National Reproductive Health Commodity Security Plan for the Gambia: 2006-2010

Publication date: 2006

[image: image1.jpg][image: image2.png][image: image3.png] DRAFT Department of State for Health National RCH Programme May 2006 [image: image4.png] Table of Contents LE OF CONTENTS Page Table of Contents … … … … … … . … 2 List of Figures … … … … … … … 4 Abbreviations … … … … … … 5 Operational Definition of Concepts … … … … … 6 Acknowledgements … … … … … … . 7 Foreword … … … … … … … 8 Executive Summary … … … … … … 9 1.0 INTRODUCTION … … … … … … … 12 The Gambia Goal … … … … 13 2.0 RHCS PLAN WITHIN THE GAMBIAN CONTEXT … … … 16 2.1 The Problem … … … … … 16 2.2 Country Context … … … … … … 16 2.3 Situational Assessment of RH Programme … … 19 3.0 STRATEGIC FRAMEWORK FOR RHCS … … 23 3.1 Goal … … 23 3.2 Strategic Objectives by Components … … … … 23 3.3 Operational Objectives and Activities by Component … … 23 3.3.1 Political Commitment and Financing … … … 23 3.3.2 Policy and Advocacy Component … … … 25 3.3.3 Demand for Services … … … 26 3.3.4 Service Delivery … … … 27 3.3.5 Logistics … … … 31 3.3.6 Coordination and M & E … … … 34 3.3.7 Partnerships … … … 34 4.0 ACTION PLAN … … … 36 4.1 Political Commitment and Financing … … … … 36 4.2 Policy and Advocacy … … … … 38 4.3 Demand for Services … … … 41 4.4 Service Delivery … … … 44 4.5 Logistics … … … … 47 4.6 Coordination and M & E … … … … 54 4.7 Partnerships … … … … 55 References … … 57 ANNEX 1. Gambia Estimated Funding Requirements for Contraceptive Commodities … … … 58 2. Estimating Future Contraceptive Requirements for The Gambia (2005-2015) … … … 59 List of Figures Figure 1: RHCS (SPARHCS) Conceptual Framework … … 12 Figure 2: SPARHCS Programme … … 13 List of Boxes Box Text 1: SPARHCS Programme Cycle … … 13 Abbreviations AIDS Acquired immune deficiency syndrome AWARE/RH Action for West African Regional Health Project/Reproductive Health AOHJ Association of Health Journalists BAFROW Foundation on Research for Women’s Health BCC Behavioural Change Communication BP Blood Pressure CMS Central Medical Store CLMS Contraceptive Logistics Management System CS Commodity Security DHTs Divisional Health Teams DOSH Department of State for Health FHD Family Health Division FP Family Planning FC Female Circumcision GAMCOTRAP Gambian Committee on Traditional Practices GFPA Gambia Family Planning Association GSMMP Gambia Social Marketing and Management Programme HARRP HIV/AIDS Rapid Response Project HIV Human immunodeficiency virus HMIS Health Management Information System IEC Information Education and Communication IMCI Integrated Management of Childhood Infection IUD Intra Uterine Device IPC Infection Prevention and Control LMIS Logistics Management Information System MIP Malaria in Pregnancy MMR Maternal Mortality Rate NAS National AIDS Secretariat NACP National AIDS Control Programme NGO Non Governmental Organization NPS National Pharmaceutical Service PHC Primary Health Care POLICY Project financed by USAID PHPNP Participatory Health, Population, and Nutrition Project PMTCT Prevention of Mother to Child Transmission RH Reproductive Health RCH Reproductive and Child Health Unit RHCS Reproductive Health Commodity Security SDPs Service Delivery Points SPARHCS Strategic Pathway to Reproductive Health Commodity Security SPs Service Providers STI Sexually Transmitted Infection TBAs Traditional Births Attendants TFR Total Fertility Rate TV Television UNFPA United Nations Population Fund USAID United States Agency for International Development UNICEF United Nations Children Fund VFT Vaginal Foaming Tablets VHS Village Health Service WHO World Health Organization Definition of Concepts in the RHCS plan Acknowledgements The Department of State for Health (DoSH) is indeed grateful to all the partners in development and other local Gambian institutions, civil society groups and members of the RCH Committee who contributed to the completion of this RHCS plan. DoSH through the Reproductive and Child Health Unit expresses its sincere thanks to the US Embassy, in The Gambia and USAID West Africa who have both collaborated effectively with other partners including, UNFPA, WHO, UNICEF and NGOs towards the development of the RHCS plan. UNFPA continues to support the provision of contraceptives for the national reproductive health programme. Finally, our thanks also go to AWARE-RH, and The POLICY Projects, for providing technical assistance, financing and for facilitating the entire process that led up to the finalization of the RHCS plan. It is our hope that these efforts will bear fruit through securing the sustainable supply of contraceptive products in support of the Gambian national reproductive health programme. Foreword Executive Summary Reproductive health commodity security and particularly the provision of contraceptives continue to receive priority among policy makers in the Gambia, but this priority has still not been adequately translated into resources in support of the programme. Several partners in development have supported the Department of State for Health (DoSH) and the Reproductive and Child Health Unit (RCH) in