and post-conflict situations. Demands for reproductive health com- modities will remain very high and only increase over time (while national alloca- tions remain well below need). In future, consider funding through the UNFPA Global Programme to Enhance Reproduc- tive Health Commodity Security. • Continue successful strategic initiatives started by the programme. This could entail, for example, allocating resources to support the functioning of RHCS 1992 1996 2000 2004 2008 $0 $1,00,000 $2,00,000 $3,00,000 $4,00,000 $5,00,000 $6,00,000 Source: JSI/USAID Project Survey, 2008: Policy, Finance, Coordination and Supply 0% 5% 10% 15% 20% 25% 30% Donor support for contraceptives in Rwanda Contraceptive prevalence rate Women in Rwanda using more contraceptives The sharp increase in use of modern methods of family planning, up from 10 percent to 27 percent, among married women in Rwanda, coincided with the ACP/UNFPA/EC programme. External evaluators say the programme contributed to this impressive jump, which occurred between 2005 and 2007/8. coordinating bodies until Governments can do so on their own. • Ensure a high level of flexibility as countries in conflict and post-conflict situations require different types of support as conditions change. • Maximize knowledge sharing at all levels, including by promoting a greater flow of information among the in-country Delegations of the European Commission that support health-sector programmes and among governments of affected countries with regard to funding sources. • Coordinate and collaborate to ensure that future activities effectively apply the Paris Declaration to achieve full results. The joint programming approach was an effective strategy that enabled the ACP, UNFPA and EC to draw on their comparative advantages. • Advocate for a leadership role by partici- pating governments and continue to sup- port regional and national advocacy efforts designed to increase budgetary allocations to reproductive health and increase the regular release of allocated funds. • Extend participation in capacity building exercises to those working in the private sector, as they play a key role in making reproductive health commodities available. • Pay particular attention to strengthen- ing logistics management information systems, with support to LMIS training within national health education. Every step from forecasting to delivery must be in place for individual women and men to be able to obtain and use affordable, quality reproductive health supplies of their choice whenever they need them. 16 ENSURING ACCESS TO REPRODUCTIVE HEALTH SUPPLIES Higher profile for maternal health Women in Sudan stand in line at a health clinic served by the ACP/UNFPA/EC Programme. Dr. Lamia Eltigani, Reproductive Health Director in Sudan’s Federal Ministry of Health, envisions better information and services for such women in the future. “Maternal health is now a national priority. We have a vision for Reproductive Health Commodity Security,” she says. For more information contact: UNFPA Commodity Security Branch United Nations Population Fund 220 East 42nd Street New York, NY 10017 E-mail: email@example.com www.unfpa.org www.unfpa.org/eu_partnership/ © UNFPA 2009 European Commission EuropeAid Cooperation Office Rue de la Loi 41 B-1049 Bruxelles E-mail: firstname.lastname@example.org http://ec.europa.eu/world http://ec.europa.eu/europeaid Programme partners ACP The African, Caribbean and Pacific Group of States consists of 79 Member-States, all of them, save Cuba, signatories to the ACP-EC Partnership (Cotonou) Agreement which binds them to the European Union: 48 countries from Sub-Saharan Africa, 16 from the Caribbean and 15 from the Pacific. A main objective is the sustainable development of Member-States. UNFPA The United Nations Population Fund is an international development agency that promotes the right of every woman, man and child to enjoy a life of health and equal opportunity. UNFPA supports countries in using population data for policies and programmes to reduce poverty and to ensure that every pregnancy is wanted, every birth is safe, every young person is free of HIV/AIDS, and every girl and woman is treated with dignity and respect. EC The European Commission, the executive arm of the European Union, manages and coordinates the provision of development cooperation aid on behalf of the Member States of the Union. The European Union is made up of 27 Member States who have decided to gradually link together their know-how, resources and destinies. Together, during a period of enlargement of 50 years, they have built a zone of stability, democracy and sustainable development whilst maintaining cultural diversity, tolerance and individual freedoms. The European Union is committed to sharing its achievements and its values with countries and peoples beyond its borders.