Malawi: A Reproductive Health Commodity Security Desk Assessment

Publication date: 2006

[image: image6.png][image: image7.jpg][image: image6.png] [image: image8.wmf] Malawi: a reproductive health commodity security desk assessment DELIVER DELIVER, a six-year worldwide technical assistance support contract, is funded by the U.S. Agency for International Development (USAID). Implemented by John Snow, Inc. (JSI), (contract no. HRN-C-00-00-00010-00) and subcontractors (Manoff Group, Program for Appropriate Technology in Health [PATH], and Social Sectors Development Strategies, 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 Paul Dowling. Bunde, Elizabeth. Chirwa, Veronica. 2005. Malawi: Contraceptive Security Desk Assessment. Arlington, Va.: DELIVER, for the U.S. Agency for International Development. Abstract The Ministry of Health (MOH) in Malawi is developing a Reproductive Health Commodity Security (RHCS) strategy to strengthen the availability and accessibility of reproductive health commodities, including contraceptives. A desk assessment based on existing data was carried out using the Strategic Pathway towards Reproductive Health Commodity Security (SPARHCS) diagnostic guide. This assessment will serve as the basis for the development of the RHCS strategy. The assessment reveals that after a period of rapid growth, increases in contraceptive prevalence have slowed recently. Unmet need remains high and so with the right interventions prevalence should continue to grow. Currently, there are major problems with availability of many essential drugs, including RH commodities although the situation is better for contraceptives. There are questions about the reliability of consumption data used for forecasting, and procurement capacity is weak, leading to major delays in procurement. There is limited oversight of the supply chain by the Central Medical Stores, and overall monitoring and supervision of supply chain functions is weak. New health priorities, particularly HIV/AIDS, may have led to less attention being given to reproductive health and family planning. However, increased spending on HIV/AIDS creates opportunities for family planning and commodity security since much of the funding is going towards overall system strengthening, particularly human resources and the supply chain. Priority areas for RHCS appear to be in strengthening the supply chain particularly information and management systems at the central and regional medical stores, training, increasing access to long term methods, and growing the private sector share of the market. Managing the health sector reform process, particularly the transition to a MOH basket fund and decentralization of decision making to the districts, poses particular challenges, but also offers opportunities. DELIVER John Snow, Inc. 1616 North Fort Myer Drive, 11th Floor Arlington, VA 22209 USA Phone: 703-528-7474 Fax: 703-528-7480 Email: Internet: Contents ivAcronyms viAcknowledgements viiiExecutive Summary 1introduction 1Rationale 1Methodology 3context 3Health situation In Malawi 4The Assessment 41. Client Utilization and Demand 122. Commodities 203. Commitment 234. Financing (capital) 255. Supply Chain Capacity 306. Service Delivery Capacity 327. Coordination 338. Context: Policies and Regulations 359. Context: Demographic, Health and Development Indicators Conclusions 36Data Gaps 40References Acronyms API active pharmaceutical ingredient ARV antiretroviral ATP ability to pay BCC behavior change communications BLM Banja La Mtsogolo CBD community based distribution CBDA community based distribution agents CHAM Christian Health Association of Malawi CMS Central Medical Stores CPR contraceptive prevalence rate CS contraceptive security DFID British Department for International Development DHS Demographic and Health Survey EHP Essential Health Package EU European Union FEFO first expiry first out FP Family Planning FPAM Family Planning Association of Malawi GNI Gross National Income HIV/AIDS human immune deficiency virus/acquired immune deficiency syndrome HTSS Health and Technical Systems and Services ICB International Competitive Bidding IEC information, education and communication IMF International Monetary Fund IPPF International Planned Parenthood Federation IUD intrauterine device JICA Japanese International Cooperation Agency JSI John Snow, Inc. LATH Liverpool Associates in Tropical Health LIAT Logistics Indicator Assessment Tool LMIS logistics management information system LSAT Logistics System Assessment Tool M&E monitoring and evaluation MASM Medical Aid Society of Malawi MCH maternal and child health MMR maternal mortality ratio MOH Ministry of Health MOS months of stock MoU memorandum of understanding MSH Management Sciences for Health MSI Marie Stopes International NDQCL National Drug Quality Control Laboratory NEDL National Essential Drugs List NORAD Norwegian Agency for Development Cooperation NGO non governmental organization NMSC National Medicines and Supplies Committee PMPB Pharmacy Medicines and Poisons Board PPP purchasing power parity PRSP Poverty Reduction Strategy Paper PS Principal Secretary PSI Population Services International RHCS reproductive health commodity security RHU Reproductive Health Unit RMS Regional Medical Stores SDP service delivery point SPARHCS Strategic Pathway to Reproductive Health Commodity Security STI sexually transmitted infection SWAp sector wide approach (basket fund) TB tuberculosis TFR total fertility rate TWG technical working group UNFPA United Nations Population Fund USAID United States Agency for International Development VAT value added tax WHO World Health Organization WTP willingness to pay Acknowledgements Many people generously helped with their time and knowledge with the writing of this paper. The authors particularly want to thank John Zingeni of DELIVER – Malawi and the rest of the DELIVER Malawi team. At the Ministry of Health, Godfrey Kadawele and Samuel Chirwa at HTSS and Dorothy Namassau and Len Van Der Hoeven at RHU provided valuable assistance and information as did Lilly Banda-Maliro at USAID and Dorothy Lazaro at UNFPA. Our sincere thanks go to them and to all the others who helped prepare this document. Executive Summary Malawi has begun the process of assuring commodity availability and accessibility through the development of a Reproductive Health Commodity Strategy (RHCS.) To help support the development of the strategy this desk-based RHCS assessment was prepared. The assessment was based on analysis of existing information, supplemented with information from key stakeholders. The primary data sources were the past and present Demographic and Health Surveys (DHS), Logistics Indicators Assessments, National Health Accounts and various policy documents and reports. While the assessment focused primarily on contraceptives, where information was available for other reproductive health (RH) commodities, it has been included. There is more information available for contraceptives, and since most RH commodities are part of the integrated supply chain, funded through the Ministry of Health (MOH) basket fund, conclusions and recommendations drawn from the situation for contraceptives will, for the most part, be applicable to other RH commodities. Malawi faces several challenges in ensuring RHCS. Demand is growing rapidly, from 7.4 percent in 1992 to 28.1 percent in 2006. The population continues to grow and there are increasing numbers of women entering reproductive age. Unmet need continues to remain high at 27.6 percent, suggesting growth will continue over the medium term at least. There are suggestions that the visibility of family planning has declined recently. Growth in the contraceptive prevalence rate has slowed considerably increasing by just 2 percent over four years from 26.1 percent in 2000 to just 28.1 percent in 2004. The HIV/AIDS epidemic is a major issue in Malawi and is rightfully receiving much attention; the challenge is to ensure that family planning (FP) continues to maintain a high profile in this environment. Current CPR is heavily weighted towards one short-term method and one in particular: injectables. There are suggestions that providers are often reluctant to promote other methods either due to lack of knowledge or over familiarity with this one method. Availability of implants and IUDS are limited though there are ongoing efforts to promote the IUD. Access to health facilities also limits RHCS. The public sector is the main provider with the Christian Health Association of Malawi (CHAM) and Banja La Mtsogolo (BLM), an NGO, also providing significant coverage. Some CHAM facilities do not offer modern methods. The only products available through social marketing are male condoms and the private commercial sector has very limited market share. There are very few private sector providers; the few that exist are concentrated in urban areas, and incomes are limited limiting the attractiveness of the commercial market. The procedures for drug selection are currently being reviewed and strengthened. The essential drug list (EDL) has not been updated in several years and it not widely disseminated. The Essential Health Package commodity list, developed from the old EDL, is used as a de facto EDL until an updated version is available. The Pharmacy Medicines and Poisons Board (PMPB) has limited capacity to regulate drug registration and quality. The National Drug Quality Control Laboratory, as well as having limited technical capacity, has no legal authority to enforce its decisions and a recent PMPB product recall was ignored for several months. The supply situation is serious for many RH commodities. There are significant stockouts particularly for STI drugs and other commodities. Stockouts are less for contraceptives, but still occur even in a situation where many facilities are actually overstocked – itself an indicator of a poorly functioning system. For some commodities, stockouts are due to inaccurate forecasting and delays in procurement. While a functioning Logistics Management Information System (LMIS) capable of tracking consumption data exists, there is little monitoring to ensure facilities and districts are correctly recording their consumption and calculating their order quantities. Even if data are accurate, rationing by the Central Medical Stores is endemic, leading to uncertainty as to what the real demand is for commodities. In addition, the data that are available are often not used by CMS to calculate procurement quantities. There are significant delays in transforming forecasts into procurements with the result that forecasts are out-of-date when they are executed. Procurement capacity at CMS is limited and due to the need to follow World Bank procurement procedures, cycle times are expected to be very long. The existing LMIS system is only functional at the facility and district levels; the CMS does not compile the data. Other problems in the supply chain include storage capacity at all levels, shortages of trained staff, lack of supervision and monitoring. Many stakeholders consider that there is adequate financing for essential drugs including contraceptives and other RH commodities. Current drug budgets are being under-spent, and this is in a situation where there are significant stockouts of many drugs. Most donors are contributing to the MOH basket fund, part of which is a fully budgeted Essential Health Package including commodities. The EHP is the minimum packet of activities that should be available to all Malawians. A number of donors, including USAID, remain outside the basket, though their contributions are included for planning purposes. USAID is funding orals, condoms and implants for at least the next two years. It is unclear if increased funding can be made available in the event of drug forecasts exceeding budgeted amounts. Budgets were prepared using data that was not very robust. EHP commodities and services are available free of charge at the public sector. Despite this, household net out of pocket spending for health care and drugs is high at 27 percent of all health expenditures. This is probably related to access to the public sector, stockouts of commodities, and quality of service. There is no significant third party health insurance scheme; the largest private health insurer does not cover preventative services including FP. Changes in the policy and health context in Malawi pose new challenges and new opportunities to strengthen RHCS. Movement to a centrally funded basket at the MOH – the SWAp – decentralization, integration of supply chains for all essential drugs and the perceived need by most stakeholders to strengthen the national supply chain, means a whole new paradigm for the supply chain for reproductive health commodities. While HIV/AIDS may divert attention from family planning it also means new funding for system strengthening particularly for supply chains and human resources that may be leveraged for all programs including family planning and RHCS. Already a management consultant is in place in CMS to strengthen capacity there. The development of a RHCS strategy is already in motion. The strategy should be approved over the coming months. Implementation will be a major challenge. Leadership for strategy development and implementation will be from the Health and Technical Support Services (HTSS) at the MOH (Pharmaceutical Unit) with support from the Reproductive Health Unit (RHU). The main coordinating and implementing body will be the Logistics Committee, a multipartner group led by HTSS including representatives of donors, technical partners, NGOs, and the private sector. The Logistics Committee is expected to work closely with the Drugs and Medical Supplies Technical Working Group, a high level multipartner group chaired by the Principal Secretary at the MOH which meets regularly to decide supply chain issues. The Logistics Committee is expected to report regularly to this group. The development of an RHCS strategy will be the first step in ensuring that Malawians enjoy RHCS in the coming years. Strategic planning to address priority issues, ensure the efficient use of available resources, and allow equitable access to reproductive health commodities, can help ensure that all Malawians can choose, obtain, and use the contraceptives and other RH commodities they need, when and where they need them. introduction Reproductive health commodity security (RHCS) exists when people are able to choose, obtain and use the reproductive health supplies they need, when and where they need them. This implies that supplies must be available, and that they must also be accessible. Rising demand