Honduras: Final Country Report

Publication date: 2007

HONDURAS: FINAL COUNTRY REPORT MARCH 2007 This publication was produced for review by the United States Agency for International Development. It was produced by the DELIVER project. HONDURAS: FINAL COUNTRY REPORT The authors’ views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government. DELIVER DELIVER, a worldwide six-year technical assistance contract, is financed by the United States Agency for International Development (USAID). Implemented by John Snow, Inc. (JSI) (contract no. HRN-C-00-00-00010-00) and subcontractors (Manoff Group, Program for an Appropriate Technology for Health [PATH], and Crown Agents Consultancy, Inc.), DELIVER strengthens the supply chains of health and family planning programs in developing countries to ensure the availability of critical health products for customers. DELIVER also provides technical management of USAID’s central contraceptive management information system. Recommended Citation DELIVER. 2007. Honduras: Final Country Report. Arlington, Va.: DELIVER, for the United States Agency for International Development. Abstract The DELIVER project carried out by JSI in Honduras benefited in particular the Ministry of Health (MOH) and the Honduran Family Planning Association (ASHONPLAFA). DELIVER’s main accomplishments were the development of local capacity to plan procurement that uses logistics information from family planning activities, the development of software for managing inventories and logistics management information for the MOH, and the formation and consolidation of the Contraceptive Security Committee and the contraceptive security (CS) national strategy, which involved a variety of national stakeholders and was ratified by the MOH. DELIVER also helped ASHONPLAFA strengthen its logistical process in the areas of storage and distribution as well as in the use of PipeLine software to produce its contraceptive procurement tables and strengthen the procurement process. Among other things, the most important achievement is the recognition and application of the CS national strategy, which is demonstrated by the routine functioning of the inter-institutional CS Committee, and the purchase of contraceptives with national funds, thus fulfilling the agreement reached with the U.S. Agency for International Development/Tegucigalpa to gradually increase funding from the national treasury to meet contraceptive needs. A foundation has been laid to incorporate other institutions into the CS process in the future by including them on the CS Committee. DELIVER John Snow, Inc. 1616 North Fort Myer Drive, 11th Floor Arlington, VA 22209 USA Tel: 703-528-7474 Fax: 703-528-7480 Email: deliver_project@jsi.com Internet: www.deliver.jsi.com CONTENTS Acronyms. vii Acknowledgments. ix Executive Summary . xi Program Background. 1 Country Context.1 Key Players and Roles .2 Key Challenges .3 Goals and Objectives. 7 DELIVER Objectives .7 Relationship to USAID and Client Objectives .7 DELIVER’s Role in Relation to Other Organizations.8 Summary of Interventions.8 Summary of DELIVER Funding and Staffing.8 Program Results. 11 Element I: Improved Logistics System.11 Element II: Improved Human Capacity in Logistics .11 Element III: Improved Resource Mobilization for Contraceptive Security.11 Element IV: Improved Adoption of Advances in Logistics .12 Element V: Estimation of USAID Contraceptive Needs .12 Lessons Learned and Future Directions. 13 References . 15 Appendices 1. CS Brief .17 2. Matrix of Program Results.19 Tables 1. Percentage of SDPs Where SOH and the ICC Coincide and Stock on Hand Coincides within 10 percent .4 2. Percentage of SDPs Whose SOH Is between Minimum and Maximum Levels.4 Honduras: Final Country Report v Honduras: Final Country Report vi ACRONYMS AIDS acquired immunodeficiency syndrome ASHONPLAFA Asociación Hondureña de Planificación de Familia (Honduran Family Planning Association) CPT contraceptive procurement table CS contraceptive security ENDESA Encuesta de Demografía y Salud ENESF Encuesta Nacional de Epidemiología y Salud Familiar (National Survey on Epidemiology and Family Health) FP family planning GOH Government of Honduras HIV human immunodeficiency virus ICC inventory control card IHSS Instituto Hondureño de Seguridad Social (Honduran Social Security Institute) IUD intrauterine device LMIS logistics management information system LIAT Logistics Indicators Assessment Tool LSAT Logistics System Assessment Tool MOH Ministry of Health NGO nongovernmental organization PAHO Pan-American Health Organization PNH Policía Nacional de Honduras (National Police of Honduras) SACI sistema automatizado para el control de inventarios (automated inventory control system) SDP service delivery point SO strategic objective SOH stock on hand UNFPA United Nations Population Fund USAID U. S. Agency for International Development Honduras: Final Country Report vii viii Honduras: Final Country Report ACKNOWLEDGMENTS The DELIVER project expresses its gratitude to all those who made possible the advances in developing the contraceptive logistics management information system and, in particular, thanks the Ministry of Health authorities of the two governments that have been in office during the project. We especially acknowledge Manuel Sandoval, vice minister of health in the previous government, who offered unconditional support for the process and approved the ministerial resolution that gave legal backing to the Contraceptive Security Committee and its strategy, and Sandra Ramirez in the present government, who upon learning about the process reactivated the committee meetings without reservation, and whose activities made it possible to secure funds for the purchase of contraceptives. Our gratitude is also extended to the other political authorities of both governments who are involved in the national contraceptive security strategy. A special acknowledgment is owed to our counterparts on the technical and normative level—Ivo Flores, Enrique Espinal, and Oscar Reyes—whose efforts and discussions made possible the achievement of the technical agreements that are being implemented through the project. We also thank our colleagues from the Honduran Family Planning Association who took ownership of the contraceptive security process. Finally, we thank the staff at the U.S. Agency for International Development/Tegucigalpa, especially Angel Coca, Fidelina Escoto, and Ruth Figueroa, who gave us constant support and made our work possible. Honduras: Final Country Report ix Honduras: Final Country Report x EXECUTIVE SUMMARY Until the end of the 1990s, all contraceptives used in the Ministry of Health (MOH) of Honduras were completely donated, principally by the United States Agency for International Development (USAID). Estimates