Mali: Final Country Report

Publication date: 2007

MALI: FINAL COUNTRY REPORT MARCH 2007 This publication was produced for review by the United States Agency for International Development. It was prepared by the DELIVER project. MALI: FINAL COUNTRY REPORT The authors’ views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government. DELIVER DELIVER, a 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, and Crown Agents Consultancy, Inc.), DELIVER strengthens the supply chains of health and family planning programs in developing countries to ensure the availability of critical health products for customers. DELIVER also provides technical management of USAID’s central contraceptive management information system. Recommended Citation DELIVER. 2007. Mali: Final Country Report. Arlington, Va.: DELIVER, for the U.S. Agency for International Development. Abstract Over the last four years, the DELIVER project in Mali assisted the Ministry of Health (MOH) and its stakeholders to carry out appropriate activities to improve the program. Major achievements, described in this report, include logistics assessment, strengthening of the logistics management information system, and monitoring of national inventory. Throughout the life of the DELIVER project, supervisory visits were conducted by a team composed of DELIVER’s resident advisor, a representative of the Direction de la Pharmacie et du Médicament, and a regional pharmacist. These visits contributed to the improvement of both the logistics system and human capacity. Through OJT, DELIVER was able to improve the skills of various personnel at all levels of the supply chain to enable them to carry out their duties. DELIVER worked to implement the Mali Strategic Contraceptive Security (CS) Plan by coordinating stakeholder activities, various Government departments, private-sector partners, and donors. In addition, DELIVER fostered engagement of political leadership for contraceptive security at all levels of Government, civil society, donors, decision makers, and opinion leaders. DELIVER carried out a number of studies and assessments in Mali to identify CS issues in general and logistics issues in particular. These assessments included the Logistics Indicator Assessment and Logistics System Assessment Tools, market segmentation, and informed buying. Some of the studies were aimed at finding solutions to CS issues and measuring the performance of the program. This report outlines major recommendations from these assessments. DELIVER also assisted the MOH in Mali over the last four years to estimate contraceptive requirements. These requirements were estimated for USAID-procured products but also for other donors such as the United Nations Population Fund. The Malian forecasting team is now able to do the estimation and procurement planning with little or minimal assistance from DELIVER. Important progress has been made in recent months in collecting dispensed-to-user data for the estimation of contraceptive requirements. Looking into the future, DELIVER has designed a transition plan for the Mission and the MOH. The DELIVER project closed out in September 2006. The transition plan covers the period October 2006 to September 2007 and is described in this report. DELIVER John Snow, Inc. 1616 North Fort Myer Drive, 11th Floor Arlington, VA 22209 USA Phone: 703-528-7474 Fax: 703-528-7480 Email: deliver_project@jsi.com Internet: www.deliver.jsi.com CONTENTS Acronyms. vii Acknowledgments. ix Acknowledgments. ix Executive Summary . xi Program Background. 1 Country Context.1 Key Players and Roles .2 Key Challenges .4 Goals and Objectives. 5 DELIVER Objectives .5 Relationship to USAID and Client Objectives .5 DELIVER’s Role in Relation to Other Organizations.5 Description of Strategies.5 Summary of Deliver Funding and Staffing.6 Program Results. 7 Element I: Improved Logistics System.7 Element II: Improved Human Capacity in Logistics .12 Element III: Improved Resource Mobilization for Contraceptive Security.13 Element IV: Improved Adoption of Advances in Logistics .17 Element V: Estimation of USAID Contraceptive Needs .19 Lessons Learned and Future Directions. 21 References . 23 Appendices 1. CS Brief .25 2. DELIVER Key CSEP Indicators and Program Results .29 3. DELIVER Mali Transition Plan (draft) .33 4. CYP 2006.51 Figures 1. Logistics Indicator Assessment Tool Results, 2001 and 2005.18 Tables 1. Mali Demographic Indicators from DNSI–RGPH 1987.2 2. Family Planning Current Use and Method Mix.2 3. Private- and Public-Sector Collaboration Framework .9 Mali: Final Country Report v Mali: Final Country Report vi ACRONYMS AIDS acquired immunodeficiency syndrome AMC average monthly consumption AMPPF Association Malienne pour la Protection et la Promotion de la Famille (the IPPF Affiliate in Mali) ASDAP Association de Soutien au Développement des Activités de Population (a Population and Development NGO) ATN Assistance Technique Nationale (USAID/Central Technical Assistance Bilateral Project) BCC behavior change communication CA cooperating agency CAG Centrale d’Achat des Génériques (Social Marketing-Central Generic Drug Store) CBD community-based distribution CIWARA Keneya CIWARA bilateral project (local name of the USAID bilateral project) CPT contraceptive procurement table CS contraceptive security CSCom Centre de Santé Communautaire (community health center) CPR contraceptive prevalence rate CSEP Country Strategy and Evaluation Plan CYP couple-years of protection DHS Demographic and Health Survey DNS Direction Nationale de la Santé (National Health Directorate) DPM Direction de la Pharmacie et du Médicament (Drugs and Pharmacy Directorate) DQA data quality assessment DRC Dépôt Répartiteur du Cercle (District Distribution Warehouse) DSR Division Santé de la Reproduction (Reproductive Health Division) DV dépôt de vente (drug store) DVC dépôt de vente du cercle (district drug store) ESS ecole secondaire de santé (preservice health school) FP family planning GPSP Groupe Pivot Santé Population (a Reproductive Health NGO) GRM Government of the Republic of Mali HIV human immunodeficiency virus Mali: Final Country Report vii IEC information, education, and communication INTRAH International Training in Health IPPF International Planned Parenthood Federation IR intermediate result IUD intrauterine device JSI John Snow, Inc. KfW Kreditanstalt für Wiederaufbau (German funding agency for international development) LIAT Logistics Indicator Assessment Tool LMIS logistics management information system LSAT Logistics System Assessment Tool MOH Ministry of Health MOS months of supply NGO nongovernmental organization OJT on-the-job training PNLS Programme National de Lutte contre le SIDA (National HIV/AIDS Program) PPM Pharmacie Populaire du Mali (Mali National Drug Store) PRB Population Reference Board PSI Population Services International RH reproductive health SDAME supply chain procedures SDP service delivery point SIGL Systeme d’Information de Gestion Logistique UNFPA United Nations Population Fund USAID U.S. Agency for International Development WHO World Health Organization viii Mali: Final Country Report ACKNOWLEDGMENTS DELIVER would like to thank the institutions and individuals that contributed to DELIVER’s work throughout the duration of the project. First and foremost, the project would like to thank the U.S. Agency for International Development (USAID) Mission in Bamako, especially Dr. Christine Sow, health team leader, and Madiou Yattara, DELIVER Mali/cognizant technical officer. Without your vision and support, none of our successes would have been possible. DELIVER was also graced with a strong and supportive working relationship with the Mali Ministry of Health. We would like to extend our heartfelt thanks to Dr. Minkaila Maiga, Directeur of the Drug of Pharmacy Directorate, Dr. Adama Diawara, and, Dr. Daouda Toure. We would like to acknowledge the regional health directors, regional pharmacists, district- and service delivery point-level heads and staff in general, and Association Malienne pour la Protection et la Promotion de la Famille, Centrale d’Achat des Génériues, and Pharmacie Populaire du Mali, who have been actively involved in the design and implementation of the Mali Contraceptive Logistics System. DELIVER also thanks the United Nations Population Fund Mali, the Keneya CIWARA Project, Assistance Technique Nationale, Population Services International, and all U.S. cooperating agencies working in contraceptive security (CS) for their collaboration in improving CS in Mali. The Mali Country Team would also like to thank our local staff for their dedication, significant contributions, and ongoing efforts. In alphabetical order, we would like to thank Adama Keita and Abdoulaye Traore for their many contributions to DELIVER’s program in Mali. Mali: Final Country Report ix Mali: Final Country Report x EXECUTIVE SUMMARY DELIVER’s major activity in Mali revolved around monitoring the Strategic Plan for Contraceptive Security and system and human performance improvement in logistics. DELIVER interventions focused on preparing contraceptive needs estimates for contraceptives supplied by the U.S. Agency for International Development (USAID) to the Ministry of Health (MOH) through the two main wholesalers: the Mali National Drug Store (Pharmacie Populaire du Mali [PPM]) and the private wholesaler, Central d’Achat des Génériques (CAG). The DELIVER project also conducted many performance improvement sessions with key personnel in basic logistics theory, as well as forecasting and monitoring techniques. A contraceptive security assessment and logistics baseline and end-of-project assessments were also completed (Logistics Indicator Assessment Tool [LIAT] and Logistics System Assessment Tool [LSAT]), as well as recommendations for logistics improvements derived from periodic monitoring. Measurable indicators of improvement were each recipient organization's ability to apply the basic logistics principles in their warehouses, provide constant contraceptive availability through their distribution networks, and collect and use reliable logistics data for program monitoring and decision making. Therefore, the focus was largely on decreasing the number of stockouts observed in the system, and improving the timeliness and accuracy of reporting from the peripheral levels of the system upward. The Mali Strategic Plan for Contraceptive Security is the leading tool for implementing, monitoring, and evaluating all contraceptive security interventions in Mali In Mali, DELIVER focused on the three principal objectives that correspond to the intermediate results (IRs) listed in the DELIVER Contract Briefing Book. These objectives are to— • improve logistics system performance • improve human capacity in logistics management • strengthen contraceptive and reproductive health commodity security. In summary, at the end of DELIVER’s interventions in Mali, the following key results had been accomplished: • The national integrated logistics management system for health commodities had standardized procedures and forms for all levels of the system. • All key central and regional level staff had the standardized forms and skills to complete logistics management information system (LMIS) forms correctly and submit them according to schedule. • Central level staff had the skills to collect and use reliable logistics data for forecasting, procurement planning, securing of stakeholder commitment to the procurement plan, and annual submission of timely and accurate contraceptive procurement tables. • Supervision and on-the-job training (OJT), using newly developed supervision guidelines and OJT tools, was taking place throughout the system. • A logistics management module had been developed for integration into curricula in all health schools and the faculty of medicine. Mali: Final Country Report xi • The Country Strategy and Evaluation Plan and DELIVER’s corresponding interventions had been implemented, monitored, and evaluated to show progress toward meeting specified objectives and the impact of DELIVER’s technical assistance. This present report outlines and documents the above information. Mali: Final Country Report xii PROGRAM BACKGROUND COUNTRY CONTEXT The Government of the Republic of Mali (GRM) adopted a National Population Policy on May 8, 1991, and prepared documents outlining general goals for the provision of health services, including family planning. In the context of decentralization, goals are in place for increasing access to quality health care services. Integrated service delivery models have been identified as a way to offer more comprehensive heath services to better meet client needs. The community-based distribution (CBD) approach, which was tested in rural areas, has raised contraceptive knowledge and practices. In the past, contraceptive logistics in Mali were a vertical system. In 1993, the Ministry of Health (MOH) decided to integrate contraceptive commodities into the newly implemented essential drug system. Public-sector commodities are distributed by the Mali National Drug Store through its regional offices. District distribution warehouses (DRCs) receive their products from the regional level and then resupply the service delivery points (SDPs, or community health centers [CSCom]). All programs supplied by the Social Marketing Program receive their products at the Centrale d’Achat des Génériques (CAG) central warehouse. CAG has no regional offices farther down the system. They deliver to mobile teams and nongovernmental organization (NGOs), who sell social marketing commodities to the clients in rural areas. Although the system is integrated, essential drugs and contraceptive commodities do not come from the same source. Essential drugs are purchased in the open market through bids, but contraceptives are donated. In the integrated logistics system, funds generated by the sale of drugs, including contraceptives, at service delivery points are put in the same basket and used to resupply and improve the quality of services. At the central level, portions of the funds are used to resupply drugs, and a percentage of the amount of contraceptive commodity value is put in a bank. The Social Marketing Program uses part of its funds to purchase repackaging materials. In terms of reproductive health policy, Mali is one of the leaders in West Africa. Mali is one of the few West African Francophone countries that have enacted a reproductive health law that describes the right of the Malian people to reproductive health (RH), the type of services that should be offered, regulations that govern RH products, and the penalties that face people who break the law. The Mali reproductive health law is being put into action, with some delays in elaborating implementation procedures. In addition, health programs are being designed and implemented by the MOH with assistance from its national, bilateral, and multilateral partners such as USAID. The 2001World Population Data Sheet (PRB 2001) estimates the population in Mali to be about 11.0 million, at a growth rate of 3.0 percent per annum. Women of reproductive age represent 23 percent of the total population. Table 1 shows demographic indicators reported from a national source in the DNSI­ RGPH 1987. Mali: Final Country Report 1 Table 1. Mali Demographic Indicators from DNSI–RGPH 1987 Crude birth rate 50 Crude death rate 20 Total fertility rate 6.8% (urban 6.3%, rural 7.3%) Modern contraceptive prevalence 5.7% (of women in union) Infant mortality rate 113% births Life expectancy at birth 56.8 Gross national income per capita U.S.