IWG Meeting the Challenge- Country Perspectives on the Future of Contraceptive Supplies

Publication date: 2001

CHALLENGE M E E T I N G T H E Country Perspectives on the Future of Contraceptive Supplies T he Interim Working Group on Reproductive Health Commodity Security (IWG) is a collaborative effort of John Snow, Inc. (JSI), Population Action International (PAI), the Program for Appropriate Technology in Health (PATH) and Wallace Global Fund. The IWG was formed in response to a meeting of the Working Group of the Global Initiative on Reproductive Health Commodity Management of UNFPA in January of 2000. At the meeting, UNFPA called on the participation of a wide variety of stake- holders to address the looming crisis represented by the shortfall in contraceptives around the world. The IWG’s objective is to further the goals of the 1994 Programme of Action by raising awareness about the importance of securing reproductive health supplies. The IWG seeks to identify the causes of failures and weaknesses in com- modity systems and to spur actions that will contribute to securing essential supplies for the delivery of repro- ductive health care. The IWG understands the importance of addressing the full range of reproductive health commodities. The group is focusing on contraceptives first, however, due to the widespread lack of consensus within the popula- tion and reproductive health field regarding which com- modities to include in an essential list of supplies. Moreover, there is little information on donor contribu- tions for non-contraceptive reproductive health com- modities. Through its efforts on contraceptive security, the IWG is working to bring together stakeholders to develop strategies for addressing the broader issues of reproductive health commodity supplies in the future. ACKNOWLEDGMENTS Country Perspectives on the Future of Contraceptive Supplies was prepared by the Program for Appropriate Technology in Health and written by Janet Vail, Clea Finkle and Jane Hutchings. The following individuals provided assistance in developing, translating, and administering the questionnaire: Carmina Aquino, María Clara Arango, Sri Djuarini, Don Douglas, Dat Duong, Walaa El Meanawy, Alan Fenwick, Michelle Folsom, Katya Gamazina, Carolina Godinez, David Hipgrave, George Kahuthia, Sérgio Lins, Anne Lion- Coleman, Cristy Llave, Robert Sharpe, R. Sridharan, Gary Steele, Lucia Ferraz-Tabor, Yanti Triswan, Nora Quesada, and Yasar Yaser. The authors are grateful to Med Bouzidi (IPPF) and Patrick Friel (UNFPA) for their thorough and careful review of the report. This material may be reproduced provided the source is acknowledged. ISBN: 1-889735-11-6 April 2001 � 1 � Country Perspectives on the Future of Contraceptive Supplies The countries and programs surveyed represent a wide mix of viewpoints due to their diverse procurement methods, histories of donors and donations, population sizes, and incomes. Yet despite their different back- grounds and experiences, all respondents anticipated that contraceptive requirements in their countries will increase in the next 3 to 5 years. Most indicated that they expect external donors and government budgets to fill this gap and meet future supply needs. Private sector approaches (i.e., shifting users from public to private sector services, private insurance coverage, and employer cost sharing) were generally not viewed as the primary means to ensure adequate contraceptive supplies. Almost three-quarters of the programs surveyed fund all or part of their contraceptive supplies, and half pro- cure at least a portion of their own supplies from domestic and/or international suppliers. While some programs claim to be wholly independent from, and some wholly dependent upon, donors for their com- modity supplies, most of the surveyed programs fall somewhere in between these two points. Other specific findings include the following: • About half of the programs surveyed segment their clients to some degree by specifically targeting vulner- able or poor populations. • Stock-outs, delays in shipments, and redundancy or oversupply of certain contraceptives are the problems most commonly cited as having a significant impact on programs. • Inadequate government commitment to commodities, inadequate donor funding for commodities, fiscal con- straints on the purchasing of contraceptives by gov- ernments, and high commodity prices on the interna- tional market are seen as the most serious threats to commodity supplies and the future success of family planning programs. • Respondents understand that threats to contraceptive supplies must be addressed both globally and nationally. • To address these threats, respondents proposed such strategies as improving logistics systems, increasing lobbying and advocacy, including contraceptives in institutional budgets, encouraging local contraceptive production, searching for alternative sources of financing and new providers, cooperating with donor agencies, encouraging NGOs to find new donors, and instituting fees for services. In 2000, John Snow, Inc. (JSI) and the Program for Appropriate Technology in Health(PATH) surveyed family planning programs in 13 countries. Intended to highlight in-countryperspectives on current and future contraceptive supply, the questionnaire solicited input on specific trends in commodity forecasting, funding, procurement, and delivery, as well as general concerns about donor coordination and future threats and responses to contraceptive security. Altogether, 23 respondents participated, 13 from government family planning programs and 10 from major in-country non-governmental (NGO) programs. Respondents were asked questions about their perspectives on supply issues, the actions they are taking to address changes in donor contributions, and how a gap between contraceptive needs and supplies would impact their programs. � 2 � • Respondents called for increased donor support and better coordination of donors at the global level. • While many respondents expect that donor support for contraceptives will decrease in the future, their responses also suggest that family planning programs are generally unsure about the future role of donors. • Respondents stated that if donors reduce support, they would like them to first help strengthen local capacity in such areas as forecasting, procurement, and Logistic Management Information Systems (LMIS) to minimize future program difficulties. Indeed, the most commonly cited solutions to com- modity supply problems (such as stock-outs and ship- ment delays) were the strengthening of procurement processes and of LMIS.1 • Respondents indicated that improving local procure- ment capacity and contributing to the financing of supplies are the most effective uses of donor resources. A number of common recommendations for action and assistance emerged from the overall results of the survey, as follows: • Increase donor funding and clarify intentions; • Increase government commitment to commodities; • Ease fiscal constraints on governments by strengthen- ing other service sectors; and • Improve national capacity by strengthening systems for logistics, private service delivery, domestic proce- dures to procure commodities, and forecasting. In September 2000, the United Nations Population Fund (UNFPA) presented a strategic approach entitled, A Global Strategy for Reproductive Health Commodity Security (RHCS). This new strategy recognizes that each partner working in this field has an important role to play according to its comparative advantage and that all partners must work together to expand their efforts on both the global and national levels. With UNFPA’s lead- ership and coordination, the success of the efforts of the various partners can be maximized. These broadened efforts are already underway, including the improve- ment of advocacy and resource mobilization, strength- ening of national capacity, and reinforcement of pro- gram sustainability and coordination.2 BACKGROUND Historically, donors have played a key role in all aspects of contraceptive supply, from direct donations of com- modities to procurement and logistics support. In recent years, however, international assistance for contracep- tives has declined, while demand for contraceptives has increased. This trend has prompted concerns about the future ability of family planning programs worldwide to fulfill their contraceptive requirements and whether men and women will be able to obtain the products and services they need to achieve and maintain good repro- ductive health. Considerable uncertainty exists about whether and how family planning programs are preparing for the changing donor environment. The annual figures for donor contributions are relatively well documented and studies have been undertaken on possible alternatives to donor assistance, including the private sector. There is less information, however, about how government and non-governmental programs view supply issues, the actions they are taking to address changes in donor con- tributions, and how a gap between contraceptive needs and supplies would affect their programs. Such informa- tion is timely for several reasons: • An increasing number of countries that receive donor assistance are assuming (or are expected to assume in the near future) responsibility for meeting all or part of their contraceptive needs. This means that more countries are or will be forecasting, financing, procur- ing, and delivering contraceptives with less donor assistance. This will have far-reaching implications for the price, quality, effectiveness, and reliability of prod- ucts and services. • Wide variations exist among countries with regard to institutional capacity. The strengths or weaknesses of national institutions will in large part determine the degree to which countries will successfully manage contraceptive supplies on their own. Country-level perceptions of the capacities and limitations of their programs can help determine the most effective way to channel sparse resources without compromising the broader mission of family planning programs to pro- vide good quality contraceptives to consumers. • Concern about the future of family planning pro- grams in developing countries in the face of diminish- More countries are or will be forecasting, financing, procuring, and delivering contraceptives with less donor assistance. This will have far-reaching implications for the price, quality, effec- tiveness, and reliability of products and services. � 3 � ing donor support has raised awareness of the need for coordinated strategies at both the national and international levels. The incorporation of country- level perspectives on supply issues is critical in order for these efforts to be effective. APPROACH AND METHODOLOGY In 2000, the Program for Appropriate Technology in Health (PATH) collaborated with John Snow Inc. (JSI) to develop a questionnaire on contraceptive supply issues and to administer it to respondents from govern- ment and non-governmental family planning organiza- tions.3 The questionnaire sought to identify issues that face service delivery programs and to solicit input on specific trends in commodity forecasting, funding, pro- curement, and delivery, as well