for procurement were based on demographic data (and, to a certain degree, continue to be), and the problems of oversupply and stockout were and remain an important issue. In addition, the Honduran government subscribed to a phaseout plan with USAID through which the MOH agrees to procure 100 percent of its contraceptive needs by 2009. To strengthen the ability of the MOH to confront this situation, the USAID/Honduras office contracted the services of DELIVER, defining the main tasks as strengthening the supply chain, improving the ability to ensure contraceptive security (CS), and developing local capacity to prepare procurement plans using contraceptive procurement tables. DELIVER developed activities aimed at improving information on the consumption of contraceptives, developing local capacity to make estimates and purchases, developing the political component to guarantee CS, and improving administrative logistics on all levels of the MOH and the Honduran Family Planning Association. The principal results of this effort were— • organizing and systematizing the functioning of the CS committee • drawing up the national CS strategy • allocating, maintaining, and disbursing funds from the national budget for the purchase of contraceptives • making estimates and procurement plans that are based on consumption data • establishing the basic guidelines for work in the immediate future for all the aspects of logistics through the Logistics Indicators Assessment Tool assessment and diagnosis of the warehouses • developing the automated system for inventory control (SACI). Moreover, DELIVER successfully encouraged the MOH to designate a national manager in charge of the contraceptive logistics system. In addition, the adaptation of the national methodological strategy for family planning services was supported, and its application facilitated, for obtaining consumption data that serve both to support the logistics process and to monitor advances in access to and use of contraceptives. To support these successes, USAID/Honduras provided U.S.$559,0001 to DELIVER during the fiscal years 2005 and 2006, which financed both local activities and external technical assistance. Following these important advances, there is the remaining task of strengthening the achievements made to date and the challenge of improving the aspects of logistics as yet barely addressed, such as storage conditions, implementation of the SACI, and timely distribution of contraceptives, all of which should be achieved in the next stage. 1 All dollar amounts are U.S. dollars unless specified otherwise. Honduras: Final Country Report xi Honduras: Final Country Report xii PROGRAM BACKGROUND Since 2000, DELIVER has intermittently supported the USAID Mission in Honduras and local institutions, mainly in improving the procurement process in the Ministry of Health (MOH) and the Honduran Family Planning Association (ASHONPLAFA) as well as strengthening contraceptive security (CS) and improving the MOH’s contraceptive logistics. In February 2005, DELIVER established an office in Tegucigalpa to offer more consistent and permanent support to local institutions and to advance more effectively in all the activities formulated in the technical assistance plan. Efforts were concentrated mainly on the MOH to help in the creation of a budget line item to guarantee funds for the purchase of contraceptives. According to the phaseout plan agreed to by the Government of Honduras and USAID, the government would gradually progress from receiving all contraceptives as donations, to purchasing all contraceptives, in the period from 2000 to 2009. The information the MOH relied on for the number of contraceptives consumed was not based on real consumption data but rather on estimates based on demographic data. Therefore, DELIVER worked on designing and developing forms that would make possible the collection of essential logistics data (consumption, stocks, and adjustments). The collection of data would then be automated through the new system for inventory control (SACI), which will be used in all regions of the country. In addition, USAID donated the computers necessary for SACI to be implemented after the finalization phase has been completed and the product is delivered to the MOH. COUNTRY CONTEXT Honduras has an area of 112,492 km2 and a population of 7,267,021 people, with a population density of 65 people per km2, of which 49.9 percent live in urban areas. In Honduras, 64.5 percent of the households live in poverty (poor and very poor households); 35.5 percent are classified as not poor. More than 40 percent of the population is below the international poverty line.2 The gross domestic product (GDP) per capita was $2,600 in 2002 (CIA 2002), and health expenditures as a percent of GDP were 6.8 percent in 2000, according to the World Development Index (World Bank 2000). The female population made up 49.9 percent of the total. Life expectancy at birth was 72.4 years: 76 years for women and 68.9 years for men. In 2006, there were 1.75 million women of childbearing age, and 222,512 births were estimated, for a total growth rate of 2.3 percent.3 The overall fertility rate is 3.3 children per woman; the prevalence rate for use of all contraceptive methods for women in relationships is 65.2 percent on the national level, 69.9 percent in urban areas, and 60.8 percent in rural areas. The use of modern methods rose from 50.8 percent in 2001 to 56.4 percent in 2005. Sixty-nine percent of births take place in health facilities. The infant mortality rate is 29 per thousand n.v., (ENDESA 2006) and the maternal mortality rate is 110 per 100,000 n.v. (Hill et al. 2005). This information shows a panorama of a poor country that because of government efforts and international cooperation shows constant improvement in health indicators but where much remains to 2 The international poverty line is defined as income below $1.08 per day at 1993 international prices, equivalent to $1.00 at 1985 prices, adjusted to the local currency using parity of purchasing power. 