Marie Stopes International- Final Report "RH Supplies in Emergency settings"
Publication date: 2009
1 Final Report ‘RH supplies in Emergency settings’ 1. Introduction The project ‘Analysing the Challenges of accessing RH supplies in Emergency Situations’ started in May 2009. The overall aim of the project was to get a better understanding and overview of the challenges in getting RH supplies to emergency settings. In line with the objectives this study achieved three main things: • technical support provided to the RAISE partners visited • evidence and data was collected for future advocacy work on RH supplies in emergencies • concrete suggestions for improving access to RH supplies for RAISE partners was provided Three project sites were selected for the consultant to visit: Malakal in South Sudan, supported by American Refugee Council (ARC); Kasongo in the Democratic Republic of Congo, Care USA; and northern Uganda, Marie Stopes Uganda. The first site visit was conducted in May 2009, the second in July and the final mission was undertaken in September. The consultant conducted semi structured interviews with numerous stakeholders in country, including, but not limited to, MoH, UNFPA, UNHCR, WHO, GTZ, local NGOs, and other international NGOs. With information from the different stakeholders an analysis of the supplies situation in the project sites was completed, and for each of the visits a full report with findings and recommendations is available. Besides the semi-structured interview, the consultant also conducted several on-site trouble shooting activities. These included, a small training on cold chain, de-blocking of a transport of key medical supplies and setting up contacts with key local actors. For each site visited, the consultant produced a simple supply matrix which clearly identifies strengths and weaknesses within the supply chain management. Using a scoring system, the project partner is able to use the matrix to identify areas for improvement and action required. All partners visited have already taken action on some of the areas identified and are in the process of addressing others. The matrices for each site are attached. Since the final field visit was conducted, Marie Stopes International has been working to distribute the findings of the consultant and ensure follow-up of the findings. For external audiences this has included presenting to the RHSC executive committee, to the SSWG, and holding a poster session at the FP conference in Kampala. This work is ongoing, and in March, one of the RAISE partners will present the findings of the study at a large humanitarian logistics conference in Atlanta. Also, MSI is working with different working Date: December 2009 Project Title: Analysing the Challenges of accessing RH supplies in Emergency Situations Working Group: Systems Strengthening Project start date: 1st May 2009 Project end date: 1 December 2009 2 groups in the RHSC to ensure the correct follow-up is provided for the findings of this study, and has recently presented a suggestion for a work stream within the RMA working group, to add strength to and create a platform for the advocacy messages identified in the study. Internally, work has been done with the different RAISE partners to ensure they take forward the concrete findings of the consultant. 2. Overview of Progress A small summary of each of the visits is provided below, in the section on general progress and in the conclusion, more analysis will be provided: 2.1 South Sudan From the 15 – 28 May the consultant visited South Sudan. The RAISE partner there is American Refugee Committee, which works to implement comprehensive reproductive health care for Internally Displaced People (IDPs) and local populations in the referral hospital in Malakal and a health clinic in Bam, a section of Malakal. The consultant went through Juba, where the main ARC headquarters for South Sudan is based, and spent 5 days in Malakal. He also spent a short time in Kampala where additional support is provided to the South Sudan team from the ARC Uganda office. He looked at the role of ARC, the Government of South Sudan (GoSS), UNFPA and other humanitarian actors. It became clear that at all levels challenges were present: • Both the hospital and the clinic suffered from stock-out, insufficient medical supplies • Lack of systems to ensure a smooth running of stocks by UNFPA and the government • Logistical capacity of ARC was weak at all levels, with tasks such as moving boxes from field office reception to the consumption point not performed and limited systems in place • Some UNFPA emergency RH kits were used, which is inappropriate in a protracted crisis such as South Sudan • UNFPA emergency kit supplies ending up in the local market or private clinics. While the consultant was there he conducted some troubleshooting activities, which included helping the ARC team de-block a medical order and send material on from Juba to Malakal. Also, he conducted some basic capacity building training with logistical staff in both Juba and Malakal. UNFPA in Juba had a great warehouse where many supplies were available, and their role in South Sudan is strong. However, the focus on using emergency kits suitable for use in implementing the Minimum Initial Service Package, such as post rape and condom kits is inappropriate in this protracted crisis setting. The consultant recommends that UNFPA and ARC set up regular procurement systems of RH supplies. For all actors there needs to be more awareness and follow-up for when the kits do get sent out of Juba to ensure they are used at the health service delivery sites for which they are intended. 