as general concerns about donor coordination and future threats and responses to commodity security. Programs in 13 coun- tries were identified to receive questionnaires. Criteria for selecting the countries to survey included: • The presence of an in-country contact to administer the questionnaire; • Diversity with regard to geography, donor assistance, income, population size, local manufacturing and pro- curement capacity, strength of the commercial contra- ceptive market and history of supply problems; and • The willingness of Ministry of Health and/or NGO representatives to participate. JSI and PATH compiled a list of potential respondents, drawing on their knowledge of and experience with the logistics and supply issues faced by programs in specific countries. The original aim was to survey two respon- dents from each of the 13 countries, one from the gov- ernment family planning program and one from a major in-country non-governmental service delivery program. In-country assistants, or consultants chosen by them, personally administered the questionnaires to ensure maximum and timely responses. The questionnaire was translated into Spanish and Arabic where appropriate. For the purposes of this questionnaire, “contracep- tives,” “contraceptive commodities,” and “commodi- ties” included the following: combined pills, proges- terone-only pills (mini-pills), IUDs, Norplant, injecta- bles, condoms (male and female) for both family plan- ning and HIV/STD prevention, diaphragms, sterilization (tubal ligation clips), spermicides (vaginal foaming tablets, foams, creams, and jellies), and emergency con- traception. It should be noted that the relatively small number of countries surveyed means that the perspectives discussed in this report do not represent all developing country family planning programs. In addition, unless explicitly noted, all information reported here was compiled from the personal replies and statements of respondents, and may therefore not represent the current or future activi- ties of programs or donors. THE RESPONDENTS Twenty-three respondents in 13 countries completed the questionnaire, 13 from governmental and 10 from non- governmental family planning programs.4 According to World Bank classifications, five of the participating countries are low-income (GNP per capita of US $760 or less); five are lower-middle-income (GNP per capital of US $761-$3,030); and three are upper-middle-income (GNP per capita US $3,031-$9,360). The populations of these countries range from 8 million (Bolivia) to more than 1 billion (India). Together they are home to well over 2 billion people, or more than 40 percent of the developing world (60 percent when China is excluded).5 Table 1 shows the distribution of respondents by coun- try and type of program. FINDINGS The programs surveyed vary widely in size, from one that covers only 1.5 percent of its country’s contracep- tive users to another that covers almost 90 percent. The governmental family planning programs are much larger than the NGO programs. All but one government pro- gram covers more than 40 percent of the population of contraceptive users, while all but one NGO program covers 10 percent or fewer. REGION/COUNTRY GOVERNMENT NGO Asia Bangladesh 1 India 1 Indonesia 1 2 Philippines 1 1 Vietnam 1 1 Africa Egypt 1 2 Kenya 1 1 Europe and Central Asia Turkey 1 Ukraine 1 1 Latin America Bolivia 1 Brazil 1 1 Mexico 1 1 Peru 1 TOTAL 13 10 < TABLE I > DISTRIBUTION OF FAMILY PLANNING PROGRAM RESPONDENTS � 4 � Estimating Future Requirements All of the respondents anticipated an increase in contra- ceptive supply requirements in the next 3 to 5 years. However, as illustrated in Figure 1 above the extent of this anticipated increase varies widely, ranging from 2 to 80 percent. When asked how they expect increased commodity needs to be supplied, two-thirds of the respondents cited external donors and an expanded government budget. The next most common answer, with eight responses, was that in-country NGOs will purchase contraceptives. Seven respondents (three government, four NGO) indi- cated that private service delivery will ensure contracep- tive supply. Only four respondents, all from government programs that are heavily donor-dependent, pointed to the receipt of loans as a way to purchase contraceptives. With the exception of the latter response, there was lit- tle discernible difference between the answers provided by NGO and government respondents. The majority of programs apparently expect future commodity needs to be met by the same sources that have dominated contra- ceptive provision in the past, i.e., external donors and governments. The programs surveyed use a variety of methods, often in combination, to estimate future commodity requirements. Most (17 programs) rely on records main- tained at the service delivery level, followed by histori- cal data (16) and demographic information (13). Eight respondents stated that their programs estimate require- ments based on distribution capacity. Responses to a question eliciting the degree to which programs target services to specific populations revealed that more than half (12) of the surveyed programs sup- ply contraceptives to anyone who requests them. Five supply anyone with an income below a certain income level; five serve only married women and men; and four serve only people in specific geographic regions. Other populations targeted include adolescents, unmarried women, women who for medical reasons should not become pregnant, or the poor, as well as emergency cases. Nine of the 23 programs (6 NGO and 3 govern- ment) segment their clients to