for contraceptives and other reproductive health supplies, coupled with stagnant donor interest in these commodities, has led to an increased global emphasis on commodity security as a strategic means to ensuring supply availability and accessibility. Commodity security emphasizes strategic planning, a medium to long-term perspective, and a holistic approach, targeting a number of programmatic areas and sectors. Malawi has begun the process of assuring reproductive health commodity security through the development and implementation of a RHCS strategy. The country faces several challenges, with increased demand for services, a growing population, and a significant unmet need for contraceptives. Capacity is weak, and stockouts occur frequently for many reproductive health commodities. Changes in the policy and health context in Malawi pose new challenges and new opportunities to strengthen RHCS. Movement to a centrally funded basket at the Ministry of Health (MOH) – the Sector Wide Approach (SWAp) – decentralization, and the integration of supply chains for all essential drugs mean the environment for RHCS is changing very quickly. Increased funding, with significant funding for HIV/AIDS, some of which is going to overall system strengthening, provides opportunities to improve commodity security. Rationale This assessment is intended to support the development of a comprehensive RHCS strategy for Malawi. While the assessment is intended to support overall RHCS, it focuses more on contraceptives than other RH commodities. There are two reasons for this. Firstly, there is more information available for contraceptives and an assessment of this nature could not do justice to a broader range of reproductive health commodities. Second, since contraceptives are part of the integrated logistics system, then conclusions drawn from the situation for contraceptives will be generally indicative of the overall situation for RH commodities. Where specific data on RH commodities is available it is provided. The assessment is based entirely on a secondary analysis of existing data, complemented with information provided by in-country stakeholders. While intended to be comprehensive, it has gaps; indeed, one of the objectives of this assessment was to identify gaps in the data that could be addressed in the subsequent strategy which are highlighted in the conclusion. The expected value-added in carrying out a more intensive survey with fieldwork was not considered to be commensurate with the time and expense needed. Strategic planning for commodity security or indeed commodity security itself is not an end point, it is a journey. The first step is often the most important one. This assessment is designed to help Malawi take that first step; to develop a RHCS strategy that itself is only part of the process of achieving sustainable reproductive health commodity security for the people of Malawi. Methodology As noted above, this assessment is strictly based on secondary analysis of existing data sources. These sources are referenced throughout, but the main sources include the 2004 Demographic and Health Survey (DHS) (MOH 2004), the 2006 Logistics System Assessment and Logistics Indicators Assessment (DELIVER 2006), the 2006 Contraceptive Procurement Tables, the 1999 National Health Accounts (MOH 2001), and various policy and planning documents from the MOH and other agencies. This data review was complemented with information provided by contacts in Malawi at the MOH and various partner organizations. This assessment loosely follows the Strategic Pathway towards Reproductive Health Commodity Security (SPARHCS) diagnostic guide (Hare 2004) which is in turn based on the SPARHCS framework (Figure 1). Figure 1: Strategic Pathway to Reproductive Health Commodity Security Framework [image: image1.png] The framework identifies the different elements that must be present in order to satisfy client demand for commodities – the center of the SPARHCS circle. Elements include commodities, capacity, coordination, capital or finance, and commitment or leadership, all of which take place in a legal, political and social environment. The diagnostic guide is based on this framework, and provides a series of questions and tables to help assess the current situation and make future projections. This assessment adapted the guide, eliminating some less relevant questions and adapting several others to the Malawi context. context Health situation In Malawi There are huge pressures on the health system in Malawi. Low income levels with as many as 65 percent of the population living in poverty, shortages of human resources, and the HIV/AIDS epidemic (HIV prevalence is around 14 percent), all contribute to poor health indicators. Life expectancy has dropped to 39 years and Malawi has among the highest maternal and infant mortality ratios in the region. The leading causes of mortality and morbidity are preventable diseases such as malaria, diarroheal diseases, respiratory infections, and of course, HIV/AIDS. The number of Tuberculosis (TB) patients is increasing and sexually transmitted infections (STIs) continue to be a major problem. National Health Policy The mission of the MOH is to, “stabilize and improve the health status of Malawians by improving access, quantity, cost-effectiveness and quality of the EHP [Essential Health Package] and related services so as to alleviate the suffering caused by illness and promoting good health, thereby contributing to poverty reduction.” The Essential Health Package (EHP) is seen as the fundamental instrument for bringing healthcare to Malawians. It refers to, “a prioritized but limited package of services that should be available to all Malawians at all times.” (MOH 2004) The package is comprised of 11 key components including malaria, STIs, nutrition, diarroheal diseases and reproductive health services (which encompasses family planning.) The EHP has been costed and is supported by an EHP commodity list based on the National Essential Drug List (NEDL.) Services to be offered are defined by the level of care: community, health center and district and includes the Christian Health Association of Malawi (CHAM) facilities. Provision of the EHP forms the basis of the MOH basket fund or Sector Wide Approach (SWAp) which is being implemented since 2005. Several donors including the World Bank, the UK Department for International Development (DFID), the Norwegian Agency for Development Cooperation (NORAD), and the United Nations Population Fund (UNFPA) will contribute to the SWAp in the future. The EHP and the SWAp are central planks of the Malawi Poverty Reduction Strategy Paper (PRSP.) Reproductive Health commodity security in malawi The Health and Technical Services and Support (HTSS) department at the MOH, with support from UNFPA and USAID, have taken the lead in developing a RHCS strategy for Malawi. A team from Malawi attended an East African regional workshop for RHCS held in Tanzania in October 2005. This was followed by an advocacy workshop held in December 2005 in Lilongwe. Development of a draft RHCS strategy began in June 2006, and a strategy is expected to be finalized by September 2006. An earlier draft version of this document was available for use in supporting the development of that strategy. The Assessment 1. client utilization and demand 1.1 Met NEED FOR CONTRACEPTION Over the past ten years in Malawi there has been a significant increase in the use of contraception, with a striking fourfold increase in the use of modern methods, from 7.4 percent in 1992 to 28.1 percent in 2004. Temporary re-supply methods (pills, IUD, injectables, implants, and male condoms) currently account for 22.4 percent of method use compared to 5.8 percent users of female sterilization. The most dramatic leap in contraceptive method use has been for injectables, growing from 1.5 percent (1992) to 18.0 percent (2004). The use of female sterilization has also increased significantly, from 1.7 percent (1992) to 5.8 percent (2004). Both injectables and female sterilization are the most significant contributors to the overall increase in the use of modern methods. Use of other temporary methods has remained relatively constant during this same time period. Table 1 below outlines past, current and projected future method use for married women. Table 1. Contraceptive prevalence by method 1992-2004, extrapolated to 2010 and 2020 PREVALENCE 1992 2000 2004 2010 2020 All methods 13.0% 30.6% 32.5% 41.6% 54.7% Modern methods 7.4% 26.1% 28.1% 36.2% 46.7% Pill 2.2% 2.7% 2.0% 2.0% 1.3% IUD 0.3% 0.1% 0.1% 0.0% 0.0% Injectables 1.5% 16.4% 18.0% 24.1% 32.1% Implants NA 0.1% 0.5% 0.9% 1.6% Condom 1.6% 1.6% 1.8% 2.0% 2.3% Female sterilization 1.7% 4.7% 5.8% 7.7% 10.8% Male sterilization 0.0% 0.1% N/A N/A N/A Married women. Source: DHS 1992, 2000, 2004. Future projections are based on straight line extrapolations from past trends, and not on programme targets, goals or objectives, or expectations of what is likely to occur in the future. Clearly, future trends do not necessarily follow the past. The figures for overall CPR may be reasonable with 41.6 percent by 2010 and 54.7 percent by 2020. However, the method mix will likely change; it does not seem realistic that pill use will continue to decline, or injectables continue to increase at their past rate. There are ongoing efforts to boost the use of IUDs, and prevalence of female sterilization is likely to level off. The population policy has a goal of reaching a total fertility rate of 4.9 by 2012. Based on this goal, CPR for modern methods will have to increase to around 40 percent by 2012 which is in line with current trends. Figure 2 below shows the trends in method mix from 1992 to 2004. Figure 2: CPR by method for married women, 1992 -2004 [image: image2.emf] Married women in urban areas are more likely to use modern contraceptive methods than rural women (34.7 percent to 26.9 percent). The predominance of contraceptive usage by urban women to rural women is also present when examining any contraceptive method (both traditional and modern), though not as significant (37.2 percent to 31.6 percent). Additionally, rural women are more likely to use traditional methods than urban women (5 percent to 3 percent respectively). Though a similar urban versus rural trend is found in both previous surveys (38 percent to 24 percent in 2000 and 23 percent to 12 percent in 1992), it is significant to note that the gap in modern method use has began to decline between the two groups, showing a decrease from 11.2 percent in 1992 to 7.8 percent in 2004. Current use of modern methods also increases with levels of education, jumping from 23.1 percent among married women with no education to 41.0 percent among married women who have at least some level of secondary education. Figure 3: CPR for modern methods, married women by wealth quintile, 1992 and 2004 [image: image3.emf] The wealthier you are, the more likely you are to use modern contraceptives in Malawi, with 21.8 percent prevalence in the lowest wealth quintile compared to 37.6 percent in the highest wealth quintile (Figure 3.) However, the gap between wealth quintiles is also closing. Prevalence for the wealthiest quintile has more than doubled from 17.2 percent in 1992 to 37.6 percent in 2004, while for the poorest quintile the increase over the same period has been more than five-fold, from 3.9 percent to 21.8 percent. The other wealth quintiles have seen similar growth to the poorest. In addition, there exists variations in modern contraceptive use by district, with Lilongwe and Blantyre showing the highest levels of modern contraceptive use (34.3 percent and 33.7 percent respectively), followed by Mzimba (27.8 percent), Thyolo (28.2 percent), and Zomba (28.2 percent), with the districts of Mangochi (17.1 percent) and Salima (19.6 percent) showing the lowest levels of modern contraceptive use. Regional characteristics are also available for 2000 and demonstrate similar trends, with the highest levels of modern contraceptive use found in Lilongwe and Blantyre (32.8 percent and 38.4 percent), and the lowest levels of modern contraceptive use in Mangochi and Salima (16.7 percent and 15.5 percent). Between 2000 and 2004, modern contraceptive use increased in most districts, with the highest increases occurring in Mzimba (6.2 percent) and Zomba (6.2 percent). However, Blantyre and Mulanje both showed slight decreases between the two years of 4.7 percent and 1.7 percent respectively. Table 2 below provides background characteristics of currently married women users where available. Table 2. Background Characteristics of Method Users PREVALENCE 1992 2000 2004 BY AGE Of current modern method users (7.4%) Of current modern method users (26.1%) Of current modern method users (28.1%) 15-19 0.4% 1.3% 1.6% 20-49 7.0% 24.8% 26.6% BY RESIDENCE Modern method (any method) Modern method (any method) Modern method (any method) Urban 17.2% (22.9%) 38.2% (41.2%) 34.7% (37.2%) Rural 6.0% (11.7%) 24.1% (28.9%) 26.9% (31.6%) BY EDUCATION No education 4.8% 21.7% 23.1% Primary (1-4) 6.0% 23.6% 25.5% Primary (5-8) 10.6% 29.5% 30.0% Secondary 37.9% 41.6% 41.0% BY WEALTH QUINTILE 1 Lowest 3.9% N/A 21.8% 2 Second 3.6% N/A 24.2% 3 Middle 5.6% N/A 25.2% 4 Fourth 6.9% N/A 31.1% 5 Highest 17.2% N/A 37.6% BY GEOGRAPHIC AREA (District) Blantyre N/A 38.4% 33.7% Kasungu N/A 26.3% 27.3% Machinga N/A 22.6% 23.8% Mangochi N/A 16.7% 17.1% Mzimba N/A 21.6% 27.8% Salima N/A 15.5% 19.6% Thyolo N/A 24.4% 28.2% Zomba N/A 22.0% 28.2% Lilongwe N/A 32.8% 34.3% Mulanje N/A 26.3% 24.6% Other districts N/A 24.9% 27.9% REGION Northern 6.9% 25.4% 28.7% Central 8.2% 27.2% 29.8% Southern 6.8% 25.3% 26.5% 1.2 UNMet NEED FOR CONTRACEPTION With the significant advances in the adoption of contraceptive methods, unmet need in Malawi has steadily been decreasing, from 36.3 percent in 1992 to 27.6 percent in 2004 though not as fast as use has been increasing. Of the total demand for contraception (current use plus unmet need), the percent of demand satisfied is only 55.2 percent. Though this represents a slight increase from 2000 (50.8 percent), and a significant increase since 1992 (26.4 percent), there still remains a significant demand that is not being satisfied. Table 3 below provides unmet need for currently married women, while Figure 4 shows graphically the total demand for FP for married women with CPR and unmet need. The scale of unmet need suggests that, provided availability and accessibility continue to improve, modern method contraceptive use will continue to grow for the foreseeable future. Figure 4: CPR and unmet need for married women, 1992 - 2004 [image: image4.emf] Table 3. Unmet Need for Family Planning for currently married women, 1992 -2004 UNMET NEED 1992 2000 2004 for spacing 19.8% 17.2% 17.2% for limiting 16.5% 12.5% 10.4% total 36.3% 29.7% 27.6% Background characteristics for unmet need are similar to those found among contraceptive users. Unmet need is greater among rural women than urban women (28.5 percent to 23.0 percent) with a similar differential found in 2000 (30.7 percent to 23.2 percent). Wealth quintile and education levels for unmet need produce similar effects to that seen among contraceptive users. As the wealth quintile increases, unmet need decreases, from 31.9 percent to 21.8 percent. This trend is also present among education levels, with unmet need of 29.7 percent for those with no education, decreasing to 23.8 percent for those with some level of secondary education. Table 4. Background Characteristics for Unmet Need UNMET NEED FOR FAMILY PLANNING 1992 2000 2004 BY RESIDENCE Total Unmet Need Total Unmet Need Total Unmet Need urban 35.8 23.2 23.0 rural 36.4 30.7 28.5 BY WEALTH QUINTILE 1 Lowest N/A N/A 31.9 2 Second N/A N/A 29.7 3 Middle N/A N/A 28.3 4 Fourth N/A N/A 27.3 5 Highest N/A N/A 21.8 BY EDUCATION No education 36.5 30.8 29.7 Primary 1-4 37.1 30.0 29.2 Primary 5-8 36.8 29.5 26.0 Secondary 25.0 24.3 23.8 BY AGE 15-19 26.5 28.8 26.1 20-24 32.1 31.6 29.9 25-29 36.5 30.2 28.7 30-34 37.0 32.7 28.7 35-39 42.2 31.0 31.7 40-44 43.5 26.0 24.1 45-49 39.8 19.8 12.8 Geographic differentials exist as well among districts, with the highest unmet need found in Mangochi (32.8 percent) and Salima (33.3 percent) and the lowest in Blantyre (21.2 percent) and Mzimba (21.8 percent). In 2000, Salima remained among the districts with the highest unmet need (34.7 percent) and Blantyre also remained among those districts with lowest unmet need (22.2 percent). Table 5. Geographic Characteristics for Unmet Need UNMET NEED FOR FAMILY PLANNING 1992 2000 2004 BY GEOGRAPHIC AREA (District) Blantyre N/A 22.2 21.2 Kasungu N/A 32.1 26.4 Machinga N/A 26.8 25.5 Mangochi N/A 23.8 32.8 Mzimba N/A 31.5 21.8 Salima N/A 34.7 33.3 Thyolo N/A 28.8 28.0 Zomba N/A 29.7 25.9 Lilongwe N/A 28.2 28.0 Mulanje N/A 28.2 28.9 Other districts N/A 32.6 29.1 REGION Northern 31.1 28.1 23.1 Central 37.2 32.6 30.3 Southern 37.0 27.5 26.6 Among currently married women who are not using a contraceptive method (non-users) but intend to adopt family planning in the future, both injectables and female sterilization account for the largest proportion of planned future contraceptive method of choice at 59.1 percent and 13.8 percent respectively (data not shown.) Other contraceptive methods chosen for future adoption include pills (10.9 percent), condoms (4.0 percent), implants (2.8 percent), IUDs (1.1 percent), male sterilization (0.2 percent), and other (5.1 percent.) 1.3 SERVICE ACCESS AND UTILIZATION Modern health care services in Malawi are obtained from either public, private non-profit, or private for-profit facilities. The modern health care system is also complemented by an extensive traditional health system, comprised of both traditional healers and traditional birth attendants. The public health system, through the MOH, remains the largest provider of health care services. Although 36 percent of contraceptive users discontinue use of their method within 12 months of starting, lack of access was not cited as a major reason. Reasons cited for discontinuation include (for all methods) method failure (3.3 percent), desire to become pregnant (8.4 percent), switched to another method (3.7 percent), or other reasons (20.3 percent). Among the different methods, the rate of discontinuation was highest among condom users (61.9 percent), followed by pills (52.3 percent), withdrawal method (40.1 percent), other methods (36.6 percent), and injectables (32.5 percent.) 1.4 SERVICES The number of facilities offering family planning services has increased dramatically, from 2 clinics in 1983, to 210 in 1995, to almost universal availability in 2006 (Solo 2005.) In addition to the increase in number of facilities offering family planning services, the expansion of offering FP services five days a week has also increased accessibility. While these factors have improved accessibility for those within reasonable distance to service delivery points, the rural population still faces greater access challenges. Only about 54 percent of the rural population has access (within a 5km radius) to formal health services compared to 84 percent of the urban population (Solo 2005.) A complimentary network of Community Based Distributing Agents (CBDAs) has helped to fill this gap for rural clients. 1.5 DEMAND While the above discussed elements address the supply side of reproductive health, equally important have been the widespread increase in reproductive health-related Information, Education and Communication (IEC) and Behavior Change Communication (BCC) efforts to increase the demand for contraceptives. According to the 2004 DHS, almost 97 percent of women know of at least one contraceptive method, and knowledge of a modern method of family planning among currently married women is 99 percent. Multiple channels of communication have been utilized, including radio, television, print media, local dramas and health talks. According to the 2004 DHS, 67 percent of women have heard a family planning message on the radio, 14 percent by newspaper or magazine, and 8 percent by television. In general, place of residence and level of education still have an effect on exposure of family planning messages through the media, with women in the Northern region more likely to have been exposed to each of the three types of media, and women with higher levels of education more likely to have been exposed to family planning messages through the media. 2. commodities 2.1 Methods Available There are currently nine major contraceptive methods available in Malawi. Short term methods include combination pills (also available as an emergency contraceptive method), progestin only pills, injectables, male condoms, and female condoms. The long term methods available are IUDs, implants, and female sterilization (permanent.) The brand of implant currently available, Norplant, is being phased out by its manufacturer to be replaced with a newer implant. Norplant is currently being procured by USAID for Malawi. USAID will shortly announce which implant it will procure as a replacement for Norplant but hopes to keep supplies available for a year or two as it transitions to the new product. Malawi hopes to be able to continue to procure Norplant through USAID until 2008, though this may not be possible. The newer implant available will likely be easier to insert and remove than Norplant and at least as safe and effective. Injectables are the most popular method in Malawi and Depo-Provera is by far the most widely used injectable. The only social marketing products available are male condoms although PSI hopes to introduce either an oral pill or injectable or both in the coming year. Also note that while most methods are available commercially, there are significant limitations for access to these products due to the limited number of outlets and prices charged. Table 6 below shows the methods and brands available by sector. Table 6. Methods available by sector with brands Method Public sector (includes CHAM) BLM Social Marketing Commercial Combination pills ( (LoFemenal) ( (LoFemenal) X ( (Microgynon, Femodene, Nordette) Emergency contraception ( (Postinor-2) ( X ( (Postinor-2, E-gen 2) Progestin only pills ( (Ovrette) ( (Ovrette) X ( (Femulen, Micronovum) Injectable ( (Depo-Provera, Petogen ) ( X ( (Depo-Provera) Male condoms ( (generic) ( (generic) ( (Chisango/PSI) Manyuchi/BLM) ( (various) Female condoms ( X X X Implants ( (Norplant) ( (Norplant) X X IUD ( (Copper-T) ( (Copper-T) X ( (Copper-T) Female Sterilization ( ( X ( (private hospitals) 2.2 Sources of Commodities Historically, the main providers of contraceptives have been DFID and USAID with smaller quantities coming from other donors like UNFPA. DFID were also a major funder for STI drugs. In the future, DFID funding will go through the MOH SWAp. Table 12 in the financing section shows the cost breakdown for contraceptive procurement for the public sector for 2006 through 2008. Of the approximately $18.3 million needed, about $15.6 million will be financed through the SWAp (85 percent) and about $2.7 million by USAID (15 percent.) This does not include some financing by UNFPA for female condoms for all sectors, PSI procurement of condoms financed by USAID or Banja La Mtsogolo (BLM) commodity requirements. The public sector dominates as the source of methods for clients (users), with its share remaining relatively constant at between 60 and 70 percent from 1992 to 2004 (Table 7.) Community-based distribution (CBD) has been cited as a major success story in Malawi and while its share of the market remains relatively small at 2.7 percent (combined public and private sector), it is important to note that CBD also plays a role in information dissemination and referrals. BLM, a Marie Stopes International (MSI) affiliate, is a major player with its share growing significantly since 1996 from 2.7 percent to 13.2 percent in 2004. Table 7. Sources of modern methods (all), 1992 -2004 Sector 1992 1996 2000 2004 Public sector 69.9 59.0 68.0 66.5 CBD 0 0.3 2.1 2.7 CHAM (Mission) N.D. N.D. 10.1 12.6 BLM N.A. 2.7 12.3 13.2 Private medical 22.3 28.7 5.1 4.2 Shop 5.5 6.7 3.7 3.1 Source: DHS 1992, 1996, 2000 and 2004. Private medical for 1992 and 1996 probably includes mission facilities. CBD figure includes both public and private Figure 5: Source of method by type [image: image5.emf] While BLM does have significant market share, it is predominantly for permanent methods. It has a 42.3 percent share of the market for female sterilization but only 5.3 percent for injections (by far the most popular method in Malawi) and 8.6 percent for pills. Note that in general, long term methods (IUDs and implants), are not popular in Malawi (see Table 1.) The private medical sector has a very small share of the overall market with 4.2 percent while pharmacies have zero percent. The share of the market for shops consists almost entirely of condoms: shops have 38.9 percent of the condom market; presumably social marketing condoms. Interestingly, the public sector has the lead market share for condoms at 45.4 percent. Figure 5 above shows the breakdown of source of method by method type. 2.3 Supply Situation There are serious problems with the availability of all essential drugs, including RH commodities, in health centers. Facilities have problems accurately estimating their demand, and when they order from the regional medical stores (RMS) they often receive less than they requested. A recent assessment (Sosolo 2006) revealed that for the three facilities analyzed, they received on average 37 percent of the supplies they ordered. All contraceptives, as part of the EHP commodity list (excepting implants and female condoms), are expected to be in full supply. The most recent evaluation of the stock situation in the public sector (including CHAM facilities), revealed some stockouts at facilities (Table 8.) The situation for Ovrette was particularly serious; however this was probably a reflection of the very low demand for this product. Injectables are by far the most popular product in Malawi with 18.0 percent prevalence for married women versus 2.0 percent for all pills. Of the figure for pills, only a small proportion will be for Ovrette, for women who are breastfeeding. Many facilities had expired Ovrette, and many had not re-ordered due to low demand even though the product was available at the RMS. Expiries of Ovrette were significant: over 41,000 cycles in 2005 which is over six months supply. Expiries of other products were not deemed significant. Table 8. Percentage of facilities stocked out day of visit and within previous six months Product Day of visit Within previous six months Rural, district hospital Health center, dispensary RMS Rural, district hospital Health center, dispensary RMS LoFemenal 0 2 0 11 11 0 Ovrette 44 40 0 53 24 0 Male condom 5 10 0 6 30 0 Depo-Provera/ Petogen 5 4 0 33 23 0 Norplant 8 0 0 9 0 33 Erythromycin 55 76 67 68 63 67 Ferrous sulfate 20 6 0 22 57 0 ORS 5 8 0 31 33 0 Determine (HIV) 17 11 67 84 60 67 Source: DELIVER 2006 logistics indicator assessment. Apart from Ovrette, the situation for the other contraceptives was much better. The next highest percentage of stockouts was for male condoms with between 5 and 10 percent of facilities stocked out on the day of visit, and between 6 and 30 percent experiencing a stockout within the previous six months. Clearly in a high HIV prevalence country, any stockouts for condoms are serious. For the most popular product by far – injectables - stockouts were between 5 and 4 percent on the day of visit and between 23 and 33 percent within the previous six months. With the exception of Ovrette, the stockouts both for day of visit and within the previous six months had decreased for all other contraceptives compared to 2004. For some STI drugs the situation was more serious with significant stockouts of erythromycin at all levels probably due to inaccurate forecasting and problems in procurement. The same could be said for Determine HIV test, the approved screening test for HIV in Malawi, which experienced significant stockouts over the previous six months at all levels. Meanwhile, Oral Rehydration Salts (ORS) and Ferrous sulfate, while stocked at the central level, both experienced significant stockouts at facilities indicating problems in the incountry supply chain. There are a number of possible reasons for these stockouts. Most providers have not been trained in logistics as the MOH only recently commenced training for providers (providers manage drugs at many facilities.) Many facility staff also claimed that they experienced delays in receiving supplies from the RMS. Facilities are supposed to maintain a minimum stock of one month’s supply so either they are not respecting this or delays in deliveries are a serious problem. There should be some evaluation of the RMS delivery schedule and performance to determine if this is a significant problem. Clearly, stockouts at the central level (RMS) were due to inaccurate forecasting and/or procurement problems or delays. The supply chain capacity section discusses supply chain issues in more detail. While stockouts are one of the most important indicators for a supply chain they are not the only one. The 2006 survey also shows average months of stock (MOS) on hand for