3 Population projections based on 2001 national census. Honduras: Final Country Report 1 achieve to have ideal development conditions. Moreover, there continues to be a wide gap between segments of the population with few socioeconomic problems and those who are excluded. KEY PLAYERS AND ROLES Health information, services, and contraceptive commodities are delivered to the public by the MOH, the Honduran Social Security System (IHSS), the Armed Forces’ health facilities, and by ASHONPLAFA and Marie Stopes (the latter two are the main nongovernmental organizations [NGOs] providing reproductive health services in the country), as well as by private health institutions (private hospitals, clinics, and practitioners) and pharmacies. Other actors in the health sector are contraceptive manufacturers and importers, private and public health insurance companies, and advocacy and community-based organizations. The role played by each of these institutions is described briefly below. • MOH. On the national level, the MOH is the regulatory and normative force in the health sector. Its responsibilities include planning, regulating, coordinating, and evaluating all public health programs; strengthening systems for delivery of services; coordinating community participation in health; and paying special attention to marginal sectors of the population. In 2001, the MOH received 45 percent of total health income and covered 41 percent of family planning (FP) users. • IHSS. The social security system in Honduras is the principal provider of health services to those individuals who are formally employed. In 2001, the IHSS registered 9 percent of health income, covering only 4.5 percent of FP users. Financed by an affiliation fee, the IHSS covers 11 percent of the population, and has health facilities throughout the country, but they are located almost exclusively in cities and important municipalities. The IHSS to date has received contraceptives free of charge from USAID. The majority of family planning users covered by the IHSS come to ASHONPLAFA and to the MOH to obtain FP services. • National Police of Honduras (PNH). With the support of the United Nations Population Fund (UNFPA), the PNH has included the subject of gender within its ranks as a way of addressing intra- family violence, family planning, and promotion of the use of condoms. These subjects are incorporated through the Police Instruction Center, the National Police Academy, and the Superior Institute for Police Education. Therefore, PNH’s participation in FP and CS is very limited. • NGOs. ASHONPLAFA (an International Planned Parenthood Federation affiliate) and Marie Stopes cover a very important part of the FP market in Honduras, especially ASHONPLAFA, which according to the National Survey on Epidemiology and Family Health (ENESF) 2001 covered 29 percent of FP users in the country. • Advocacy Groups. (a) The Women’s Rights Center was founded in 1989 and basically focuses on the impact of changes in public policy that improve women’s well-being. It offers services of sensitization, counseling, and communication and is made up of a collective of women against violence, which in turn is made up of 12 grass-roots organizations. Its present focus consists of reforming the penal code to include fair penalization for cases of intra-family violence and sexual offenses. (b) The Honduran Women’s Studies Center, founded in 1984, focuses on promoting knowledge and use of family planning methods as part of human rights as well as on the right to receive quality care in public health facilities. The center also promotes FP services through other NGOs with whom they have agreements for referrals (for example, with ASHONPLAFA), especially in the south-central zone of the country. • Private providers. These include private doctors, nurses, hospitals, and clinics. The ENESF 2001 attributes 10 percent of the provision of contraceptives to the private sector, which mainly focuses on intrauterine devices (IUDs). • Pharmacies. Present in all cities and towns, including remote rural areas, pharmacies constitute a small portion of contraceptive methods provided in comparison with the MOH and ASHONPLAFA. In Honduras: Final Country Report 2 comparing the ENESF 1991–1992 and the ENESF 2001, it can be seen that the contraceptive market share of pharmacies has declined from 14 percent to 12 percent, respectively, due to a large increase in the provision of contraceptives by the MOH and by ASHONPLAFA. It should be noted that ASHONPLAFA has a contraceptive social marketing program and its main distribution channel is pharmacy chains. • Health insurance companies. In Honduras, there are companies that insure or finance health services, but these are affordable mainly for people with high incomes. These private insurance companies do not cover drugs or contraceptives; however, they cover surgical sterilization. • Manufacturers and importers of contraceptives. With the exception of condoms, which are packaged by CPR-Honduras, there is no local production of contraceptives. Nevertheless, there are various local distributors who import and sell contraceptives to pharmacies, the MOH, and other organizations. Schering is the principal importer of hormonal contraceptives and offers a wide range of hormonal contraceptives, mainly at high prices, for the Honduran population. In implementing the CS strategy, the political, normative, and technical levels of the MOH have played an important role. These levels have facilitated the participation of key players such as the administrative head of the MOH and the representative of the Ministry of Finance in the CS Committee, which has made possible the allocation of funds for the purchase of contraceptives. KEY CHALLENGES At the beginning of DELIVER activities in Honduras, the primary challenge was a lack of ownership by the government for supplying contraceptives, which resulted in the absence of a national budget for funding supplies, inadequate storage and distribution facilities, lack of a logistics management information system (LMIS) and data for decision making, donor dependency for supplies, and no mechanism for procuring contraceptives independent of donors. The most important challenge that DELIVER addressed was developing ownership for supply provision by building political support for funding and conducting contraceptives procurement by the institutions themselves. In the case of the MOH, this has been achieved since 2004, but in the case of ASHONPLAFA, there is still a certain degree of dependency on donors. The absence of an effective LMIS was also a primary issue to address, since the data to be collected on consumption and stock levels were essential for accurately forecasting, budgeting, and procuring supplies. The development and use of the SACI in the MOH addresses the challenge by providing up-to-date information on the consumption of contraceptives on a sustained basis, which will make it possible to update the PipeLine software so as to produce forecasts, develop budgets, and procure supplies in an efficient and timely way. In April–May 2006, DELIVER conducted a baseline assessment of the contraceptive logistics system using its Logistics Indicators Assessment Tool (LIAT). Among the findings were the needs to improve storage conditions at regional warehouses and to train and supervise personnel at service delivery points (SDPs) in managing stocks of contraceptives. Only 53.5 percent of the regional warehouse met nine of the 12 