some degree. Funding Contraceptives Almost three-quarters of the programs surveyed (17) fund all or part of their contraceptive supplies, while the remaining 6 programs are wholly dependent on external donors. Of the 17 programs that fund contraceptives, 13 receive contraceptive support through loans, grants, and/or direct donations. Almost 70 percent of the gov- ernment programs (9) have a line item for contracep- tives in their budgets; three of these are in upper mid- dle-income countries, three in lower middle-income countries, and three in low-income countries. The amount of money allocated to contraceptive procure- ment in 1999 ranged from US $4000 in Ukraine to more than US $37 million in India. Table 2 provides a breakdown of assistance for con- traceptive supply given to the surveyed programs. The figures supplied by programs should be interpret- Ba ng lad esh Bo liv ia Bra zil Eg yp t Ind ia Ind on esi a Ke ny a Me xic o Pe ru Ph ilip pin es Tur ke y Uk ra ine Vie tna m 0 10 20 30 40 50 60 70 80 90 NGO Government < FIGURE 1 > EXPECTED PERCENT INCREASE IN CONTRACEPTIVE REQUIREMENTS IN THE NEXT 3-5 YEARS FOR 22 PROGRAM RESPONDENTS � 5 � ed cautiously because of the complexity of the donor assistance process. However, certain broad inferences can be made about the funding status of the surveyed programs. While four programs claim to be wholly independent from, and six wholly dependent upon, donors for their commodity supplies, most of the sur- veyed programs fall somewhere in between these two points. In other words, the majority of countries finance at least a portion of their commodity requirements. Among the respondents whose programs receive con- traceptive support from donors, ten expect current lev- els of such support to increase and eight expect it to decrease. NGOs seem to be somewhat more optimistic than governments about future donor assistance: six of eight NGO respondents expect donor funds to increase over the next 3 to 5 years, while six of ten government respondents anticipate a decrease. Interestingly, those respondents who expect donor support for contraceptives to decrease nonetheless believe that donors will continue to be a central source of contraceptive supplies in the future. They are also confident that government budgets for contraceptives will increase. Moreover, they expect that in the future, these two sources will support supplies to a greater degree than will in-country NGOs, private service deliv- ery systems, or loans. This discrepancy suggests that family planning programs are generally uncertain about the future role of donors with regard to contraceptive supplies. Respondents who expect donor support for contra- ceptives to decrease answered an open-ended question on the probable impact of this decline on their pro- grams and adjustments the programs would undertake to cope with such a change. Respondents from two pro- grams explicitly stated that reduced donor support for contraceptives would “harm the program severely” and “hamper expansion of access.” Almost all the respon- dents who expect donor support for contraceptives to decrease addressed the need to prepare for this trend in the future by attaining greater financial independence today. Some programs have already started to work toward financial sustainability by initiating cost recovery mech- anisms, diversifying funding, shifting low-income clients to less expensive contraceptive methods, and pursuing other undefined “independence initiatives.” Two respondents also mentioned the importance of building capacity at the institutional level in areas such as pro- curement, forecasting, and LMIS in order to make their programs more self-reliant. Procuring Contraceptives Eleven of the surveyed programs (seven government and four NGO) procure at least a portion of their own con- traceptives. Seven of these programs have full-time dedi- cated procurement staff. Primary procurement sources include both international and in-country manufactur- ers. The most common factor governing the selection of Respondents from two programs explicitly stated that reduced donor support for contraceptives would “harm the program severely” and “hamper expansion of access.” PROGRAM TYPE FUNDING SOURCE Programs that wholly fund Programs that rely on loans, Programs that rely on loans, Programs that wholly contraceptive supplies (no loans, grants, or direct donations for grants, or direct donations for rely on direct grants, or direct donations) less than 50% of total more than 50% of total donations for contraceptive supplies contraceptive supplies contraceptive supplies Government 3 1 7 2 NGO 1 3 2 4 Total 4 4 9 6 < TABLE 2 > PROGRAM FUNDING SOURCES suppliers is the requirement that products be purchased from domestic manufacturers. The seven respondents who cited such a mandate represent programs in five large countries (Brazil, India, Indonesia, Mexico, and Vietnam) that have launched efforts to strengthen local suppliers. In addition, respondents from two other pro- grams stated that choice of procurement method, regu- latory approvals, and supply mandates are governed by funders or lenders. Programs use various methods to ensure standards of quality, as indicated in Figure 2 below. Among all 23 respondents, the most common methods named were evaluation of product documentation, regulatory test- ing/sampling, monitoring acceptability to users, and visual inspection. Overall, all but five respondents stated that their programs use two or more of these methods to ensure quality standards.6 Delivering Contraceptives Respondents were shown a list of problems and asked which had