various products. Facilities should maintain between one and three MOS. Hospitals had on average between five and six MOS of LoFemenal, Ovrette and Depo-Provera while health centers had nearly 20 MOS of LoFemenal, 32 MOS of Ovrette and 6 MOS of Depo-Provera. Overstocks were also higher for Norplant (21 MOS at hospitals) although this may be linked to undercounting of consumption (and hence an overestimation of MOS.) For male condoms there is little recording of consumption at the service delivery level. In general, overstocking had increased since 2004. For erythromycin and Determine HIV all levels had on average less than two MOS with many less than one MOS. The exceptions were health centers with on average almost six MOS of Determine HIV. All levels were overstocked for ORS and Ferrous sulfate: hospitals had almost 10 MOS of ORS while health centers had over 7 MOS. For Ferrous sulfate hospitals and health centers both had about 6 MOS on average. Note that average MOS figures conceal the fact the some facilities are understocked (or stocked out), some stocked correctly and some overstocked. Overstocking, especially in a situation where stockouts still occur, indicate incorrect ordering by facilities, is wasteful of resources and may lead to high levels of expired products in a system. Table 9: Average months of stock by type of facility for various commodities, 2006 Product Average Months of stock Rural, district hospital Health center, dispensary RMS LoFemenal 6.9 19.3 40.7 Ovrette 6.1 31.7 4.4 Male condom 16.9 N.D. 1.8 Depo-Provera/ Petogen 4.6 5.8 10.6 Norplant 21.3 3.2 6.8 Erythromycin 0.6 1.0 0.1 Ferrous sulfate 6.4 6 23.4 ORS 9.9 7.2 6.5 Determine (HIV) 1.7 5.9 0.1 2.4 Commodity requirements (forecast) Based on the 2006 forecast exercise, Table 10 below shows the estimated contraceptive commodity requirements for 2006 to 2008. Table 12 in the financial section shows the estimated financing needed based on these requirements. Commodity requirements are based on forecasted consumption, stock on hand, lead times, expected expiries (if any), and the necessity to maintain stock levels between preset minimum and maximum levels. The quantities therefore do not correspond exactly to expected annual consumption; hence the yearly variations. Table 10. Commodity requirements (units) 2006 -2008 Method 2006 2007 2008 Total LoFemenal 829,200 457,200 916,800 2,203,200 Ovrette 118,800 98,400 69,600 286,800 Depo-Provera 3,198,600 2,376,000 3,916,800 9,491,400 Copper-T 0 200 400 600 Norplant 8,728 8,680 5,822 23,230 Male condoms 34,437,000 25,445,000 35,860,000 95,742,000 Source: 2006 CPTs. Procurements either planned for 2006-2008 or already received. Total for male condoms includes public sector only Note that the table above includes only commodity requirements for the public sector including CHAM; it does not include the commodity needs for BLM or for PSI for male condoms. 2.5 Product Quality The National Drug Quality Control Laboratory (NDQCL) is responsible for quality control testing of incoming products. There are a number of issues related to the NDQCL that have been identified in the draft Malawi National Drug policy. Firstly, the statutory authority of the NDQCL seems unclear. Apparently the NDQCL has no mandate to enforce decisions based on the result of its analyses (what is not clear however is why this authority cannot be vested in the PMPB which in turn can subcontract out the actual physical testing to laboratories like the NDQCL.) Second, the capacity of the laboratory to do testing needs to be strengthened. This includes personnel, equipment and systems. An estimate has been made that the NDQCL is only able to carry out about 60 percent of the procedures needed due to lack of equipment, tests, expertise and finance (Sosolo 2006.) It is not clear to what extent the NDQCL currently samples and tests incoming essential drugs including contraceptives. The laboratory has no capacity to test condoms or other contraceptive devices such as implants and IUDs. There are current issues with product quality which serve to underline the weakness of the system in assuring product quality. Locally manufactured sulphadoxine-pyrimethamine, procured for the public sector, recently failed quality testing and PMPB issued a product recall. However, the product remained in the public sector supply chain; essentially the order to recall the product was ignored. Contraceptives procured by USAID are subject to USAID’s pre-shipping testing requirements, and USAID also has a contract laboratory available to do additional testing if the client requires it. BLM report having their own laboratory in their head office in Blantyre that does some quality control testing. 2.6 Product Registration The Pharmacy, Medicines and Poisons Board (PMPB), as established by the Pharmacy Medicines and Poisons Act of 1991, is the statutory body responsible for authorizing the marketing of drugs in Malawi. All drugs are required to be registered with the board. Generic products must demonstrate bioequivalence, and samples must be submitted to a laboratory for quality and bioequivalence testing and then for registration (Lewis-Lettington 2004.) While they also have a mandate to regulate devices, to date enforcement for devices has been weak. While the PMPB has done fast tracking of drug registration in the past - particularly for antiretrovirals (ARVs) – fast tracking is not legally recognized. The draft National Drug Policy (MOH 2005) recognizes a number of areas that need to be strengthened at the PMPB. The Pharmacy and Medicines Act, under which the PMPB operates, needs to be reviewed and revised, and the capacity of the PMPB itself needs to be strengthened. Shortages of experienced and trained staff to review registration dossiers and carry out plant inspections were identified as particular weaknesses. The Malawi National Essential Drugs list (NEDL) was last revised in 1998. The current list is not widely available or disseminated. The National Medicines and Supplies Committee (NMSC), charged with revising and updating the list, last met in 1998 although there are plans to revive it. The EHP medicines and supplies list appears to be used as a de-facto NEDL for planning purposes by the SWAp, although since an actual copy of the NEDL could not be obtained this assessment could not compare the two. The EHP list contains all the major contraceptives except for female condoms. All are listed as Category A items, in other words they will be routinely procured and stocked by the CMS. Implants (Norplant) are listed as Category B, indicating they will not be routinely procured or stocked by CMS and their availability is primarily the responsibility of the user facility (MOH 2004.) 2.7 Local Manufacturing Malawi has a small local pharmaceutical manufacturing base. There are three local manufacturers – Pharmanova and its sister company SADM, Malawi Pharmacies and Kentam Pharmacies - mostly producing finished drugs from imported active pharmaceutical ingredients (APIs) (Lewis-Lettington 2004). Production is almost entirely for the domestic market for commonly used essential drugs such as sulphadoxine-pyrimethamine for malaria. Production, research, and development capacity is extremely limited. The small size of the local market, the necessity to import most ingredients, expensive overheads, and the inability to obtain international registration or prequalification, all limit the viability of local manufacturing. Value-added tax (VAT) is charged on imported APIs at 17 percent and although this can be reimbursed, the process is cumbersome and not always successful. There are ongoing discussions on simplifying this process. There is no VAT charged on finished drugs. Local manufacturers do not currently produce contraceptives and given the complexities involved, in particular the requirements for handling hormones, are not expected to enter this field. 2.8 Donor Support Donor support is discussed in more detail in the section on financing. Briefly, most future donor support will be channeled through the SWAp. USAID will probably finance LoFemenal, Ovrette and implant procurement for the public sector through 2008. In addition, USAID is currently supporting condom procurement for PSI. UNFPA will likely to continue to support some small NGOs and some public sector sites for female condoms. 2.9 The commercial market The commercial market share for family planning in Malawi is very small. There are a number of likely reasons for this: low incomes, small market size, the limited number of private sector providers including pharmacies, a predominantly rural population, and the absence of subsidized social marketing products (apart from male condoms) to help develop a market. NHA data from 1998/1999 (MOH 2001) shows that revenues for the private-for-profit health sector were 10 percent of total expenditures for healthcare, showing a sizable existing market with growth potential in RH and family planning. Table 11 below shows some indicators for prevalence, market shares for contraceptives, and income levels for Malawi and various neighboring countries. Note that there is no data available for commercial market share for other RH commodities; apart from ORS socially-marketed by PSI, share for other commodities is likely to be as low as for contraceptives. The most striking data from the table is the low market share for the private sector in Malawi, 4.2 percent, less than half of that of the next lowest country, Mozambique, with 10.7 percent. The pharmacy share of zero is even more striking, with the next lowest country, neighboring Zambia, having a 5.7 percent share for private pharmacies. Previous government policies, which until a few years ago did not allow private medical practice, are probably a major reason for this. Clearly, income levels hamper development of the private sector and incomes in Malawi are among the lowest in the region though they are higher than in Tanzania which has a 15 percent share for the private sector with 10 percent for pharmacies. Apparently there have been no studies in Malawi on either the ability or willingness of Malawians to pay for contraceptives or other RH commodities. The number of pharmacists is also an issue, though here again while Malawi has one of the lowest pharmacist to population ratios in the region; it is lower still in Rwanda where the private medical share is 14 percent and that of pharmacies 5.9 percent. Note that Kenya and Uganda have both a social marketing pill and injection available, while Zambia has a pill . Table 11. Population, health and economic indicators for East and Southern African countries Indicator Malawi 2004 Kenya 2003 Rwanda 2005 Tanzania 2004 Mozambique 2003 Zambia 2002 Uganda 2002 Population, mid 2005 (millions) 12.3 33.8 8.7 36.5 19.4 11.2 26.9 CPR 28.1% 39.3% 10.3% 20.0% 20.8% 25.3% 18.2% Unmet need 29.7% 24.5% 37.9% 21.8% 18.4% 27.4% 34.6% GNI per capita (PPP), 2004 $830 $1,050 $1,300 $660 $1,160 $890 $1,520 Private medical share (contraceptives) 4.2% 29.3% 14.0% 15.1% 10.7% 15.5% 45.8% Pharmacy share (contraceptives) 0.0% 6.3% 5.9% 10.0% 7.2% 5.7% 7.1% Number of pharmacists per 100,000 people 0.322 5.0 0.133 1.006 2.346 0.80 0.50 CPR, unmet need, and market shares from DHS (year in brackets). Population data from UN. GNI data from World Bank. Pharmacist data from WHO. Pharmacy market share is included in private medical share. In conclusion, there is probably limited scope for a commercial private sector in Malawi for contraceptives, but there is certainly potential for the private sector share to grow over the next few years to a figure comparable to some of its neighbors, particularly if a subsidized product could be made available. As noted above, PSI is currently studying the possibility of introducing social marketing pills and/or injectables. While income levels and limited numbers of providers restrict viability, the overall size of the market is growing rapidly with increasing prevalence and growing numbers of women entering reproductive age. The development of a commercial market, targeting people from the highest income quintile, would reduce pressures on the public sector, where presumably, many of these clients are currently receiving supplies. MARKET SEGMENTATION Market segmentation refers to the divisions in a market, in this case who sells what contraceptives and other RH commodities to whom. In business it refers to a strategy that targets specific groups of customers based on specific needs, wants, or characteristics of those customers. There are no data available on how well segmented the market in Malawi is; in other words what are the profiles of clients who receive their products and services from the different sectors. That would require secondary analysis of DHS data to show distribution of clients by income level across the sectors. Such analysis would probably only be of value in profiling public sector and perhaps mission and BLM clients; the small sample sizes for other sectors would preclude statistically significant data from clients of those sectors. The last full NHA showed inequitable out-of-pocket payments for healthcare by the lower income quintiles, in other words lower-income people are paying a larger proportion of their incomes for healthcare; the corollary probably holds true, i.e., that wealthier income groups derive more benefit from public sector subsidies. BLM say they target low-income women. Due to the locations of their clinics in urban areas they probably target urban women most effectively. However many of their clinics are in small towns and so significant numbers of rural women will have access. PSI branded condoms target mostly males for disease prevention (including HIV/AIDS) and not specifically for family planning. 