conditions evaluated. Among the SDPs, only 49 percent had received any logistics training in the previous two years, over 57 percent had never received a supervision visit, and only 28 percent had received a visit in the previous six months. Table 1 shows the low percentage of SDPs that maintain accurate storage records, i.e., the inventory control card (ICC) was compared to a physical inventory of stock on hand (SOH). Honduras: Final Country Report 3 Table 1. Percentage of SDPs Where SOH and the ICC Coincide and Stock on Hand Coincides within 10 percent (LIAT Baseline, April–May 2006) Method SOH Coincides SOH Coincides within 10 Percent Condom 22 40 Lo-Femenal 41 49 IUD 26 52 Depo-Provera 28 52 Table 2 shows the results of poor inventory control: either too little stock (at risk of stocking out) or too much stock (at risk of stock expiring unused). Forty percent of the SDPs visited were stocked out of one or more of the basic contraceptive methods (condoms, oral pills, IUDs, or injectables) at the time of the visit. Table 2. Percentage of SDPs Whose SOH Is between Minimum and Maximum Levels Method Between Min and Max Less Than Min More Than Max Condom 9 46 45 Lo-Femenal 10 43 47 IUD 0 46 54 Depo-Provera 22 51 27 In the future, we foresee the following challenges: SUSTAINABILITY OF THE CS COMMITTEE It is essential that the CS Committee continues to meet and discuss key aspects of CS in Honduras to guarantee that the dynamism that has come to characterize its activities continues without interruption, not only in the MOH but also in the other member institutions. PURCHASE OF CONTRACEPTIVES THROUGH UNFPA The use of this procurement mechanism by the member institutions of the CS Committee, such as the MOH, ASHONPLAFA, and the IHSS will not only produce savings in the procurement of contraceptives but will also guarantee greater efficiency in the process. DEVELOPMENT OF THE LMIS The first steps for the country to have an adequate LMIS have been taken during this period. Nevertheless, emphasis has been put on the level of processes for gathering information on contraceptive consumption and estimating needs and procurement as well as developing favorable policies for family planning activities. Much remains to be done in the areas of storage and distribution of contraceptives; this is work that is pending for the near future. IMPLEMENTATION OF THE REVISED NATIONAL STRATEGY FOR FAMILY PLANNING SERVICES The Estrategia Metodológica de los Servicios de Planificación Familiar (Methodological Strategy for Family Planning Services) (MOH 2006) is the national policy document, with norms and standards, that guides health personnel in planning, monitoring, and evaluating family planning activities. Revised with the assistance of the DELIVER project, it now requires the collection of routine and up-to-date Honduras: Final Country Report 4 information on the consumption of contraceptive methods, and it includes routine logistics operations. This is an essential element both for supporting the logistics system and for monitoring and evaluating activities in the country. Therefore, DELIVER and the other players involved must participate in overseeing its application. ORGANIZATION OF THE DISTRIBUTION SYSTEM In April–May 2006, DELIVER conducted an assessment of the logistics system using the LIAT. One of the key findings of the LIAT is that systematic and timely distribution of contraceptives is one of the MOH’s main problems. Organizing this is a priority activity, given that the distribution channels for contraceptive supplies are still not formally defined within the MOH structure. IMPROVEMENT OF STORAGE CONDITIONS The LIAT also found that, at both the regional and the health facility levels (including hospitals), storage conditions are inadequate. There is no consistent use of ICCs; people in charge of the warehouses have not been trained so as to guarantee that standard storage guidelines are followed appropriately and consistently. Honduras: Final Country Report 5 Honduras: Final Country Report 6 GOALS AND OBJECTIVES The USAID Regional Strategy for Central America and Mexico FY 2003-2008, Volume 2: Annex B: Honduras Country Plan states that USAID has three strategic objectives (SOs): SO 1: Justice and Democratic Governance: More Responsive, Transparent Governance SO 2: Economic Freedom: Open, Diversified, Expanding Economies SO 3. Investing in People: Healthier, Better Educated People. DELIVER’s technical assistance to the USAID Mission in Honduras comes under SO 3. DELIVER OBJECTIVES DELIVER’s objectives in Honduras were to— • Strengthen the supply chain (financing, storage, procurement, and distribution) of the MOH. • Support the Honduran government and ASHONPLAFA in the procurement process for contraceptives. • Increase CS by designing the national CS strategy and making it work, which included the formation of the CS Committee and the inclusion of funds for the purchase of contraceptives in the national budget. RELATIONSHIP TO USAID AND CLIENT OBJECTIVES Under SO 3, there are a number of areas in which DELIVER has worked to assist the Mission in achieving its strategic objective: Intermediate Result 3.3: Improved Integrated Management of Child and Reproductive Health. DELIVER has supported the Mission with the expansion of family planning services by strengthening the MOH’s supply chain (financing, forecasting, procurement, and distribution) and by working with ASHONPLAFA on its forecasting needs. The DELIVER motto “No product? No program.” is very applicable in the Honduran context. Information gathered from the MOH and ASHONPLAFA has helped the Mission in planning its contraceptive procurement tables (CPTs). USAID negotiated a gradual shift in responsibility to the Government of Honduras (GOH) for the procurement of contraceptives, and DELIVER has worked with the GOH and other concerned organizations to help the GOH through the process. Intermediate Result (IR) 3.4: Spread of AIDS and Other Infectious Diseases Controlled. By strengthening the MOH’s supply chain, and in preparing the CPTs for the MOH and ASHONPLAFA, condoms for disease prevention are more widely available to the Honduran population. This is DELIVER’s contribution to IR 3.4. USAID/Honduras requested technical assistance from DELIVER to offer support to the USAID Mission and to local institutions, mainly to improve the procurement process of the MOH and ASHONPLAFA, as well as to strengthen CS and to improve the contraceptive logistics system of the MOH. In February 2005, DELIVER established an office in Tegucigalpa to offer more consistent and permanent support to the local institutions and to advance more effectively all the activities formulated in the DELIVER technical assistance plan. Honduras: Final Country Report 7 Framed by SO 3, “Investing