had a significant impact on their program in the last three years. The most commonly cited problems were stock-outs and delays in shipments (nine responses for each) and redundancy/oversupply of certain contra- ceptives (seven responses). More than one-quarter of the programs experienced one or more of the following problems: poor contraceptive quality and storage condi- tions, difficulties with the agency’s procurement system, excessive lead times for supplies, product loss, and brand switching when donors change. The frequency of these problems is clearly illustrated in Figure 3. In addi- tion, four programs reported other problems not shown in Figure 3: high national tax and custom fees; a lack of logistics management; inadequate knowledge of logistics staff; frequent shifts in contraceptive methods among users; insufficient funds available to the government and insufficient incomes throughout the population. Four government programs account for almost half of the problems reported by all 23 respondents. Three of these programs procure all or almost all of their own commodities, although one receives its entire supply in the form of direct donations from several donors. All four programs also receive donor assistance in the form of forecasting and logistical support, but only one of the three programs that undertake procurement receives assistance for this process. All things considered, it is difficult to identify with any certainty the characteristics of a program that is more or less likely to be afflicted with the types of problems listed in Figure 3. Respondents from both government and NGO pro- grams cited weakness in the procurement system and the LMIS as the most common source of problems. Programs that procure their own contraceptives expressed the need for alternative procurement sources and earlier procure- ment preparation and to prepare for procurement in advance. One government program with a decentralized system asserted that centralized procurement would more � 6 � 0 2 4 6 8 10 12 14 16 Evaluation product documentation Regulatory testing/sampling Monitoring acceptability to users Visual inspection Licensing of manufacturers Inspection of manufacturing facilities Government approval Number of Programs < FIGURE 2 > QUALITY ASSURANCE METHODS � 7 � effectively ensure that products are purchased in a timely manner. Another program that relies on donors to pro- cure contraceptives underscored the need to strengthen national procurement capacity in order to reduce the inci- dence of stock-outs, shipment emergencies and delays, and general procurement problems. Similarly, many respondents felt that their program’s LMIS should be strengthened in order to more effective- ly manage stocks and ensure adequate supplies. Finally, respondents from two programs indicated that improved targeting of supplies to particular populations would solve some of their delivery system problems, while respondents from two others pointed to the need for better planning and coordination with, as well as commitment from, donors. Respondents were also asked which mechanisms pro- grams had used to obtain product-related input from clients in the last two years. Many programs seem to have used a combination of methods, the most common of which were the integration of a feedback component into management information systems (MIS), client interviews or focus groups, and periodic surveys. In addition, seven programs had conducted market studies and six had used complaint forms in order to obtain client feedback. Program Capacity The questionnaire sought information on program capacity by eliciting information on the existence of full-time, dedicated staff for logistics or procurement, a budget line item for commodities, a forecasting unit, and a management information system (MIS). Eighteen programs have dedicated staff members whose primary, full-time jobs focus on logistics, while seven have full- time staff who focus on procurement. Nineteen pro- grams have a special unit or individual who is responsi- 0 1 2 3 4 5 6 7 8 9 10 Stock-outs Redundancy/oversupply of certain commodities Product loss Problems with agency’s procurement system Contraceptive quality Emergency shipments Storage capacity Inadequate hard currency Number of Programs No or unclear commitments from donors Transport capacity Providing free or subsidized commodities to persons who could pay commercial prices Storage conditions Excessive lead time for supplies Brand switching when donors change Delays in shipments < FIGURE 3 > SIGNIFICANT PROBLEMS WITH CONTRACEPTIVE SUPPLIES ble primarily for forecasting contraceptive requirements, 14 have a line item for contraceptives in their budgets, and 21 have an information system that is used as a management tool. Table 3 illustrates the distribution of these capacities according to the type of program. The overall number of programs with full-time pro- curement staff is noticeably low compared to other capacities. However, several respondents indicated that, although their programs lack “full-time” procurement staff, they do have one or more staff members who are dedicated to procurement in addition to other functions. Furthermore, the questionnaire did not obtain informa- tion regarding the complexity of the information obtained and handled by an MIS. It is clear that MIS capacities differ widely, with some systems consisting of stock cards while others are computerized. The fact that respondents so frequently attribute problems to a weak procurement system and/or MIS suggests the need for a more in-depth study of each program’s system in order to understand how