Health Policy Initiative- Contraceptive Security Committees: Their role in Latin America and the Caribbean

Publication date: 2007

SEPTEMBER 2007 This publication was produced for review by the U.S. Agency for International Development (USAID). It was prepared by Veronica Siman Betancourt of the Health Policy Initiative, Task Order 1. CONTRACEPTIVE SECURITY COMMITTEES: Their Role in Latin America and the Caribbean The USAID | Health Policy Initiative, Task Order 1, is funded by the U.S. Agency for International Development under Contract No. GPO-I-01-05-00040-00, beginning September 30, 2005. Task Order 1 is implemented by Constella Futures, in collaboration with the Centre for Development and Population Activities (CEDPA), White Ribbon Alliance for Safe Motherhood (WRA), Futures Institute, and Religions for Peace. CONTRACEPTIVE SECURITY COMMITTEES: Their Role in Latin America and the Caribbean SEPTEMBER 2007 The views expressed in this publication do not necessarily reflect the views of the U.S. Agency for International Development or the U.S. Government. iii TABLE OF CONTENTS Acknowledgments . iv Abbreviations . v Introduction. 1 Background . 2 Key Issues in Establishing Contraceptive Security Committees . 3 Composition of the CS Committees . 3 Level of International Donor Support. 4 Importance of Regional Meetings . 4 Content of Committee Meetings. 5 Role of CS Committees in Achieving Results. 5 The Prototypical Committee. 5 Current Situation of the CS Committees . 7 Bolivia . 7 Dominican Republic . 8 El Salvador . 8 Honduras. 11 Nicaragua. 12 Paraguay . 14 Conclusion . 16 Appendix A. People Interviewed By Country . 18 Appendix B. Interview and Needs Assessment Guide . 21 Appendix C. Informed Consent Form . 23 Appendix D. Situation of the CS Committees in Countries of the Latin America and Caribbean Region . 24 References. 25 ACKNOWLEDGMENTS The author would like to thank Elaine Menotti, Rachel Sanders, and Patricia Mostajo of the USAID | Health Policy Initiative, Task Order 1 for conducting the interviews. In addition, the author would like to thank the respondents (in Bolivia, the Dominican Republic, El Salvador, Honduras, Nicaragua, and Paraguay), who shared their views and expertise to inform this case study. For their valuable comments and editorial contributions, we would also like to thank Lindsay Stewart of the USAID LAC Bureau, Patricia Mostajo of the Health Policy Initiative, and Harry Cross, consultant. iv ABBREVIATIONS AIDS acquired immune deficiency syndrome ADOPLAFAM Dominican Association for Family Planning ADS Salvadoran Demographic Association ASHONPLAFA Honduran Association for Family Planning CEASS Central Procurement and Health Supplies Office (Bolivia) CEPEP Paraguayan Center for Population Studies CIES Center for Sexual and Reproductive Health Research, Education, and Services (Bolivia) CONAPOFA National Council for Population and Family (Dominican Republic) CS contraceptive security DIGEMIA Direction for Maternal, Child, and Adolescents FP family planning HIV human immunodeficiency virus IDSS Dominican Social Security Institute IHSS Honduran Social Security Institute INSALUD National Health Institute (Dominican Republic) INSS Nicaraguan Social Security Institute IPPF International Planned Parenthood Federation IPS Paraguayan Social Security Institute ISSS Salvadoran Social Security Institute LAC Latin America and the Caribbean MINSA Ministry of Health (Nicaragua) MOH Ministry of Health MSD Ministry of Health and Sports (Bolivia) MSPAS Ministry of Public Health and Social Assistance (El Salvador) MSPBS Ministry of Public Health and Social Welfare (Paraguay) NGO nongovernmental organization PAHO Pan American Health Organization PASMO Pan American Social Marketing Organization PROFAMILIA Nicaraguan Family Welfare Association PROMESE/CAL Essential Medications Program/Central Logistics Support (Dominican Republic) PRONAISA National Program for Children and Adolescents’ Health (Dominican Republic) RH reproductive health SdeS Ministry of Health (Honduras) SENASA National Health Insurance (Dominican Republic) SESPAS Secretary of State for Public Health and Social Assistance (Dominican Republic) STI sexually transmitted infection(s) SUMI Universal Maternal and Infant Insurance (Bolivia) UNFPA United Nations Population Fund USAID United States Agency for International Development WHO World Health Organization v vi 1 INTRODUCTION This case study was conducted under the auspices of the USAID | Health Policy Initiative, Task Order 1 and is part of ongoing efforts by the Bureau of Latin America and the Caribbean (LAC) and its Health, Population, and Nutrition office to advance contraceptive security (CS) in the region. Contraceptive security exists when all individuals are able to choose, obtain, and use high-quality contraceptives when they need them. This report summarizes portions of four case studies about the innovative regional strategies that LAC countries have been implementing since 2003 to achieve contraceptive security. In numerous countries, locally formed contraceptive security committees have been spearheading and coordinating these CS efforts, generally operating at a technical level. The objective of this study was to analyze the experience of six committees and assess their role in working to achieve contraceptive security. The study focused on the activities of CS committees in Bolivia, the Dominican Republic, El Salvador, Honduras, Nicaragua, and Paraguay from 2003 to early 2007. According to the results of the analysis, these committees played a key role in making progress toward contraceptive security. Several other LAC countries made significant political and legislative progress without establishing CS committees. This report has four sections. The first section presents the study background and context, particularly within the CS regional initiative for LAC and the activities implemented to date. The second section describes CS committees’ organization, functionality, and role in making progress toward contraceptive security. The third section describes the current status of the six CS committees and their main achievements. The final section presents conclusions and lessons learned. The data in this report were generated from interviews with 67 key informants during February–March 2007 in the six countries (see Appendix A). The study team used an interview guide1 (see Appendix B) and an informed consent form (see Appendix C). During the interviews, researchers collected various committee materials (e.g., guidelines, resolutions, and workplans) to support and supplement the interview findings. 1 The information collected in sections E, F, and G of the interview guide will serve as input for the other case studies and activities conducted within the framework of the Health Initiative Project, Task Order 1. BACKGROUND The Regional Initiative on Contraceptive Security for Latin America and the Caribbean provides technical assistance to identify the main CS problems facing countries in the region, raise awareness about each issue, and help design national strategies and plans aimed at achieving contraceptive security. Participating countries include Bolivia, the Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Nicaragua, Paraguay, and Peru. In July 2003, under a USAID LAC Bureau initiative, more than 70 representatives of nine countries met in Managua, Nicaragua, marking the official beginning of the regional initiative. During this meeting, participants learned about contraceptive security, demographic trends, and perspectives on international cooperation in the field of family planning (FP). Participants represented government institutions (mainly the ministries of health and social security institutions); nongovernmental organizations (NGOs); and international aid agencies, including USAID and the United Nations Population Fund (UNFPA). A key outcome of the meeting was the concept and formation of country- level contraceptive security committees. These committees, with international technical assistance, would support country CS strategies by coordinating the efforts of all actors involved in contraceptive financing, procurement, and distribution in each country. Within the framework of the regional initiative and following the meeting in Managua, USAID cooperating agencies assessed the CS situation in five countries (Bolivia, Honduras, Nicaragua, Paraguay, and Peru). They also carried out secondary analysis of reproductive health (RH) surveys in El Salvador and Guatemala. Based on the situation and survey analyses, these agencies prepared a regional CS report, as well as reports for each individual country. In October 2004, the regional initiative held a “Contraceptive Security Forum” in Lima, Peru. Donors shared the results of studies on the current status of and impediments to contraceptive security in some LAC countries. In addition, delegations from each country shared experiences and presented their progress on various CS issues. The forum resulted in regional and national proposals and plans aimed at achieving contraceptive security in each country. The country delegations agreed to implement the strategies and plans upon returning to their countries. The meeting in Lima was expanded to involve more participants, including some higher level functionaries from several countries. This led to sensitizing important decisionmakers in the region and further progress toward officially establishing country committees.2 Since then, USAID has supported several important activities with country CS committees: workshops on estimating contraceptive needs and financial planning; a study analyzing the FP market that included RH surveys showing demand for different methods; and the design of strategies and working plans to reach a contraceptive supply and financing structure that would most appropriately meet the FP needs of the population. USAID also supported policy analyses of legislation related to contraceptive security, economic analyses of contraceptive prices by suppliers in the region, and an evaluation of various contraceptive logistical systems. 2 In Spanish, these contraceptive security committees are called Comites para la Disponibilidad Asegurada de Insumos Anticoncpetivos or Comites DAIA. 2 KEY ISSUES IN ESTABLISHING CONTRACEPTIVE SECURITY COMMITTEES The key informant interviews revealed several issues central to the organization, role, and effectiveness of the CS committees and their impact on their country’s CS situation. These issues, described below, included the (1) composition of the CS committees, (2) level of international donor support, (3) importance of regional meetings, (4) content of committee meetings, and (5) role of the CS committee in achieving identified results. Lastly, the key informants were asked to describe their prototypical CS committee on the basis of their experience. Composition of the CS Committees In most cases, the initial formation of a CS committee resulted from a delegation’s attendance at the regional CS meeting in Managua in 2003. This delegation generally included one or two representatives of the Ministry of Health (MOH) (particularly linked to the family planning program); a representative from the social security institution; an NGO affiliated with the International Planned Parenthood Federation (IPPF), and representatives from USAID and UNFPA. In time, other key players were identified and invited to join some committees. By and large, most committees predominantly comprise representatives of three main groups: the public sector (ministries of health and social security); the private sector (generally an NGO affiliated with the IPPF); and international agencies (generally USAID, its cooperating agencies, and the UNFPA). Note that among the MOH representatives participating in CS committees, some people are responsible for FP services as well as administrative areas such as contraceptive procurement and management. Additionally, some committees found it valuable to have among their members several government representatives from other sectors besides health (e.g., representatives from the ministries of finance, revenue, or education or from a women’s secretariat). “Yes, it [private sector participation] should be part of the working agenda of the committee, maybe not with a representative but as a sector that is part of the contraceptive commodities suppliers in the private sector. We believe that it is always good to know their expectations and their point of view about what the committee is doing.” ~ Representative of a Ministry of Health Regarding the possible participation of the private sector3 in CS committees, the key informant opinions were divided. In the Dominican Republic and Paraguay, representatives of the private sector already participate, but they do not regularly attend meetings (as reported by the other committee members in those countries). Those who support the private sector’s involvement base their position on the substantial market share enjoyed by the private sector in most LAC countries. They reasoned that if the private sector became more involved in “growing” the market to meet FP needs, pharmaceutical companies could offer better prices. Accordingly, they could be invited to train the committees on certain technical issues related to the essential drugs list and also generics. Some key informants stated that private sector representatives should be invited as observers. Some also said that the private sector’s experience with publicity and promotion could be useful to the overall effort. 3 In this section, the private sector is defined as the private commercial sector—for example, comprising pharmaceutical companies and pharmacies. 3 Other key informants stated that private sector representatives should not be included in the committee because they are concerned about profit and thus could be biased or misunderstood because of possible conflicts of interest. Some key informants suggested that private sector representatives be invited to participate occasionally. Level of International Donor Support Respondents acknowledged the important role of international agencies in the regional initiative, especially USAID’s support of the CS committees. In particular, USAID staff was effective at engaging host- country counterparts in policy dialogue about the future of contraceptives supplies in their countries and the need to develop locally sustainable substitutes for soon-to-be phased-out free donor commodities. In addition, USAID provided significant technical support to help countries make further progress toward contraceptive security, including doing market segmentation studies that helped countries understand the need to focus public sector efforts on providing contraceptives to the poorest people. Projects such as the POLICY Project, USAID’s Health Policy Initiative, and the DELIVER Project funded research; financed international exchanges and participation in regional meetings; and helped strengthen the institutional capacity of countries for planning, projecting needs, forecasting, and managing logistics. “In spite of the number of transitions within the Ministry of Health, the commitment of the CS committee has continued. I believe in part s because of the impulse USAID has given to the issue.” ~ NGO Representative Importance of Regional Meetings Study respondents reported that participation in the regional meetings had a large influence on the effectiveness of their CS committee efforts at home. Four meetings occurred between 2003 and 2007: Managua in July 2003, Lima in October 2004, Antigua, Guatemala in October 2006, and Santo Domingo in September 2007. Respondents noted the benefits they received in terms of learning about contraceptive security. Some participants were not even aware of the concept of contraceptive security before these meetings. Participants from countries yet to embrace contraceptive security were able to learn from those that already had direct experiences with CS initiatives. In this manner, participants were stimulated by understanding what was possible and by obtaining first-hand knowledge. For example, they learned that some governments were able to make discounted contraceptive purchases through UNFPA and were thus encouraged to explore the practice in their countries. After the first meeting in 2003, the organizers and country representatives sought to expand the number of people involved both in the regional meetings and in activities at home. Thus, for the Lima meeting in 2004 and the Antigua meeting in 2006, high-level officials were invited to participate; and in this manner, the “critical mass” for moving toward contraceptive security grew in each country. The involvement of these high-level officials subsequently resulted in their later playing a key role in the passage of policies to improve contraceptive security. “Information of the successful experiences of other CS committees in the region…that is what we get when we attend these international meetings…they are important…” ~ NGO Representative These regional meetings have also provided important opportunities to strengthen the technical capacities of key players—for example, their capacity to use CS advocacy tools. 