$250–300 Source: Mali DHS III. Table 2 outlines contraceptive prevalence by method and method mix from the same source. Table 2. Family Planning Current Use and Method Mix Family Planning Methods % Current Use % Method Mix Pills 2.8 48.27 Intrauterine device (IUD) 0.2 3.45 Injectables 2.1 36.21 Condoms 0.3 5.17 Sterilization (female) 0.3 5.17 Sterilization (male) 0.0 0.00 Implants 0.1 1.72 Total use of modern methods 5.8 100.00 KEY PLAYERS AND ROLES In the area of commodity security, key players include the institutions listed below. PHARMACIE POPULAIRE DU MALI (PPM) This institution is a parastatal and has been assigned the objective of procuring, warehousing, and distributing essential drugs in the entire country. PPM also manages other health products. PPM’s headquarters are in Bamako and regional warehouses are located in all eight regions of the country. DIRECTION DE LA PHARMACIE ET DU MÉDICAMENT (DPM) DPM is the Pharmacy Directorate within the MOH. This division is in charge of— • developing regulations in the area of pharmaceutical services and products, including manufacture, storage, and distribution of pharmaceutical products • assuring the administrative control of importation of pharmaceutical products as well as medicines manufactured in the country • developing and implementing programs related to essential drugs • carrying out research and defining regulation concerning the sale and transactions of medicines in Mali. Mali: Final Country Report 2 CENTRALE D’ACHAT DES GÉNÉRIQUES (CAG) CAG is a national private wholesaler created in 1998 and authorized to import and sell pharmaceutical products. CAG has two divisions: one for essential drugs and the other for contraceptives. The contraceptives division runs a social marketing program of three products. The contraceptives are donated by the U.S. Agency for International Development (USAID) in support of the MOH. Population Services International (PSI) has signed an agreement with CAG to provide technical assistance for repackaging the products and distributing them throughout the country. A Memorandum of Understanding has been signed between USAID, the MOH, and CAG to manage the social marketing programs of contraceptives. ASSOCIATION MALIENNE POUR LA PROTECTION ET LA PROMOTION DE LA FAMILLE (AMPPF) This institution is the local International Planned Parenthood Federation (IPPF) affiliate. Its mission is to contribute to the well-being of Malian families through the development of family planning (FP) services and the promotion of the right of all people to have access to quality RH services. AMMPF is one of the main purchasers of contraceptive products in the country. REPRODUCTIVE HEALTH DIVISION (DIRECTION NATIONALE DE LA SANTÉ; DSR) DSR is the division of family health within the Direction Nationale de la Santé, and is in charge of— • determining the strategic policy guidelines in reproductive health for the MOH • developing service delivery standards and their implementation • participating in research and training in reproductive health • coordinating donor-sponsored programs. • integrating gender issues in RH programs and projects. THE NATIONAL AIDS PROGRAM (PROGRAMME NATIONAL DE LUTTE CONTRE LE SIDA; PNLS) In the past, PNLS focused primarily on free distribution to an urban population (students, bar and hotel patrons, sex workers) but now primarily conducts information, education, and communications (IEC) activities and follow-up of HIV/AIDS clients nationwide. GROUPE PIVOT SANTÉ POPULATION (GPSP) GPSP is a consortium of approximately 30 NGOs. Their main activities include health education, distribution of condoms, and resupplying of pills. INTERNATIONAL DONORS USAID is the main donor for contraceptives and provides technical assistance in the logistics area. USAID-funded cooperating agencies (CAs) such as Care, Abt Associates, PSI, POLICY Project, and Save the Children implement various programs in support of contraceptive security (CS). The United Nations Population Fund (UNFPA) is one of the main contributors to contraceptive security in Mali and provides some contraceptives to the MOH and NGOs. These contraceptives include IUDs, implants, and, occasionally, condoms to the public sector, and female condoms to the IPPF affiliate. It also provides financial support in IEC, training, supervision, and equipment such as computers, printers, and vehicles. Mali: Final Country Report 3 KEY CHALLENGES Prior to DELIVER’s arrival in August 2002, the Mali FP program faced many challenges. Findings from the 2003 Lostistics System Assessment Tool (LSAT) identified the following major logistics and contraceptive security issues that DELIVER had to address: • The 2001 baseline assessment recommendations made to ensure financial sustainability of the family planning and commodities were not implemented. • The cost recovery system used the same prices for contraceptives in the social marketing programs and the public-sector program, which leads clients to choose the products of the social marketing program. There is a perceived competition between the social marketing programs and the public-sector programs instead of the programs being complementary. • Consumption data were not available to make reliable forecasting of contraceptive requirements. • There are a multitude of data collection forms. • Quality control of drugs by the national quality control laboratory did not include contraceptives. • There was no compliance with the existing maximum and minimum inventory control system. • Service providers failed to promote all contraceptive methods authorized by the program. • Storage conditions often did not meet internationally accepted standards. For instance, only about 75 percent of the DELIVER recommended storage conditions were met. • Training events were rare and were often of substandard quality. Appropriate methodology and technical content needed to be revised and updated. Mali: Final Country Report 4 GOALS AND OBJECTIVES DELIVER OBJECTIVES The goal of the DELIVER project is to improve reproductive health commodity availability at service delivery points. The following three objectives were defined to help achieve this goal: 1. improve health commodity logistics system performance 2. improve human capacity in logistics 3. strengthen reproductive health commodity security in Mali. RELATIONSHIP TO USAID AND CLIENT OBJECTIVES DELIVER objectives feed into the two MOH objectives to— 1. ensure the transition of contraceptive commodity procurement from donors to the GRM 2. improve the contraceptive logistics management system and the quality of family planning services. DELIVER objectives were developed to help achieve USAID Mali intermediate results, which read: • IR1: policy environment for high-impact health services established (key indicator: accomplishment of family planning/contraceptive security development) • IR2: demand for high-impact health services increased (indicator: couple-years of protection [CYP]) • IR4: quality of high-impact health services improved (indicator: percentage of community health centers reporting stockouts for contraceptives). DELIVER’S ROLE IN RELATION TO OTHER ORGANIZATIONS DELIVER’s role was mainly to collaborate with other organizations using its comparative advantages to help achieve USAID and MOH objectives. DELIVER sought to play a major role in coordination with other CAs and organizations such as the Keneya CIWARA bilateral project (CIWARA), SAVE CS 20, the Association de Soutien au Développement des Activités de Population (ASDAP), and GPSP, and leverage their resources to achieve contraceptive security in Mali by providing the appropriate technical assistance in logistics management. DESCRIPTION OF STRATEGIES DELIVER’s interventions and strategies were developed in the Mali Country Strategy and Evaluation Plan (CSEP) and were designed, as stated earlier, to meet the MOH and USAID strategies. The main points are outlined below. • improve health commodity logistics system performance by— - redesigning the integrated logistics system (maximum and minimum levels and review period) - establishing mechanisms to collect and report reliable dispensed-to-user data at the central level Mali: Final Country Report 5 - assisting in the automation of the collection and analysis of data to facilitate its use in the decision-making process - estimating country requirements for reproductive health commodities based on data collected and reported from SDPs. • improve human capacity in logistics through— - skill building among staff members from recipient organizations in managing their stock, as well as to interpreting and using the data collected through their logistics systems for forecasting and decision making - providing supervision and on-the-job training (OJT) - providing preservice training in health schools. • strengthen reproductive health commodity security in Mali by— - assisting the MOH in implementing the Contraceptive Security Strategic Plan - coordinating donor interventions - assisting the MOH in conducting studies covering fields such as pricing policy, market segmentation, and others, as proposed by the Mali MOH - following up on the milestones of DELIVER’s assistance within the Mali CSEP. SUMMARY OF DELIVER FUNDING AND STAFFING FUNDING The Mali program is funded by USAID/Mali. Funding received to date totals U.S.$3,066,697.1 Total expenditures as of 7/31/06 were $2,769,234. STAFFING DELIVER’s office in Bamako was staffed with a full-time resident technical advisor in charge of managing the program and providing technical assistance. An administrative assistant and a driver were hired. In-country staff were assisted from the headquarters in Washington by a coordinator for country programs, a country team leader for management and technical backstop, and a country coordinator for financial and operational backstops. A team of advisors in various technical areas based in Washington collaborated on an as-needed basis on implementation of the DELIVER program. All dollar amounts are U.S. dollars unless specified otherwise. Mali: Final Country Report 6 1 PROGRAM RESULTS ELEMENT I: IMPROVED LOGISTICS SYSTEM DELIVER Mali assisted the MOH and its stakeholders to carry out appropriate performance improvement activities to enhance national family planning program outcomes. Major achievements include providing logistics assessment, strengthening the logistics management information system (LMIS), and enhancing national inventory. REVERSING THE TREND: UPSWING IN CYPS The decrease in commodity distribution in Mali between 2003 and 2004 was followed by a CYP decline of about 13 percent between 2003 (192,483) and 2004 (167,375). In 2005, the trend was reversed as CYP increased by 18 percent (205,961) over 2004 due to three major factors that impacted the entire Mali system. LOGISTICS ASSESSMENT A logistics qualitative and performance assessment was carried out early in the program (January 2003) using the LSAT and the Logistics Indicator Assessment Tool (LIAT) to assess the strengths and weaknesses of the system and its performance. Findings of these assessments served as baseline data for future assessments. An action plan to address weaknesses and build on strengths was then developed. Major logistics system improvements included— • development of new LMIS forms to enhance reliable data collection and reporting, which will allow capture of dispensed-to user data at the SDP level (see section below) • an annual national physical inventory, which in 2005 included visits to 100 percent of DRCs, 100 percent of dépôt de vente du cercles (district drug stores [DVCs]), and 75 percent of CSComs, and through which 85 percent of the national consumption volume has been captured • achievement of self-sustainability of the National Forecasting Committee, which can currently produce contraceptive procurement tables (CPTs) with minimal external technical assistance • an 18 percent jump in CYPs between 2004 and 2005, which represents great performance due to the MOH’s large-scale FP campaign and pipeline streamlining efforts. • significant improvement in the logistics system, illustrated by the increased availability of products at the SDP level, as demonstrated by the two LIATs and LSATs carried out three years apart. STRENGTHENING OF LMIS Strengthening of the LMIS began by presenting to the MOH the type of data that are appropriate for logistics managers to collect for proper management decision making. The MOH agreed on essential logistics data to be collected, which are stock on hand, dispensed-to-users data, losses, and adjustments. A new reporting format was adopted in 2004 and includes columns for losses and adjustments. New LMIS forms were adopted as well, including stockcards, a daily activity register, a weekly activity summary, issue vouchers, a prescription sheet, physical inventory forms and, a reporting and requisition voucher. Mali: Final Country Report 7 A reporting mechanism was adopted in 2004 for all levels of the logistics system. The new reporting forms were pilot tested in three regions—Kayes, Sikasso, and Bamako—for six months. At the end of the testing period an evaluation of the LMIS forms was performed during a workshop attended by DRCs and pharmacists of the regions involved in the test. All the LMIS forms used during the pilot-test were reviewed and improved based on information collected during the test to make them more accurate. The workshop validated the improved LMIS forms and recommended their dissemination, as soon as possible, to all service delivery points in the country. The newly adopted forms included stockcards, the daily activity register, a weekly activity summary, and a requisition and issue voucher. SUPERVISION TO STRENGTHEN STOREKEEPERS’ COMPETENCY AND ADDRESS ISSUES RELATED TO THE LMIS Throughout the life of DELIVER project, supervisory visits were conducted by a team composed of DELIVER Resident Advisor, a representative of the DPM and a regional pharmacist. Supervision is facilitative and includes job-aids to address a weaknesses uncovered during the supervision. A supervision guide was developed to address the following points: • warehouse management • staffing • product storage • stock levels • use of LMIS forms. The supervision methodology was as follows: observation of store environment and products stored; review of LIMS forms; and comparison between information on the forms and information given by