to achieve effective capacity. Donor Coordination A number of donors provide program support in a wide range of areas, from provision of commodities to tech- nical assistance. As indicated in Table 4, survey respon- dents reflect the breadth of agencies from which they receive commodity support. Ten agencies provide com- modity support to 15 programs, of which 10 (6 govern- ment and 4 NGO) receive support from two or more agencies. The majority of programs receive donor assistance (i.e., either training or infrastructure improvement) in specific areas, as follows: • Contraceptive logistics (17) • MIS (16) • Policy and strategy formulation and planning (13) • Service delivery (12) • Quantity estimation (12) • Family planning advocacy (12) Ten programs also receive external assistance for social marketing, seven for contraceptive procurement, and six for establishing a correct contraceptive mix. However, the questionnaire did not solicit information about which agencies are providing the programs with these varied types of assistance. When asked how donor resources can best be used to ensure that a program’s future contraceptive require- ments are met, respondents from eight programs raised issues surrounding procurement and financing. Some expressed the wish for more feedback on procurement operations, while others want donors to “transfer skills” in procurement and forecasting to relevant gov- ernment ministries. Even some governmental programs that currently procure contraceptives would like donors to assist with financing or, as stated by one respondent, “to a certain extent, give us support for commodi- ties…[to] release the pressure on our budget” so that “funds can be used for other services.” A number of respondents mentioned the heavy burden borne by their programs as a result of procurement costs and expressed the need for donors to reduce this burden. Respondents from two programs also stated that they would like donor rules and conditions to be less cum- bersome. A representative of one government program stated that “these rules and conditions should be stan- dardized to help easy and timely procurement through effective donor coordination. Some donors provide tied funds, which results in procurement at high cost. Donors should provide untied funds.” Several respon- dents also complained that donors supply “unpopular brands of contraceptives” and stated that they “should � 8 � Program type Full-time dedicated logistics staff Forecasting unit Full-time dedicated procurement staff Budget line item MIS Government 12 12 6 9 12 NGO 6 7 1 5 9 Total 18 19 7 14 21 < TABLE 3 > PROGRAM CAPACITY Agency Number of Programs United Nations Population Fund (UNFPA) 7 U.S. Agency for Int’l Development (USAID) 6 International Planned Parenthood Federation 5 World Bank 4 In-country government 3 Kreditanstalt für Weideraufbau (KfW) 3 Department for International Development (DFID) 3 Canadian International 2 Development Agency Swedish International Development Agency 1 European Union 1 < TABLE 4 > SUPPORT FOR COMMODITIES be more involved in the requirement needs of the pro- gram they subsidize” and provide generic rather than brand name products. Finally, a number of programs would like donors to assist them in using their resources more effectively. One respondent suggested that, to this end, donors could provide assistance by determining which clients receive full, partial, or no subsidies, while another expressed the need for help in shaping a strategy of program serv- ice fees. In addition, respondents from two programs felt that donors should help “develop the market” and strengthen private sector participation and involvement in direct service delivery in order to “ease…the burden of total subsidies provided by government.” When asked how each program coordinates multiple donors, the most common answers were sharing contra- ceptive requirements and forecasts and coordinating procurement. Eleven respondents cited each of these cat- egories. Six programs apparently share information on prices, delivery constraints, and new suppliers; six use joint development of country assistance; and six negoti- ate with each donor on an individual basis. All pro- grams with two or more donors currently coordinate the efforts of their donors to some degree. CHALLENGES AND RESPONSES As indicated in Figure 4, respondents most widely cited inadequate government commitment to and inadequate donor funding for contraceptive supply, as well as fiscal constraints on governments for the purchase of contra- ceptives, as the issues that pose a “very serious threat” to the future success of family planning in their coun- tries. However, when responses to the questions of “moderate threat” and “very serious threat” are evalu- ated together, high contraceptive prices on the interna- tional market also emerged as posing a critical challenge to family planning programs. While respondents from government and NGO pro- grams did not differ markedly in their perceptions of these issues, it is notable that those in the former cate- gory perceived “fiscal constraints on governments to purchase contraceptives” as the most formidable threat. Among all 13 government respondents, six perceived this issue as a “very serious threat,” four as a “moder- ate threat,” and only two as “no threat.” This percep- tion of the threat of fiscal constraints is consistent with the comment made by a number of respondents that donor resources are best used to help programs finance contraceptives. At the same time, all of the government � 9 � 7 12 7 6 8 9 9 9 7 8 8 6 6 11 6 10 10 6 5 5 5 6 5 5 6 5 0 2 4 6 8 10 12 14 