4 Content of Committee Meetings The key informants considered committee meetings to be important venues for sharing information on all CS-related issues. Without regular meetings to review progress and deal with ongoing and new issues, it is unlikely that the CS committees would have been successful. Committee meeting topics have included the following: • Acquisitions (prices, processes, regulations, joint procurement, budgets) • Logistics (reports, monitoring, supply situation) • Statistical tools “Those of us who work in FP service institutions feel support on what is being done; we feel comfortable… when there are problems…. We don’t have to face them by ourselves.” ~ Social Security Officer “Almost always the issues addressed are (Ministry of) Health issues and one tries to help them.” ~ NGO Officer • Contraceptive quality • Financial sustainability • Statistical data and research • Information systems • Market segmentation • Forecasting • New contraceptives • Sensitizing authorities on contraceptive security • Event planning • Membership • Follow-up on commitments and workplan adjustments Given the multisectoral nature of the CS committees, internal issues understandably arise and must be addressed by the members. In two of the six countries, key informants from institutions outside of the MOH complained that the committee meetings were occasionally monopolized by issues of interest only to the ministry. They would also like to discuss and address issues of interest to other institutions. Role of CS Committees in Achieving Results All the respondents agreed that the existence and active involvement of the CS committees was instrumental in the achievement of many significant results in the six countries. Some respondents noted that progress on contraceptive security in their countries could have been made without the committees, but it would have required greater dedication by the government to make contraceptive security a priority, or alternatively, would have taken longer. Yes, it would have been possible if FP was a priority for the public sector; in my opinion the problem is that it is not a priority. ~ NGO Officer Probably, yes , (the achievements would have been reached without a committee) but the point is that the discussion within the committee strengthens this work. ~ International Cooperation Project Officer The committee is a mechanism for pressure and direct action. I see it difficult without this mechanism. ~ Ministry of Health Officer The Prototypical Committee Given the effectiveness of the six CS committees in furthering progress toward contraceptive security, the study team asked key informants to describe the “ideal” committee. The logic behind this exercise was to identify the essential common characteristics for a successful CS committee. Such information would be useful to other countries considering the establishment of committees to improve their CS situation. 5 Coordination Most respondents thought that the MOH should coordinate the committee in its capacity as steward of the health sector. They also agreed that the committee should have institutional representation from all groups working on reproductive health, including cooperating agencies and the Congress or Parliament. A minority of respondents believed that the coordination role should either rotate among members or be permanently placed with the nongovernmental sector. Ideal membership In the countries that have decentralized their health systems, respondents consider it pertinent that the committee include regional authorities. The possibility of forming a regional CS committee was suggested. Respondents also thought that the participation of nongovernmental actors as well as a diverse group of donors is necessary for the success of a committee. In addition, those who participate must be highly committed, proactive, and empowered; and must participate regularly in committee meetings. Ideal functioning According to the interviews, it is clear that the committee must have a workplan to define activities and should meet at least monthly to follow up on the plan. Some respondents noted that one person should work full time on committee coordination and that the committee should have an independent budget (its own resources), in addition to international agency support. In most countries, key informants stated that the committee should have two levels, political and technical. However, if only technical, it should have at least a mechanism to periodically inform policymakers. In addition, the CS committee should meet with the Minister of Health at least twice a year. To operate as an ideal committee, many respondents believed that the committee should be supported by a legal document that formally establishes the entity. In addition, the committee should work with the social cabinet (a formal or informal group of government ministers who work on social issues), actors who work to prevent maternal mortality, and local-level stakeholders. Often, showing how family planning saves lives can help position FP and CS issues on the MOH’s agenda. Part of the El Salvador CS Committee during work group in training. © 2006 Health Policy Initiative, Task Order 1. 6 CURRENT SITUATION OF THE CS COMMITTEES In this section, we will examine in more detail the status of the six CS committees. The committees are in different stages in their development, in the roles they play, and in progress made to date. Their status at any given time also depends on current FP needs, the plans and strategies of donors and ministries of health, and the political situation, among others, in each country. Appendix D includes a comparative table with the most important characteristics of the six committees. Bolivia Establishment Ten years before the establishment of the Bolivian Contraceptive Security Committee, a subcommittee on logistics was created as a part of the Reproductive and Sexual Health Committee of the Ministry of Health and Sports (MSD). The subcommittee included representatives from the ministry, NGOs, Central Procurement and Health Supplies Office (CEASS), and cooperating agencies. In 2002, the government of Bolivia created the National Council on Reproductive and Sexual Health under the aegis of the MSD to coordinate all the areas related to reproductive health. The CS committee was established after the meetings in Managua in July 2003 and became associated with the National Council. Although the CS committee is not officially part of the ministry’s organizational structure (e.g., it does not have a ministerial resolution or a decree of creation), it has internal functioning statutes. The Bolivian CS Committee includes participants from the following institutions: • MSD (Vice Minister, National Health Department, National Department of Medicines, National Program on Reproductive and Sexual Health) • USAID/DELIVER • Japan International Cooperating Agency • UNFPA • CEASS • Maternal and Child Universal Insurance (SUMI) Operations The committee’s internal regulations were approved in a meeting on September 17, 2003, and dictate that meetings will be held every six weeks. The committee also has a CS Strategic Plan for 2005–2008 that includes four strategies around these areas: (1) political commitment and leadership, (2) acquisition and funding, (3) market segmentation, and (4) logistics in times of reform. At the time of the study, the committee had not held meetings since December 2005; according to respondents, this is a result of staff turnover and other urgent priorities faced by the person responsible for convening the meetings. Achievements The respondents reported that the most important achievement of the Bolivian CS Committee was the signing of a decree in 2005 to include a reproductive and sexual health package in SUMI (see Box 1). Respondents said that promotion and advocacy activities with members of Congress and key decisionmakers were the main factors behind these achievements. They also noted that these achievements may not have been possible without the work of the CS committee—at the least, the passage of these decrees would have been difficult and more time consuming. 