in People,” in IR 3.3, “Improve Integrated Management of Child and Reproductive Health,” the main focus of DELIVER was at the MOH, to help create a budget line item that guarantees funds for the purchase of contraceptives. This was important given that the phaseout plan subscribed to between the GOH and USAID stipulates that the government will gradually progress from receiving all contraceptives as donations to purchasing all contraceptives in the period from 2000 to 2009. DELIVER’S ROLE IN RELATION TO OTHER ORGANIZATIONS Even before setting up its office in Honduras, DELIVER had become the facilitator of the CS Committee. Meetings are held periodically to share information about advances that have been made and to review the tasks pending for each one of the committee members. This committee is composed of the MOH, ASHONPLAFA, USAID, UNFPA, the National Women’s Institute, the Pan-American Health Organization (PAHO), the Ministry of Finance, the IHSS, and the Center for Women’s Rights (civil society). Interventions of advocacy and in support of institutions in favor of family planning are planned within the committee. SUMMARY OF INTERVENTIONS At the beginning of the project, the main interventions were directed toward getting information on consumption data, which until then were not reliable. Between 2004 and 2006, five national physical inventories of contraceptives were carried out that substantially improved the preparation of procurement plans. Soon after, actions aimed at achieving the organization and functioning of the CS Committee were begun. Fortunately, the committee has been functioning and holding monthly meetings since March 2005, which were interrupted only during the difficult change of government. At the present time, its functioning is routine, and the committee has a ministerial resolution that supports its activities. Important results were achieved, such as obtaining funds for the purchase of contraceptives in 2005 and 2006 and the designation by the MOH of a person in charge of the contraceptive logistics system at the central level. The national CS strategy was drawn up and was approved by both the USAID Mission and the GOH through a ministerial resolution. The strategy was published in September (MOH 2006). DELIVER energetically supported the adaptation of the Methodological Strategy for Family Planning Services to include supply chain functions as well as the strategy’s publication and the training of personnel on all levels of the MOH for its implementation. The most important aspect of the adaptation is the changes in the official information system of the MOH, which gives the process sustainability and guarantees the gathering of essential logistics data. An important intervention, which was very difficult to achieve and required a great deal of effort and technical and financial resources, was the design and implementation of the SACI at the central and regional levels. The system will collect data on consumption and stocks on hand from the central, regional and health facility levels. The system will also improve management of the program. DELIVER also supported the distribution of contraceptives by providing technical and financial assistance for transporting products from the central warehouse to the various regional warehouses. In special situations of oversupply and dates near expiration, redistribution was carried out to avoid expiration of products such as the copper T 380 IUD and Depo-Provera. SUMMARY OF DELIVER FUNDING AND STAFFING During 2000–2005, the funds assigned for DELIVER activities in Honduras were $1,065,000. The technical assistance offered was through external consultants and focused on preparing annual estimates of contraceptives for the MOH and ASHONPLAFA, by means of CPTs, as well as implementing physical Honduras: Final Country Report 8 inventories every six months. In addition, activities were coordinated with the regional CS strategy, financed by the Regional Office for Latin America of USAID/Washington. In February 2005, José Ochoa was hired as resident advisor on assured availability of inputs and contraceptives in order to implement all activities related to CS that were identified through the assessment carried out in May 2004. Dr. Ochoa has extensive and diverse experience in the areas of mother–child health, FP, and advocacy. In the past, he served as the national director of FP in the MOH and was the advisor for mother–child health and FP for the local office of the Pan-American Health Organization in Honduras. For administrative activities, the resident advisor hired Sofia Flores, who joined the local office in February 2006. Honduras: Final Country Report 9 Honduras: Final Country Report 10 PROGRAM RESULTS The main results achieved by the DELIVER project in Honduras in the last 2 years are summarized below: ELEMENT I: IMPROVED LOGISTICS SYSTEM Five national physical inventories of contraceptives were carried out, one every six months beginning in June 2004, which served as the basis to prepare the CPTs. The CPTs were used to determine the quantity of contraceptives that USAID and the MOH would procure in that period and helped to calculate the quantity to be included in the phaseout plan of donated contraceptives. Personnel at the central level and in Health Region No. 3 participated in the Logistics System Assessment Tool (LSAT) exercise, and a LIAT study was also done, to provide a baseline for monitoring the development of the contraceptive logistics system. The Methodological Strategy for Family Planning Services was adapted to include logistics functions. This strategy has a national scope and guides health personnel in planning, monitoring, and evaluating family planning activities. Through its implementation, information on consumption and stocks on hand will be collected on a monthly basis. The strategy is now more operational and easier to implement. During 2006, the SACI was developed. It will be implemented in 20 regional warehouses and at the central level. The information will be collected on the basis of the methodology described in the FP strategy. In addition, an assessment of the warehousing conditions was conducted at regions and hospitals, which includes information about physical conditions and skills of staff in charge of contraceptives. This report will be helpful for organizing technical cooperation in this area in the near future. ELEMENT II: IMPROVED HUMAN CAPACITY IN LOGISTICS The National Program for Comprehensive Care for Women, which is responsible for family planning activities at the MOH, was strengthened in 1999 by creating the position of a person in charge of the contraceptive logistics system. This skilled person was trained by JSI. Personnel on all levels of the MOH were trained to apply the