16 18 20 Inadequate government commitment to commodities High commodity prices on international market Inadequate donor funding for commodities Fiscal constraints on government to purchase contraception Inadequate domestic procedures to procure commodities Inability of private sector to supply affordable commodities Insufficient data availability Inadequate domestic infrastructure and procedures to deliver commodities Insufficient promotion of family planning Inability of clients to pay for services and/or supplies from private sector Inadequate regulatory system Unreliable source(s) of commodities Inadequate access to hard currency Number of Programs Moderate Threat Very Serious Threat < FIGURE 4 > PERCEPTIONS OF THREATS TO FAMILY PLANNING PROGRAMS programs that wholly fund their own contraceptive sup- plies perceived “inadequate donor funding” as posing “no threat” to the future success of family planning in their country. The issues that respondents most frequently cited as “no threat” to the future success of family planning in their countries were unreliable source(s) of contracep- tives, inadequate access to hard currency, insufficient promotion of family planning, and insufficient data availability. However, half or more of respondents per- ceived even these issues as “moderate” or “very seri- ous” threats. Not surprisingly, programs that anticipate larger increases in their future contraceptive requirements gen- erally perceived a greater number and level of threat than programs that anticipated smaller increases. This is particularly clear in the case of “inadequate donor fund- ing for contraceptive commodity supply.” No respon- dents from the eight programs that are expected to increase by 10 percent or less in the next 3 to 5 years perceived this as a “very serious threat,” while respon- dents from only three such programs perceived it as a “moderate threat.” On the other hand, all but one of the 14 respondents who expect their program’s require- ments to increase by more than 10 percent perceived this issue as a “moderate” (4) or “very serious” (9) threat. The exception is a government program whose entire contraceptive supply is donated. Respondents provided a wide variety of answers to the question of how programs address threats. Most of the answers indicate that programs are just beginning to explore possible solutions. Programs have started look- ing for alternative sources of financing and ways to encourage the local production and manufacturing of contraceptives. Sustainability plans are being developed and closer coordination between government and donor agencies, as well as direct collaboration with donors and NGOs, are now clear goals. Other planned initiatives include the identification of mechanisms and strategies to expand the availability of contraceptives; conducting studies to explore other sources of contraceptives (such as social marketing); the generation of income through services; lobbying legisla- tors, political leaders, and other “influentials;” and investing in institutional capacity so that programs can become more effective and self-reliant. A number of respondents also mentioned the need for international support for technical training, logistics, LMIS, and mar- keting in order to help their programs build capacity and operate with maximum self-reliance. When asked how programs can effectively ensure an adequate supply of contraceptives in the future, respon- dents cited more efficient use of current logistics systems (17 responses); diversification of funding sources for contraceptives (16 responses); the introduction or increase of user fees for services and/or contraceptives (14); and the strengthening of forecasting systems (14). In addition, 12 respondents cited the need for more, new, and/or better coordination of donors. The impor- tance of targeting subsidies to those most in need and of raising the awareness of new constituencies were each cited by ten respondents. Additional options for ensuring contraceptive supply include shifting users to the private commercial sector, private insurance coverage, and employer cost sharing. These options, which all involve the private sector, gar- nered the least support (with six, four, and three responses, respectively), suggesting a lack of optimism about the private sector’s ability to solve supply prob- lems. The limited support expressed for the private commercial sector may seem particularly surprising given the fairly strong support for the introduction of user fees (14 responses). If, as many respondents sug- gested, clients would be willing to pay for contracep- tives charged by the surveyed programs, one might expect that those clients would also be willing to pur- chase contraceptives from the private commercial sector. One possible explanation for this apparent discrepan- cy is the perception among a large number of respon- dents that the private sector is unable to provide afford- able contraceptives to poorer clients. About two-thirds of the respondents cited this problem as a serious threat to the future success of family planning in their coun- tries. In other words, respondents seem to think that the private commercial sector can and should alleviate future program demands made by wealthier clients. However, the problem of affordability prevents this sec- tor from playing a significant role in solving future sup- ply problems. Nonetheless, respondents support the seg- mentation of program fees, and several expressed a desire for donor assistance in broadening understanding of the private sector and the opportunities it affords to reduce the financial