7 Assessment The respondents were in agreement that the CS committee was a success—evident by the decree to include FP/RH services for all women in SUMI. As a result of the new government in early 2006 and new MSD priorities, the issue of contraceptive security is receiving less attention today. All the key informants agreed that it is important to press for re-activation of the committee. Box 1. SUMI Expanded, Bolivia The Law 2426 dated November 21, 2002, named SUMI as a priority in Bolivia’s Poverty Reduction Strategy. It provides universal, comprehensive, and free services to cover pregnancy, birth, and postpartum care for up to six months, including the provision of services for all the pathologies women may have during this period. Family planning is also included. SUMI was expanded in December 2005 by Supreme Decree 3250 that mandates the provision of FP/RH services to women who are not pregnant. These services include family planning and cervical cancer control. Dominican Republic Establishment Box 2. Presidential Decree 327-07, Dominican Republic Issued on July 3, 2007 by the President, this decree mandates the CS Committee to coordinate strategies and plans to achieve contraceptive security for “the female and male population of reproductive age, of low income” (Article 1). According to this decree, the committee is part of the country’s national health system and will perform its activities in collaboration with the public and private sectors and NGOs. The decree also permanently authorizes the budget office to allocate funds for the procurement of contraceptive commodities as requested by SESPAS. The Dominican Contraceptive Security Committee was established after the meeting in Peru in 2004 and was made official by Ministerial Resolution Number 14, dated May 11, 2005. The resolution states that “the National Contraceptive Committee is provisionally created.” Article 5 states that “the present resolution will be in effect as long as it takes until the Executive Power issues the Decree creating the Contraceptive Security Committee in the Dominican Republic.” On July 9, 2007, the President of the Republic signed Decree 327-07 to make the committee official (see Box 2). According to a norm dated July 19, 2005, the committee includes representatives of the National Council on Population and the Family (CONAPOFA); the Secretary of State for Public Health and Social Assistance (SESPAS); the National Program for the Prevention and Control of STI/HIV/AIDS; the Direction for Maternal, Child, and Adolescents (DIGEMIA); the National Program for the Comprehensive Health Care of Adolescents; PROFAMILIA; the Dominican Association of Family Planning (ADOPLAFAM); the Commissioner for Health Reform; the Secretariat for the Armed Forces, the Dominican Institute for Social Security (IDSS); the Program of Essential Medicines; the Women’s Secretariat; the National Health Insurance Program (SENASA), the Dominican Pharmaceutical Association; the University of Santo Domingo; the National Association of Private Clinics; the National Health Institute; and the Dominican Society of Obstetrics and Gynecology. Additionally, the committee can invite representatives of donors and projects—including the UNFPA, USAID, USAID’s CONECTA project, PAHO/WHO, German Technical Cooperation, and the Project for Health Reform and Decentralization—as committee advisors. To form the committee, a small group representing SESPAS, USAID/CONECTA, and UNFPA identified the key organizations in FP/RH and invited them to participate. In the process, additional important stakeholders joined the committee. If a committee member suggests that someone else be added, then the proposal is analyzed and, if accepted, the committee sends an invitation. The Dominican CS Committee is the largest of all the CS committees in the region and enjoys a high attendance rate at meetings. Despite its size, some committee members believe that their work would benefit by expanding the membership even further. They suggest including representatives of different faith-based groups, youth 8 NGOs, the Secretariat of Education, the Directorates of Revenue, grassroots organizations, and universities. CS Committee in Dominican Republic during training © 2006 Health Policy Initiative, Task Order 1. Operations Resolution Number 19 issued by the Secretary of State for Public Health and Social Assistance in July 2005 outlines the “Norms of the National Contraceptive Security Committee.” According to this document, the committee has three subcommittees: logistics administration, policy and strategy, and finance. The main committee generally meets once a month; there can be additional meetings, depending on the urgency of the issues. The subcommittees also have separate meetings. A member that does n attend a meeting needs to provide a legit excuse (as stated in the resolution); thus, there is a strong commitment to attend meetings. ot imate SESPAS and CONAPOFA prepare the meeting agenda, which is sent in advance to all members, along with the meeting invitation. The agendas are flexible and include follow-up items from the previous meeting as well as any new items that members wish to address. Achievements Respondents reported that the committee achieved the following: • Contraceptive security made a priority for SESPAS and other government agencies dealing with health; • FP norms and an expansion of coverage approved; and • Significant savings realized as a result of contraceptive procurement through UNFPA. Some of the contributing factors leading to such achievements included the following: • The ability to share with and learn from CS committees of other countries in regional meetings; • A strong CS committee organizational structure with defined subcommittees; • A defined mandate from the government and the president; • The availability of government funds for contraceptive procurement; • The leadership of the committee chair and the level of commitment of committee members; • An unusual spirit of cooperation and collaboration by agencies and groups that generally work independently; • The determination of CONAPOFA to rescue the FP program after such difficult stockout problems; and • The support of technical assistance organizations. Assessment The Dominican CS Committee has made great strides in establishing itself as a model of a dynamic inter- agency organization and in making tremendous progress toward contraceptive security. 9 El Salvador Establishment The Salvadoran Contraceptive Security Committee was established and began functioning after the regional meeting in Peru in 2004; however, it did not become a legal government entity until September 20, 2006, with the signing of Ministerial Resolution #2215. Committee members were sworn in by the Minister of Health on January 23, 2007. The committee includes representatives of the Ministry of Public Health and Social Assistance (MSPAS), including the Women’s Program Coordinator, the person in charge of family planning, the Institutional Finance Unit, and the Medicines and Medical Supplies Regulation Unit (Planning Division); the Salvadoran Institute for Social Security (ISSS); the Salvadoran Demographic Association (ADS); USAID; and UNFPA. These organizations were identified as lead agencies in the area of family planning, and, for this reason, they were selected to form the committee. Box 3. Committees Sharing Experiences on Legislation, El Salvador Within the framework of the CS regional meetings, the Salvadoran CS Committee learned about a FP law issued by the Guatemalan Congress. The committee became interested in learning about the promotion and advocacy that led to the law (Guatemala Decree 7-2005, Law of Universal and Equal Access to Family Planning Services and its Integration into the National Program on Sexual and Reproductive Health). With support from the USAID | Health Policy Initiative, three key actors in the Guatemalan law process were invited to visit El Salvador to meet with the Salvadoran CS Committee and the directors of different areas of the MSPAS to share their experiences regarding this