Methodological Strategy for Family Planning Services, which improves the logistics process on the local level by allowing the service providers to become familiar with the situation of consumption and stock on hand and enables them to better organize their monthly contraceptive orders. The people in charge of contraceptives at the central and regional warehouses, as well as the technical personnel in charge of the FP program in the health regions, were trained to use the SACI, which greatly improves managerial capacity at these levels. ELEMENT III: IMPROVED RESOURCE MOBILIZATION FOR CONTRACEPTIVE SECURITY The inter-institutional CS Committee was organized and continues to function, holding monthly meetings that were interrupted only during the change of government. The committee has a regulatory document (Organizational and Operational Regulations), which is legally recognized by a ministerial resolution. The national CS strategy was drawn up and has been legally recognized by a ministerial resolution, accepted by the USAID Mission, and approved by all the committee members and organizations. Honduras: Final Country Report 11 One of the most important achievements of the DELIVER project is the disbursement of funds from the national budget for the purchase of contraceptives. In 2004, the MOH invested $304,396; in 2005, $450,024; and in 2006, it is scheduled to make available approximately $1,000,000 for contraceptive procurement. $1,200,000 has been included in the budget for 2007. ELEMENT IV: IMPROVED ADOPTION OF ADVANCES IN LOGISTICS The distribution of contraceptives from the central to the regional level, as well as from the regional warehouses to the health units, changed from being defined on the basis of plans drawn up with population statistics to a process based on data of average monthly consumption. The warehouses and regions will have the inventory control program SACI. USAID donated computers to run the SACI at each region and at the central level. Therefore, we expect the logistics process will be strengthened beginning in the last half of 2006. Through the different assessments carried out in this period, we know there are important needs for logistics support, for the sustainability and strengthening of the advances achieved to date, and for all the work that remains to be done in the areas of storage, distribution, and inventories, especially at SDPs. ELEMENT V: ESTIMATION OF USAID CONTRACEPTIVE NEEDS Both the MOH and ASHONPLAFA developed their local ability to use the PipeLine software and to estimate the quantities of contraceptives they need to procure. ASHONPLAFA personnel were trained on the job through periodic meetings with the people in charge of the process in their workplace. At the MOH, workshops were held for the people in charge of the warehouses, and technicians at the central and regional levels, to train them in the use of PipeLine. As a result, there are personnel, especially at the central level, who prepare the CPTs with minimal external assistance. Honduras: Final Country Report 12 LESSONS LEARNED AND FUTURE DIRECTIONS The continuance of the inter-institutional CS Committee is a useful and necessary strategy for keeping the authorities of the member institutions motivated to support CS activities, especially in assigning their own resources for the purchase of contraceptives. The committee is also a valid forum for highlighting the importance of family planning as a frontline strategy to reduce maternal and infant mortality. The presence of DELIVER’s external technical assistance and the hiring of a resident advisor who is accepted by the political levels of the institutions have been fundamental in achieving the objectives of the project. The change of authorities due to the transfer of power to a new government, while delaying somewhat the activities of the project, demonstrated that timely contact with the new working team made it possible for funds from the national budget to continue to be allocated for the purchase of contraceptives and to resume with the same diligence the remaining activities of the process. Working closely with the regulatory and technical levels, such as with the director of health divisions, and making the people in charge of programs and their staff participants in the project activities strengthen and ensure the sustainability of the activities. In the future, we foresee the following needs for cooperation: • Strengthen the CS Committee through the continuation of meetings and the implementation of activities described in the action plan. • Implement the national CS strategy, and keep CS on the political agenda of the different institutions. • Continue advocating for funds from the national budget for the purchase of contraceptives. • Assist in the implementation of the Methodological Strategy for Family Planning Services as a vehicle for improving the logistics process with respect to stocks on hand, consumption, and contraceptive orders. • Standardize the use of the SACI. • Improve inventory control at health facilities by implementing the use of ICCs. • Improve the distribution system for contraceptives. • Improve storage conditions for contraceptives. Honduras: Final Country Report 13 Honduras: Final Country Report 14 REFERENCES Central Intelligence Agency (CIA). 2002. The World Factbook. Washington, DC: CIA. DELIVER. 2006. Pautas para la implementación de sistemas de información de administración logística computarizada [Guidelines for implementing computerized information systems for administrative logistics]. Arlington, Va.: DELIVER, for the United States Agency for International Development. (Unpublished). ENDESA. 2006. Encuesta Nacional de Salud (National Health Survey). Honduras: ENDESA. Hill, K., R. Pande, M. Mahy, and G. Jones. 2005. Trends in child mortality in the developing world: 1990 to 2003. Bulletin of the World Health Organization. 83:171–177.7. Instituto Nacional de Estadísticas (INE) [National Statistics Institute]. 2006. Encuesta Nacional de Demografía y Salud [National Demographic and Health Survey]. Tegucigalpa, Honduras: INE, for the Ministry of Health. Ministry of Health (MOH), Honduras. September 2005. Estrategia Nacional para la Disponibilidad Asegurada de Insumos Anticonceptivos [National Contraceptive Security Strategy]. Tegucigalpa, Honduras: MOH. Ministry of Health (MOH), Honduras. 2006. Estrategia Metodológica de los Servicios de Planificación Familiar [Methodological Strategy for Family Planning Services]. Tegucigalpa, Honduras: MOH. USAID. 