the provision of contraceptives and other basic RH equipment and supplies. It is important to note that unmet need for contraception remain high while funds dedicated to the purchase of contraceptives has been largely donor dependent, and in recent past, on the decline. The DoSH, through the RCH Unit therefore started the development of the reproductive health commodity security (RHCS) plan to ensure the continuous supply of contraceptive products in the Gambia. While the overall focus of this Reproductive Health Commodity Security Plan is on ensuring steady supply of RH commodities in general, initial emphasis will be placed on ensuring contraceptive security and the provision of other basic RH equipment (blood pressure machines, bathroom scales, pregnancy test kits, haemoglobin metres etc.) to meet the increasing demand for family planning services reflected in the high unmet need for family planning. With the support of AWARE/RH, DELIVER and POLICY Project and with financing by USAID West Africa, the process for the development of the RHCS plan was launched in February 2005 and has followed the stages of the SPARHCS approach. This approach consists of raising awareness on obtaining the support of authorities, on analysing the situation, on obtaining a consensus on prioritised problems around which the strategic plan is developed, implemented and then monitored. The National Reproductive Health Commodity Security Plan was developed within the context of the National Reproductive Health Policy, which served as the basis for defining the approach and issues mentioned above. The Goal of the Gambian RHCS is that “Reproductive health commodity security exists when clients can make an informed choice and reliably obtain and use affordable, quality contraceptives, condoms, and other essential reproductive health supplies.” To help identify the action areas in support of the development of the plan, a commodity security assessment was carried out in July 2005. This led to the identification of the strengths and opportunities within the reproductive health programme setting. Following this, a consensus on priorities was agreed upon using the SPARHCS approach. The main prioritised problems identified are summarised below: Political commitment is not translated into an increase of resources in favour of contraceptive products; financing of contraceptives and of FP products is overly dependent on the development partners Unmet need for FP remains high (32% in 1998 and 25% in 2001) with a decrease in demand for IUD Quality shortfalls in FP clinical benefits (equipment shortage, supervision and high rate of losing track and abandonment) Weak capacity in inventory control in the distribution system causing stock interruptions and emergencies Management shortfalls, and coordination meetings are irregular and non-structured at central and divisional levels) Poor mobilization of additional resources. Clearly therefore, this reproductive health commodity security plan is part of efforts to respond to these challenges, and further support the implementation of the National RH Strategic Plan developed by DoSH and adopted in 2003. In total, seven (7) key strategic programme components have been identified, with 18 strategic objectives and …. main activities outlined by component for achieving the goal indicated above. Monitoring and evaluation will be carried out as a routine part of the implementation of the individual component of the strategy. STRATEGIC OBJECTIVES BY PROGRAMME COMPONENT Strategic Elements (components) Strategic objectives Political Commitment and Financing Advocate for higher political commitment by government, NGOs, donors, partners (UNFPA, WHO, UNICEF, USAID etc) Civil Societies organizations for improved RH commodity security in order to: To increase awareness of politicians, community and religious leaders on the need for commodity security To promote the provision of secure and permanent financial support for contraceptives among government, non governmental and private organisation and individuals Assess feasibility of integrating contraceptives into essential supply chain of the National Pharmaceutical Service Policy and Advocacy Support the revision of the RH policy to strengthen the case for commodity security and incorporate roles and responsibilities of service providers on contraceptive technology Advocate for inclusion of contraceptives into National Drug Policy Advocate for more male involvement in CS Advocate for sales tax exemption on contraceptives as Essential Drugs products Demand for Services Create increased demand for family planning services and thereby reduce high unmet need for FP Service Delivery Increased availability, affordability and accessibility of quality RH services in both the public and private sectors Logistics Strengthen the logistic management system for contraceptives and other basic RH equipment to ensure their continuous availability at all levels Institute a system to ensure the effective and uninterrupted supply of affordable contraceptives and basic RH equipment at all levels Strengthen the RH