law. This was an enriching process for both parties and resulted in more awareness and sensitization among the members of the Salvadorian CS Committee. According to those interviewed in El Salvador, it would be desirable to include additional actors both from other parts of MSPAS (Adolescents’ Program, Regulation Division, Institutional Procurement and Contracts Unit); and from other government agencies (Military Health, Teachers’ Welfare, Ministry of Finance, the Legislative Assembly, the National Secretariat for the Family), and civil society. Furthermore, the exchange with a Guatemalan delegation who participated in the drafting and approval of the Guatemalan FP law highlighted the importance of civil society participation in the CS committee (see Box 3). Operations In 2005, the committee prepared its workplan, which is reviewed and updated periodically. The committee held regular meetings from the end of 2004 until the end of 2006. Since the committee was made official in 2007, meetings have been held with more frequency (seven meetings in six months), and minutes of each meeting are taken. The meeting’s agenda is prepared by the MSPAS; however, according to committee members, the agenda is flexible enough to include items needing attention on the day of the meeting or in advance for the next meeting. The committee approved a regulations manual, which was recently made official by the Minister of Public Health and Social Assistance in July 2007. Achievements According to the respondents, the achievements of the Salvadoran CS Committee include • Legalizing the committee and swearing in the members; • Raising the profile of CS within the institutions represented on the committee; • Gaining significant cost savings by purchasing contraceptives through UNFPA; • Writing a multi-year workplan; • Carrying out a FP market segmentation study; and 10 11 • Signing an addendum letter with USAID, which obliges the government to take on responsibility for an increasing percentage of total contraceptives purchased for use by the public sector. Some of the contributing factors leading to the aforementioned achievements include • Follow-up and encouragement by international organizations, particularly USAID and UNFPA, to implement actions leading to progress toward contraceptive security; • Joint work, ownership, and empowerment of the people constituting the committee; • Political will and support to elevate family planning as a foundation for safe motherhood; and • Participation in regional meetings, which facilitated the induction of new members, motivated the committee’s work, and introduced the successful experiences of other countries. Respondents stated that these achievements would have been difficult and time consuming if a committee had not been playing an active role. They also thought that changing the membership of the committee too frequently could adversely affect the committee’s work; and that, in the short term, it would be advantageous to maintain the current membership until the committee is fully institutionalized. Assessment CS Committee El Salvador, during swearing in ceremony with Minister of Health. © 2007 El Salvador Ministry of Health. Since the legalization and swearing in of members, the committee has become re-energized and is now better positioned within the MSPAS. This increased sense of ownership as well as general acknowledgement of the CS committee as an item of national priority (and not just an internal entity of the MSPAS) bodes well for the achievement of contraceptive security in El Salvador. Honduras Establishment The CS committee in Honduras was founded after the regional meeting in Nicaragua in 2003. Officially named the Inter-institutional Contraceptive Security Committee, the government sanctioned the committee through Agreement No. 5326 of the Ministry of Health (SdeS), dated December 12, 2005. According to the founding agreement, the committee includes the MOH (the Vice Minister/General Director of Family Care, the Vice Minister of Health Services Network, the Chief of the Family Care Department, the Women’s Care Unit, the Men’s Care Program, the National Program for the Prevention of STI/HIV/AIDS, General Manager, the Technical Unit for Supplies and Medicines); women’s groups; the Honduran Institute for Social Security (IHSS); the Honduran Association for Family Planning (ASHONPLAFA); USAID; FP-related projects supporting the SdeS; UNFPA; the Pan American Health Organization (PAHO)/World Health Organization (WHO); and the Finance Secretariat. In addition, the committee has advisory members, including university representatives, associations of health professionals, NGOs providing related health services, social marketing firms, and pharmaceutical companies. Most respondents believed that the committee’s membership is appropriate. However, some respondents thought that other people should be included, such as a pharmaceutical chemist who can provide information on the composition of contraceptives; a member of the Acquisition Commission (established by the President to purchase all the SdeS’ medicines); representatives of the Joint United Nations Program on HIV/AIDS (UNAIDS) and the Global Fund to Fight AIDS, Tuberculosis and Malaria; and the budget chief from the Ministry of Finance. Operations Agreement No. 5326 of the SdeS stipulates the structure and function of the CS committee and includes a log frame of the CS strategy for 2005–2009. The committee does not have a formal workplan at this time. Nevertheless, the committee holds meetings every month using an agenda prepared by the SdeS. There is good follow up to these meetings and unfinished agenda items are taken up again in the next meeting until fully addressed. Achievements The respondents reported the following achievements for the Honduran Inter-institutional Contraceptive Security Committee: • Establishing a CS committee and keeping it active; • Raising the profile and importance of contraceptive security within the government; • Helping to more closely align the SdeS’ contraceptive inventory to FP needs; • Improving the efficiency of an automatic system of inventory control; and • Obtaining a budget line item for contraceptives and getting the government to provide funds for contraceptive procurement. Among the many factors contributing to the CS committee’s success are • A positive attitude and high level of motivation among the committee members; • The continuity of membership; • The Vice Minister of Health, the former chair’s stature, motivation, and support to the committee; • The SdeS’ strong political will and appreciation for the role the committee could play to support the government FP/RH program; • Agreement between the SdeS and USAID on CS objectives and USAID’ s follow-up assistance to the committee; and • Donors’ agreement to maintain their joint position that the government has to assume more responsibility for contraceptive security, and their firmness in setting phaseout timetables. As with the other countries, the majority of respondents believed the CS committee was the key element in Honduras’ progress toward contraceptive security during 2003–2007. Assessment While respondents were enthusiastic about the committee’s accomplishments, they also felt that the CS committee could do even better. They believed that for the committee to be fully effective, it needs to devise a workplan with specific objectives, component strategies, and detailed activity plans. Nicaragua Establishment During the 2003 Managua meeting, participants and their colleagues in Nicaragua decided to establish a Contraceptive Security Committee as a means of stimulating movement toward contraceptive security. This group received an additional impetus as a result of participating in the 2004 regional meeting in Peru. While the committee in Nicaragua did not take the formal bureaucratic step of legalization, the committee members did prepare a “founding” document with organizational definitions and guidelines. 