3. commitment 3.1 Public Sector The introduction of multi-party democracy in Malawi in 1994 led to a new commitment to family planning. While child-spacing had been an integral part of the MCH program from the 1980s, support had been at best lukewarm. The new political openness led to more intensive and focused programmatic efforts (Solo 2005.) The government demonstrated their support with the launch of a new population policy in 1994. Family planning was implemented as a vertical program with the newly formed Reproductive Health Unit (RHU) providing leadership at the MOH. District level family planning coordinators promoted family planning at the districts. Donor support was forthcoming, with DFID and USAID in particular, providing financial support for commodities. In addition, both provided technical support, with DFID providing management support to the RHU, and USAID technical support for strengthening the national supply chain. Malawi recorded impressive growth in CPR, from 7.4 percent in 1992 to 28.1 percent in 2004 (modern methods, women in union.) There have been suggestions that explicit support for family planning has been on the wane, and that the recent slowing in growth in CPR is a reflection of this. CPR only increased by two percent from 2000 to 2004, from 26.1 percent to 28.1 percent. Increasing emphasis on HIV/AIDS may be a factor in this. There is also a perception that particular emphasis on individual programmes may weaken commitment to overall health sector strengthening: the so-called “verticalization” of healthcare. There has been renewed focus on maternal mortality with a new road map to decrease maternal mortality (MOH 2005.) However family planning is not specifically noted as a component of the road map. In addition, the RHU is understaffed although this is a problem common to most of the health sector (Solo 2005.) While support for family planning remains strong at all levels of the government and among donors, its visibility has declined recently, and there is probably need for further advocacy to ensure that it continues to receive the attention it deserves. Reproductive health commodity security (RHCS) is a relatively new concept in Malawi which is receiving some support at the mid levels of the MOH. The RHU perceives it as an opportunity to strengthen family planning services while the CMS sees it as a means of strengthening the integrated supply chain. The public sector LMIS for contraceptives is seen as having been a success in Malawi, and has served as the starting point for implementing an integrated LMIS for all essential drugs. RHCS is thus perceived as a possible driver for other supply chain improvements for all commodities. 3.2 Advocacy There is little advocacy for family planning or RHCS by civil society in Malawi. BLM as the major non public sector provider of RH products and services is an important voice. The Family Planning Association of Malawi (FPAM), an International Planned Parenthood Federation (IPPF) affiliate, is also active. While there has been some recent reporting of initiatives in RHCS by some national newspapers, in general family planning or RHCS receive modest media attention. 3.3 Health Sector Reform and Development Assistance The Malawi Poverty Reduction Strategy Paper (PRSP), while not specifically mentioning family planning, does clearly support it. Maternal health is specifically addressed, and maternal and infant mortality are major indicators. The PRSP endorses the EHP approach as the key to providing comprehensive and sustainable health care and family planning, and contraceptive provision is integral to the EHP. The 2005 PRSP progress report (IMF 2005) specifically notes the recent increases in the number of family planning acceptors as a success. The major health sector reform initiatives in Malawi are the implementation of the SWAp and decentralization. As noted elsewhere, SWAp implementation is framed around the provision of an EHP, with family planning as a component, and an EHP priority commodity list that includes all the major contraceptives apart from female condoms. The SWAp does provide challenges particularly as the modalities are worked out. Contraceptives are actually in a stronger position than many other commodities due to the availability of reliable consumption data which in turn helps provide accurate forecasts of commodity needs that are used to plan procurements and budgets by the SWAp secretariat. There have been recent problems with the procurement of some contraceptives, for example Depo-Provera, due to delays in procuring directly linked to the operationalization of the SWAp and new procurement system. Fortunately USAID managed to step in to provide emergency procurement for Depo-Provera. The impact of decentralization on family planning and RHCS is harder to gauge. Malawi is devolving responsibility for the health service delivery to locally elected district assemblies. Direct budget allocations are being made to the districts. District health management teams (DHMTs) will be accountable to the District Assemblies for expenditures and for service quality. Districts are currently developing district implementation plans (DIPs) for health service delivery. While decentralization is advancing rapidly, the modalities are still being worked out and the operational implications are unknown. Districts have drug budgets and in theory, once their budget is exhausted, they will not be able to procure more commodities. Policy will continue to be developed at the central level and with the EHP as the cornerstone of healthcare policy, thus making family planning, in theory, secure. However, there may need to be some advocacy at the district level to ensure family planning and RHCS are fully supported. Family planning is for the most part integrated at the service delivery level. Family planning is offered at district and local facilities although there may be a separate “unit” in the facility where FP is offered. In some health centers there may be a medical assistant providing clinical care with a second staff member such as a nurse or midwife providing FP. There may be opportunities to strengthen integration of service delivery with specific vertical programs, particularly with HIV/AIDS programs. The contraceptive supply chain is for the most part integrated with storage, distribution, transport, and LMIS fully integrated. Forecasting is becoming more and more integrated with the annual forecast overseen by the Logistics Unit and DELIVER including contraceptives, STI drugs, many key essential drugs (but not all) and some consumables. Procurement will in the future be mainly integrated via the SWAp with USAID continuing to procure some contraceptives directly with its own financing. While there has been some discussion among policy makers of cost recovery for healthcare it is not yet on the policy agenda in Malawi. The EHP commodities and services are provided free of charge at public sector facilities. Currently CHAM facilities and BLM charge clients for products and services. The government has signed a Memorandum of Understanding (MoU) with both of these organizations to provide for reimbursements for maternal and child health services that are on the EHP including family planning. In addition, many districts have signed service agreements with the CHAM facilities in their districts – particularly where there is no alternative public sector facility – providing for reimbursement for the full EHP package services. Note that the health sector policy environment is changing rapidly and the above analysis is likely to be quickly out of date. 3.4 leadership for RHCS A case can be made for leadership for RHCS to come from two public sector structures. The Pharmacy Unit at HTSS is responsible for the public sector supply chain and all commodities, while the RHU is responsible for reproductive health service delivery. HTSS has taken responsibility for steering the RHCS strategic plan development and implementation, but RHU will need to work closely with them and will be responsible for overseeing many aspects of implementation. USAID and UNFPA have championed the initiation of the process, but clear leadership needs to come from the MOH. Leadership is needed to ensure the completion of the strategy and eventual implementation of the strategy, including coordination of activities. A second related issue is which multi-partner structure will be responsible for steering the RHCS process. It is envisaged that the Logistics Committee, which meets quarterly under the leadership of the HTSS to discuss general commodity issues, will take up this responsibility. The committee contains representatives of a number of groups, including: HTSS, RHU, CMS, USAID, UNFPA and CHAM. A second group has also been established to discuss general pharmaceutical commodity issues, the Drugs and Medical Supplies Task Force. This group meets as needed, and reports directly to the Principal Secretary (PS) at the MOH who usually chairs the meetings. This is a much higher profile group than the Logistics Committee and has real decision making authority. While stakeholders feel that this group would not be a suitable venue for day to day RHCS implementation, stronger coordination will be needed between both groups to ensure visibility and success for RHCS. 4. financing (capital) 4.1 GOVERNMENT, DONOR FUNDING The major source of future funding for RH commodities including contraceptives will be the MOH basket fund also known as the SWAp. Starting in 2005, major donors including the government, DFID, NORAD, UNFPA, UNICEF, and the World Bank, began to channel their support through the SWAp. While USAID is not actually putting their financing into the SWAp, their contributions in terms of commodities are counted for planning purposes. USAID funds procurement of LoFemenal, Ovrette and Norplant and is expected to support an alternative implant when production of Norplant ceases over the next year or so. USAID is expected to continue their commitment through 2007 and probably 2008 although since their funding is reviewed annually there can be no definite commitment. As for the SWAp, in theory since all contraceptives, apart from implants and female condoms, are part of the EHP commodity list, then they must be fully funded. However, the EHP will only be sustainable with donor support, and donor funding levels are based on estimates of the cost of implementing the EHP. If actual costs increase above budgeted levels, it is not known if donor support will also increase. USAID also supports procurement of condoms by PSI. BLM used to receive financing for commodities directly from DFID, but from now on will be expected to receive their supplies through SWAp financing. BLM are concerned with the modalities of this change in their financing mechanism. The table below shows the future projected financing needs for contraceptives for the public sector for 2006 through 2008. Note that the amount of funding from USAID was particularly high in 2006 as USAID funded emergency procurements of Depo-Provera and male condoms in this year. BLM requirements are not included as yet. Table 12. Financing required for public sector contraceptives, 2006-2008 Supplier 2006 2007 2008 Total MOH (SWAp) $3,180,452.28 $4,825,334.77 $7,609,845.71 $15,615,632.76 USAID $1,913,171.90 $372,355.38 $410,977.82 $2,696,505.1 Total $5,093624.18 $5,197,690.15 $8,020,823.53 $18,312,137.86 Source: 2006 CPTs. Note amounts are based on the procurement plan and so do not reflect exactly actual annual consumption. Costs include an estimate for freight. 4.2 HOUSEHOLD FUNDING There is little data available on household out-of-pocket spending on contraceptives, family planning or reproductive healthcare. The last full National Health Accounts (NHA) analysis was in 1998/1999 and did not break down expenditures by type of health care received (e.g. reproductive health.) Total expenditures for all health care however, indicates a high percentage of out-of-pocket financing – 26 percent – in spite of free health care, including drugs, in the public sector. This spending is distributed inequitably across the income quintiles, with the bottom three income quintiles (corresponding roughly to the approximately 65 percent of Malawians estimated to be living in poverty) spending 51.8 percent, and the top two quintile spending only 48.2 percent. The poorest quintile spends 15.4 percent and the richest 20.4 percent (MOH 2001). This suggests poor targeting of public sector subsidies. Rural Malawians spend slightly more per capita than their urban counterparts, and females spend more than males. Most spending is on out-patient services, mainly for the purchase of drugs, despite free drugs being available in the public sector. While there has been no complete NHA analysis since 1999, net out-of-pocket expenditure as a percent of total health expenditures have remained relatively unchanged in the interim; in 2004 it stood at 27 percent (WHO.) The experience of BLM with cost recovery points to the potential limits of cost recovery from households as a financing mechanism. BLM eliminated subsidies in 2000 and saw their family planning client numbers drop from 174,548 in 1999 to 94,257 in 2001. Donor support from DFID allowed them to reintroduce subsidies in 2002, and client numbers increased to 136,373 in that year, and then tripled (helped by more outreach) to 349,823 in 2003 (Solo 2005.) BLM currently provides subsidized products and services. They charge KW 30 for a pack of three Manyuchi social marketing condoms and also sell generic unbranded condoms at KW 1 per piece at their clinics. PSI retail Chisango condoms at KW 20 for a pack of three. 4.3 THIRD PARTY FINANCING There is no national health insurance scheme or employer-mandated health insurance in Malawi. The main private health insurance company is the Medical Aid Society of Malawi (MASM), which in 1998 had a membership of 22,000. Since then a number of other private insurance companies, notably OMED and Prosperity Health, have commenced business. Expenditure on private health insurance as a percentage of total private healthcare expenditure has remained relatively unchanged from 1998 to 2004 at less than 2 percent (1.6 percent in 2004.) MASM does not cover family planning services. Low income levels and the small numbers of the population formally employed restrict the size of the private medical insurance sector. The absence of cost recovery in the public sector has probably been a factor in the absence of any major community based financing schemes in Malawi. There are believed to be a number of drug revolving funds in operation (e.g. in Machinga district) although it is hard to say how widespread these are and what their future will be. If the supply problems continue at the CMS then these types of alternative financing mechanisms may remain as facilities seek alternative sources of supply as the current financing mechanism from the central MOH does not allow them alternative procurement. 