2.2 Democratic Republic of Congo The RAISE partner in the DRC is Care International, which works in Kasongo to provide comprehensive RH care to the referral hospital and 21 clinics in the area. The consultant met with relevant CARE and other NGO and UN staff in the project site, Kasongo as well as in Goma, the main humanitarian hub of the humanitarian response in Eastern Congo. Not long before the consultant’s arrival, CARE had received a large order of family planning methods. However, nearly all other RH supplies were lacking from the centres. The 3 logistical challenges in this area are enormous, for all kinds of supplies due to the remote location, poor roads and lack of human resources. During visit it became clear that there are many actors other than the MoH and UNFPA involved in RH supplies which the consultant looked at in some detail. The MoH of the DRC was present, but had very little to no capacity or role in the procurement of RH supplies. The main findings in DRC were there are considerable logistical challenges, with hardly any infrastructure, high security risks and a general difficulty in obtaining RH supplies. It became clear that UNFPA had too limited a capacity to really take on the function of RH lead in this emergency. Most of the UNFPA staff were based in Kinshasha, with only a small number of staff in Goma. UNFPA post rape kits were seen, but UNFPA did not have other RH supplies available. As in Sudan, the situation is now more stable and reliance on the UNFPA emergency kits is not no longer appropriate Some of the problems identified in the desk review were seen most clearly in DRC – the time taken for the kits to arrive and the delay between arrival at the port of entry and arrival at the project site. When the kits did arrive, they often had expired or almost expired drugs. The logistics capacity of CARE was quite good, with evidence of a recent and ongoing emphasis on improving the overall supply system. However, it was noted that RH supplies were not a priority for the logistical hub of Care International in Goma. Without dedicated logistics staff in Goma or Kasongo, the lack of procurement and forecasting skills were visible in stock-out of many RH supplies at the time the consultant arrived. A key opportunity to develop a local solution was identified in a large medical warehouse called ASRAMES, run as an NGO and supported through EU money. Currently, CARE is not using this potentially excellent resource. A number of essential RH supplies, including misoprostol, magnesium sulphate and implants are not available at ASRAMES. However, as CARE increases the number of clients services requiring these supplies, it is well positioned to advocate for the inclusion of these supplies at the ASRAMES warehouse. 2.3 Uganda Uganda was quite a different location than the others, for several reasons. 1. Uganda is a relatively stable country 2. The government has clear responsibility for RH supplies and logistics, for which it has received substantial international support over a number of years 3. The RAISE partner in Uganda is Marie Stopes Uganda, an NGO that focuses most of its activities on RH services. Through the MoH most of the RH supplies should be available in country. The main donors for the supplies were UNFPA and USAID. These supplies were distributed through the MoH structures and ultimately also reached the North of the country. MSU works in the North of Uganda to ensure comprehensive RH services for the Internally Displaced People affected by the conflict. At the time of the visit, MSU had a special arrangement with the MoH and can order its own supplies through the Ministry. Therefore, the responsibility of getting the right supplies to the right place at the right time was largely in the hands of MSU. Like ARC and CARE, MSU also did not have a dedicated logistician in place and logistics systems are somewhat weak. Also, despite the special arrangement with the Ministry, the relationship is somewhat fragile. In-country opportunities included the need to ensure good relationships with the MoH, but also with a church run medical store, which does not have RH specific supplies, but many of the other supplies needed for RH services (antibiotics etc). Furthermore, in the North, there was a constant lack of long term family planning methods. In part, due to the lack of a dedicated logistician and due to high prices, no in country solution was sought. 