12 Moreover, the committee’s workplan was approved through a ministerial resolution that recognizes the committee’s existence and role. Adhering to its organizational guidelines, the CS committee includes representatives of the Ministry of Health (MINSA), Nicaraguan Social Security Institute (INSS), Provisional Medical Enterprise (health services to the insured), pharmaceutical sector, Federation Red NicaSalud (NicaSalud Federation Network), the Nicaraguan Family Welfare Association (PROFAMILIA), UNFPA, USAID’s Sexual and Reproductive Health Project, DELIVER, Pan American Social Marketing Organization (PASMO), Georgetown University/Institute of Reproductive Health, and the Quality Assurance Project (QAP). According to some members, the committee is too small and more policymakers/decisionmakers should be invited to participate. Also, some stated that the membership should include officials from the President’s Office, the Ministry of Industry and Commerce, and the Nicaraguan Chamber of Health; more pharmaceutical representatives, such as distributors; more donors; and additional NGOs. Others believed that the committee should also represent contraceptive users and the consumers’ defense league. Operations In 2005, the Nicaraguan CS Committee approved organizational guidelines. In addition, the committee prepared a Contraceptive Security Workplan for 2005–2008, which was recognized as the government’s official plan in December 2006 through MINSA Resolution 384-2006. The committee meets regularly on the first Thursday of each month. Members take the responsibility of attendance seriously, and attendance is high. MINSA coordinates the committee, while USAID’s DELIVER Project is the Executive Secretariat. MINSA and DELIVER jointly prepare meeting agendas and send them to members in advance. The committee has four working commissions—logistics, advocacy and policy, market segmentation, and funding—which are active as needed. Achievements According to the respondents, the achievements of the Nicaraguan CS Committee include • Developing an official workplan; • Raising awareness among high-level authorities about the need to begin procuring contraceptives using government funds; • Stimulating the allocations of $10,000 in 2006 and $100,000 in 2007 of MINSA funds to purchase contraceptives through UNFPA; and • Holding a workshop, with representatives from the Local Systems of Integrated Health (decentralized health system entities), on projecting contraceptive commodity requirements— contributing to capacity building at the regional level. The factors contributing to the achievements of the committee include • The high caliber of the people involved in the CS committee work and their sense of empowerment to make a difference; • Teamwork and good coordination, as well as clear objectives; • Advocacy at the technical level to inform decisionmakers and foster action; • Political, technical, and financial support from decisionmakers and donors, especially USAID; • MOH leadership and active involvement; and • Judicious selection of committee members. Respondents agreed that progress toward contraceptive security would not have been made without the committee. Regarding changes in membership and their effect on the committee, several respondents 13 pointed out that the government changed in 2006 and that change had not yet had an impact on MINSA— although the INSS is no longer participating in the CS committee. Assessment While Nicaragua’s CS committee has not gained the level of achievement of some other committees, it continues to work on the issues and press for contraceptive security. According to the respondents, the DELIVER Project’s technical support to the committee has been important. They also stated that it is critical that the member national agencies increasingly assume total responsibility for the committee and its work program. Paraguay Establishment The Paraguayan Contraceptive Security Committee was established during the Managua meeting in 2003. The National Council of Sexual and Reproductive Health, led by the Minister of Public Health and Social Welfare, approved the creation of the committee, which operates under the aegis of the council. The committee membership comprises representatives of the MSPBS (Program Direction), the Social Security Institute (IPS), the Paraguayan Center for Population Studies (CEPEP), PROMESA, the Paraguayan Chamber of Pharmacies, USAID/DELIVER, USAID, PAHO, and UNFPA. Respondents observed that expanding the committee’s membership would have advantages for the future effectiveness of the committee. New members could include, for example, representatives of the Ministry of Education, women’s groups (Women’s Coordination Unit of Paraguay), regional MSPBS offices, and the Professional Pharmaceutical Association. Some respondents believe the committee would benefit from increased participation in the meetings by UNFPA and the Paraguayan Chamber of Pharmacies. Operations Although the committee considers itself to be effective in making progress toward contraceptive security, it does not have formal statutes or organizational guidelines. The committee has an operational workplan that is reviewed and updated at each monthly meeting. Achievements Respondents reported the following main achievements of the committee since 2003: • Law 2907 (see Box 4) guaranteed funding for contraceptive purchases (even though full implementing regulations are still being developed); • MSPBS allocated $261,753 to purchase contraceptives in 2006—equal to 60 percent of its contraceptive needs; • The MSPBS committed $551,000 to purchase contraceptives in 2007; • A logistics person was appointed at the MOH; • Resolution 598 in August 2006 established that all MSPBS-procured contraceptive methods would be provided free in all facilities; Box 4. Law 2907, Paraguay To ensure funding for MSPBS FP/RH programs and birthing kits, the Paraguayan Congress approved Law 2907 on May 23, 2006. This law ensures that there is enough money in the national budget to finance both programs and to provide the contraceptives and birthing kits for free under standardized principles of voluntary and informed choice. Moreover, the law ensures that the IPS includes its own resources in its budget to acquire contraceptives for its beneficiaries. The CS committee played a key role in the passage of this law by sensitizing members on CS issues through its participation in regional CS meetings as well as through its teamwork. 14 • The MSPBS, USAID, and UNFPA sign a tripartite agreement to phase out all donated contraceptives; and • The Paraguayan CS Committee is permanently established to oversee contraceptive security in the country. The achievements of the committee were attributed to the following factors: • Support from USAID and UNFPA; • Successfully pursuing advocacy and technical activities with high-level officials and policymakers; • The active participation of key actors in regional meetings, including members of Congress who supported the passage of Law 2907; • Leadership, diplomacy, and commitment; and a spirit of cooperation among CS committee members; • Political will of the Minister of Public Health and Social Welfare; and • Combining the key needs of contraceptive security and safe motherhood into a single legislative package that members of Congress could easily support. A regulatory motion signed by Congress is being negotiated to allow direct, noncompetitive procurement from the UNFPA, including the payment of contraceptives in advance (a requirement of UNFPA). Assessment The Paraguayan CS Committee is dynamic and committed, and all national institutions represented should continue to work as they have, strengthening national government responsibilities to better prepare for phaseout. 