5. supply chain capacity 5.1 FORECASTING Forecasts for contraceptives, as well as for STI drugs and some essential drugs, are prepared annually and are based on consumption data provided by the integrated LMIS. Forecasts are coordinated by the Pharmacy Unit at HTSS with technical assistance from USAID’s DELIVER project. Forecasts take place some time during the second quarter of the GOM financial year (usually around January.) Participants in the 2006 forecast included representatives from the CMS, the three RMS, the RHU, the Pharmacy Unit at HTSS, and the TB unit. Forecasts are usually prepared for a period of three years and are fully costed based on the best price information available. Consumption data is adjusted for non-reporting and also for any stockouts that may have occurred. Growth factors to account for program growth are used to adjust the forecast (growth for the 2006 forecast was 5 percent for most commodities.) The costed procurement quantities, based on adjusting the forecast for stock on hand, stock on order, quantities expected to expire before use etc., are provided to the SWAp secretariat for budgeting purposes. The reliability of contraceptive forecasts has been such that the process has been gradually extended to a range of commodities including, at the last such exercise held in January 2006, STI drugs, other select essential drugs, and medical supplies. The main issues around forecasting are questions concerning the quality of the consumption data being reported, lack of participation of program staff in forecasting exercises, absence of realistic expectations of likely increases in consumption due to programmatic factors, and the delays in transforming forecasts into procurement plans. This latter point is currently a major problem; the current forecast is six months old and the procurement plan still has not been implemented meaning that the forecast probably needs to be updated and the procurement plan modified. 5.2 PROCUREMENT The Logistics Unit at the HTSS is responsible for utilizing the forecast to prepare a procurement plan. Procurement planning takes into account the forecast, the quantities of products on hand, expiries, lead times and requirements for safety stock. The Logistics Unit provides the procurement plan to the Planning Unit at the MOH for approval and the approved plan is passed to CMS for execution. The Logistics Unit also ensures coordination on procurement between the Procurement Unit, USAID and other donors who may be procuring directly. The Logistics Unit also monitors deliveries, changes in expected lead times, consumption, and stock levels for commodities on an ongoing basis to ensure continuous availability. Procurement for all drugs is limited to pre-qualified suppliers and to drugs on the national EDL. Malawi follows International Competitive Bidding (ICB) procedures, although there are procedures in place for emergency procurements. There is a current requirement for 15 percent of tenders to be awarded locally although this may be reviewed. Products need to be registered before they can be ordered (but not before tendering.) Samples are required from suppliers for quality testing before shipping. Procurement capacity at the CMS is limited. There is only two full time staff members involved in procurement. As of July 2006, the 2006/2007 procurement plan had not been implemented despite the fact that the forecast had been prepared in January. The CMS explained the delay as being due to the necessity to prequalify suppliers; it is not clear to other partners how these two things are linked. Availability of RH commodities and other essential drugs at the central level have been linked to two major issues: firstly, unreliable forecasts, mainly due to the non-availability of consumption data or the reliability of the data itself, and second, delays in developing and executing procurement plans. In addition to this, procurement lead times are expected to be long, much longer than with direct procurement by donors: for example lead times for DFID using Charles Kendall as a procurement were about 12 weeks whereas in the future with MOH procurement following World Bank standards, cycle times are expected to be 12 months or more. ICB procedures are onerous and time consuming. Already the impact of the transition has been seen with procurement delays leading to USAID stepping in to procure Depo-Provera and male condoms on a one off basis in 2006 to assure supplies. 5.3 INVENTORY CONTROL There are essentially two levels in the Malawi essential drug supply chain. The CMS receives all supplies but operates only as a cross docking facility, storing products only for a very short period of time. They are quickly distributed to the three RMS – North, South and Central. Products are allocated to the three RMS based on preset levels: South gets 45 percent, Central 35 percent and North 20 percent. This allocation system is consistent for all supplies, and is somewhat arbitrarily based on population and not on current consumption levels. While in theory RMS could transfer supplies between themselves to even out the pipeline (balance overstocks and understocks), since there is little routine sharing of data between RMS this rarely happens in practice and usually only when stockouts have already occurred. The RMS distribute drugs directly to facilities based on a pull system, with facilities estimating their quantities of drugs to order based on consumption and stock on hand. Facilities are expected order sufficient product to give themselves three months of stock, though since rationing is widespread this may be difficult to do. Figure 6: Movement of health commodities and information in public health sector There are pre-established stock levels at the RMS and facilities; for the RMS, contraceptives are stocked at a minimum of 10 months of stock (MOS) and a maximum of 18 MOS. For facilities the minimum is one MOS and the maximum is three MOS. Clearly not all facilities respect these preset maximum and minimum levels and there are provisions for emergency orders. Almost 14 percent of facilities had placed emergency orders for contraceptives over the past three months. This high level indicates a problem in stock management or supply. There is a first-expiry first-out (FEFO) policy for distribution or consumption, but application of this is uneven particularly at RMS; there is no automated inventory control system which makes this difficult to apply at the RMS. While there is a system for tracking losses and adjustments (space on forms), program managers report that few staff actually record the information. 5.4 TRANSPORT, STORAGE AND DISTRIBUTION The CMS/RMS has vehicles to ensure delivery of products to the facilities. There is a preset delivery schedule, with the RMS delivering to facilities on a monthly basis. Facilities report delays in receiving deliveries but there is no tracking of data by the CMS or RMS regarding on time delivery to confirm if this is a real problem; the RMS attribute the problem to delays in receiving orders. Facilities also complain of an absence of standardized delivery dockets; usually delivery notes do not allow comparison between what was ordered and what was received. In general, managers report that vehicles are adequate for the task on hand. Some form of vehicle tracking to monitor delivery would be desirable. There are serious storage limitations particularly at the RMS. Storage space is either limited, or if the space is adequate, there is insufficient racking and materials handling equipment like forklifts. Storage space at many facilities is also limited. The 2006 logistics survey revealed that the percentage of health centers with unacceptable storage conditions had increased from 5 percent in 2004, to 44 percent in 2006 although the percentage of hospitals with unacceptable storage conditions had decreased from 35 percent to 25 percent (DELIVER 2006.) While there are procedures in place for the handling, storage, and destruction of expired or damaged products, they are cumbersome and not disseminated to facilities or districts. In practice, facilities treat expired and damaged products on an ad hoc basis, and many districts report significant build up of unusable products (damaged or expired), some going back over several years, awaiting destruction. 5.5 LOGISTICS MANAGEMENT INFORMATION SYSTEM There is an LMIS system for contraceptives and STI drugs that has been extended to all essential drugs. The system works reasonably well from the facilities to the districts. Facilities report monthly to districts with their monthly order form acting as a monthly logistics report. The districts have received computers and Supply Chain Manager software to automate the compiling and reporting of the orders from the facilities in their district to the RMS. Districts verify the facility orders and pass them on to their respective RMS. Where the system breaks down is at the RMS and CMS level. Neither the CMS nor any of the RMS has any system for compiling district reports to obtain aggregates of consumption at facilities. The RMS do not compile the district data into aggregate reports, and they do not report at all to the CMS. In other words the LMIS stops at the RMS. They supply the quantities ordered by the facilities (if available) but do not use the information to estimate their own reorder quantities. The CMS is hoping to introduce an automated stock control system but it is not known when this will be operational. On time reporting rates for facilities to the districts are estimated at around 94 percent, while for districts to the RMS they are estimated at around 90 percent. Understaffing at facilities and districts, resulting in too high a workload, are the reasons most often cited for non or late reporting. Though the LMIS system provides the data that are needed to make decisions regarding resupply quantities (which is compiled at districts and reported to RMS who uses the information to supply facilities), there is no reporting to the CMS. The data is not aggregated nor used to calculate resupply quantities for the CMS. Pipeline monitoring by the Logistics Unit and DELIVER for contraceptives, STI drugs and some essential drugs, ensures that aggregated consumption data is available for annual forecasts. These data are provided to the CMS who participate in the forecasting exercises. This oversight by the Logistics Unit and DELIVER does not replace the need for the CMS to take the prime responsibility in this area. Currently the CMS is totally dependent on the data that is provided to them by the Logistics Unit from Supply Chain Manager reports. They do not obtain their own data. The Logistics Unit is understaffed, and the DELIVER project provides temporary technical assistance to the unit. In the event of DELIVER assistance ending, there may not yet be capacity at the MOH continue to provide this data to the CMS. 5.6 Monitoring and EvAlauation Contraceptives receive special attention in the supply chain mainly due to oversight by the DELIVER project staff attached to the Logistics Unit at the MOH. Logistics indicators surveys have been carried out in 1998, 2000, 2002, 2004, and most recently in 2006, to monitor the supply chain. The surveys have been expanded from just contraceptives to include STI drugs, some other MCH commodities and most recently, HIV test kits. Routine monitoring and evaluation (M&E), consists of review of quarterly LMIS reports from districts, quarterly logistics meetings, monthly reviews of the stock situation at the RMS, and reconciliation of RMS stock status reports with LMIS reports. This M&E is assured by the Logistics Unit; the CMS takes little responsibility in this area. According to the recent logistics indicators survey, there has been a decrease in the percentage of health centers receiving supervisory visits that included drug management within the previous six months, decreasing from 80 percent to 68 percent, although for hospitals the figures had improved from 65 percent to 75 percent. Of greater concern is the percentage that reported never having received a supervisory visit; this increased from 15 percent in 2004 to 20 percent in 2006, although again for hospitals there was a significant improvement from 29 percent in 2004 to 5 percent in 2006 (DELIVER 2006). 5.7 human resources In most health facilities, drugs are managed not by pharmacy staff but by medical personnel. At virtually all health centers, nurses or medical assistants manage the drug supply including the logistics function. At hospitals the situation is more varied. According to MOH policy, drugs should be managed by pharmacy technicians at the hospitals (the position of pharmacy assistant is being phased out to be replaced by technicians). In the northern region, 57 percent of hospitals are managed by pharmacy technicians, in the southern region the figure is 83 percent, while in the central region it is only 14 percent. While the northern and southern regions have shown an increase for this indicator, in the central region it has declined from 50 percent in 2004. The 2003 Human Resource Strategy identified a shortage of staff at all levels including pharmacy staff. In 2003, there were only three pharmacists and eighty-six pharmacy related staff employed in the public sector (Hornby 2003.) The plan sets ambitious targets to increase medical staff at all levels with an estimated 37 pharmacists and 267 pharmacy related staff needed by the public sector by 2013 (the total need for the country was estimated at 47 pharmacists and 454 pharmacy related staff.) In addition, since medical providers are responsible for logistics function at health centers, these will require training in supply chain management. Obviously, human resources is a major challenge for the entire health system in Malawi, and not just for the supply chain or indeed drug management overall. The ability of the health sector to implement the EHP is dependent on training, hiring, and retaining adequate staff. The ability of the supply chain to support the EHP to ensure availability of contraceptives and all essential drugs is dependent on adequate numbers of pharmacy and health staff at all levels, trained in supply chain management. Current training efforts are focused on providing logistics training to medical assistants from the health facilities. However, in some instances there are separate FP providers – nurses and midwives – at facilities who manage contraceptives, and who are not receiving logistics training. Ideally, all providers at health facilities who manage commodities should receive training. A cadre of 10 trainers has been established across the country that will be responsible for leading future training in the integrated logistics system. 