4 It was clear that the RAISE project in Uganda had the most RH supplies available to them and as such had the least implementation constraints. Implementation of basic logistics tools such as stock cards and introduction of buffer stocks would help with supply chain management. This in turn, would enable MSU to rely less on ad-hoc requests to the MOH and thus improve relations. 2.4 Presentations of the findings During the RHSC general assembly meeting in June, MSI prepared a poster presentation that highlighted the issue of RH Supplies in Crises, besides this, brief updates of the project were provided in the SSWG and the plenary meeting. In November, Marie Stopes International presented a poster on the project at the Family Planning conference in Kampala. MSI poster provided the opportunity to discuss the issue of RH in emergencies with the wider RH community. This poster was one of the only aspects of the conference that focussed specifically on RH in emergency settings and as such presented a big opportunity to continue to push this important issue within the RH community. Starting with the fact that the poster generated great interest in humanitarian donors, such as the US Bureau for Population and Migration. On the request of the RHSC secretariat, MSI provided a presentation of the main results to the executive committee of the RHSC. The main findings presented there echo the findings of this report. Finally, a debrief of the project was provided to the SSWG during their meeting in Copenhagen. During this session a brainstorming exercise was conducted to see with the different members of the SSWG how to take the issue of RH in emergency forward within the RHSC. MSI facilitated this discussion and aimed to create a sense of ownership of the topic within other actors than MSI. The main outcome of this session was that RHSC should convene a meeting of key humanitarian and reproductive health actors to identify concrete actions on how to work together in the future. It was noted in the SSWG that this would be more an action that should be carried out by the RMA working group. The meeting was deemed necessary as it was noted that the two worlds currently do not interact. As a consequence humanitarian actors do not know where and how to get the right RH supplies, and on the other hand, RH actors do not know how to get started in emergency response. This meeting will be an important first step to establish where priority for action lies and how best to overcome this divide between the humanitarian actors and the RH agencies. 2.5 General progress The project has run smoothly with the visits being carried out in a timely manner. The findings and conclusions have started to be distributed before the end of the project, and MSI will continue to work with the findings to ensure the important topic of RH supplies in emergencies is addressed. It is important to note some key aspects of emergency response that have an influence over all solutions that need to be found to ensure RH supplies in emergency settings: 1. In emergencies and protracted crises, the government systems are often lacking, and therefore do not offer a reliable solution to the supply challenges 2. Logistics and supply chain management is extra challenging in these settings due to the absence of infrastructure, insecurity due to conflict, and unwillingness on the part of many RH agencies to work in unstable settings 3. The main actors in any humanitarian response are not RH actors. UNFPA is a relatively small player in emergency settings, and is overshadowed in logistical capacity by World Food Programme, UNHCR, MSF, ICRC and others. 5 3. Conclusion This study provides a first step to ensure RHSC Focus Area 2.4 – Support a coordinated response to provide RH supplies to countries suffering from conflict, natural disaster, and other crises. The study only provides a snapshot of some of the challenges faced by RAISE partners in three different conflict affected settings. Findings from the three settings, suggest similar challenges faced by all, yet the potential actions and solutions are different due to the context. Each setting has its own set of findings and recommendations, which can be found in the country specific reports. The over-arching finding common to all three settings was that ensuring that supplies are available at the health centres was not prioritized, this was clearly demonstrated in the lack logistician positions. The findings highlight weak logistical systems and a sense that it is someone else’s responsibility, whether that someone is another organisation or institution, such as the government or UNFPA, or another staff member within the organisation, such as an unfilled logistician post. All this confirms the conclusions of the desk based review around weak logistical systems in humanitarian settings. However, we had not anticipated such lack implementation of basic tools, such as stock cards and limited attention to the locally available solutions. 