physical inventory. A meeting with staff to discuss and address the issues concluded the supervision visits. Problems that could not be addressed during the supervisory visits were addressed later in national or regional workshops; however, recommendations were made to the DPM so that these issues were taken into account in future planning. Supervision visits in regions and districts were scheduled in advance and information was provided ahead of time to store managers so they could prepare. A total of 25 supervision visits were carried out and helped address the following issues: • gaps in filling out and updating LMIS forms • inadequate needs estimation and reporting issues • insufficient storage conditions • maintenance of appropriate stock status levels. COLLABORATION BETWEEN PRIVATE AND PUBLIC SECTORS FOR BETTER AVAILABILITY OF PRODUCTS AND IMPLEMENTATION OF THE CONTRACEPTIVE SECURITY STRATEGIC PLAN The private-sector contribution is crucial for contraceptive availability on a sustained basis. To reach that objective, a workshop was conducted to regroup public and private wholesalers as well as health professional organizations dealing with reproductive health products, including private pharmacists and Mali: Final Country Report 8 doctors’ associations. At the end of the workshop, the framework shown in table 3 had been developed to present the areas and axes of collaboration between private and public sectors. Table 3. Private- and Public-Sector Collaboration Framework Area Collaboration Axis Forecasting • Improve data collection and analysis systems for both sectors. • Integrate consumption data into the existing HIS. • Reinforce the National Forecasting Committee. • Implement the Mali CS Plan. Procurement/distribution Financing Logistics management • Emphasize training, information, and awareness building in FP activities in both sectors. • Improve need estimation mechanisms. • Evaluate/process monitoring indicators. • Elaborate mechanisms that will foster respect for SDAME (supply chain procedures). • Integrate the private sector into the SDAME. • Disseminate the Schéma Directeur in the private sector. • Evaluate stockout causes at peripheral levels. • Reinforce storage capacity in both sectors. • Disseminate the product list by level. • Strengthen the cost recovery program. • Develop funding mechanisms to supplement product procurement. • Seek new funding sources. • Disseminate logistics management tools. • Integrate the private sector into activity planning. DELIVER PARTICIPATION IN REGIONAL PLANNING EXERCISES In Mali, each regional health team holds an annual planning session for its region. The regional plans take into account all aspects of health programs; however, logistics had not been integrated into these health plans. The DPM and DELIVER convinced all health authorities that logistics should be discussed and included in the regional health plans for implementation. As a result of this successful advocacy, DELIVER participated in all regional planning exercises, and the following components of logistics have been integrated in all regional health plans: • LMIS— - training of storekeepers and CBD workers - periodic monitoring meetings at regional and district levels - supervision based on the OJT approach, integrating all logistics aspects of the LMIS. • supply chain management— - stock management, procurement, and distribution skill-building methods Mali: Final Country Report 9 - coordination of MOH supply chain management - stock level evaluation at DRCs and drug stores (dépôt de vente [DV]). • quality service and distribution— - information/communication to promote essential drugs and rational use training - supervision specifically for essential drugs to control/inspect private institutions and reinforce distribution channels. • sustainability— - application of prices according to MOH policy - motivation mechanisms for health and social workers. Inclusion of logistics elements in the regions’ plans started in 2003 and has made logistics more visible to all health workers, who have taken advantage of opportunities to get trained either in formal workshops or on the job during supervision visits in logistics. They now apply their skills in their daily work, thereby strengthening the logistics system. NATIONAL PHYSICAL INVENTORY Physical inventory was conducted in 2004 and 2005. The objectives of the assessments were to— • assess contraceptive commodities stock status at all levels • survey stockouts and overstock situations • assess the supply chain distribution for both public and private sectors • assess losses in the pipeline. To achieve the above objectives, the following main activities were conducted in all regions visited: • reviewing stockcards to assess their accuracy and see if they were updated • recording physical stocks on the inventory sheets • conducting physical inventory to determine stock gaps • recording dispensed-to-user data for the prior six months and the beginning and end dates of any stockouts • bringing back to the regional level all expired commodities for destruction. The partners involved in this activity were PSI, CAG, PPM, and AMPPF; the Mission also actively participated in the inventory. PSI and CAG provided a vehicle and took care of the per diem for their staff. Stock Status • Average monthly consumption (AMC) is higher at DVs than at DRCs for all products. • DRCs are overstocked in condoms. 10 Mali: Final Country Report • CAG's AMC is higher than PPM’s for all three commodities they have in common (Duofem/Pilplan-d, Depo-Provera/Confiance, and Condom No Logo/Protector). • At the PPM central warehouse, the number of months of supply (MOS) is very high for the following products: condoms, 83.3 MOS; Ovrette, 51.4 MOS; and Conceptrol, 25.8 MOS. However, in 2005 a more decentralized approach was used to carry out the national physical inventory, putting more responsibility at the district level. The national team worked with the regional pharmacists in a couple of districts and about 10 CSComs. The regional pharmacists then worked with all DRCs, visiting a few CSComs with them. Finally, DRCs conducted the inventory in their areas, visiting at least 75 percent of their CSComs. This approach allowed the program to reach 100 percent of DRCs, 100% of DVCs; and 75 percent of CSComs, which represent 85 percent of the national level of consumption. Lessons Learned from the Inventory Positive aspects included— • Stockcards are available in all DRCs and in 88.2 percent of DVs. • Duofem and Depo-Provera are available in almost all SPDs. • CAG wholesalers provide about 92 percent of condoms. • Prices are generally respected throughout the system, except in the Mopti region. Aspects to be improved were— • Stockouts and expiry are frequent for condoms, Ovrette, and Conceptrol. About 52 percent of SDPs were stocked out on the day of visit. • Condoms are not supplied in the public or communal SDPs. • Storage requirements are not complied with by the social marketing wholesalers. Reasons for stockouts at the SDP level could be explained by the following four issues: 1. Orders are not processed correctly nor on time. 2. CSComs only order commodities that are in demand in their locality. Most commonly demanded commodities are Duofem, Depo-Provera, and Ovrette. 3. Service providers do not include all methods in their counseling sessions. 4. There are problems related to unavailability of products at the DRC level. Recommendations Made and Implemented to Improve Stock Management Based on the 2005 Physical Inventory • Apply fixed prices for contraceptives at all levels. • Ensure product availability to meet estimated needs. • Fight parallel contraceptive marketing by service providers. • Redistribute the discovered stock in the warehouses in the respective regions, but also in peripheral regions if need be. Mali: Final Country Report 11 • Implement appropriate procedures to ensure proper storage conditions among the social market wholesalers. • Adhere to the supply chain regulations. The public sector should be supplied by the PPM. • Ensure that service providers include all authorized commodities in their counseling sessions. • Train SDP (CSCom) storekeepers in basic logistics management, including needs estimation and LMIS. The dissemination of the LMIS forms is a good opportunity to tackle this issue. ELEMENT II: IMPROVED HUMAN CAPACITY IN LOGISTICS Training the right people to do the right logistics management jobs is one of the major objectives of the Malian MOH. To date, logistics performance improvement activities conducted throughout the system have had the following results: • Central: 100 percent of program managers are trained in logistics management. • Regional: 100 percent of regional pharmacists and their assistants are trained in logistics management. • DRC: 100 percent of district warehouse managers are trained in logistics management. • DVC: 85 percent of district warehouse keepers are trained in logistics management. • CSCOM: 12 percent of CSCom warehouse keepers are trained in logistics management. • Relais (CBD workers): This is not applicable for CBD workers. Logistics workshops conducted with DELIVER technical assistance were built around the logistics system simulation exercise designed by DELIVER and covered the following essential logistics functions: • needs estimation (average monthly consumption, months of stock on hand, and order quantity) • LMIS • data collection and reporting • storage guidelines. In addition, DELIVER supervision visits contributed to improvement of both the logistics system and human capacity in logistics. Through OJT, DELIVER has been able to upgrade the skills of various personnel at all levels of the supply chain to enable them to carry out their duties. To date only 12 percent of CSCom storekeepers have been trained in logistics management. The MOH is planning to continue this effort in 2006/2007 with the financial assistance of the Mission. LOGISTICS INSTITUTIONALIZATION PRESERVICE TRAINING AT THE NATIONAL HEALTH SCHOOL OF BAMAKO (ECOLE SECONDAIRE DE SANTÉ) One hundred and twelve participants (senior year students), including 21 faculty members, attended a workshop on logistics held at the National Health School of Bamako in April 2004. The planned outcome of this activity was to introduce a logistics module in the school curricula. As the cooperative agency identified by the Mission, INTRAH (International Training in Health) cofacilitated some of the sessions with DELIVER and took an active role in the simulation exercise. 12 Mali: Final Country Report Workshop objectives were to— • Conduct a logistics system simulation exercise. • Identify the essential logistics functions. • Estimate contraceptive needs. • Identify and correctly fill out LMIS forms. • Analyze and discuss storage conditions. The Director of the ESS stressed the necessity of introducing a logistics module in the school reproductive health curriculum. Next steps to these activities include— • curriculum design with the faculty • a Faculty Training Workshop in collaboration with INTRAH • teaching of the first module with the faculty (during next school year 2007/2008) • a mid-term and final evaluation. Unfortunately, due to cut in funding this activity was dropped off DELIVER’s work plan in Mali. LOGISTICS MANAGEMENT WORKSHOP FOR DISTRICT WAREHOUSE MANAGERS In an effort to strengthen district-level storekeepers’ skills in conducting their logistics management tasks and responsibilities, DEILVER/DPM and the new USAID bilateral (district-level) project manager, Kenya CIWARA, organized a logistics management workshop in November 2004. The workshop was funded by Assistance Technique Nationale (ATN, the other USAID bilateral project at the central level), with DELIVER/DPM’s technical assistance. Thirty-three district warehouse managers from different regions in addition to the regional warehouse managers of the National Drug Store and the main social marketing program attended the workshop. The following topics were covered during the workshop— • essential logistics functions • needs estimation (average monthly consumption, months of stock on hand, and order quantity) • LMIS • data collection and reporting • storage guidelines. ELEMENT III: IMPROVED RESOURCE MOBILIZATION FOR CONTRACEPTIVE SECURITY CONTRACEPTIVE SECURITY STRATEGIC PLAN DELIVER’s role was to assist in the implementation of Mali’s contraceptive security strategic plan that includes resource mobilization to purchase contraceptives. The objective of the contraceptive security Mali: Final Country Report 13 strategic plan is to ensure sustainable availability of contraceptives and family planning services. Specific strategies to achieve this goal include— • Policy and Sustainability: The strategy in this domain is to improve the political and regulatory environment conducive to financial sustainability through a gradual increase in GRM contributions to contraceptive purchases. The private sector will be involved in the procurement and distribution of contraceptives. • Human Resource Management: In this domain emphasis will be put on developing the competency of personnel in charge of carrying out tasks related to family planning and stock management. Staff will then be more motivated to carry out their duties effectively. • LMIS: The data collection system will be revised to have adequate data to estimate product requirements and evaluate the program. • Quality Control and Distribution of Products: Quality of products will be ensured at all storage facilities and at all levels of the supply chain, along with sustained availability of products at all storage facilities. • Monitoring and Evaluation— - Integrated supervision of activities will take place. - The plan will be implemented through annual operational plans. - Monitoring meetings will be organized. - Activities will be analyzed and feedback provided. ADVOCACY FOR CONTRACEPTIVE SECURITY CONFERENCE In an effort to speed up the implementation of the contraceptive security strategic plan, DELIVER assisted the DPM in organizing an advocacy conference for contraceptive security in May 2004. A total of 41 participants attended the conference. All donor institutions involved in reproductive health activities in Mali as well as stakeholders representing the public and private sectors and USAID CAs attended the workshop. Representatives of the local media were invited as participants. The main objective of this conference was to develop new strategies to advocate for contraceptive security while using the media as partners. The Secretary General of the Ministry of Health provided opening remarks. He described contraceptive security as an integral and important part of the MOH's work plan, and expressed his support for the creation of a budget line item for contraceptive procurement. The following key concerns were discussed during the conference: 1. coordination and integration of various activities, including coordination among stakeholders, various Government departments, private-sector partners, and donors, to include consideration of the CS committee 2. engagement of political leadership for CS at all levels of Government, civil society, donors, decision makers, and opinion leaders. The conference received extensive media attention through newspapers, TV, and radio. DELIVER’s Resident Advisor and USAID’s representative were interviewed on TV during prime time. In addition, five articles were published on the event highlighting the necessity for the GRM to demonstrate political engagement. 