burden of programs. � 10 � All but one of the 14 respondents who expect their program’s requirements to increase by more than 10 percent perceived [inadequate donor funding] as a “moderate” (4) or “very serious” (9) threat. This study highlights in-country perspectives on current and future contraceptive supply. It examines the key problems facing family planning programs, the activities they are undertaking to address these problems, and the areas where respondents feel donor resources could be directed most effectively. Overall, programs plan to strengthen, expand, and refine the existing supply sys- tem with regard to institutional capacities, clients, and donor funding. It is clear that family planning programs around the world anticipate an increase in contraceptive require- ments in the coming years. The expectation that exter- nal donors and government budgets will provide sup- plies in the future is very high. At the same time, even though most program representatives surveyed recog- nize the need to initiate cost recovery measures and tar- get clients, the private sector is generally not viewed as the solution to supply problems. Survey respondents frequently asserted that procure- ment and MIS systems are weak. This is of critical importance, since 11 surveyed programs procure at least a portion of their own contraceptives. At present, about two-thirds of the programs receive MIS assis- tance, while less than one-third receive any assistance for procurement. Only three of the 13 government fami- ly planning programs surveyed receive any technical < CONCLUSION > assistance for procurement. Given the dominant role of these public sector programs in the surveyed countries, this finding suggests that donors need to greatly expand the training and transference of skills in procurement if greater self-reliance is to be achieved. There was a strong perception among respondents that the future success of family planning programs is threatened. Key problems cited were high commodity prices on international markets, inadequate donor fund- ing for and government commitment to contraceptive commodity supplies, and fiscal constraints on govern- ments to purchase contraceptives. For these reasons, donor resources should be used to improve procurement and financing in the future. However, donors need to take a broad view of contraceptive supply by concen- trating resources and training in ways that respond to each country’s needs and level of self-reliance. The next step for donors, developing country govern- ments, NGOs, and technical agencies is to consider how to achieve increased contraceptive commodity security, what the contributions of each group will be, and how to coordinate those contributions. The 1994 International Conference on Population and Development called for universal access to safe, afford- able, and high-quality contraceptives. Any strategy to meet this important goal will require concerted effort and willingness by a range of actors at both the global and national levels. � 11 � The expectation that external donors and government budgets will provide supplies in the future is very high…the private sector is generally not viewed as the solution to supply problems. NOTES 1 Currently, about two-thirds of the programs receive LMIS assis- tance, while less than a third receive assistance for procurement. 2 UNFPA News Feature. “UNFPA Fully Committed in Ensuring Universal Access to Reproductive Health Care by 2015: A Global Strategy for Reproductive Health Commodity Security,” available from http://www.unfpa.org/news/features/rhcs.htm; Internet; accessed 2 March 2001. 3 In addition, members of the Interim Working Group on Reproductive Health Commodity Security (IWG) and staff mem- bers of the technical division of the United Nations Population Fund (UNFPA) commented on the survey. 4 A non-governmental response was received that is not considered in the current analysis because it was from an international rather than a local program. We did not receive an NGO response from Turkey because the four major NGOs providing commodities to clients there had stopped doing so following the withdrawal of donations from the United States Agency for International Development, although some later received contraceptives from UNFPA expressly for earthquake victims. 5 Population Reference Bureau. 2000 World Population Datasheet (Washington, DC: PRB, 2000). 6 For a detailed examination of how family planning programs per- ceive and apply quality assurance issues, see PATH, Contraceptive Quality Assurance: Findings of a 22 Country Survey. Reproductive Health Reports No. 2 (Seattle, WA: Program for Appropriate Technology in Health, July 1997). � 12 � M E E T I N G T H E CHALLENGE Securing Contraceptive Supplies T he Interim Working Group on Reproductive Health Commodity Security (IWG) is a collaborative effort of John Snow, Inc. (JSI), Population Action International (PAI), the Program for Appropriate Technology in Health (PATH) and Wallace Global Fund. Recognizing the important leadership role of the UN Population Fund (UNFPA) in meeting the goals of the 1994 Programme of Action, the IWG’s objective is to further these goals by raising awareness about the importance of securing reproductive health supplies. The IWG seeks to identify the causes of failures and weaknesses in commodity systems and to spur actions that will contribute to securing essential supplies for the delivery of reproductive health care. S E C U R I N G S U P P L I E S F O R R E P R O D U C T I V E H E A L T H Printed on Recycled Paper

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