logistic management information system Build capacity for management of contraceptive and RH drug and other medical supplies Government and Private Sector Partnership Expand RH programme output through partnership and a well co-ordinated use of meagre resources Formalize and expand role of private sector in the import and provision of contraceptive products and family planning services Coordination and Monitoring and Evaluation Develop national capacity to monitor implementation of RH commodity security plan and report on progress achieved Budget Summary The budget is drawn up on the basis of the activities to be implemented directly within the framework of the present RHCS strategic plan. However, certain costs have not been included, notably human resources and other costs related to activities integrated into other programmes of the Department of State for Health (DoSH). Component Estimated budget Dalasi $ USD Political Commitment & Financing 405,000 14,464 Policy & Advocacy 1,162,500 41,517 Demand for services 424,600 15,164 Service Delivery 2,427,480 86,692 Logistics 3,991,000 142,535 Coordination and M& E 880,000 31,428 Government and Private Sector Partnership 650,000 23,214 Purchase of contraceptives 7,504,000 268,000 Purchase of basic RH equipment* Total D 17,444,392 $623,014 1 $ USD = 28 Dalasi * 1.0 Introduction Reproductive health commodity security and particularly the provision contraceptives continue to receive priority among policy makers in the Gambia, but this priority has still not been adequately translated into resources in support of the programme. Several partners in development have supported the Department of State for Health (DoSH) and the Reproductive and Child Health Unit (RCH) in the provision of contraceptives and other basic RH equipment and supplies. It is important to note that unmet need for contraception remain high while funds dedicated to the purchase of contraceptives has been largely donor dependent, and even more worrying is that in the recent past, donor support has been on the decline. The DoSH, through the RCH Unit therefore started the development of the reproductive health commodity security (RHCS) plan to ensure the continuous supply of contraceptive products in the Gambia. While the overall focus of this Reproductive Health Commodity Security Plan is on ensuring steady supply of RH commodities in general, initial emphasis will be placed on ensuring contraceptive security and the provision of other basic RH equipment (blood pressure machines, bathroom scales, pregnancy test kits, haemoglobin metres etc.) to meet the increasing demand for family planning services reflected in the high unmet need for FP. The Department of State for Health (DoSH) through its National Reproductive & Child Health (RCH) programme has formulated a National Reproductive Health Policy and Strategy in partnership with stakeholders at all levels to guide the delivery of quality RH services countrywide. The National RH Policy, among other priorities, seeks to "ensure regular availability of supplies through the use of a RH/Contraceptives Logistics Management System". SPARHCS reaffirms the link between “logistics,” on which the emphasis is usually placed, and all critical things that needs to be done to ensure that supplies are available to clients, i.e, policies, financing, service delivery, advocacy, etc. The adaptation of SPARHCS in the Gambia began with the organization of a stakeholders’ workshop that helped to define the vision for RHCS and to adapt SPARHCS framework in July 2005. Subsequently the following activities were carried out: Assessment (July-November 2005 Desk research Projections to estimate future trends Group discussions and interviews with stakeholders in public and private sectors, including central and field staff (DoSH, GFPA, GSMMP, UNFPA, WB, etc.) Detailed assessments in specific areas Logistics assessment Build consensus around priorities for improvements Develop action plans for specific areas (e.g., policy, logistics) – The SPARHCS is conceptualized as follows: Figure 1 RHCS (SPARHCS) Conceptual Framework Reproductive health commodity security (RHCS) is ensured when everybody can choose, obtain, and use reproductive health supply of their choice. To secure the supply of commodities including contraceptives is dependent, among other factors, on consistent financial contribution for the purchase of products, the conception and implementation of service delivery activities, the rationalization of the role of public and private sectors and, the use of methods and tools for efficient management of the logistics component. The Gambian Goal: “Reproductive health commodity security exists when clients can make an informed choice and reliably obtain and use affordable, quality contraceptives, condoms, and other essential reproductive health supplies.” The situation analysis helped in identifying the strengths, opportunities, and weaknesses of the RCH programme, and was used as the basis for determining the various activities spelled out in the plan. A multi-sectoral committee was set up to develop this present