14 Mali: Final Country Report Recommendations from workshop participants included— • Current advocacy efforts for CS in Mali should be extended to the National Assembly. A joint POLICY/DELIVER presentation using Rapid Model Presentation for Advocacy and the work of DELIVER to illustrate the CS situation should be carried out as soon as possible. Deputies at the CS conference expressed a strong desire for such a presentation to both the Population and the HIV/AIDS Network of Parliamentarians Deputies (committees). DELIVER will also send copies of CS documents to the National Assembly Library. • Contacts with parliament, the first lady, the media, etc., should be strengthened with advocacy emphasis on reproductive rights, maternal and child health, and socioeconomic impact of rapid population growth, and less on the technical aspects of strategic planning for CS. The links between FP and health, personal freedom, and economic development are probably not well enough understood by the Malian population, opinion makers, and community leaders, and therefore should be further explained. • Annual review meetings of CS strategy implementation should be institutionalized. Specific objectives of meetings would be to review progress, approve changes to the plan, set priorities for the coming year, and prepare work plans. • The CS committee, as created by the CS plan, has not been meeting frequently due to its size. In practice, a monitoring committee has been established with representatives from DELIVER, USAID, DPM, Direction Nationale de la Santé (DNS, the National Health Directorate), PSI/CAG, and the NGOs. The committee should formally be made part of the plan and have its role defined. The monitoring committee is a subcommittee of the main committee charged with executing the plan and reporting on progress to the main committee. Particular emphasis needs to be placed on DNS participation. To avoid duplication of effort, USAID and DELIVER should ensure that the existing CS strategy and plan, including the CS committee, are included in any reproductive health program being developed by the MOH. At this time, CS in Mali is characterized by the following activities: • Resource mobilization is occurring, including an increase in contributions from UNFPA in CS activity funding over the course of the last four years. • In terms of commodity procurement, USAID remains committed to securing commodities. KfW took over social marketing commodities in December 2006. • CS advocacy efforts are taking place with congressmen, journalists and, community leaders, who are new partners and CS champions in their respective areas. • There is synergy among CAs who have funded some of DELIVER’s planned activities such as training collaboration and commodity availability in the field. • The CS Steering Committee is functional. USE OF THE MEDIA IN MOBILIZATION OF RESOURCES FOR CONTRACEPTIVE SECURITY Building on the Senegal CS Media Seminar in April 2005, a committee of two journalists, three RH technicians, and a congresswoman developed a work plan to ensure further development of CS advocacy in Mali. The work plan was financed by PRB (approximately $6,000). DELIVER’s role was to manage implementation of work plan activities and budget. Mali: Final Country Report 15 The work plan outlined major activities like press article production around the topic of CS as well as awareness building among journalists and congressmen. The rationale behind this involvement is that— • Media and congress are important advocates for CS. • Journalists and congress need to be educated on CS issues and brought to the CS table. • Journalists can then be CS champions. Several radio broadcasting programs, TV interviews, and newspaper articles were produced and/or published by journalists from different institutions on the topic of advocacy for contraceptive security. REGIONAL ADVOCACY MEETINGS FOR CONTRACEPTIVE SECURITY Regional CS meetings were held (between January and August 2005) in the northern part of the country, in Kayes, Sikasso, and Segou. The goal of these meetings funded by UNFPA was to build CS awareness among regional decision makers and community leaders. DELIVER provided appropriate technical assistance for all of these meetings in collaboration with the DPM. Participants came from all districts and represented a vast range of institutions. Local community leaders, decision makers, health technicians, and local NGO leaders attended the meetings. The concept of contraceptive security was presented, and discussions revealed a real interest in the topic. Participants argued the need for communities to take a more active role in commodity management, which would in turn allow them to contribute more efficiently to contraceptive procurement. The cost- recovery program that is in place and decentralization should be seized as an opportunity to empower communities to foster contraceptive security. The DPM presented the Mali Contraceptive Security Plan and facilitated discussions. The major outcome of this session was that local leaders recommended that political leaders include the topic of CS in their meeting agenda at the Regional Parliament sessions. The process of advocating for a line item budget for contraceptive procurement was also widely discussed. Before ending these meetings, participants reviewed the activities already accomplished in the CS plan and the road ahead. Finally, participants designed a mini action plan to be implemented at the regional level. NATIONAL FAMILY PLANNING CAMPAIGN From March 14 to May 13, 2005, a national family planning campaign was implemented, with participation of high-level political leaders and all MOH stakeholders. The Prime Minister of the Government of Mali officially opened the campaign and the ceremony was widely broadcast in Bamako. DELIVER was asked to participate in this campaign by ensuring contraceptive availability in all Keneya CIWARA areas and training DVC storekeepers. The campaign was successful in mobilizing the population and its leaders around family planning issues, including service delivery, for a limited period of time. This influenced the utilization of family planning services in the period that followed the sensitization campaign. Major activities conducted during the campaign fell under the following categories: • behavior change communication (BCC) • media involvement • community mobilization • service provider training 16 Mali: Final Country Report • contraceptive and IEC material availability • advocacy for repositioning FP through media education programs • monitoring and evaluation of implemented activities. Major recommendations of the campaign included— • institutionalizing the campaign by electing a National FP Day, for which March 14 was chosen • strengthening the communication approach for FP by using local radio stations with adapted messages developed by communities • Better involving the private sector in such a campaign through financial and technical contributions • developing regional, district, and community leadership in campaign preparation and implementation. The organization of the FP campaign was a great opportunity to reinforce collaboration among stakeholders and relaunch FP activities, as well as build partnerships with end-users. DELIVER played an important role in the campaign by ensuring contraceptive availability, developing human capacity, building logistics management, and contributing to BCC messages. ELEMENT IV: IMPROVED ADOPTION OF ADVANCES IN LOGISTICS DELIVER carried out a number of studies and assessments resulting in advances in logistics in Mali. Some of the studies were aimed at finding solutions to CS issues and measuring the performance of the program. LOGISTICS QUALITATIVE AND PERFORMANCE ASSESSMENT USING LSAT AND LIAT The above-mentioned tools were developed by DELIVER and applied to the Mali program in 2001 and 2005. The 2001 assessment was used as baseline data to show the changes that occurred in the logistics system after the recommendations for improvements resulting from this assessment were implemented in DELIVER’s subsequent work plans. LIAT results for 2005 showed that products were available at SDPs. Stockouts of products were minimal. Most SDPs visited did not have expired products and physical inventory was carried out in all warehouses visited. Almost all warehouse managers had been trained in logistics. There was an overall improvement compared with 2001, as shown in figure 1. LSAT results showed significant strengths in forecasting, storage, coordination, distribution, and organizational support. However there were weaknesses, which were addressed in a plan of action with the participation of MOH stakeholders. Mali: Final Country Report 17 Figure 1. Logistics Indicator Assessment Tool Results, 2001 and 2005 79.2 54.7 45.3 86.8 98.1 77.4 83.0 98.1 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 % 100.0 Duofem/Pilplan Ovrette Condom /Protector Depo-Provera /Confiance LIAT I 2001 LIAT II 2005 ADVANCE FROM MARKET SEGMENTATION STUDY The conclusion drawn from the market segmentation study conducted in 2004 was that, given the low contraceptive prevalence rate, the priority goal should be to boost prevalence. There are, nevertheless, opportunities through market segmentation to improve cost recovery. Improved cost recovery will increase contraceptive security in Mali by ensuring a better allocation of scarce Government resources to the neediest and by cross-subsidizing products offered to lower-income clients. A change in the social marketing distribution system from a reliance on delivery to individual sellers to the use of private-sector wholesalers is a strategy that should contribute to greater coverage by the private sector. However, it requires more flexibility in private-sector margins than is currently allowed by the supply chain system. CAG is looking to make unilateral pricing decisions that technically require DPM approval since they contravene the SD and CAG’s contract with the DPM. COORDINATED INFORMED BUYING SYSTEM FOR REPRODUCTIVE HEALTH PRODUCTS An assessment was done in Mali in 2005 to find out whether procurement agencies would support the regional initiative of sharing reproductive products price information among Economic Community of West African States countries. The countries would take advantage of low-price, good-quality products obtained by other countries to order their own products. The assessment found that in Mali the two procurement agencies, PPM and CAG, are in support of information sharing and are in favor of setting up a coordinated informed buying system at the West African Health Organization. The assessment also found that there will be political support for such a system in Mali. 18 Mali: Final Country Report ADVANCE FROM DATA QUALITY ASSESSMENT DELIVER Mali collaborated with a USAID consultant in August 2005 to assist in a data quality assessment (DQA). The objectives of this assessment included— • carrying out an extensive data quality assessment of the CYP indicator • identifying any data quality issues associated with the indicator and proposing solutions, if possible • making recommendations for improved data collection, storage, and management. Major recommendations to advance DQA included— • DPM and DELIVER should continue to conduct an annual national physical inventory to ensure collection of accurate contraceptive commodity consumption data. The results of this activity should be used as a crosscheck to the use of contraceptive commodity distribution data in calculating CYP, and eventually, as the basis for calculation of CYPs reported. • Logistics training in data entry, reporting, and contraceptive commodity ordering for pharmacy managers in community health centers (CSComs) should be provided with DELIVER technical assistance, if possible, during fiscal year 2006. • Supervision of CSComs needs to be strengthened, which will be a continuous challenge due to cost and sustainability issues. • All operating units should retain copies of their commodity orders on file. All commodity requests made by telephone should be immediately written down and maintained in files at the requesting facility. All health facilities should compare commodity orders placed to actual deliveries received and identify any discrepancies encountered. • Efforts need to be made to ensure that nascent, community-based distribution programs are better integrated into the CSComs since the CSComs will ultimately be responsible for commodity resupply and supervision. CBD reports prepared by relais (CBD workers) should be provided to CSComs (SDPs), as well as to local NGO supervisors. CBD program results should be separately identified in circle and health regional reports submitted to DPM. DELIVER began implementing all recommendations of the assessment to advance data quality in Mali. ELEMENT V: ESTIMATION OF USAID CONTRACEPTIVE NEEDS DELIVER assisted the MOH in Mali over the four years of the project to estimate contraceptive requirements. These requirements are estimated for USAID-procured products but also for other donors such as UNFPA. DELIVER trained 12 staff members at the MOH and in the private sector to unable them to estimate requirements and do procurement planning using the PipeLine software. Estimates of requirements are updated every year for the current and following two years. The Malian team is now able to do the estimation and procurement planning with minimal assistance from DELIVER. Important progress has been made in recent months in collecting dispensed-to-user data for the estimation of contraceptive requirements. • LMIS and Pipeline Streamlining: DELIVER is working closely with the new social marketing program to continue cleaning up the pipeline and striving to collect more accurate data. In January 2005, new LMIS forms (including an innovative Requisition, Issue, and Receipt Voucher [RIRV]) were introduced throughout the system to allow the capture of accurate consumption data. These new LMIS forms were pilot tested in two regions and the district of Bamako, and are now being implemented at all SDP levels. Dispensed-to user data are starting to be available for forecasting purposes, and will thus result in more accurate CYP counts. Mali: Final Country Report 19 • MOH FP Campaign: In March 2005, the MOH and its partners (with USAID taking the lead) organized a thorough three-month campaign to reposition FP in Mali. With the commitment of political and religious leaders, the campaign reached the entire country and demand reached a new peak. Data collected during the second semester of 2005 (during and after the campaign period) reflected the success of this FP campaign. Stock imbalances throughout the system have been reduced and DELIVER has taken the necessary steps to better monitor the pipeline by conducting yearly national physical inventories, assessing stock status regularly, and introducing new data collection and reporting systems. 