15 CONCLUSIONS In the six focus countries of this study, it is clear that the majority of achievements since 2003 in working toward contraceptive security have been the direct result of activities and synergies generated by the CS committees. Some factors stand out as being most relevant to the committees’ success: • The committees have been strengthened and empowered through effective inter- institutional integration. The participation of people from different institutions linked to reproductive health and related areas within the committees has allowed the sharing of relevant information, as well as the coordination of actions to advance toward contraceptive security. In most cases, a monthly meeting facilitated these processes. Having inter-institutional participation (and within one single institution, with representatives of its different areas) made it possible to have promoters and champions of the CS issue in various national departments and agencies. The leadership qualities and dynamism of the person chairing the CS committee is an important indicator of the committee’s degree of “success.” Political representation on the committee is necessary to strengthen political will and establish working relationships with political representatives, such as a minister or vice-minister, to keep them updated on the committee’s work and needs. As a result, many respondents suggested that an ideal committee would include both technical and political representatives and could even be two separate committees—one for political representatives and one for technical representatives. The legalization of CS committees through ministerial resolutions or executive decrees provides more confidence to members—they know they are supported by the legal, bureaucratic, and political structure. However, the most important factors seem to be the intangibles of teamwork, coordination, and synergy—rather than the formality of a document. Three of the six committees have a resolution or decree, while the other three do not. The majority of respondents were pleased with the make-up of the committee membership. However, many respondents suggested bringing in new and diverse members who could improve the effectiveness of the committee’s work. The potential new members most cited were from institutions related to public finances and civil society. • Exchange of information and experiences multiplies the effect of the committees. Regional meetings have been key venues for conveying messages about the importance of contraceptive security to decisionmakers and have served as catalysts for the committees’ country activities. The sharing of experiences among members within a committee and among committees in the region—especially those experiences related to achievements and difficulties—has greatly facilitated the implementation of country CS strategies. 16 • International cooperation has played a key role in supporting the formation and work of the committees. International technical cooperation—particularly that of USAID/Washington and their in-country projects and UNFPA—provided the committees with orientation, technical and financial assistance, as well as facilitation for the sharing of experiences among countries in the region. In the future, higher levels of financial and technical support at the outset of CS activities may allow national institutions to assume leadership and direction at an earlier stage in the development and functioning of CS committees. Note that although these committees have made important progress, countries (in particular, CS committees) still face many challenges, including • Having sufficient public funds in a timely manner to procure contraceptives; • Obtaining adequate estimates of contraceptive needs; • Procuring contraceptives at low prices; and • Having good logistics systems that can guarantee that users will have access to desired methods whenever they want them. Therefore, there is still much work to do in the study’s six countries. Full institutionalization of the CS committees should include flexible, multiyear agendas and workplans aimed at achieving contraceptive security. 17 APPENDIX A. PEOPLE INTERVIEWED BY COUNTRY BOLIVIA March 26–28, 2007 NAME INSTITUTION JOB TITLE Margarita Flores MSD Public Insurance Chief Lourdes Peralta CEASS National Director Fernando Álvarez CIES General Manager Jorge Parra UNFPA Representative Oscar Vizcarra UNFPA Reproductive and Sexual Health Program National Office Marjorie Vizcarra EngenderHealth/ACQUIRE Technical Area Director Patricia Sáenz John Snow/Management and Quality Logistics Manager Rocío Lara Health Office, USAID Program Officer EL SALVADOR February 4–9, 2007 NAME INSTITUTION JOB TITLE Ena García MSPAS Planning Director Jorge Cruz González MSPAS Women’s Healthcare Coordinator Esmeralda de Ramírez MSPAS Responsible for Family Planning Program Simón Baltasar Ágreda ISSS Chief of Regulatory Technical Unit Georgina Santamaría ISSS Technical Staff on Health Prevention, Rafael Avendaño ADS Executive Director José Mario Cáceres ADS Director, Social Programs and Evaluation Maricarmen de Estrada USAID Health Officer Leonor Calderón UNFPA Resident Representative Mario Morales Velado UNFPA Reproductive Health Officer 18 HONDURAS March 12–15, 2007 NAME INSTITUTION JOB TITLE Sandra Ramírez SdeS General Director Enrique Espinal Zelaya SdeS Chief of Family Care Department Ivo Flores Flores SdeS Chief of Women’s Healthcare Program Miriam Chávez Rivera IHSS National Medical Director Manuel Sandoval ASHONPLAFA Medical Director Elena Boesch ASHONPLAFA Chief of Operations Emma Iriarte USAID Health Officer Álvaro González USAID/QAP General Coordinator José Ochoa USAID/QAP Maternal-Child Health Coordinator Alba Lidia Sánchez USAID/EngenderHealth Country Director Flor María Matute UNFPA Reproductive Health Component Manager NICARAGUA April 16– 9, 2007 NAME INSTITUTION JOB TITLE Flor de María Cardoza MINSA Responsible for Family Planning Indiana Herrera MINSA Responsible for Program and Budgeting, Planning and Development Division Oscar Aráuz MINSA Medical Supplies Procurement and Management Martha María Solórzano MINSA Procurement Unit Director Elizabeth Guevara INSS Former Officer (Supervisor of medical supplies) Coralia Cuadra PROFAMILIA Responsible for Physical Resources Donald Moncada PASMO Country Manager Wilfredo Barreto Legislative Assembly Advisor to the Heath and Social Security Commission Connie Johnson USAID Social Investment Office Director Claudia Evans USAID RH Project Specialist Carolina Aráuz USAID/DELIVER Project Country Representative Pedro Pablo Villanueva UNFPA Representative in Nicaragua (and Director for Costa Rica and Panama) 19 PARAGUAY April 23–25, 2007 NAME INSTITUTION JOB TITLE Rubén Darío Ortíz MSPBS Director of Health Programs Noemí Gómez MSPBS Logistics Director Olga Fernández de Camé IPS Technical Assistant, Health Management Darío Castagnino IPS Technical Assistant, Health Management Teresa León IPS Preventive Medicine and Health Programs Director (Former Minister of Health) Cynthia Prieto CEPEP Executive Director Bernardo Uribe USAID/DELIVER Project Country Representative Graciela Ávila USAID Health Officer Roberto Kriskovich UNFPA RSH Advisor Nafio Inaussa UNFPA Administrator DOMINICAN REPUBLIC February 19–22, 2007 NAME INSTITUTION JOB TITLE Héctor Eusebio Polanco SESPAS Director, DIGEMIA Cándido Rivera CONAPOFA Executive Director Eleodoro Pérez Sierra CONAPOFA National Coordinator of the FP Program Alexi Martínez CONAPOFA Administrative Assistant Director Luis Américo Lara IDSS Reproductive Health Programs Coordinator Juan Miguel Houellemont PROFAMILIA Marketing and Sales Manager Iradia Caraballo PROFAMILIA Commercial Sales Supervisor Jorge Velasco USAID Health Office Acting Director Sonia Brito USAID/CONECTA Reproductive Health Manager Luz Mercedes UNFPA Medical Coordinator Ramón Portes Carrasco ADOPLAFAM Director Luis Rafael Pérez Bidó ADOPLAFAM Planning and Development Director José Cender Figueroa Dominican Society of Obstetrics and Gynecology President Mildred Ramírez State Secretariat for Women Technical Staff Kelvin Bautista SENASA Marcela Disle SENASA Responsible for Pharmacy and Medications Guillermo Guilme SENASA María Luisa Romero Dominican Women in Development, Inc. Services Coordinator at the Women and Health Collective 20 APPENDIX B. INTERVIEW AND NEEDS ASSESSMENT GUIDE A. About the CS Committee 1. How long have you known about contraceptive security? 2. Is there a CS committee in this country? 3. Since when? 4. Does this committee have a legal or official framework? What is it? Obtain a copy. 5. Who forms the CS committee? 6. How was the formulation decided and who decided it? 7. Are there representatives of international cooperation agencies? 8. Do you think that those who formed the committee should be there? Who is missing and what do you suggest can be done about it? 9. Do you think that the private-business sector should have a role in the committee? Why? What role? Should the private-business sector have a role in the FP market? B. How the CS Committee Operates 1. Are there regulations and norms for the work of the committee? Obtain copies. 2. Does the committee have a workplan? 3. Since when? 4. Is it reviewed periodically? 5. How often does the committee hold meetings? 6. How are these meetings structured? 7. Who coordinates the committee? 