6. service delivery capacity The health care system throughout Malawi has a mix of public and private facilities as well as a network of traditional medicine practitioners. Approximately 68 percent of all health care workers are employed in the public sector. Despite remarkable improvements over the past decade in terms of an increased contraceptive prevalence rate and greater accessibility to family planning services, Malawi still faces severe constraints in the area of service provider capacity that have the potential to significantly hamper future growth. Service provider capacity is affected primarily by two elements: staffing levels and technical capacity. A third factor, the availability of FP services in facilities is difficult to assess: there is little new data on service availability. Some CHAM facilities do not offer FP due to ethical issues; it is not known how many. The 29 BLM facilities nationwide, typically located in urban areas and small towns are a valuable complement to the public sector. We were unable to obtain data on the number of private sector pharmacies, doctors clinics that offer RH services, or other drug outlets. 6.1 SERVICE PROVIDER STAFFING LEVELS The ratio of health worker to population in Malawi is relatively low, at 1:587 (Hornby 2003.) According to the Ministry of Health, there are fewer than 100 doctors and 400 registered nurses in the public health care system (Solo 2005.) Estimates from 2002 place approximately 20 medical specialists, 70 medical officers and 4500-5000 health surveillance assistants in the MOH system, and 2001 estimates claim 323 clinical officers, 350 medical assistants, 374 registered nurses and 1,268 enrolled nurse midwives deployed (Hornby 2003.) These levels indicate there is approximately one physician for every 90,000 – 100,000 people. Rural facilities are particularly prone to understaffing constraints. Understaffing is not a challenge for the public sector alone. The CHAM network for example reports that only 33 percent of its clinical (nursing) positions are filled and only approximately 50 percent of its medical posts filled (Solo 2005.) Even if these positions are filled to full capacity, the client-provider ratio would still be low. These severe shortages in health care personnel at both the public and private levels place strains on both availability and quality of health services provided to clients. The MOH has already begun taking steps to address the importance of the staffing levels situation through the implementation of the Emergency Human Resources Program. Recent achievements have included implementing 52 percent salary top-ups, increasing the intake to training schools, deploying volunteer specialist doctors and nurse tutors, and the development of a non-monetary incentive package for health workers to encourage greater deployment to more remote rural locations (MOH 2006.) However, adequate staffing levels are required within the MOH itself as well as more effective mechanisms to better coordinate human resource deployment. Exacerbating problems with provider staffing levels are the continuous loss of skilled personnel due to emigration, movement of personnel from the public to private sectors, and death and disability, primarily the result of the AIDS epidemic. As time is required in order to build an appropriate level of trained and skilled personnel, understaffing in all facilities will continue to be a challenge in the near future. 6.2 SERVICE PROVIDER TECHNICAL CAPACITY One notable feature regarding the skill set of providers in Malawi is the deficiency in the middle technical grades in terms of the mix of skills. There is a low skilled to unskilled mix among staff capacity, with 42 percent of the workforce falling in the unskilled support staff category and 74 percent in the unskilled and semi-skilled category. During the past decade, intensive efforts have been placed on training to ensure health care providers receive up-to-date information in the provision of family planning services. This effort has included both pre-service and in-service training efforts to ensure needed knowledge and skills with respect to method provision, infection prevention, side effects management, counseling and supervision are up-to-date (Solo 2005.) Training efforts have also included whole-site sensitization to family planning for anyone working at a health facility in order to encourage a receptive whole-site environment to family planning as well as to curb the spread of misinformation. Despite the these efforts, training is still lacking in terms of both quantity of training offered as well as content issues, and often weak in practical application of skills for participants. It is also an intensive effort that requires a continuous input of resources and systematic training efforts to ensure the maintenance of skilled personnel levels. Retention of trained personnel is further threatened by the same elements that threaten staffing levels, in particular emigration, movements from the public to the private sector and loss of skilled personnel due to death and disability, primarily by the AIDS epidemic. JHPIEGO is currently planning to improve training levels of staff particularly for long term family planning methods. 7. cOORDINATION At the service delivery level, the major partners for family planning and RHCS are: the MOH (represented by the RHU, the SWAp secretariat, the Procurement Unit and the Pharmacy unit at HTSS), CHAM, BLM, and PSI. Other partners include FPAM, and the Pharmacists Association as well as the midwives association. Major bilateral donors include DFID and USAID. Multilateral partners include UNFPA, World Bank and WHO. Technical agencies involved in providing support to the family planning program include DELIVER (USAID), providing support to the HTSS for supply chain functions; Management Science for Health (MSH), supporting drug management in a number of districts; Liverpool Associates for Tropical Health (LATH), providing support for service delivery to the RHU; and JHPIEGO, providing technical assistance for improving service delivery particularly for long term methods such as the IUD. There are a number of structures that coordinate general drug commodity issues. There is a Logistics Committee that brings together the MOH, various donors and technical partners. Membership includes the Planning Unit, RHU, CMS, BLM and DELIVER, USAID, TB programme. However, the group has a mandate to deal with logistics issues for all drugs, and so contraceptives and other RH commodities are only a small component of their work. The group meets quarterly and is chaired by HTSS. A second group that deals with logistics issues is the Drugs and Medical Supplies Technical Working Group (TWG). This group is chaired by the PS at the MOH, and brings together the Planning Unit and the Pharmacy Units at the MOH, the RHU, CHAM, the CMS, and various donors such as the World Bank and UNICEF. This group meets on an as-needed basis, and since it is chaired by the PS, tends to be a decision making body. A third group, the Reproductive Health TWG, under the RHU, is expected to commence meetings in the near future. This group will be mainly responsible for coordinating technical issues for RH. The intention of stakeholders is that the Logistics Committee will be the main coordinating group for RHCS. Recent initiatives to boost RHCS include an advocacy workshop held in November 2005, and in addition Malawi participated in a regional workshop in October 2005 organized by DELIVER and held in Tanzania. As a result of those two activities, there is currently some impetus to develop an RHCS strategy. HTSS, USAID and UNFPA hope to develop a draft RHCS strategy in June 2006, which this assessment is intended to support. A committee drawn from Malawian participants at the Tanzania regional workshop was formed to work on RHCS issues but it is not clear how active this group has been. The annual forecasting and procurement planning exercise facilitated by DELIVER on behalf of HTSS and USAID provides an opportunity for partners to meet to discuss future commodity issues particularly related to financing and procurement. The SWAp secretariat at the MOH will probably become a key coordinating body. Vertical programs, districts, and central bodies like the CMS are supposed to provide the SWAp with forecasts and consumption data to help in budgeting and procurement decisions. The Pharmacy Unit at HTSS, with help from DELIVER, will continue to provide this data, along with USAID planned procurements for contraceptives. 8. CONTEXT: POLICIES AND REGULATIONS Malawi has undertaken a consistent political and programmatic commitment to family planning. This has been demonstrated through the establishment of several key strategies and policies that have encouraged the establishment and implementation of family planning-related programs. NATIONAL POPULATION POLICY (1994) A national population policy was developed and adopted in 1994 in order to achieve a reduction in the growth rate that would be compatible with the attainment of social and economic goals. Through the establishment of this policy, the government of Malawi has recognized that one of the keys to reducing poverty levels, addressing resource constraints and ensuring increasing standards of health and living among the population has been a controlled population growth rate, achievable through the implementation of programs that specifically address reproductive health and contraceptive availability and use. Policy strategies include ensuring an appropriate infrastructure for the implementation of the population program, provision of family planning services, and mounting mass awareness campaigns regarding population, environment, development and poverty. Successful increases in contraceptive use are due in part to a favourable reproductive health policy environment. NATIONAL REPRODUCTIVE HEALTH POLICY (2002) First disseminated in 2002, the Reproductive Health Policy supports comprehensive reproductive health care. It is considered an integral part of the national development policy and identifies reproductive health as a major component of Malawi’s poverty reduction plan. The Family Planning Policy and Guidelines, which were adopted in 1992, were reviewed and revised in 1996. Revisions included liberalizing family planning services to open them to all groups who may require them; removing limitations on use of family planning methods based on parity, age and marital status; and promoting new approaches for accessing and expanding family planning services. Reducing policy restrictions has helped to increase access to contraceptives. NATIONAL CONDOM STRATEGY (2005) Though directed toward decreasing a high estimated HIV prevalence of approximately 14 percent, the National Condom Strategy, drafted in 2005, has direct implications on reproductive health behaviors and accessibility. Promoting safer sex behaviors among the sexually active population has been a challenge, particularly in the context of harmful cultural beliefs and practices, stigma, misconceptions, access and gender-related inequalities. The strategy creates a cohesive policy to address condom-related financing, procurement, delivery, coordination, monitoring, and utilization issues in an effort to “improve access to quality condoms at affordable process through an effective and efficient delivery system” (MOHP 2005.) The multi-sectoral approach specifically addresses condom promotion and demand creation; supply and distribution of condoms; condom quality control; and financing for condoms. Both the public and private health sectors currently distribute condoms through Malawi’s expansive health care network at service delivery points, health facilities, CBDAs and other mechanisms. NATIONAL HIV/AIDS POLICY (2003) Though not directly addressing reproductive health, the National HIV/AIDS Policy, adopted in 2003, does address one of the critical areas that cripples the health service industry as a whole: preventing death and disability of qualified staff due to AIDS. The goals of the policy are, “(1) to prevent the further spread of HIV infection; and (2) to mitigate the impact of HIV/AIDS on the socioeconomic status of individuals, families, communities and the nation” (NAC 2003.) The policy enumerates several approaches, including promoting HIV/AIDS prevention, treatment, care and support; and responding to HIV/AIDS in the workplace. As noted above the policy makes no direct mention of HIV/AIDS, not even in the context of Prevention of Mother to Child Transmission (PMTCT) of HIV and the potential role that provision of family planning plays in that programme. NATIONAL GenDER POLICY (2000) Recognizing that sustainable economic and social development in Malawi requires equal and full participation for both males and females, the Government of Malawi developed and adopted a National Gender Policy in 2000. The goal of the policy is “to mainstream gender in the national development process to enhance participation of women and men, girls and boys for sustainable and equitable development for poverty eradication” (Ministry of Gender, Child Welfare and Community Services). Reproductive health is identified as one of the priority areas and advocates for equal access to reproductive health and other health education programs, developing strategies to create greater gender awareness among policymakers, intensifying IEC services for reproductive health at the community level and on human sexuality/reproductive rights as well as encouraging the provision of equal management and training opportunities and promoting increased access to RH health services. 