20 Mali: Final Country Report LESSONS LEARNED AND FUTURE DIRECTIONS A number of lessons have been learned through DELIVER’s assistance to Mali: 1. Innovative interventions such as facilitative supervision to address problems encountered by warehouse managers and flaws in product management helped improve system performance. 2. Both the MOH and the Mission recognized that DELIVER played a pivotal role in coordinating CS activities in Mali by assisting the CS committee and helping to rethink the CS strategic plan. Without this technical assistance, CS activities would not have moved forward as planned. 3. Without DELIVER’s presence, leveraging resources from other donors to carry out important technical activities vital to the logistics system would have been impaired. 4. A mass sensitization campaign on family planning led by high Government officials contributed to raising awareness about family planning and, to some extent, about contraceptive security and increased utilization of FP services in the short term following the campaign. However, sensitization should be sustained and seen as a medium- and long-term effort if contraceptive security is to be a reality in Mali. 5. Although the general atmosphere in Mali is one of a strong political commitment to CS and family planning as a whole, there is still palpable resistance to making bold decisions to improve the financial status of the family planning program, specially in the area of commodity procurement. 6. The Mali MOH has a great idea of training students and teachers in logistics in schools of health professionals. However, the idea should be further considered by integrating logistics into the school curriculum so it is taught permanently at health professional schools. 7. DELIVER’s advocacy work in favor of CS paid off. Through implementation of DELIVER programs, UNFPA derived a useful activity in sensitizing the regions in Mali on CS. 8. For CS activities to be efficiently implemented, more emphasis should be put on increasing service delivery performance. From the lessons learned, directions can be proposed for the future: 1. The CS strategy should be broadened to lay emphasis on additional aspects of contraceptive security. By focusing on logistics, the current contraceptive security strategy lacks the very much needed political support to free the resources for contraceptives. The strategy should also put more emphasis on service delivery so that contraceptive prevalence rates can be raised. 2. The reproductive health division should be given more responsibility in the oversight of the CS strategic plan, as it is in other countries. This will facilitate broadening the strategy to address service delivery, BCC, political commitment etc. Greater involvement of the reproductive health division will also improve the implementation of the strategic plan. 3. The DELIVER project closed out in September 2006, and the Mission requested a transition plan to ensure continuity in CS and logistics activities. This plan covers the period October 2006 to September 2007 and revolves around the following points: Mali: Final Country Report 21 • A CS coordinating body will be put in place and led by the DPM. Members are point persons from USAID, MOH/DPM, the bilateral project, CAG, and PPM. • Quarterly meetings will be held to assess the stock status situation and make appropriate decisions to resolve issues. These meetings should also be seized as an opportunity to monitor CS activity implementation. • Quarterly logistics supervision will occur in the regions to follow up on activities already in place and strengthen the logistics system. An OJT approach is recommended for these activities. The DPM and the Mission will need to conduct this activity jointly. • The DPM will continue conducting annual national physical inventories to palliate the lack of consumption data for forecasting purposes. This must continue until the new reporting system becomes fully functional nationwide. Major activities identified for the transition plan include— • Advocacy for CS Plan Implementation: This includes resource mobilization for financing CS activities and contraceptive procurement. • Needs Estimation: The forecasting committee should complete annual needs estimations and review them six months later. The MOH/DPM is the lead for this activity. Effort should be made to improve data collection and on-time reporting for forecasting. • Activity Planning: CS activities should be integrated into district annual operational plans, and districts should be assisted with their planning. • Logistics Management Performance Improvement: Storekeepers’ competencies should be strengthened though OJT visits. Supply chain norms and procedures should be respected at all levels through integrated supervision and OJT training. • Data Collection and Reporting: Availability of LMIS forms should be ensured, along with transmittal of information from SDPs to upper levels. LMIS forms should be printed and made available in all SDPs. SDPs should also integrate LMIS reprinting in their annual plans to ensure sustainability. The national physical inventory should continue to be conducted as an alternative solution until the system becomes more efficient in terms of reliable data collection. • Logistics Institutionalization: A logistics management module should be introduced in all preservice schools. • Monitoring and Evaluation of the CS Plan: Monitoring and evaluation should take place through reports and periodic, coordinated internal or external evaluations planned by the MOH. 22 Mali: Final Country Report REFERENCES Aronovich, Dana, Briton Bieze, Ibnou Diallo, and Youssouf Ouedraogo. 2005. Evaluation des Indicateurs et du Système de Gestion Logistique des Contraceptifs et des Médicaments de Traitements des IST du Mali. Arlington, Va.: DELIVER, for the U.S. Agency for International Development. DELIVER: Mali Annual Work Plans. 2002–2006. Arlington, Va.: DELIVER, for the U.S. Agency for International Development. Diallo, Abdourahmane, and Meba Kagone. 2005. An Assessment of Interest and Potential for Informed Buying for Reproductive Health Commodities in Mali. Arlington, Va.: DELIVER, for the U.S. Agency for International Development. Diallo, Ibnou. Mali Quarterly Performance Reports. 2002–2006. Arlington, Va.: DELIVER, for the U.S. Agency for International Development. Diarra, Aoua. 2002. Mali: Country Strategic and Evaluation Plan. Arlington, Va.: DELIVER, for the U.S. Agency for International Development. Dowling, Paul, and David Sarley. 2004. Contraceptive Market Segmentation and Pricing Analysis. Arlington, Va.: DELIVER, for the U.S. Agency for International Development. USAID Mali. 2002. Country Strategic Plan FY 2003–2012: Reducing Poverty and Accelerating Economic Growth Through Partnerships. Bamako, Mali: U.S. Agency for International Development. Mali: Final Country Report 23 24 Mali: Final Country Report APPENDIX 1 CS BRIEF MALI 2006 Contraceptive Security Brief Population Population growth rate Women of reproductive age Fertility rate CPR (modern methods) Public sector Private medical sector Other source HIV/AIDS prevalence rate Health regions, districts, and SDPs providing RH/FP services (their numbers) 11,000,000 (PRB) 3.0% per annum 6.8% (Mali DHS III 2000) 5.8% (Mali DHS III 2000) 51.0% (Mali DHS III 2000) 34.0% (Mali DHS III 2000) 11.5% (Mali DHS III 2000) 2.03% (UNAIDS/WHO Epidemiological Fact Sheet, 2000) 9 regions (including the district of Bamako) 56 districts 595 SDPs (as of March 2003) Forecasting 1. Current method mix and projected trend (Mali DHS III 2000) Pills, 48.27%; IUDs, 3.45%; injectables, 36.21%; condoms, 5.17%; female sterilization, 5.17%; implants, 1.72% (Mali DHS III 2000) Consumption trends show a growing increase in use of injectables. 2. Presentation and use of CPTs in management decision making • By the Local Government: The government has adopted a list of contraceptive commodities to be integrated into the essential drug system based on the consumption rate of products in the past CPTs. Also, the shipment schedule by recipient is based on the ratio of distribution of each recipient. The CPTs allow the MOH to make its request for assistance and commodities (in quantities and shipment date) from all donors (USAID, UNFPA). • For USAID: The CPTs allow the Mission to determine the level of its funding for supplying contraceptive commodities. They also help to set the objective of contraceptive distribution within the projects supported by USAID and the assistance to the MOH (IEC, training, research, etc.) Mali: Final Country Report 25 • There is an existing Forecasting Committee (lead by the DPM) which is becoming sustainable in forecasting. 3. Assumptions related to data used in the CPTs (approach used) During CPTs, each program’s data are analyzed and adjusted. Future projections are based on past increases and program objectives and perspectives. 4. Sources and accuracy of data used in forecasting (data quality) The main issue concerning logistics data in Mali is that the LMIS collapsed when contraceptives were integrated into the essential drug system and no dispensed-to-user data are available for forecasting. CPT field visits need to be conducted prior to data validation for any CPT exercise. In the meantime, district warehouse issues are used in CPTs. An effective data collection mechanism is being put in place now to allow the system to obtain dispensed-to-user data in the future. New LMIS forms are designed to ensure accurate data collection, analysis, and reporting. 5. Role of technical assistance The Mali MOH has prepared a strategic plan for contraceptive security for the period 2002–2011. The purpose of the plan is to guarantee sustainable availability of contraceptive commodities and the provision of quality services in the area of contraception. The DELIVER project appointed a resident advisor in Mali in August 2002 on request of the MOH and the Mission. He is responsible for global coordination of the Contraceptive Security Strategic Plan and translation of the national commission’s directives into action; specifically, in collaboration with the DPM. Procurement 1. Existence and role of the Procurement Unit The National Drug Warehouse (PPM) has a Procurement Division, whose role is to plan and procure essential drugs for the public sector. Contraceptives are donated in Mali and there is no such Procurement Unit for contraceptive commodities. 2. Stock Status Analysis over a one-year period (overstocks, stockouts, and consistency of procurement plans) PPM Central Warehouse Managers have difficulty controlling the established review period of clients. This situation results in a regular stock imbalance at the central PPM Warehouse. Procurement plans are not consistent, especially with the social marketing program and UNFPA commodities. There were no true stockouts at the central level over the past couple of years. However, down the pipeline fictive stockouts do occur, often for operational reasons and not because of lack of product availability at higher pipeline levels. 3. Contraceptive supplier situation (percentage of commodities provided by supplier) USAID is the main supplier/donor of contraceptives in Mali for both the public sector (PPM) and the social marketing program (CAG). USAID-supplied commodities are Duofem, Depo-Provera, Blue and Gold condoms, Ovrette, and IUDs. UNFPA provides Neo-Sampoon and Norplant. IPPF supplies Noristerat and Femidon (female condom) to AMPPF. KfW is supplying all social marketing commodities (since December 2006), which will free up some field support money. 26 Mali: Final Country Report 4. Historical, current, and future role of USAID Historically, USAID has been the major contraceptive as a contraceptive donor supplier in the country. However, in the context of the Contraceptive Security Plan, USAID’s contribution is expected to decrease gradually in the future. With the arrival of KfW, USAID will have more field support money that can be used to finance additional logistics and service quality activities. Financing 1. Commodity funding mechanism (i.e., basket funding, cost recovery, local public funds, etc.) There is no basket funding. This used to be the case with the Projet Sante Population et Hydraulique Rurale, which ended in 1998. USAID is now funding through DELIVER field support money and direct allocation to the MOH/DAF (Finance and Management Office). 2. Current and future donor contribution in commodity financing plan over the next five years Currently, USAID provides about 98% of commodities; UNFPA, around 2%; and other, less than 1%. Over the next five years, USAID will provide 85%; KfW, 10% (especially social marketing products); UNFPA, 2%; MOH, 3%; and other, less than 1%. 3. USAID/Mission intervention strategies (strategic objectives and plan for contraceptive security) According to the recent USAID/Mali country strategic plan parameters paper for fiscal years 2003–2012, drafted in March 2001, the Mission plans to change its approach. In this paper, one strategic objective focuses on “responsible reproductive and child health,” which aims to “increase the use of selected health services,” with an emphasis on stemming the HIV/AIDS epidemic in Mali, increasing contraceptive use, and targeting priority child health problems. The paper also clearly states that achieving this objective will require the consistent availability of standardized HIV test kits and family planning and child survival products. It continues, “commodity logistics systems will be strengthened in order to ensure product availability.” Supply Systems 1. Length of the pipeline 21 months: central, 12; regional, 3; district, 4; SDP, 2 2. Major institutions involved in RH/FP activities MOH, USAID, UNFPA, World Bank, Prime II, Policy Project, bilateral projects, PSI, JSIDELIVER, local NGOs 3. LMIS status (level of efficiency) The LMIS was redesigned and put in place during fiscal year 2005, with new LMIS forms that capture dispensed-to­ user data. Training and OJT supervision are being carried out on an ongoing basis to help strengthen the new LMIS system. 4. Commodity availability at SDPs According to DPM’s recent supervisory visits, commodity availability is estimated at 80% at SDPs. Mali: Final Country Report 27 Major Issues 1. The National Contraceptive Security Plan is officially approved by MOH and its financial partners. There are some procedural difficulties hindering the introduction of a line item budget for contraceptive procurement as stated in the CS Plan. The Mission and the MOH are working together to make this happen before the end of 2006. 