3.1 Main findings: Although all three sites and agencies visited are very different, a number of common themes were identified. A simple observation, but one which was not identified from the desk review, is the lack of logistics coordinator, whether a skilled logistician or simply an individual with a role dedicated to logistics and supplies. In two of the sites visited there was no such role, whilst in the third the post existed, but was vacant at the time of the consultant’s visit. This implies that logistics is not seen as an area requiring particular attention and focus within the project sites visited. A second observation from the site visits is the particular challenge faced in getting reproductive health supplies recognized as a priority among agencies and governments in post conflict or protracted crisis settings visited. Observations made in the desk review regarding the lack of attention to RH supplies within humanitarian agencies and the unwillingness of the RH development community to expand into unstable settings were clearly seen during the site visits. The main constraints of getting RH supplies to conflict affect settings can be summarized as follows: 1. Weak Government Logistical Systems • Lack of government systems at national, district and local levels • Poor monitoring systems at health centre level, so consumption figures can only be approximations • Lack of resources to ensure RH supplies reach the health centres • New reproductive health technologies not on essential medicines lists or suppliers’ lists, for example misoprostol and implants • Continued reliance on old medicines, no move to newer drugs, even when on EML - eg magnesium sulphate • Poor communication with NGOs and other actors 2. Weak NGOs Logistical Systems • No dedicated logisticians in the project sites • Acceptance of stock-out as usual and unavoidable 6 • Limited stock inventories and use of warning systems • No system of buffer stock • No contingencies for breakdown in usual (weak) supply chain system, despite frequent breakdowns • No cold chain. For most RH supplies, this is not an issue, but oxytocin an essential drug and key RH medicine, requires cold chain. • Poor communication between consumption points and field office, from where supplies are ordered • Poor warehouse management, with poor storage, monitoring and despatch as well as limited security systems 3. Lack of Knowledge on how to access RHS • Actors did not know where to get the right supplies • UNFPA kits were known (esp. the post-rape kit), but underused due to the constraints in getting them to the project • NGO staff at two sites did not know the key RH supplies which are required 4. Lack of solution finding in country • Stock-outs of RH supplies accepted as normal and as such not communicated throughout supply chain • Lack of relationships with broader humanitarian actors to facilitate transport of goods • Lack of creative thinking about how to include RH supplies into current medical supply chains of the humanitarian response • Lack of utilization of local markets and known regional hubs • Lack of use of alternative means of transport (when no roads, use of trains, boats, planes etc.) 5. RH not priority in humanitarian actors • RH not included in the general supply chain of goods in a humanitarian setting, not even in the medical supplies • RH understood to be of secondary importance, even among staff of RAISE partners. • Gender Based Violence responses not necessarily linked to wider RH responses 6. External issues (infrastructure, security, corruption) • Absence of roads between logistical hubs like Goma and Juba and the project sites • High level of corruption, or leakages, in the supply chain, both in the government supply chain, and in the use of UNFPA kits. • Security issues made operating in these environments very challenging, and as such, monitoring of the use of supplies very difficult. Internally, RAISE continues to work with its partners to ensure follow-up of the findings of the consultant and ensure that action is taken to put in place solutions to the challenges highlighted in the individual reports. These differ for each partner and key ongoing activities are highlighted below: ARC: Logistician post filled and ongoing support provided by HQ CARE: Improved communication of accurate service delivery data from consumption sites to field office MSU: Changes in key staff at MOH and MSU are providing an renewed communication and discussion of existing arrangements. Discussions are currently on going. 7 3.2 Next Steps: 1. Advocacy to humanitarian and RH actors • The importance of logistical systems to ensure a better understanding of procurement bottlenecks, warehousing and transport challenges. If an NGO chooses to operate in an emergency setting, it has to prioritize logistical systems. i. NGOs need to have a dedicated logistician in post for all projects ii. There needs to be improved communication between the health service delivery point and the field offices, which includes consumption figures and projections iii. In country flexibility in solution finding is needed to ensure all solutions are utilized to ensure the right supplies get to the right location on time. • Inclusion of RH in the primary logistics response to any emergency. This needs to include: i. In the settings such as those visited, RH supplies should be part of the regular supply chain. ii. Getting the UNFPA kits into the existing warehouses of WFP, UNHCR