strategic plan on reproductive health commodity security and also to support its implementation. Figure 2: SPARHCS Programme Cycle Box Test 1: SPARHCS and the Programme Cycle The development of the National RHCS Strategy document lies within the framework of The Vision of the Gambian Road Map on Maternal and Newborn Morbidity and Mortality Reduction, which, in itself was developed within the context of the National Health Policy “Changing for Good” is the Attainment of accessible quality health care for the Gambian population that would be a model in the African region by the year 2020”. This is also consistent with the goal of the National Reproductive Health Policy: to improve the quality of reproductive life of all persons living in the Gambia through promotion of reproductive health, and prevention and reduction of morbidity and mortality associated with reproductive ill health”. RHCS in The Gambia therefore requires the following: Commitment by stakeholders Supportive policies Coordination/ M& E among stakeholders Adequate financing Effective logistics system Quality service delivery Demand for and use of RH supplies by clients 2.0 RHCS Plan within the Gambian Context 2.1 The Problem Significant unmet need currently exists for family planning in the Gambia. Recent survey findings put the number of women who approved of family planning, but not using any method of contraception at 32 percent in 1998 and 25 percent in 2001 respectively (MMR/CPR, 2001). With this high unmet need for family planning (FP), the Gambia has been entirely reliant on donors for financing and procurement of contraceptives. Financing is largely by UNFPA, supplemented by some World Bank funds. All procurement has been handled by UNFPA. In addition to these, the country’s in-bound supply has been neither predictable nor reliable. No shipments were received in 2004 and for some months into 2005 from the World Bank/PHPNP supported procurement in the year 2004. The reasons are unclear. Even more worrying is that the two previous World Bank projects that have helped to finance contraceptives and condoms in the Gambia came to an end in 2005. Linked to the need to expand and provide quality RH service, as stipulated in the National RH Policy and Strategy is the provision of basic RH equipment and supplies. An evaluation of the then National MCH/FP (now RCH) programme conducted in 2001 clearly showed that service providers lack basic equipment, drugs and other consumables. For example, 32 percent did not have access to a functioning blood pressure machine, 34 percent had no haemoglobin metres, and 50 percent, a sterilizer (MCH/FP, DOSH: 2001). In addition to the initial focus on ensuring contraceptive security, this plan will also address the shortage or lack of basic RH equipment to support quality aspects of family planning service provision. 2.2 Country Context The Gambia is located in West Africa and has a surface area of 10,690 sq km. It is bordered by Senegal on the North, East, and South, with the Atlantic Ocean on the West. The Gambia River runs from East to West through the entire length of the country. The country is divided into five administrative divisions: North Bank Division (NBD), Western Division (WD); Lower River Division (LRD); Central River Division (CRD); and Upper River Division (URD), and two municipalities; Banjul City Council (BCC) and Kanifing Municipal Council (KMC). The 2004 population estimate of the Gambia is 1,546,848 million (Gambia Census)? The growth rate of the population is 2.98 percent per annum (2004 estimate). Characterized by its “youthfulness”, over 44.7 percent of the population is under 15 years of age. The total fertility rate is now 5.46 and life expectancy is 55.8 years for both sexes. Approximately fifty percent of the population lives in the far Western portion of the country (Banjul, Kanifing, and Brikama local government areas). The results from the 2001 maternal mortality and contraceptive prevalence rate study indicate that maternal, newborn, infant mortality, and maternal mortality rate (MMR) is high with an estimated 730 maternal deaths per 100,000 live births. Maternal mortality is attributed mainly to haemorrhage and infections. There is a high disparity between urban and rural MMR rates (some rural areas are about 1.5 – 2 times as high as the urban areas. The lack of access to family planning services is a key factor leading to high MMR. HIV/AIDS is a relatively recent phenomenon. Since the first HIV/AIDS case was reported in The Gambia in 1986, a reported number of 1,400 Gambians have died of the disease. HIV prevalence among the adult population aged 15-49 increased from 1.3 percent in 2000 to 2.1 percent in 2005, and an estimated 16,761 Gambians are living with HIV – the virus that causes AIDS (NAS and NACP/DoSH, 2006). Health care services in The Gambia are limited; the majority of health care facilities and personnel are located in the urban areas, resulting in unequal access to care. Since the current government came into power in 1994, major investments have been made in the health sector with the construction