2. UNFPA is contributing heavily in the Plan’s implementation activities. 3. Market segmentation is still an issue. Commodity prices are the same for both social marketing and the public sector. Prices should be differentiated. 28 Mali: Final Country Report APPENDIX 2 DELIVER KEY CSEP INDICATORS AND PROGRAM RESULTS Indicator Data Source Baseline (yr) Target (yr) Achieved Comments • Stock data quality • LMIS data quality • Percentage of facilities reporting according to schedule • Stock status between max/min • Frequency of stockouts Physical Inventory Report LMIS Pilot-test Report USAID Data Quality Analysis 2003 2005 Ongoing Level of stockouts are lower (47% of SDPs surveyed during the national inventory) Established mechanisms to collect and report reliable dispensed- to-user data to the central level New LMIS forms are being implemented to allow accurate data collection. Condom overstock is being resolved though more realistic CPTs. • Forecast accuracy at central level • Stock status between max/min at central level CPT 2005 2002 2005 Transfer of expertise in forecasting and procurement planning at the central level Multi-year procurement plan to ensure adequate stock levels Accurate forecasts of requirements are based on logistics data. Estimation of needs, procurement plans, and stakeholder commitment to procurement plans are reviewed semi-annually, resulting in timely and accurate CPTs submitted annually. Mali: Final Country Report 29 Stakeholder commitment to procurement plan Percent of facilities receiving supervision visits according to schedule Reports of logistics supervisory visits Local supervisors are trained in how to use the supervision guidelines and OJT tools at the central and regional levels. 2002 2005 Four regions supervised this year Existence of curriculum developed according to schedule Percent of trainees completing competency-based training Existence of a coordinated approach to addressing issues from CS Strategic Plan Logistics System Assessment Tool (LSAT) exercise conducted annually LIAT and LSAT indicators Curriculum developed (and tailored) to be used in all MOH logistics management training programs Meetings reports Market and pricing TA LSAT TA report LIAT 2003 2004 Training curriculum on logistics management developed Donor contribution secured (USAID and UNFPA) 2002 2005 2003 2001 2005 2005 LSAT conducted in November 2005 LIAT conducted in December 2005 Forty-nine DRC storekeepers and 53 central district storekeepers have been trained. All recommendations and activities from studies are complementary and address issues from the CS Strategic Plan. Qualitative indicators of logistics management are used to monitor progress towards meeting objectives using the LSAT annually. Source: (DELIVER. Mali Annual Work Plans. 2002–2006.) 30 Mali: Final Country Report Annual Indicators Table: Indicator IR1.1: Contraceptive Security Policy Environment Performance Indicator Values 2005 Composite Score Values Notes 1 Membership is permanent. National steering committee meetings held as planned (1 point) 1 The committee also meets on exceptional cases. 1 Forecasting is reviewed halfway through. The inventory was conducted in 53 out of 56 DRCs this year. The MOH proposed this following line item: "Essential Drugs Procurement, including Contraceptives" for 2005/2006 vote. Total health budget set-aside for contraceptives increased from past year (1 point) 0 6 5 Joint procurement completed based on forecasting (MOH contribution required) (1 point) 1 Donor contribution is secured. 1 Development of a national steering committee for contraceptive security (1 point) Joint donor-MOH forecasting done every year (1 point) Annual national inventory completed (1 point) Existence of line item within health budget for contraceptives (1 point) Total Score Target Score Market segmentation study carried out every three years (1 point) 1 The next study should be planned for 2007. 0 Mali: Final Country Report 31 32 Mali: Final Country Report APPENDIX 3 DELIVER MALI TRANSITION PLAN (DRAFT) PLAN DE TRANSITION DELIVER MALI OCTOBRE 2006 - SEPTEMBRE 2007 Aoua Diarra Ibnou Diallo Mali: Final Country Report 33 DELIVER DELIVER est un contrat d’assistance qui s’étale sur six ans et qui vise à fournir une aide technique à niveau mondial. DELIVER est financé par l’Agence des États-Unis pour le Développement International (USAID). Mis en oeuvre par John Snow, Inc. (JSI) (contrat no HRN-C-00-00-00010-00), et par les sous-traitants Manoff Group (Groupe Manoff), Program for Appropriate Technology in Health (Programme pour la Technologie Appropriée en matière de Santé) et Crown Agents Consultancy, Inc., le projet DELIVER vise à renforcer les chaînes d’approvisionnement des programmes de santé et de planification familiale dans les pays en voie de développement, et ce afin d ’assurer la disponibilité des produits de santé d’importance capitale pour les clients des dits programmes. DELIVER fournit également une assistance technique pour le système central de l’USAID pour la gestion des contraceptifs. Le présent document ne réflète pas nécessairement les points de vue ou les opinions de USAID. Il peut être reproduit uniquement si le nom de DELIVER est mentionné. Citation recommandée Diarra Aoua, Ibnou Diallo, 2006. Plan de transition deliver mali, octobre 2006 - septembre 2007, Arlington, VA: DELIVER, pour l’Agence des États-Unis pour le Développement International (USAID). 34 Mali: Final Country Report EXTRAIT Le gouvernement du Mali à travers le Ministère de la Santé a décidé en 2001 de se doter d’un Plan Stratégique Décennal de Contraception Sécurisée afin de rendre autonome le programme national en termes d’acquisition des produits contraceptifs et de financement de toutes les activités liées à la gestion de la chaîne d’approvisionnement de ces produits, ainsi qu’à l’offre de services de qualité dans le domaine de la contraception. De fin 2002 à nos jours, le projet DELIVER de John Snow, Inc., sur requête de l’USAID, a porté une assistance technique au Ministère de la Santé à travers sa Direction de la Pharmacie et du Médicament dans la planification et la mise en œuvre du plan stratégique pour la contraception sécurisée Le système de gestion logistique des contraceptifs a connu un support continu de divers partenaires depuis 2001 et a actuellement tous les atouts nécessaires pour une excellente gestion. Cependant des efforts doivent être faits pour améliorer le système d’information de gestion logistique, renforcer la compétence de gestionnaires de stock, assurer le financement continu de l’approvisionnement avec une contribution maximale de l’Etat et appliquer les normes élaborées en matière de gestion logistique. Les activités prioritaires proposées pour la phase de transition sont les suivantes : - Plaidoyer pour le financement des activités du plan de contraception sécurisée et mobilisation des ressources pour le financement des activités du plan et l’approvisionnement en contraceptifs - Estimation annuelle des besoins en contraceptifs par le comité de prévision : Placer cette activité sous l’initiative et la responsabilité de la DPM. - Amélioration de la collecte des données nécessaires pour les prévisions et collecter ces informations en temps opportun - Planification des activités : Intégrer les activités du plan stratégique pour la contraception sécurisée dans les plans d’opération (PO) des cercles et donner un appui aux cercles lors de l’élaboration des PO - Développement des capacités du personnel en gestion logistique. Privilégier la supervision formative comme outil de renforcement des capacités des gestionnaires. Assurer l’application correcte des procédures et normes à tous les niveaux de la chaîne d’approvisionnement par la supervision intégrée et la formation des agents sur le site à travers les projets et ONG dans leurs aires respectives. - Collecte des données et rapports de gestion logistique : veiller à la disponibilité et l’utilisation des supports de gestion logistique et la transmission de l’information, surtout au niveau des points de prestations de services. Multiplier les nouveaux supports de collecte de données et les mettre à la disposition de toutes les structures en dotation initiale. Les structures devront incorporent cette activité dans leurs plans d’opérations en vue de la pérennisation du système. Continuer l’inventaire physique national comme une solution alternative en attendant le fonctionnement efficace du nouveau système d’information - Institutionnalisation de la gestion logistique des produits de santé dans le pays en introduisant un module de gestion logistique dans le curriculum des écoles de formation de base en santé - Suivi et évaluation du plan stratégique à travers les rapports des structures, les réunions de coordination et les évaluations internes et externes DELIVER John Snow, Inc. 1616 North Fort Myer Drive, 11th Floor Arlington, VA 22209 USA Phone: 703-528-7474 Fax: 703-528-7480 Email: deliver_project@jsi.com Internet: deliver.jsi.com Mali: Final Country Report 35 36 Mali: Final Country Report TABLE DES MATIÈRES REMERCIEMENTS.38 DOMAINES DE GESTION LOGISTIQUE DES CONTRACEPTIFS NECESSITANT UNE ATTENTION ROLE DES DIFFERENTS ACTEURS DE LA CONTRACEPTION SECURISEE DURANT LA PHASE DE CONTEXTE.39 BUT DU PLAN DE TRANSITION.39 INTERVENTIONS DU PROJET DELIVER AU MALI .40 FORCES DU SYSTEME LOGISTIQUE ACTUEL DES CONTRACEPTIFS .41 PARTICULIERE.43 SUGGESTIONS POUR L’AMELIORATION DU SYSTEME.45 ACTIVITES PRIORITAIRES POUR LA PHASE DE TRANSITION.47 TRANSITION (1ER OCTOBRE 2006 - 30 SEPTEMBRE 2007).48 Mali: Final Country Report 37 REMERCIEMENTS Les auteurs de ce document remercient le Ministère de la Santé du Mali et plus particulièrement le personnel de la Direction de la Pharmacie et du Médicament pour la collaboration fructueuse que le personnel de cette Direction a su établir avec le Projet DELIVER au Mali pendant ces quatre dernières années Notre reconnaissance va également à tous les membres du comité de coordination pour la contraception sécurisée et à tous les intervenants en matière de planification familiale au Mali. Leur engagement et leur contribution ont, à n’en pas douter, contribué au renforcement du système logistique des produits contraceptifs. Une attention particulière va aux personnels des directions régionales de santé, et des centres de santé qui ont fortement contribué à la planification et à la mise en œuvre du plan stratégique sur le terrain. Les auteurs tiennent à remercier également l’équipe Santé de l’USAID et tous les partenaires financiers et au développement qui n’ont ménagé aucun effort pour promouvoir la santé des populations maliennes spécialement dans le domaine de la santé de la reproduction. Nous n’oublions pas le personnel malien du Bureau DELIVER Mali pour leur dynamisme et leur engagement pendant toute la durée du Projet. Enfin nous remerciements vont à tous ceux qui de près ou de loin ont contribué d’une façon ou d’autre à l’exécution des activités du plan stratégique pour la contraception sécurisée et ont facilité le travail du Projet DELIVER au Mali. 38 Mali: Final Country Report CONTEXTE Le ministère de la santé a enregistré des progrès dans le domaine de la planification familiale au Mali, mais il se trouve aussi confronté à certaines insuffisances par rapport à la disponibilité des produits contraceptifs et à la pérennisation de l’approvisionnement en contraceptifs du pays. Le gouvernement du Mali à travers le Ministère de la Santé a décidé de se doter d’un Plan Stratégique Décennal de Contraception Sécurisée afin de rendre autonome le programme national en termes d’acquisition des produits contraceptifs et de financement de toutes les activités liées à la gestion de la chaîne d’approvisionnement de ces produits, ainsi qu’à l’offre de services de qualité dans le domaine de la contraception. Un atelier national regroupant tous les intervenants en matière de planification familiale au Mali a été organisé en juillet 2001 à Bamako, à l’issu duquel, un draft de plan stratégique a été présenté par les participants. Ce plan a été finalisé et validé par une commission nationale de mise en œuvre et de suivi du plan en mars 2002 et adopté par le conseil élargi de cabinet du ministère de la santé en avril de la même année. La version finale du plan a été présentée aux bailleurs de fonds lors d’une table ronde organisée en Mai 2002. De façon spécifique, le plan de contraception sécurisée du Mali vise à : 1) assurer la transition des dons de produits contraceptifs par les partenaires au développement à une acquisition graduelle de ces produits par l’Etat, 2) améliorer la gestion de la logistique contraceptive, 3) améliorer la qualité des services planification familiale (PF) fournis aux clients, et 4) relancer la distribution à base communautaire (DBC) des contraceptifs. Entre autres partenaires au développement, l’USAID s’est engagé à apporter son soutien au gouvernement malien pour la mise en œuvre du plan stratégique de contraception sécurisée. Pour ce faire, il a requis l’assistance technique d’une agence de coopération américaine spécialisée dans la conception, la mise en œuvre et le suivi/évaluation des systèmes de gestion de la chaîne d’approvisionnement des produits de santé, en l’occurrence le projet DELIVER géré par John Snow, Inc. (JSI). Un bureau de DELIVER a été ouvert au Mali et un conseiller résident affecté à ce poste le 1er Août 2002 pour appuyer la Direction de la Pharmacie et du Médicament du Ministère de la Santé dans la mise en œuvre et le suivi du Plan Stratégique pour la Contraception Sécurisée au Mali. Le projet DELIVER de JSI tire à sa fin et la clôture des activités est prévue pour le 30 septembre 2006. L’USAID a demandé au projet DELIVER de présenter un plan de transition pour la gestion logistique des contraceptifs au Mali. BUT DU PLAN DE TRANSITION Ce plan de transition vise à assurer une continuité dans la gestion logistique des produits contraceptifs (estimation des besoins, acquisition et distribution des produits), et dans le suivi du plan stratégique pour la contraception sécurisée au Mali (environnement politique, financement des activités, suivi et évaluation du système), à partir de la fin du projet DELIVER en Septembre 2006. Mali: Final Country Report 39 INTERVENTIONS DU PROJET DELIVER AU MALI DELIVER est un contrat d’assistance qui s’étale sur six ans et qui vise à fournir une aide technique au niveau mondial. DELIVER est financé par l’Agence des États-Unis pour le Développement International (USAID). Mis en oeuvre par John Snow, Inc. (JSI) (contrat no HRN-C-00-00-00010-00), et par les sous-traitants Manoff Group (Groupe Manoff), Program for Appropriate Technology in Health [PATH] (Programme pour la Technologie Appropriée en matière de Santé) et Crown Agents Consultancy, Inc., le projet DELIVER vise à renforcer les chaînes d’approvisionnement des programmes de santé et de planification familiale dans les pays en voie de développement, et ce afin d ’assurer la disponibilité des produits de santé d’importance capitale pour les clients des dits programmes. DELIVER fournit également une assistance technique pour le système central de USAID de gestion des contraceptifs. De fin 2002 à nos jours, le projet DELIVER, sur requête de l’USAID, a porté une assistance technique au Ministère de la Santé à travers sa Direction de la Pharmacie et du Médicament dans la planification et la mise en œuvre du plan stratégique pour la contraception sécurisée. Les interventions du projet ont essentiellement porté sur : - L’amélioration du système de gestion logistique - L’amélioration des compétences du personnel en gestion de la chaîne d’approvisionnement en contraceptifs - Les prévisions et l’estimation des besoins en contraceptifs - Le stockage et la distribution de ces produits - La formation et la supervision du personnel chargé de la gestion de la chaîne d’approvisionnement en contraceptifs - Le suivi et l’évaluation du système de gestion logistique - Les études de prix des contraceptifs Ces interventions ont porté sur la gestion des produits distribués aussi bien dans le réseau publique que dans le réseau privé du marketing social. Les évaluations du système logistique des contraceptifs effectuées en 2001 et 2005 ont permis de déterminer les forces et les faiblesses du système logistique des contraceptifs au Mali comme décrit dans les chapitres suivants2. 