and other UN family humanitarian response capacity iii. Working closely with MSF and ICRC to ensure their response include RH • UNFPA needs to clarify their role in getting RHS into emergency settings. The kits include most of the necessary RH supplies, however, are not readily available when needed and are not included in the UN family logistical preparation for emergency response. i. Advocacy is needed towards UNFPA to improve their role in RH in emergencies. ii. Better coordination between the Humanitarian Response Unit and Commodities Management Unit of UNFPA iii. UNFPA needs to work more closely with WFP, the logistical cluster lead in humanitarian settings iv. UNFPA needs to address the bottlenecks of the their RH kits procurement systems, like for example warehousing and transport. • Broader advocacy is needed to ensure the right actors are informed about the importance of RH in emergencies. This includes working with the RHSC to increase its members’ understanding of the challenges and work with them to find solutions. 2. Facilitating access to RH supplies for humanitarian actors • NGOs, MoH and other key actors in humanitarian response, the ordering of the right supplies needs to be made easier. • Ensuring follow-up of the use of supplies, and putting in place systems of monitoring usage, needs to be standardized across humanitarian actors working on RH. One of the ways that this can be facilitated is to create a toolkit for humanitarian NGOs as to inform them how and where they can order the right RH supplies. This toolkit could include a list of each of the 12 UNFPA RH kits and their contents. In addition, details of suppliers, which could be adapted for the national level would be included, as well as example prices. A spreadsheet to enable costings of all supplies would be developed, with formulae to allow for changes in unit cost and quantity. Bringing together in a single tool the contents of the RH kits as well as calculations on how many supplies are needed in any given setting as well as a step by step guide to getting supplies from supplier to the consumption point, this toolkit would be an easy to follow guide to RH supplies for actors in humanitarian settings who have not previously included RH supplies in their response. The role of RHSC As described above, the findings of this project was discussed during the SSWG meeting in Copenhagen in December 2009. The above mentioned findings of this project have relevance for SSWG and RMA working groups of the RHSC, however, the internal challenge of the RHSC to widen the actors involved in tackling this issue remains, and it is of the upmost importance that ownership of this topic is created within the RHSC. 8 The outcomes of this project show that the challenge of getting both humanitarian actors to understand RH and RH actors to understand humanitarian response is one of the major obstacles to getting the right supplies in humanitarian settings. MSI has provided the RHSC with a desk study and now a field study that show similar outcomes and can be picked up by various RHSC members but it needs to be more broadly owned, understood and prioritized within the RHSC. MSI is attempting to do exactly that, by highlighting the issues, presenting at all RHSC meetings, holding bi-lateral meetings with various RHSC members and has been successful in helping the RHSC meet objective 2.4 of its workplan. However, in order for this issue to really take hold within the RHSC, more ownership is needed by other RHSC members. The RHSC secretariat and executive committee have a role to play in that, as to ensure facilitating progress towards achieving the RHSC workplan. As agreed with the SSWG, the members agreed that the main role of the RHSC in taking this issue forward lies within the scope of getting the right people around the table. This was deemed to be the work of the RMA working group, and as such has been taken onboard as a work stream within that group. MSI will work with RMA WG to set up the meeting suggested by SSWG and ensure the right humanitarian actors (WHO, WFP, UNHCR, MSF, ICRC), the right RH actors (UNFPA, JSI, MSI, others) and the right suppliers (IDA, others) sit around the table and discuss concrete measures on how they can work together, set up MoUs, include each other in emergency responses and generally are better informed about the overlapping and different challenges faced by these actors. 4. Milestones Objectives/ Activities Milestones Completion Dates Achieved Objective 1: Field visits • Hiring Consultant • 3 countries visited • Report finalised • By middle of April 2009 • By end of September 2009 • By end of October 2009 ü Objective 2 Advocacy Messages • Report includes key outcomes of three main issues: • Role UNFPA • NGO Capacity • Infrastructure • Advocacy messages developed with RAISE and JSI staff • October 2009 • October 2009 ü Objective 3 Moving Forward • In country advice given • Minimum of 3 messages formulated on how to use the findings and move forward • Presentations of findings held to different parties • During field trips (May – September 2009) • October 2009 • November 2009 ü