8. Who defines the agenda of the meetings and how? 9. Are the meetings used to share information of issues of interest for the committee members? 10. What are the issues addressed in the committee meetings? 11. Do committee members consider the issues addressed as relevant? 12. On average, how many people attend the committee meetings? 13. On average, what is the percentage of attendance to the meetings? (What is the % of members who attend them?) C. Achievements of the CS Committee 1. What are the main achievements of the CS committee, if any? 2. What factors led to these achievements? (Coordination, person who coordinates committee members, chance, etc.) 3. Would these achievements have been possible if there was not a committee? 4. Do you think that the CS committee has been successful in its administration? 5. Why? 6. What factors have contributed to the perception of a successful committee? 7. Do you think that key actors in the health sector recognize the CS committee? 8. Is the CS committee linked with important health initiatives in the country (such as health reform, for example)? 9. Do you think that the committee’s work is sufficiently integrated into the institutions so that its work would not be affected if there were changes in administration? 10. If there was a change in government, how would this affect its support of CS? 21 D. The Ideal CS Committee 1. What are the characteristics of an ideal CS committee? Consider: a. Composition (technical/political level, members) b. Coordination c. Working procedures E. Use of Information for Decisionmaking within the CS Framework 1. For decisionmaking purposes, has the committee used relevant information produced by USAID- funded agencies or other pertinent information? a. Information from market segmentation studies b. Information on Spectrum and/or financial planning workshops c. Analysis information on family planning and the Millennium Development Goals d. Information about the experiences of other CS committees in the region (including contraceptive procurement experiences) e. Any other information? 2. The purpose of the information that the committee used or shared was the following: a. Promotion and defense b. To provide feedback for decisionmaking and planning processes 3. What kinds of decisions or commitments were adopted as a result? 4. What kind of information do you think is missing? What are the information gaps? 5. (If you have not done it): Could you provide concrete examples of the use of information for decisionmaking purposes? F. CS Activities and Technical Assistance Needs 1. What do you think the committee needs to make progress toward contraceptive security in the country? a. Advocacy b. Finance c. Procurement mechanisms d. Market segmentation e. Regulatory and legal framework f. Logistical systems g. Support for CS strategic planning h. Others (please specify) 2. Which of these areas requires technical assistance for the CS committee? 3. What is the order of priorities? 4. Is there any activity implemented by another CS committee in the region that you think this committee could and would like to learn from? Which one? G. Additional Comments 1. Is there anything else you wish to add? 22 APPENDIX C. INFORMED CONSENT FORM Good morning/afternoon. My name is _______ and I work for Constella Futures, an organization funded by USAID to perform a study in the region about contraceptive security committees. The study will focus on committees from six countries, yours among them. Using the information collected through these interviews, we will prepare a document to summarize the information on the six committees. We want to make it clear that your participation in this study is voluntary. We are interested in your points of view about the constitution, functioning, and activities of the committee; what would be an ideal committee, the use of information for decisionmaking within the committee, and the perceived technical assistance needs. If you do not feel comfortable with any of the questions, do not worry, you are not obliged to reply; and you may interrupt the interview whenever you wish to do so. The information collected will be documented; and if we deem it necessary, we may quote part of the interview, indicating your job title and the institution where you work. Do you agree? Yes No _______________________________ _____________ Name and signature of the interviewee Date ____________ Job Title ___________________________ Institution 23 24 APPENDIX D. SITUATION OF THE CS COMMITTEES IN COUNTRIES OF THE LATIN AMERICA AND CARIBBEAN REGION BOLIVIA DOM. REP. EL SALVADOR HONDURAS NICARAGUA PARAGUAY Non-official start date of committee July 2003 November 2004 November 2004 2003 2003 2003 Official start date of committee August 2003 May 2005 September 2006 December 2005 2004 N/AV Resolution (R) or decree (D) of creation? No R, May 2005 R, September 2006 R, December 2005 No, but the ministerial resolution of the working plan acknowledges the existence of the committee No, although it is stated in CNSSR Act Regulations or working guidelines? Yes, Internal Regulations, September 2003 Yes, Resolution 19, July 2005 Being reviewed Yes Yes No Committee Coordinator MSD SESPAS/CONAPOFA MSPAS SdeS MINSA Rotating Workplan Yes, November 2005 Yes, 2006, by subcommittees Yes, 2005 No Yes, 2006, by Resolution 384-2006 Yes, 2005, by National Council of SRH Periodical review of plan No Yes Yes N/A Yes Yes, monthly Average number of people attending meetings 5 24 7 15 9 N/AV Percentage of average attendance (%) 50% 90% 80% 80% 90% N/AV Frequency of meetings They were not meeting at the time Monthly Quarterly; since January 2007, monthly Monthly Monthly Monthly Do they have functioning subcommittees? No, but it is considered in the internal regulations Yes No No Occasionally No Agenda written by: N/A CONAPOFA proposes agenda and consults it MSPAS DELIVER did and now MOH MINSA and DELIVER DELIVER Agenda consulted by: N/A Yes No, but it is possible to request the inclusion of items No, but it is flexible Yes Yes, very flexible Key actors of the health sector recognize the CS committee They recognize the technical work of John Snow, Inc., but not the committee Majority yes, although some think there needs to be more No Majority yes, but mostly at technical level Majority yes Yes The committee is considered successful While it worked Yes Majority, yes Divided Majority, yes Yes The committee is connected to important initiatives in the health sector While it worked Divided No Majority no Divided N/AV N/A=Not applicable N/AV=Not available 25 RESOURCES Hare, L., Hart, C., Scribner, S., Sheperd, C., Pandit, T. (ed.) and Bornbusch, A. (ed.). 2004. SPARCHS: Strategic Pathway to Reproductive Health Commodity Security. A Tool for Assessment, Planning, and Implementation. Baltimore, MD. Information and Knowledge for Optimal Health (INFO) Project/Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health. Ministerio de Salud. 2005. Guía de organización y funciones del Comité DAIA en Nicaragua. Ministerio de Salud. 2005. Plan para la Disponibilidad Asegurada de Insumos Anticonceptivos en Nicaragua 2005-2008. Secretaría de Estado de Salud Pública y Asistencia Social, SESPAS; Consejo Nacional de Población y Familia, CONAPOFA; Comité para la Disponibilidad Asegurada de Insumos Anticonceptivos del Programa de Planificación Familiar. 2005. Normas del Comité Nacional para el Aseguramiento de Anticonceptivos. Santo Domingo. Secretaría de Salud. 2005. Estrategia Nacional para la Disponibilidad Asegurada de Insumos Anticonceptivos. Tegucigalpa, Honduras. Stewart, Lindsay. 2006. Disponibilidad asegurada de insumos anticonceptivos en América Latina. Powerpoint presentation presented at the Contraceptive Security Promotion and Defense Workshop held in Antigua Guatemala in October 2006. Taylor, Patricia A., Nora Quesada, Wendy Abramson, Varuni Dayaratna and Leslie Patykewich. 2004. Regional Report: Contraceptive Security in Latin America and the Caribbean. Results and Recommendations. Arlington, VA: John Snow, Inc./DELIVER, and Washington, DC: Futures Group/POLICY II, for the U.S. Agency for International Development (USAID). Health Policy Initiative, Task Order 1 Constella Futures One Thomas Circle, NW, Suite 200 Washington, DC 20005 USA Tel: (202) 775-9680 Fax: (202) 775-9694 Email:

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