2 Evaluation des Indicateurs et du Système de Gestion Logistique Des Contraceptifs et des Médicaments de Traitements des ISTdu Mali - Projet DELIVER, USAID, Décembre 2005 40 Mali: Final Country Report FORCES DU SYSTEME LOGISTIQUE ACTUEL DES CONTRACEPTIFS POLITIQUE ET CONTEXTE ORGANISATIONNEL Au Mali le contexte organisationnel est favorable à l’obtention d’un système logistique fonctionnel. Un Schéma Directeur d’Approvisionnements en Médicaments Essentiels (SDAME) a été conçu et appliqué. Il existe des guides et standard de gestion des médicaments. A ce jour le Mali est en excellente position dans le processus d’accès à la sécurité contraceptive. Ceci se traduit par l’existence d‘un comité de coordination, d’un plan d’action stratégique et d’un coordinateur mandaté. Des réunions de coordination sont tenues pour discuter des problèmes identifiés en cours d’exécution du plan et proposer des solutions. FINANCEMENT L’USAID et l’UNFPA se sont engagés jusqu’à présent à assurer la couverture contraceptive du pays. KfW devrait prendre en charge les approvisionnements en produits du marketing social à partir de Décembre 2006. PREVISIONS Il existe un comité national chargé des prévisions et de l’estimation des besoins du pays en contraceptifs. Ce comité a atteint un bon niveau d’autonomie technique lui permettant d’assurer les prévisions sans grand appui technique extérieur. SYSTEME D’INFORMATION DE GESTION LOGISTIQUE (SIGL) - L’utilisation des supports de données logistiques au niveau cercle s’est nettement améliorée. Il a été observé une existence des supports du SIGL dans la plupart des centres visités (Fiche de Stock, Bon de Commande). - De nouveaux supports SIGL ont été introduits par la DPM avec l’assistance du projet DELIVER. Ces supports permettent la collecte et la transmission de données fiables sur la consommation des produits et la situation des stocks - Une dotation initiale en supports de collecte d’information logistique a été fournie à toutes les régions. - Le système de commande de produits fonctionne conformément aux directives au niveau de toutes les structures de cercle visitées lors de l’évaluation susmentionnée. GESTION DES INVENTAIRES ET CONTROLE DES STOCKS AU NIVEAU CERCLE - La majorité des DRC appliquent la formule de la quantité à commander pour leur réapprovisionnement. Les quantités reçues correspondent aux quantités commandées. Les rapports de gestion de stocks de produits contraceptifs sont utilisés dans la totalité des entrepôts pour le réapprovisionnement des structures. - Il a été observé une réduction des ruptures de stock de contraceptifs en 2005 comparé à la situation présentée en 2001. La plupart des centres visités lors de la dernière évaluation du système effectuée en 2005 n’ont pas enregistré de péremption de produits contraceptifs. Un inventaire mensuel des stocks de contraceptifs est effectué dans toutes les structures visitées. Mali: Final Country Report 41 - Les gérants de DRC sont en majorité compétents en matière de prise d’inventaire dans les CSCOM de leurs aires géographiques. STOCKAGE DES PRODUITS Le système d’entreposage et de stockage répond en général aux conditions requises avec 80% des structures remplissent au moins 75% des conditions appropriées de stockage. TRANSPORT ET DISTRIBUTION Les délais de livraison sont très courts (moins de 2 semaines en majorité). Les structures sont responsables du transport de leurs produits et trouvent divers moyens pour acheminer à temps les produits GESTION DU PERSONNEL Le ministère de la santé a défini une approche intégrée et un plan de supervision des différents niveaux de la pyramide sanitaire. Une équipe de la Direction Régionale de la Santé, qui comprend normalement le pharmacien régional, visite les Centres de Santé de Référence (CSref) et les DRCs chaque trimestre. Cette pratique qui était irrégulière en 2001 est devenue plus fréquente en 2005 et la majorité des structures visitées (60%) ont reçus au moins une visite de supervision courant 2005. La totalité des agents impliqués dans la gestion logistique au niveau central a été formé. Il en est de même pour les pharmaciens régionaux et les gérants des DRC. 85% des gérants de DV ont également été formés. 42 Mali: Final Country Report DOMAINES DE GESTION LOGISTIQUE DES CONTRACEPTIFS NECESSITANT UNE ATTENTION PARTICULIERE POLITIQUE EN MATIERE DE CONTRACEPTION SECURISEE ET CONTEXTE ORGANISATIONEL Il a été noté que l’application des principes de gestion dans les points de prestations de services demeure encore, largement en dessous de celle des entrepôts. La plupart des gérants de CSCom n’arrivent pas à tenir correctement les supports logistique et à estimer les besoins des leurs structures en contraceptifs. Ceci s’explique en partie par le fait que le personnel est recruté par les comités de santé qui, pour la plupart du temps, ne tiennent pas compte du niveau technique des candidats mais plus de leur crédibilité et de leur relation sociale. Ces gérants n’ont pas dans la majorité des cas le niveau d’éducation scolaire nécessaire pour suivre les enseignements donnés lors des sessions de formation. FINANCEMENT DE L’APPROVISIONNEMENT EN CONTRACEPTIFS L’approvisionnement du pays en contraceptifs est toujours dépendant des subventions des partenaires financiers. L’inscription d’une ligne budgétaire dans les dépenses du MS pour l’achat de contraceptifs est à l’étude mais se heurte encore à des obstacles administratifs. SYSTEME D’INFORMATION DE GESTION LOGISTIQUE (SIGL) AU NIVEAU DE LA PRESTATION DE SERVICES - En général les principes de gestion logistique pour les commandes, les rapports et l’utilisation des données essentielles de logistique ne sont pas toujours respectés, surtout au niveau des CSCom. La tenue des supports logistique n’est pas bonne dans son ensemble et certains gérants de dépôts manquent de formation. Il a aussi été observé que certains gérants de dépôts n’ont pas le niveau minimum requis pour assumer leur fonction - Les formulaires de gestion quoique disponibles ne sont pas utilisés dans la majorité des dépôts de vente et on observe une insuffisance dans la transmission des rapports de gestion logistique des prestataires. - Le nouveau système d’information logistique n’est pas encore appliqués sur l’ensemble le du pays. De ce fait, les bons de commande n’incluent pas encore de façon uniforme les informations essentielles pour la gestion logistique. - L’utilisation des rapports de gestion de stocks de produits contraceptifs se fait dans seulement 61% des points de prestations de service. GESTION DES INVENTAIRES ET CONTROLE DES STOCKS - Dans la majorité des dépôts de vente de CSCom le personnel ne maîtrise pas la méthode d’estimation des quantités pour le réapprovisionnement et applique différentes procédures de commande de produits. - La non-disponibilité de l’information sur la gestion logistique est aussi une cause importante des insuffisances du système de réapprovisionnement des structures de prestations de services. Mali: Final Country Report 43 STOCKAGE DES PRODUITS Un aspect important dans les conditions idéales de stockage des produits est cependant négligé dans la plupart des dépôts périphériques. Malgré l’apport incontesté des médicaments dans les revenus des structures sanitaires, les dépôts ne disposent pas dans la plupart des cas de matériel de sécurité incendie, ce qui peut avoir comme conséquences la destruction totale d’un magasin en cas d’incendie. GESTION DU PERSONNEL/ SUPERVISION - La supervision intégrée, bien qu’effectuée n’accorde pas assez d’importance à la composante gestion logistique notamment des contraceptifs et le temps alloué aux activités de supervision par structure ne permet pas d’assurer une formation du personnel sur le site. - Seulement 12% des gérants de CSComs ont été formés en gestion logistique. La DPM n’a pas suffisamment de ressources pour effectuer une formation en cascade du personnel jusqu’à ce niveau. Cette activité devrait de façon idéale s’intégrer dans les activités des projets qui sont actuellement mis en oeuvre sur le terrain (Ciwara, Save, Groupe Pivot et ASDAP) OFFRE DES SERVICES DE PF - Bien qu’il ait été constaté une amélioration de la disponibilité des produits contraceptifs au niveau des DRC, tous les points de prestations de services n’offrent pas encore la gamme complète des méthodes modernes de contraception, soit parce tous les produits ne sont pas disponibles - le recouvrement de coûts impliquant que les gestionnaires ne réapprovisionnent qu’en produits utilisés - soit parce que le personnel n’est pas formé ou qu’il n’a pas le matériel nécessaire pour offrir la méthode (exemple : DIU, implant). - Malgré l’existence de normes et procédures en santé de la reproduction, on constate qu’elles ne sont pas toujours appliquées; la supervision telle que faite n’y contribue pas et la demande des méthodes contraceptives reste encore faible. 44 Mali: Final Country Report SUGGESTIONS POUR L’AMELIORATION DU SYSTEME POLITIQUE ET CONTEXTE ORGANISATIONNEL - Assurer l’application correcte des procédures et normes à tous les niveaux de la chaîne d’approvisionnement - Rendre disponible le matériel pour l’insertion du DIU et implants auprès des prestataires formés. - Faciliter l’accès des clients aux produits contraceptifs (exemple des produits qui ne nécessitent pas que les clients aient une ordonnance pour s’approvisionner ou se réapprovisionner). - Respecter les principes du schéma directeur d’approvisionnement en contraceptifs - Intégrer les activités du plan stratégique pour la contraception sécurisée dans les plans d’opération (PO) des cercles PREVISIONS - Utiliser au mieux le comité de prévision pour l’estimation annuelle des besoins en contraceptifs et améliorer la collecte des données nécessaires pour les prévisions et collecter ces informations en temps opportun. - Informer tous les partenaires des résultats des prévisions et des tableaux d’acquisition des contraceptifs et obtenir leur engagement à financer l’approvisionnement en contraceptifs du pays FINANCEMENT DE L’APPROVISIONNEMENT EN CONTRACEPTIFS - S’assurer du respect des engagements des partenaires financiers et de inclure une contribution graduellement croissante de l’Etat dans l’approvisionnement du pays en contraceptifs - Renforcer les activités de plaidoyer en faveur de la contraception sécurisée (pour mobiliser les ressources internes (recouvrement de coûts, participation de la population, subventions de l’Etat, système de sécurité sociale, etc) et externes (partenaires financiers) nécessaires à l’approvisionnement en contraceptifs et pour l’exécution des activités du plan stratégique pour la contraception sécurisée.) SYSTEME D’INFORMATION DE GESTION LOGISTIQUE (SIGL) - Améliorer la disponibilité et l’utilisation des supports de gestion logistique et la transmission de l’information, surtout au niveau des points de prestations de services. La DPM a conçu de nouveaux supports de gestion qui permettent de collecter les données essentielles de logistique et qui sont à la phase introductive. Il est important que ces supports soient multipliés et mis à disposition de toutes les structures en dotation initiale et que les structures incorporent cette activité dans leurs plans d’opérations en vue de la pérennisation du système. - Informatiser la gestion logistique au niveau des DRC, les doter en outils informatiques (logiciel et ordinateurs), former les gérants à l’utilisation du logiciel de gestion des stocks, et créer une base des données de gestion logistique. - Continuer l’inventaire physique national comme une solution alternative en attendant le fonctionnement efficace du nouveau système d’information qui devrait permettre de collecter et de transmettre les informations essentielles pour la gestion logistique (quantités de produits utilisées, pertes de produits dans le système et quantités de produits disponibles dans l’ensemble du circuit logistique). Mali: Final Country Report 45 GESTION DES INVENTAIRES ET CONTROLE DES STOCKS - Veiller à l’application des directives et méthodes préconisées en matière de réapprovisionnement des dépôts et points de prestations de services et des paramètres de fonctionnement du pipeline. - Renforcer les capacités du personnel des points de prestations de services en estimation des besoins pour le réapprovisionnement et en analyse de la situation des stocks STOCKAGE DES PRODUITS S’assurer que les dépôts de médicaments à tous les niveaux répondent aux normes d’entreposage et disposent du matériel approprié pour le stockage des produits et l’assurance qualité des produits. GESTION DU PERSONNEL/ SUPERVISION - Relever le niveau de recrutement des gérants des dépôts et recruter sur la base de descriptions de poste du personnel - Former en logistique tous les agents responsables de la gestion logistique et veiller à l’application des compétences acquises - Veiller à une meilleure intégration de la gestion logistique dans les supervisions intégrées par le développement et l’utilisation d’outils de supervision appropriée et donner une place importante au SIGL dans les termes de référence des supervisions intégrées. - Privilégier la conduite régulière de supervisions formatives en gestion logistique. - Introduire la gestion logistique dans le curriculum des écoles de formation de base en santé OFFRE DE SERVICES - Améliorer l’offre de services de planification familiale par le renforcement institutionnel des structures et le renforcement des capacités des prestataires de services (technologie contraceptive), et des gestionnaires de stocks notamment aux points de prestations de services - Améliorer l’accès aux services et aux produits par la distribution à base communautaire (DBC) des contraceptifs intégrés à d’autres produits et services à base communautaire. - Assurer une coordination des programmes impliqués dans la DBC afin d’utiliser au mieux les ressources existantes et d’éviter une duplication des actions sur le terrain. - Différencier les prix aux clients des produits du secteur public et du secteur privé. 