2003. USAID Regional Strategy for Central America and Mexico FY 2003-2008. Volume 2: Annex B: Honduras Country Plan. http://usaid.gov/sv/central (accessed August 2006). World Bank. 2000. World Development Index 2000. Washington, DC: World Bank. Honduras: Final Country Report 15 Honduras: Final Country Report 16 APPENDIX 1 CS BRIEF Country: Honduras Total Funds: $1,065,000 Local office No. of local personnel: 2 Presence established in February 2005 Technical focus areas Family planning x Tuberculosis Donor coordination X Integrated systems Contraceptive security x Market segmentation Financing Pelvin Inflamatory Disease (PID) HIV/AIDS Essential drugs Principal client organizations MOH/Department of Comprehensive Family Health and ASHONPLAFA; coordination with UNFPA, the UNICEF, PAHO, and others DELIVER objectives • Strengthen the supply chain (financing, storage, procurement, and distribution) of the MOH. • Support the Honduran Government and ASHONPLAFA in the procurement process for contraceptives. • Increase CS by designing the national CS Strategy and making it work, which includes the formation of the CS Committee and the inclusion of funds for the purchase of contraceptives in the national budget. Principal interventions • Organized and supported the inter-institutional CS Committee. • Developed and disseminated the national CS strategy. • Supported the MOH in the process of ensuring funds in the national budget for the purchase of contraceptives. • Developed and deployed the automated inventory control program SACI at the central and regional warehouses. • Supported the MOH in the adaptation and application of the Methodological Strategy for Family Planning Services at the national level. • Supported the MOH and ASHONPLAFA in the development of periodic physical inventories to prepare procurement plans. Key results • Physical inventories of contraceptives conducted every six months starting in June 2004, which served as a basis for preparing the contraceptive procurement tables (CPTs). • CPTs prepared every six months for the year, beginning in 2001, which served as the basis for USAID and MOH procurement plans. • Personnel trained at the central and Health Region No. 3 levels in the use of the LSAT. • Inter-institutional CS Committee strengthened, and holding monthly meetings, interrupted only during the change of government. • Regulatory document prepared for the inter-institutional CS Committee and legally recognized through a ministerial resolution • The national CS strategy prepared, with its legal recognition through a ministerial resolution and acceptance by all the member institutions and organizations of the committee. • National strategy for planning, monitoring, and evaluating family planning activities prepared, which is now more operational and easier to apply. • MOH personnel trained at all levels in the application of the national strategy for family planning services. • The SACI deployed in 20 regional warehouses and at the central level. Honduras: Final Country Report 17 Related publications • National Contraceptive Security Strategy (MOH 2006) • Regulatory Document of the inter-institutional CS Committee • Methodological Strategy for Family Planning Services (MOH 2006) Honduras: Final Country Report 18 APPENDIX 2 MATRIX OF PROGRAM RESULTS Objectives/strategies Results Contribution to the Elements of DELIVER Observations An automated inventory control system (SACI) functioning at the central level and 20 regional warehouses Contraceptive security strengthened The Methodological Strategy for Family Planning Services adapted and implemented. Developed and installed the SACI at the central level and in 20 regional warehouses. One-hundred percent of personnel were trained in the use of SACI: 24 health technicians and 21 individuals in charge of contraceptives in the warehouses. The national CS strategy was prepared, published, and distributed Inter-institutional CS Committee meets on a regular basis. Budget line Item for the purchase of contraceptives was included in the national budget, using government funds. The Methodological Strategy for Family Planning Services was adapted to include routine logistics operations, and printed. Application of the strategy was systematized to make it operational and functional. Personnel at the central, regional, and operational levels nationwide were trained in the implementation of the strategy Improved logistics system management capacity Improved human capacity in logistics Improved mobilization of resources for CS Improved logistics system Improved human capacity in logistics Honduras: Final Country Report 19 National capacity to prepare CPTs developed Five national physical inventories were conducted, and procurement plans were prepared using the PipeLine software. CPTs were prepared and used for planning purchases and donations in the past three years. Improved adoption of advances in logistics Honduras: Final Country Report 20 For more information, please visit www.deliver.jsi.com. DELIVER John Snow, Inc. 1616 North Fort Myer Drive, 11th Floor Arlington, VA 22209 USA Phone: 703-528-7474 Fax: 703-528-7480 www.deliver.jsi.com KEY PLAYERS AND ROLES KEY CHALLENGES SUSTAINABILITY OF THE CS COMMITTEE PURCHASE OF CONTRACEPTIVES THROUGH UNFPA DEVELOPMENT OF THE LMIS IMPLEMENTATION OF THE REVISED NATIONAL STRATEGY FOR FAMILY PLANNING SERVICES ORGANIZATION OF THE DISTRIBUTION SYSTEM IMPROVEMENT OF STORAGE CONDITIONS DELIVER OBJECTIVES RELATIONSHIP TO USAID AND CLIENT OBJECTIVES DELIVER’S ROLE IN RELATION TO OTHER ORGANIZATIONS SUMMARY OF INTERVENTIONS SUMMARY OF DELIVER FUNDING AND STAFFING ELEMENT I: IMPROVED LOGISTICS SYSTEM ELEMENT II: IMPROVED HUMAN CAPACITY IN LOGISTICS ELEMENT III: IMPROVED RESOURCE MOBILIZATION FOR CONTRACEPTIVE SECURITY ELEMENT IV: IMPROVED ADOPTION OF ADVANCES IN LOGISTICS ELEMENT V: ESTIMATION OF USAID CONTRACEPTIVE NEEDS << /ASCII85EncodePages false /AllowTransparency false /AutoPositionEPSFiles true /AutoRotatePages /All /Binding /Left /CalGrayProfile (Dot Gain 20%) /CalRGBProfile (sRGB IEC61966-2.1) /CalCMYKProfile (U.S. Web Coated \050SWOP\051 v2) /sRGBProfile (sRGB IEC61966-2.1) /CannotEmbedFontPolicy /Warning /CompatibilityLevel 1.4 /CompressObjects /Tags /CompressPages true /ConvertImagesToIndexed true /PassThroughJPEGImages true /CreateJDFFile false /CreateJobTicket false /DefaultRenderingIntent /Default /DetectBlends true /DetectCurves 0.0000 /ColorConversionStrategy /LeaveColorUnchanged /DoThumbnails false /EmbedAllFonts true /EmbedOpenType false /ParseICCProfilesInComments true /EmbedJobOptions true /DSCReportingLevel 0 /EmitDSCWarnings false /EndPage -1 /ImageMemory 1048576 /LockDistillerParams false /MaxSubsetPct 100 /Optimize true /OPM 1 /ParseDSCComments true /ParseDSCCommentsForDocInfo true /PreserveCopyPage true /PreserveDICMYKValues true /PreserveEPSInfo true /PreserveFlatness true /PreserveHalftoneInfo false /PreserveOPIComments false /PreserveOverprintSettings true /StartPage 1 /SubsetFonts true /TransferFunctionInfo /Apply /UCRandBGInfo /Preserve /UsePrologue