9. CONTEXT: DEMOGRAPHIC, HEALTH AND DEVELOPMENT INDICATORS While Malawi has made several positive strides with regard to key health indicators over the past decade, there are several indicator trends worthy of particular note. The Total Fertility Rate (TFR) for example, is a significant indicator regarding the impact of population programs on reproductive behavior. Though exhibiting a decreasing trend, it had not dropped significantly in the 2004 DHS, and still remains one of the highest fertility rates in Sub-Saharan Africa. The average age at first marriage, a proximate determinant to fertility, has not changed significantly over the past decade either. Eighteen years still remains the average age for women and 23 years remains the average age for men. A younger age at first marriage can be an indicator of greater lifetime reproductive risk for women. A similar trend is found with the average age of first delivery. While increasing slightly between 1992 and 2000, the average age actually drops slightly in 2004, from 19.3 years to 19.0 years. Like average age at marriage for women, average age of delivery of first child is also a proximate determinant for lifetime reproductive risk. Table 12: Selected demographic, health and development indicators for Malawi Indicator 1987 2000 2004 Total Population 7,988,507 9,933,868 (1998) 13,013,926 Percent of Population Urban 11% 14% (1998) 14% Percent of Population Rural 89% 86% (1998) 86% Population Growth Rate 3.2% 2.4% Number of Women of Reproductive Age (15-64) 3,530,920 3,332,907 -- % Literate 62.7% -- % Not Literate 37.3% Total Fertility Rate (TFR) 6.7 6.3 6.0 HIV Prevalence 14.6 (2001) 14.0 (2005) Infant Mortality 151 99.6 Maternal Mortality (per 100,000 live births) 620 (1992) 1,800 Average age at marriage for women and men 18 years women; 24 years men (1992) 18 years women; 23 years men 18 years women; 23 years men Average age at delivery of first child 18.9 years (1992) 19.3 years 19.0 years CONCLUSIONS Malawi’s success in increasing contraceptive prevalence has paradoxically presented it with a major challenge in ensuring RHCS. Unmet need remains high despite the near four-fold increase in CPR since 1992, as well as population growth, meaning demand for contraceptives and other RH commodities will continue to grow over the short and medium term at least. The other major challenge is to make sure that available commodities are efficiently and effectively made available to clients. There are major deficiencies in the incountry supply chain which this assessment has highlighted. Forecasts are not always reliable due to a lack of reliable consumption data. There are significant delays in executing procurement plans and procurement capacity at the CMS is weak. Cycle times for procurement are very long and it is not clear how current stock outs for vital drugs can be dealt with. The existing LMIS system needs to be strengthened, and a compatible system implemented at the RMS level. Staff at all levels of the system need to be trained in using the LMIS to ensure they are accurately recording their consumption and ordering the correct amounts of commodities. CMS delivery schedules need to be reviewed and monitored. Storage capacity and conditions at all levels need to be improved but particularly at the RMS. Donors need to review their financial commitments to ensure that budgets are adequate for RH and other drugs. Current contributions were based on budget estimates that have to be validated in practice; if they prove to be insufficient then the SWAp may be under-funded, although this remains to be seen. Malawi’s success in increasing CPR and improving commodity security were borne of strong leadership and commitment to FP and that commitment remains; the challenge is to ensure that in an environment of new challenges, and complex health sector reform, that policy makers remain aware of the importance to continue to support FP and RH. There are many opportunities to improve RHCS in Malawi. The various ongoing health sector reforms, particularly the introduction of the SWAp and decentralization, will potentially strengthen all aspects of healthcare delivery. There is donor support for overall health spending in Malawi. Increased funding for HIV/AIDS offers opportunities to strengthen overall systems. The supply chain has been identified as a particular area that needs strengthening, and already management consultants have been engaged to work with the CMS. This assessment was prepared to help guide the development of a strategic plan for RHCS for Malawi. That plan is now being finalized. Data Gaps In order to help the RHCS process, this assessment also has the objective of identifying where information gaps exist. The hope would be that future RHCS activities, including assessments, may address some of these gaps depending on what the priorities of the RHCS strategy are. Among the gaps identified were: Facility data for service delivery. Though a facility survey was completed by JICA in 2002, it is not widely available. There is no data available on the ability or the willingness of clients to pay for contraceptives or other RH products and services. Without this data, it is difficult for policy makers or program managers to set prices or to discuss the potential of cost recovery to enhance program sustainability. There is no information on how the market in Malawi is segmented that would illustrate what is the profile of users for each sector. A well segmented market would have a commercial sector serving clients who can pay, a subsidized NGO sector serving clients who can pay a little, and a free or heavily subsidized public sector for those who cannot afford to pay. Without information on the current situation, it is difficult to make recommendations to improve the market. Secondary analysis of DHS data could provide useful information. While there is some logistics information on other RH commodities from the 2006 stock status assessment (DELIVER 2006), in general, there is less information on other RH commodities than for contraceptives. Future evaluations could focus more on these commodities. References 2002 Malawi Poverty Reduction Strategy Paper. Final draft. Available at Accessed on August 22nd, 2006 DELIVER. 2006. Malawi Logistics System Assessment and Stock Status Report, 2006. Draft Hare, L., Hart, C. Scribner, S., Shepherd, C., Pandit, T. (ed.) and Bornbusch A. (ed.). 2004. SPARHCS Strategic Pathway to Reproductive Health Commodity Security: A Tool for Assessment, Planning and Implementation. Baltimore, MD: Information and Knowledge for Optimal Health Project/Center for Communication Programs, John Hopkins Bloomberg School of Public Health. Hornby, P., Ozcan, S. 2003. Malawi: Human Resources for Health Sector Strategic Plan 2003 -2013. Draft for Ministry of Health. IMF 2005. Malawi Poverty Reduction Strategy 2003/2004 progress Report. International Monetary Fund Ministry of Gender, Child Welfare and Community Services. 2000. National Gender Policy 2000-2005. The Government of Malawi. Ministry of Health. 2005 Draft National Condom Strategy 2005. Lilongwe, Government of Malawi. Ministry of Health. 2001. Malawi National Health Accounts: A Broader Perspective of the Malawian Health Sector. Sources of Finance in the Health Sector 1998/1999 Lilongwe: Department of Planning, Ministry of Health. Ministry of Health. 2004. A Joint Programme of Work for a Health Sector Wide Approach (SWAp) 2004-2010 Lilongwe, Malawi: Department of Planning, Ministry of Health. Ministry of Health. 2005. Road Map for accelerating the reduction of Maternal and Neonatal Mortality and Morbidity in Malawi Lilongwe, Ministry of Health. Ministry of Health. Unpublished May 2006. Malawi National Drug Policy (zero draft) Lilongwe, Malawi: Ministry of Health. Ministry of Health. 2006. National Reproductive Health Strategy 2006 -2010. Draft 4. Lilongwe, Government of Malawi National AIDS Commission 2003. National HIV/AIDS Policy: A Call for Renewed Action. Lilongwe, Government of Malawi National Statistical Office. 1996. Malawi Knowledge Attitudes and Practices in Health Survey 1996. Zomba. National Statistical Office Robert Lewis-Bettington, Banda, C. 2004. A Survey of Policy and Practice on the Use of Access to Medicines Related TRIPs Flexibilities in Malawi. London. The Department for International Development Julie Solo, Jacobstein, R., Malema, D. 2005. Repositioning family planning-Malawi case study: Choice, not chance. New York: The ACQUIRE Project/EngenderHealth. Sosolo A. A Jowo, C. Mudondo, Y Ratsma. 2006. Mid Year Review of the Health Sector. Report on Pharmaceuticals and Procurement by the Joint Field Analysis Team. World Health Organization. 2006. Malawi National Health Accounts database (accessed June 2006) CENTRAL/MENTAL HOSPITALS PHARMACIST HEALTH CENTRE HEALTH CENTRE-IN-CHARGE Back Inside Cover All chapters start on a right-hand side. REGIONAL MEDICAL STORES PHARMACIST-IN-CHARGE Ministry of Health/DONORR CLIENTS DELIVER John Snow, Inc. 1616 North Ft. Myer Drive, 11th Floor Arlington, VA 22209 USA Tel: 703-528-7474 Fax: 703-528-7480 Malawi: A Reproductive health commodity security desk assessment CENTRAL MEDICAL STORES CHIEF PHARMACIST HTSS SENIOR LOGISTICS OFFICER DISTRICT PHARMACY PHARMACY TECHNICIAN/ASSISTANT CHAM CLIENTS CLIENTS June 2006 This publication was produced for review by the United States Agency for International Development. It was prepared by the DELIVER project. Note: This blank page is intentional. All chapters start on a right-hand side. Note: This blank page is intentional. All chapters start on a right-hand side. NGO/CLINICS NGO/CLINIC Legend Information Flow Supply flow CLIENTSS For more information, please visit Back Cover All chapters start on a right-hand side. � Available as a pilot in a number of districts. Currently procured by JHPIEGO � The MOH procures some generic Depo-Provera, currently a brand called Petogen from a South African manufacturer � Implants are on the list but are listed as a non-essential item to be procured normally by the actual facilities. Despite this status however the RHU is committed to supporting procurement of implants. � Rwanda is planning to launch social marketing pills and injections in the second half of 2006 � Unacceptable storage conditions are defined as being in compliance with 70 percent or less of established storage criteria. Criteria include a clean, dry, secure store, protected from insects; adequate space; presence of fire safety equipment; products clearly identified and organized etc. � Supply Chain Manger is a LMIS software system developed by DELIVER for USAID. iv    Publication title (Running head-right: Arial, 9/9, flush left) _1217078214.xls Chart1 0.039 0.218 0.036 0.242 0.056 0.252 0.069 0.311 0.172 0.376 Female 1992 Female 2004 CPR by quintile CPR by Income Quintile, Urban and Rural locations Poorest Second Middle Fourth Richest Female 1992 3.9% 3.6% 5.6% 6.9% 17.2% Male 1992 4.8% 8.6% 6.1% 13.2% 24.9% Female 2004 21.8% 24.2% 25.2% 31.1% 37.6% 23.7% 34.4% Urban 5.6 6.7 4.5 4.5 2.2 Female 0.0% 14.1% 8.1% 7.7% 21.1% Male 0.0% 0.0% 0.0% 20.7% 25.8% Rural Female 3.9% 3.4% 5.5% 6.9% 14.1% Male 4.3% 8.9% 6.0% 12.4% 24.1% Gwatkin et al, Socioeconomic differences in HNP, Malawi, World Bank, 2000 (Based on 1992 DHS) CPR by quintile 0 0 0 0 0 0 0 0 0 0 Female 1992 Male 1992 Quintile CPR by income quintile, Malawi, 1992 0 0 0 0 0 0 0 0 0 0 Female Male Quintile CPR for urban location by income quintile, Malawi,1992 0 0 0 0 0 0 0 0 0 0 Female Male Quintile CPR for rural location by income quintile, Malawi, 1992 Paul Dowling: insufficent data Paul Dowling: small sample Paul Dowling: insufficent data Paul Dowling: insufficent data Paul Dowling: insufficent data Paul Dowling: small sample Female 1992 Female 2004 0 0 0 0 0 0 0 0 0 0 _1217078351.xls Chart3 0.13 0.363 0.306 0.297 0.325 0.276 CPR Unmet need Sheet1 PREVALENCE 1992 2000 2004 2010 2020 All methods 13.00% 30.60% 32.50% 41.60% 54.70% Modern methods 7.40% 26.10% 28.10% 36.20% 46.70% Pill 2.20% 2.70% 2.00% 2.00% 1.30% IUD 0.30% 0.10% 0.10% 0.00% 0.00% Injectables 1.50% 16.40% 18.00% 24.10% 32.10% Implants NA 0.10% 0.50% 0.90% 1.60% Condom 1.60% 1.60% 1.80% 2.00% 2.30% Female sterilization 1.70% 4.70% 5.80% 7.70% 10.80% Male sterilization 0.00% 0.10% N/A N/A N/A 1992 2000 2004 CPR 13.0% 30.6% 32.5% Unmet need 36.3% 29.7% 27.6% Sector 1992 1996 2000 2004 Public sector 69.9 59 68 66.5 CBD 0 0.3 2.1 2.7 CHAM (Mission) N.D. N.D. 10.1 12.6 BLM N.A. 2.7 12.3 13.2 Private medical 22.3 28.7 5.1 4.2 Shop 5.5 6.7 3.7 3.1 Public Mission Private BLM Shop Female sterilisation 39.4% 17.4% 0.9% 42.3% 0.0% 100.0% Pill 72.9% 11.5% 5.4% 8.6% 1.0% 99.4% Injectables 77.9% 11.1% 5.4% 5.3% 0.0% 99.7% Condoms 45.4% 8.6% 3.2% 1.4% 38.9% 97.5% Total 66.5% 12.6% 4.2% 13.2% 3.1% 99.6% Sheet1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Pill IUD Injectables Implants Condom Female sterilization Sheet2 0 0 0 0 0 0 CPR Unmet need Sheet3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Public sector CBD CHAM (Mission) BLM Private medical Shop 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Public Mission Private BLM Shop _1217078999.xls Chart1 0.394 0.174 0.009 0.423 0 0.729 0.115 0.054 0.086 0.01 0.779 0.111 0.054 0.053 0 0.454 0.086 0.032 0.014 0.389 0.665 0.126 0.042 0.132 0.031 Public Mission Private BLM Shop Sheet1 PREVALENCE 1992 2000 2004 2010 2020 All methods 13.00% 30.60% 32.50% 41.60% 54.70% Modern methods 7.40% 26.10% 28.10% 36.20% 46.70% Pill 2.20% 2.70% 2.00% 2.00% 1.30% IUD 0.30% 0.10% 0.10% 0.00% 0.00% Injectables 1.50% 16.40% 18.00% 24.10% 32.10% Implants NA 0.10% 0.50% 0.90% 1.60% Condom 1.60% 1.60% 1.80% 2.00% 2.30% Female sterilization 1.70% 4.70% 5.80% 7.70% 10.80% Male sterilization 0.00% 0.10% N/A N/A N/A 1992 2000 2004 CPR 13.0% 30.6% 32.5% Unmet need 36.3% 29.7% 27.6% Sector 1992 1996 2000 2004 Public sector 69.9 59 68 66.5 CBD 0 0.3 2.1 2.7 CHAM (Mission) N.D. N.D. 10.1 12.6 BLM N.A. 2.7 12.3 13.2 Private medical 22.3 28.7 5.1 4.2 Shop 5.5 6.7 3.7 3.1 Public Mission Private BLM Shop Female sterilisation 39.4% 17.4% 0.9% 42.3% 0.0% 100.0% Pill 72.9% 11.5% 5.4% 8.6% 1.0% 99.4% Injectables 77.9% 11.1% 5.4% 5.3% 0.0% 99.7% Condoms 45.4% 8.6% 3.2% 1.4% 38.9% 97.5% Total 66.5% 12.6% 4.2% 13.2% 3.1% 99.6% Sheet1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Pill IUD Injectables Implants Condom Female sterilization Sheet2 0 0 0 0 0 0 CPR Unmet need Sheet3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Public sector CBD CHAM (Mission) BLM Private medical Shop 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Public Mission Private BLM Shop _1217078035.xls Chart2 0.022 0.003 0.015 0 0.016 0.017 0.027 0.001 0.164 0.001 0.016 0.047 0.02 0.001 0.18 0.005 0.018 0.058 Pill IUD Injectables Implants Condom Female sterilization Sheet1 PREVALENCE 1992 2000 2004 2010 2020 All methods 13.00% 30.60% 32.50% 41.60% 54.70% Modern methods 7.40% 26.10% 28.10% 36.20% 46.70% Pill 2.20% 2.70% 2.00% 2.00% 1.30% IUD 0.30% 0.10% 0.10% 0.00% 0.00% Injectables 1.50% 16.40% 18.00% 24.10% 32.10% Implants NA 0.10% 0.50% 0.90% 1.60% Condom 1.60% 1.60% 1.80% 2.00% 2.30% Female sterilization 1.70% 4.70% 5.80% 7.70% 10.80% Male sterilization 0.00% 0.10% N/A N/A N/A 1992 2000 2004 CPR 13.0% 30.6% 32.5% Unmet need 36.3% 29.7% 27.6% Sector 1992 1996 2000 2004 Public sector 69.9 59 68 66.5 CBD 0 0.3 2.1 2.7 CHAM (Mission) N.D. N.D. 10.1 12.6 BLM N.A. 2.7 12.3 13.2 Private medical 22.3 28.7 5.1 4.2 Shop 5.5 6.7 3.7 3.1 Public Mission Private BLM Shop Female sterilisation 39.4% 17.4% 0.9% 42.3% 0.0% 100.0% Pill 72.9% 11.5% 5.4% 8.6% 1.0% 99.4% Injectables 77.9% 11.1% 5.4% 5.3% 0.0% 99.7% Condoms 45.4% 8.6% 3.2% 1.4% 38.9% 97.5% Total 66.5% 12.6% 4.2% 13.2% 3.1% 99.6% Sheet1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Pill IUD Injectables Implants Condom Female sterilization Sheet2 0 0 0 0 0 0 CPR Unmet need Sheet3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Public sector CBD CHAM (Mission) BLM Private medical Shop 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Public Mission Private BLM Shop

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