46 Mali: Final Country Report ACTIVITES PRIORITAIRES POUR LA PHASE DE TRANSITION - Plaidoyer pour le financement des activités du plan de contraception sécurisée et mobilisation des ressources pour le financement des activités du plan et l’approvisionnement en contraceptifs - Estimation annuelle des besoins en contraceptifs par le comité de prévision : Placer cette activité sous l’initiative et la responsabilité de la DPM. Améliorer la collecte des données nécessaires pour les prévisions et collecter ces informations en temps opportun - Planification des activités : Intégrer les activités du plan stratégique pour la contraception sécurisée dans les plans d’opération (PO) des cercles et donner un appui aux cercles lors de l’élaboration des PO - Développement des capacités du personnel en gestion logistique. Privilégier la supervision formative comme outil de renforcement des capacités des gestionnaires. Assurer l’application correcte des procédures et normes à tous les niveaux de la chaîne d’approvisionnement par la supervision intégrée et la formation des agents sur le site à travers les projets et ONG dans leurs aires respectives. - Collecte des données et rapports de gestion logistique : veiller à la disponibilité et l’utilisation des supports de gestion logistique et la transmission de l’information, surtout au niveau des points de prestations de services. Multiplier les nouveaux supports de collecte de données et les mettre à la disposition de toutes les structures en dotation initiale. Les structures devront incorporent cette activité dans leurs plans d’opérations en vue de la pérennisation du système. Continuer l’inventaire physique national comme une solution alternative en attendant le fonctionnement efficace du nouveau système d’information - Institutionnalisation de la gestion logistique des produits de santé dans le pays en introduisant un module de gestion logistique dans le curriculum des écoles de formation de base en santé - Suivi et évaluation du plan stratégique à travers les rapports des structures, les réunions de coordination et les évaluations internes et externes Mali: Final Country Report 47 ROLE DES DIFFERENTS ACTEURS DE LA CONTRACEPTION SECURISEE DURANT LA PHASE DE TRANSITION (1ER OCTOBRE 2006 - 30 SEPTEMBRE 2007)3 Activités de la Phase de Transition Agents ou Structures Responsables Remarques Désigner un point focal pour le suivi de la contraception sécurisée à la DPM pour les activités suivantes : - Collecte de l’information nécessaire pour les prévisions et l’estimation des besoins - Prévision et estimation des besoins annuels du pays en contraceptifs - Planification et organisation des réunions de coordination - Inventaires physiques annuels - Suivi et supervision du système logistique - Appui technique à la - Appui technique à la formation des gérants de CScom Ministère de la Santé / DPM/ DNS Le Ministère de la Santé est le département titulaire de l’exécution plan stratégique pour la contraception sécurisée La DPM est l’entité du Ministère de la Santé responsable de la gestion logistique des médicaments. Le point focal de la DPM sera responsable de la coordination et du suivi des activités du plan stratégique pour le ministère de la Santé. Il aura en charge la planification et l’exécution des activités décrites dans la colonne 1 Désigner un point focal pour le suivi de la contraception sécurisée au Projet ATN pour : - Le plaidoyer en faveur de la contraception sécurisée - L’introduction de la logistique dans les écoles de formation de base en santé - La participation à l’identification et la résolution des problèmes liés à la contraception sécurisée lors des réunions de coordination Ministère de la Santé Projet ATN Le point focal de ATN sera responsable du suivi des activités de gestion des approvisionnements au niveau central en collaboration avec la DPM, la DNS, la PPM et l’agence responsable du marketing social des contraceptifs 3 Ce plan est élaboré pour une phase de transition et est susceptible de changer en fonction des directives et plans futures de l’USAID pour son appui au développement au Mali 48 Mali: Final Country Report Activités de la Phase de Transition Agents ou Structures Responsables Remarques Désigner un point focal pour le suivi de la contraception sécurisée à Keneya CIWARA : - Assurer la disponibilité des produits contraceptifs et des supports de gestion dans leurs zones d’interventions - Former les gérants de CScom dans leurs zones - Participer à l’identification et la résolution des problèmes liés à la contraception sécurisée lors des réunions de coordination Ministère de la Santé Projet Keneya Ciwara Le point focal de Keneya CIWARA sera responsable du suivi des activités de gestion des approvisionnements au niveau des districts et PPS Désigner un point focal pour le suivi de la contraception sécurisée au niveau des partenaires financiers pour: - Suivre le plan d’approvisionnement en contraceptifs et le compte financier des partenaires - Participer et faciliter les interventions des projets qu’ils financent en matière de contraception - Garantir la fourniture d’assistance technique extérieure en gestion logistique et sécurité des produits au besoin - participer à l’identification et la résolution des problèmes liés à la contraception sécurisée lors des réunions de coordination USAID, FNUAP, KfW, OMS, Banque Mondiale Le point focal des partenaires financiers sera chargé d’instituer le dialogue avec les autres partenaires pour une coordination des interventions des partenaires dans la mise en œuvre du plan stratégique de CS Approvisionnement en contraceptifs - Participer aux activités de prévision - Donner un engagement ferme pour l’approvisionnement en produits en coordination avec les autres partenaires - Commander les produits et assurer le suivi de l’approvisionnement national - Veiller à l’assurance qualité des produits commandés Ministère de la Santé, USAID, UNFPA, KfW UNFPA sera chargé de l’approvisionnement en contraceptifs du secteur public et des ONGs USAID sera chargé de l’approvisionnement en contraceptifs du secteur public et du marketing social KFW prendra la relève de l’approvisionnement en produits du marketing social à partir de Décembre 2006 Mali: Final Country Report 49 Activités de la Phase de Transition Agents ou Structures Responsables Remarques Supervision formative : - Intégrer la gestion logistique notamment le suivi du SIGL dans les activités de supervision intégrée - Développer les outils appropriés - Former les gestionnaires sur le site - Collecter les données logistiques lors des supervisions DPM, DNS, DRS, CSC, CSCom, projets et ONG La DPM sera responsable de l’harmonisation des outils de supervision et de la coordination des activités de supervision et de collecte des données lors des supervisions effectuées par les structures publiques, le personnel des projets et les ONG Collecte et transmission des données logistiques - Multiplication et distribution des supports de gestion - Formation des agents notamment des CSCom au remplissage des supports - Remplissage régulier des supports de gestion - Rédaction et acheminement des rapports de gestion au niveau supérieur DPM, Direction Régionales de Santé, CSC, CSCom, Agents DBC, Projets de développement, ONG Partenaires financiers La DPM sera responsable de la mise en commun des informations fournies à travers les rapports des différentes structures, de les organiser et de les mettre à la disposition de tous les intervenants pour l’estimation des besoins en produits et l’évaluation des programmes. Appui des partenaires financiers pour la dotation initiale en supports, la formation des agents et la supervision Suivi et Evaluation du plan de contraception sécurisée : - Présentation de l’état d’avancement des activités lors des réunions de coordination - Identification des problèmes - Résolution des problèmes - Organisation d’évaluations (internes et externes) périodiques des indicateurs - Réajustement des interventions sur la base des résultats du suivi et des évaluations - Rétroinformation aux structures périphériques et à tous les intervenants de la CS sur l’état d’avancement des activités du plan Comité de Coordination du plan La DPM reste le maître d’œuvre et l’instigatrice des actions du Comité de Coordination. Elle jouera ce rôle en collaboration avec la DNS pour les aspects de prestations de services et de renforcement des capacités institutionnelles et des agents 50 Mali: Final Country Report APPENDIX 4 CYP 2006 Products 2002 2003 2004 2005 2006 2007 2008 Qty CYP % CYP Qty CYP % CYP Qty CYP % CYP Qty CYP % CYP Qty CYP % CYP Qty CYP % CYP Qty CYP % CYP Condom 8574520 71454.3 30.39 5835593 48629.94 24.97 5872290 48935.75 28.1 6449448 53745.4 26.09 8095000 67458.33 23.58 8095000 67458.33 23.58 8095000 67458.33 23.58 Duofem 1099092 73272.8 31.17 1127624 75174.93 38.6 933482 62232.133 35.73 1108643 73909.533 35.89 1507000 100466.7 35.12 1507000 100466.7 35.12 1507000 100466.7 35.12 Depo- Provera 321735 80433.8 34.21 249570 62392.5 32.04 209926 52481.5 30.13 274444 68611 33.31 418000 104500 36.53 418000 104500 36.53 418000 104500 36.53 Concep­ trol 207955 1732.96 0.737 391007 3258.392 1.673 72417 603.475 0.346 59600 496.66667 0.241 Norplant 714 2499 1.063 482 1687 0.866 1016 3556 2.042 682 2387 1.159 800 2800 0.979 800 2800 0.979 800 2800 0.979 Ovrette 49859 3323.93 1.414 42398 2826.533 1.451 34479 2298.6 1.32 33688 2245.8667 1.09 35000 2333.333 0.816 35000 2333.333 0.816 35000 2333.333 0.816 Tcu 679 2376.5 1.011 223 780.5 0.401 1098 3843 2.206 1274 4459 2.165 2400 8400 2.936 2400 8400 2.936 2400 8400 2.936 Femidon 26458 220.48333 0.1 12801 106.675 0.1 15000 125 0 15000 125 0 15000 125 0 Total 235093 100 194749.8 100 174170.94 100 205961.14 100 286083.3 100 286083.3 100 286083.3 100 Mali: Final Country Report 51 52 Mali: Final Country Report For more information, please visit www.deliver.jsi.com. DELIVER John Snow, Inc. 1616 North Fort Myer Drive, 11th Floor Arlington, VA 22209 USA Phone: 703-528-7474 Fax: 703-528-7480 www.deliver.jsi.com COUNTRY CONTEXT KEY PLAYERS AND ROLES PHARMACIE POPULAIRE DU MALI (PPM) DIRECTION DE LA PHARMACIE ET DU MÉDICAMENT (DPM) CENTRALE D’ACHAT DES GÉNÉRIQUES (CAG) ASSOCIATION MALIENNE POUR LA PROTECTION ET LA PROMOTION DE LA FAMILLE (AMPPF) REPRODUCTIVE HEALTH DIVISION (DIRECTION NATIONALE DE LA SANTÉ; DSR) THE NATIONAL AIDS PROGRAM (PROGRAMME NATIONAL DE LUTTE CONTRE LE SIDA; PNLS) GROUPE PIVOT SANTÉ POPULATION (GPSP) INTERNATIONAL DONORS KEY CHALLENGES DELIVER OBJECTIVES RELATIONSHIP TO USAID AND CLIENT OBJECTIVES DELIVER’S ROLE IN RELATION TO OTHER ORGANIZATIONS DESCRIPTION OF STRATEGIES SUMMARY OF DELIVER FUNDING AND STAFFING FUNDING STAFFING ELEMENT I: IMPROVED LOGISTICS SYSTEM REVERSING THE TREND: UPSWING IN CYPS LOGISTICS ASSESSMENT STRENGTHENING OF LMIS SUPERVISION TO STRENGTHEN STOREKEEPERS’ COMPETENCY AND ADDRESS ISSUES RELATED TO THE LMIS COLLABORATION BETWEEN PRIVATE AND PUBLIC SECTORS FOR BETTER AVAILABILITY OF PRODUCTS AND IMPLEMENTATION OF THE CONTRACEPTIVE SECURITY STRATEGIC PLAN DELIVER PARTICIPATION IN REGIONAL PLANNING EXERCISES NATIONAL PHYSICAL INVENTORY Stock Status ELEMENT II: IMPROVED HUMAN CAPACITY IN LOGISTICS LOGISTICS INSTITUTIONALIZATION PRESERVICE TRAINING AT THE NATIONAL HEALTH SCHOOL OF BAMAKO (ECOLE SECONDAIRE DE SANTÉ) LOGISTICS MANAGEMENT WORKSHOP FOR DISTRICT WAREHOUSE MANAGERS ELEMENT III: IMPROVED RESOURCE MOBILIZATION FOR CONTRACEPTIVE SECURITY CONTRACEPTIVE SECURITY STRATEGIC PLAN ADVOCACY FOR CONTRACEPTIVE SECURITY CONFERENCE USE OF THE MEDIA IN MOBILIZATION OF RESOURCES FOR CONTRACEPTIVE SECURITY REGIONAL ADVOCACY MEETINGS FOR CONTRACEPTIVE SECURITY NATIONAL FAMILY PLANNING CAMPAIGN ELEMENT IV: IMPROVED ADOPTION OF ADVANCES IN LOGISTICS LOGISTICS QUALITATIVE AND PERFORMANCE ASSESSMENT USING LSAT AND LIAT ADVANCE FROM MARKET SEGMENTATION STUDY COORDINATED INFORMED BUYING SYSTEM FOR REPRODUCTIVE HEALTH PRODUCTS ADVANCE FROM DATA QUALITY ASSESSMENT ELEMENT V: ESTIMATION OF USAID CONTRACEPTIVE NEEDS << /ASCII85EncodePages false /AllowTransparency false /AutoPositionEPSFiles true /AutoRotatePages /All /Binding /Left /CalGrayProfile (Dot Gain 20%) /CalRGBProfile (sRGB IEC61966-2.1) /CalCMYKProfile (U.S. Web Coated \050SWOP\051 v2) /sRGBProfile (sRGB IEC61966-2.1) /CannotEmbedFontPolicy /Warning /CompatibilityLevel 1.4 /CompressObjects /Tags /CompressPages true /ConvertImagesToIndexed true /PassThroughJPEGImages true /CreateJDFFile false /CreateJobTicket false /DefaultRenderingIntent /Default /DetectBlends true /DetectCurves 0.0000 /ColorConversionStrategy /LeaveColorUnchanged /DoThumbnails false /EmbedAllFonts true /EmbedOpenType false /ParseICCProfilesInComments true /EmbedJobOptions true /DSCReportingLevel 0 /EmitDSCWarnings false /EndPage -1 /ImageMemory 1048576 /LockDistillerParams false /MaxSubsetPct 100 /Optimize true /OPM 1 /ParseDSCComments true 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De gemaakte PDF-documenten kunnen worden geopend met Acrobat en Adobe Reader 5.0 en hoger.) /NOR <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> /PTB <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> /SUO <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> /SVE <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> /ENU (Use these settings to create Adobe PDF documents for quality printing on desktop printers and proofers. Created PDF documents can be opened with Acrobat and Adobe Reader 5.0 and later.) >> /Namespace [ (Adobe) (Common) (1.0) ] /OtherNamespaces [ << /AsReaderSpreads false /CropImagesToFrames true /ErrorControl /WarnAndContinue /FlattenerIgnoreSpreadOverrides false /IncludeGuidesGrids false /IncludeNonPrinting false /IncludeSlug false /Namespace [ (Adobe) (InDesign) (4.0) ] /OmitPlacedBitmaps false /OmitPlacedEPS false /OmitPlacedPDF false /SimulateOverprint /Legacy >> << /AddBleedMarks false /AddColorBars false /AddCropMarks false /AddPageInfo false /AddRegMarks false /ConvertColors /NoConversion /DestinationProfileName () /DestinationProfileSelector /NA /Downsample16BitImages true /FlattenerPreset << /PresetSelector /MediumResolution >> /FormElements false /GenerateStructure true /IncludeBookmarks false /IncludeHyperlinks false /IncludeInteractive false /IncludeLayers false /IncludeProfiles true /MultimediaHandling /UseObjectSettings /Namespace [ (Adobe) (CreativeSuite) (2.0) ] /PDFXOutputIntentProfileSelector /NA /PreserveEditing true /UntaggedCMYKHandling /LeaveUntagged /UntaggedRGBHandling /LeaveUntagged /UseDocumentBleed false >> ] >> setdistillerparams << /HWResolution [2400 2400] /PageSize [612.000 792.000] >> setpagedevice

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