false /ColorSettingsFile () /AlwaysEmbed [ true ] /NeverEmbed [ true ] /AntiAliasColorImages false /CropColorImages true /ColorImageMinResolution 300 /ColorImageMinResolutionPolicy /OK /DownsampleColorImages true /ColorImageDownsampleType /Bicubic /ColorImageResolution 300 /ColorImageDepth -1 /ColorImageMinDownsampleDepth 1 /ColorImageDownsampleThreshold 1.50000 /EncodeColorImages true /ColorImageFilter /DCTEncode /AutoFilterColorImages true /ColorImageAutoFilterStrategy /JPEG /ColorACSImageDict << /QFactor 0.15 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /ColorImageDict << /QFactor 0.15 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /JPEG2000ColorACSImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /JPEG2000ColorImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /AntiAliasGrayImages false /CropGrayImages true /GrayImageMinResolution 300 /GrayImageMinResolutionPolicy /OK /DownsampleGrayImages true /GrayImageDownsampleType /Bicubic /GrayImageResolution 300 /GrayImageDepth -1 /GrayImageMinDownsampleDepth 2 /GrayImageDownsampleThreshold 1.50000 /EncodeGrayImages true /GrayImageFilter /DCTEncode /AutoFilterGrayImages true /GrayImageAutoFilterStrategy /JPEG /GrayACSImageDict << /QFactor 0.15 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /GrayImageDict << /QFactor 0.15 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /JPEG2000GrayACSImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /JPEG2000GrayImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /AntiAliasMonoImages false /CropMonoImages true /MonoImageMinResolution 1200 /MonoImageMinResolutionPolicy /OK /DownsampleMonoImages true /MonoImageDownsampleType /Bicubic /MonoImageResolution 1200 /MonoImageDepth -1 /MonoImageDownsampleThreshold 1.50000 /EncodeMonoImages true /MonoImageFilter /CCITTFaxEncode /MonoImageDict << /K -1 >> /AllowPSXObjects false /CheckCompliance [ /None ] /PDFX1aCheck false /PDFX3Check false /PDFXCompliantPDFOnly false /PDFXNoTrimBoxError true /PDFXTrimBoxToMediaBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXSetBleedBoxToMediaBox true /PDFXBleedBoxToTrimBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXOutputIntentProfile () /PDFXOutputConditionIdentifier () /PDFXOutputCondition () /PDFXRegistryName () /PDFXTrapped /False /Description << /CHS <FEFF4f7f75288fd94e9b8bbe5b9a521b5efa7684002000500044004600206587686353ef901a8fc7684c976262535370673a548c002000700072006f006f00660065007200208fdb884c9ad88d2891cf62535370300260a853ef4ee54f7f75280020004100630072006f0062006100740020548c002000410064006f00620065002000520065006100640065007200200035002e003000204ee553ca66f49ad87248672c676562535f00521b5efa768400200050004400460020658768633002> /CHT <FEFF4f7f752890194e9b8a2d7f6e5efa7acb7684002000410064006f006200650020005000440046002065874ef653ef5728684c9762537088686a5f548c002000700072006f006f00660065007200204e0a73725f979ad854c18cea7684521753706548679c300260a853ef4ee54f7f75280020004100630072006f0062006100740020548c002000410064006f00620065002000520065006100640065007200200035002e003000204ee553ca66f49ad87248672c4f86958b555f5df25efa7acb76840020005000440046002065874ef63002> /DAN <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> /DEU <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> /ESP <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> /FRA <FEFF005500740069006c006900730065007a00200063006500730020006f007000740069006f006e00730020006100660069006e00200064006500200063007200e900650072002000640065007300200064006f00630075006d0065006e00740073002000410064006f00620065002000500044004600200070006f007500720020006400650073002000e90070007200650075007600650073002000650074002000640065007300200069006d007000720065007300730069006f006e00730020006400650020006800610075007400650020007100750061006c0069007400e90020007300750072002000640065007300200069006d007000720069006d0061006e0074006500730020006400650020006200750072006500610075002e0020004c0065007300200064006f00630075006d0065006e00740073002000500044004600200063007200e900e90073002000700065007500760065006e0074002000ea0074007200650020006f007500760065007200740073002000640061006e00730020004100630072006f006200610074002c002000610069006e00730069002000710075002700410064006f00620065002000520065006100640065007200200035002e0030002000650074002000760065007200730069006f006e007300200075006c007400e90072006900650075007200650073002e> /ITA <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> /JPN <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> /KOR <FEFFc7740020c124c815c7440020c0acc6a9d558c5ec0020b370c2a4d06cd0d10020d504b9b0d1300020bc0f0020ad50c815ae30c5d0c11c0020ace0d488c9c8b85c0020c778c1c4d560002000410064006f0062006500200050004400460020bb38c11cb97c0020c791c131d569b2c8b2e4002e0020c774b807ac8c0020c791c131b41c00200050004400460020bb38c11cb2940020004100630072006f0062006100740020bc0f002000410064006f00620065002000520065006100640065007200200035002e00300020c774c0c1c5d0c11c0020c5f40020c2180020c788c2b5b2c8b2e4002e> /NLD (Gebruik deze instellingen om Adobe PDF-documenten te maken voor kwaliteitsafdrukken op desktopprinters en proofers. De gemaakte PDF-documenten kunnen worden geopend met Acrobat en Adobe Reader 5.0 en hoger.) /NOR <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> /PTB <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> /SUO <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> /SVE <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> /ENU (Use these settings to create Adobe PDF documents for quality printing on desktop printers and proofers. Created PDF documents can be opened with Acrobat and Adobe Reader 5.0 and later.) >> /Namespace [ (Adobe) (Common) (1.0) ] /OtherNamespaces [ << /AsReaderSpreads false /CropImagesToFrames true /ErrorControl /WarnAndContinue /FlattenerIgnoreSpreadOverrides false /IncludeGuidesGrids false /IncludeNonPrinting false /IncludeSlug false /Namespace [ (Adobe) (InDesign) (4.0) ] /OmitPlacedBitmaps false /OmitPlacedEPS false /OmitPlacedPDF false /SimulateOverprint /Legacy >> << /AddBleedMarks false /AddColorBars false /AddCropMarks false /AddPageInfo false /AddRegMarks false /ConvertColors /NoConversion /DestinationProfileName () /DestinationProfileSelector /NA /Downsample16BitImages true /FlattenerPreset << /PresetSelector /MediumResolution >> /FormElements false /GenerateStructure true /IncludeBookmarks false /IncludeHyperlinks false /IncludeInteractive false /IncludeLayers false /IncludeProfiles true /MultimediaHandling /UseObjectSettings /Namespace [ (Adobe) (CreativeSuite) (2.0) ] /PDFXOutputIntentProfileSelector /NA /PreserveEditing true /UntaggedCMYKHandling /LeaveUntagged /UntaggedRGBHandling /LeaveUntagged /UseDocumentBleed false >> ] >> setdistillerparams << /HWResolution [2400 2400] /PageSize [612.000 792.000] >> setpagedevice

View the publication

You are currently offline. Some pages or content may fail to load.