of new hospitals, rehabilitation of health centres and the creation of a Faculty of Medicine and Allied Health Science. In spite of these tangible gains, however, there are acute shortages of both personnel and facilities. For example, the public sector has 1,500 beds, 211 doctors and dentists, 8 pharmacists, 655 nurses, of which only 260 are state registered nurses This has created a serious constraint for the efficient delivery of health care services in the Gambia. In addition to the high MMR indicator mentioned above, other selected reproductive health indicators for the Gambia are given as follows: Contraceptive prevalence rate among married women is 17.5% TFR (total fertility rate) from the most recent survey was 5.55 children (in 2003) 54.0 percent of deliveries are attended by qualified medical personnel (doctor, nurse, mid-wife), 25 percent of the deliveries are administered by traditional birth attendants (TBAs) 19 percent of deliveries are attended to by relatives/friends, Female Circumcision (FC) is widely practiced in The Gambia, with estimates that over two-thirds of Gambian women and girls have undergone FC. The RCH programme offers a range of decentralised and integrated services such as: antenatal care, child birth and newborn care, postpartum care, family planning, sexually transmitted infections (STIs) management, prevention of mother to child transmission of HIV (PMTCT), malaria in pregnancy/intermittent preventive treatment (MIP/IPT), the integration of birth registration of children under-five and the integrated management of childhood infection (IMCI) strategy for the child health component of the RCH programme. These services are delivered through: * 6 Major Health Centres * 12 Minor Health Centres * 15 Dispensaries * 4 Maternity Clinics * 192 RCH Outreach/trekking Stations, and * 450 PHC Villages. Family planning services are offered on a free-of-charge basis at all government health facilities while at the Primary Health Care level only a token of approximately US$0.05 is charged. Private sector institutions are also involved in the supply of contraceptives such as private pharmacies, Gambia Family Planning Association (GFPA), and Gambia Social Marketing Management Programme (GSMMP) established by DoSH/PHPNP in collaboration with GFPA, Ghana Social Marketing Foundation, and Futures Group. The National AIDS Control Program (NACP) of DoSH also orders condoms but uses the same storage facility of the RCH programme. In general, the DoSH through its National Pharmaceutical Services (NPS) operates a standardized system of bi-monthly supply of essential drugs, equipment and other medical supplies to the divisional stores of the six divisional health teams responsible for the overall supervision of health services countrywide. However, the RCH programme centrally manages some RH commodities such as contraceptives, basic equipment for antenatal care and delivery including TBA kits, obstetric record card/registers and furniture for RCH outreach services. Furthermore, the procurement of contraceptives has been mainly borne by UNFPA on behalf of the government for nearly two decades. Quite recently, through its HARRP and PHPNP Projects, DoSH contributed substantially to the financing of condoms and contraceptives. These supplies were also procured through UNFPA and distributed through the same system to the health divisions for onward supply to the basic health facilities and community-based providers. The RCH programme unit operates manually kept records of RH supplies for both in and outward flows of supplies. Similar records of distribution are kept inconsistently by the six Divisional Health Teams (DHTs). In addition, monthly/quarterly returns are collated from the field using the DoSH standardised Health Management Information System (HMIS) reporting form. As a result of poor functioning of the DoSH statistical system at both the central and divisional levels, data for planning has not been forthcoming. During 2004, the UNFPA Country Office provided the RCH programme unit with a "Country Commodity Manager" software to be installed and used for ordering and managing contraceptives. However, the need for capacity building in this area cannot be overemphasized. The current workload on few staff as a result of the on-going attrition among personnel at all levels points to the significance and urgency for an efficient RH commodity logistics management system to aid proper quantification, timely procurement for continuous availability to avoid stock outs while ensuring quality and safety for improved RH services at all levels of care. In early 2005, the Reproductive and Child Health Programme of DoSH (RCH) therefore requested USAID West Africa assistance to improve its RHCS/CLMS. The desk review of contraceptive financing further showed the following: For more than two decades, UNFPA has been the sole donor for Contraceptives. UNFPA generally spends one million DALASIS ($35,715) per year for contraceptives. In 2004, PHPNP, a DoSH/WB project, mobilized one million Dalasis ($35,715) to buy contraceptives for a year: Lofemenal (70,000), Microgynon (80,000), Ovrette (30,000), Depo provera (65,000), male condom (50 Gross), syringes 2ml with needles (65,000). NAS (National AIDS Secretariat) that is under the Presidency also finances condoms under the HARRP (HIV/Aids Rapid Response Project), another World Bank funded project. NACP (National AIDS Control Program) has funds for condom Applying fees for contraceptives has not been pursued because it is against government policy. RH services are highly subsidized. Clients pay D5 ($0.17) for RH services: antenatal care, screening, immunization throughout the pregnancy period. Family Planning services are free of charge. 2.3 Situational Assessment of RH Needs and Identified Priorities by Components The situation analysis was carried out and this helped in identifying the strengths, opportunities, and weaknesses of the RCH programme in each area according to the SPARHCS methodology. The strengths tend to be more contextual, while weaknesses in the system are seen as the opportunities that helped in identifying the action areas outlined in the plan. 2.1.1 Strengths and Opportunities Political Commitment and Financing: Strengths: Favourable policy environment for RH, with national commitments spelled in National RH Policy and Road Map. Contraceptives are expected to be part of a revised National Essential Drug List. Weakness: Political commitment for RH has not been backed by adequate resources No designated logistics unit or staff for RH supplies Funding for contraceptive supply volatile (unpredictable and unreliable) Policy and Advocacy Strengths National RH vision and strategy defined Weakness: Culture defines societal expectation to womanhood, childbearing and sexual relations. Issues of contraception are antagonized by sections of The Gambian society. Cultural status accorded to women disadvantage them in terms of reproductive choices and even their access to health care. Demand for Services Strengths RCH has shown commitment to expand RH services Weakness Contraceptive prevalence remain relatively low (17.0% in 2001) with high unmet need for FP (32% and more recently dropped to 25% in 2001) Demand for IUD is on the decline Low acceptor rate of Family Planning Services Socio cultural and religious barriers to Family Planning Services Inadequate IEC materials Service Delivery Strengths Service standards developed Weakness Inadequate skills for service quality improvement High attrition among service staff Poor counselling skills of service providers Logistics Strengths There is some semblance of a logistics management information system (LMIS) and an appreciation of the need for improved data keeping and reporting. Many facilities keep some stock data in notebooks. There are procedures in place for handling expired/damaged products. Expiry does not appear to be a major problem, with some exceptions. Storage conditions are adequate in many facilities, in part because the requirements are minimal for the small quantities handled. RCH staff is committed to improving the CLMS and seeking USAID assistance. Reporting is done on a quarterly basis using the DoSH-HMIS Return FP Form from Village Health Services (VHS) and BHF to DHT and Central level. Weakness: Information at all levels in the supply chain is often incomplete and not updated; reporting is erratic; standard forms, where they exist (rarely), are not consistently used. Many health centres and even some divisional stores do not keep track of stock balance. The system is a “pull” one where lower levels request re-supply when they determine they need it. Higher levels do not monitor stock at lower levels. There is no forecasting according to standard methods. Min/max procedures are not used. Divisional stores and health centres “eyeball” how much to order and when. Storage conditions in the central RCH store fall far short of what is needed. High staff attrition works against sustaining human capacity for logistics management. Supervision for contraceptive management is weak to non-existent. Supply to The Gambia is at a critical point and there has been product rationing from the central level. Stock outs have been frequent and occur at all levels, including central stores. Private sector, especially those in Category B are only allow to import and stock condoms and a limited range of other contraceptive products. Coordination and M& E Strengths Existence of RCH Committee Donor support and participation is encouraged Weakness Poor coordination of RH activities between Government/NGO/ private Sector Lack of joint planning and coordination of activities Partnerships Strengths The imbalance in provision of contraceptive supplies presents an opportunity for private sector to fill in gap and actively contribute to ensuring consistent pipeline of contraceptive supply Private sector recognizes that they have a role to play to ensure commodity security Weakness Public facilities are not user friendly Public sector operating hours are inconvenient for clients Traditional perception that RHCS in the Gambia perceived as Public/NGO sector led with limited participation of private sector 3.0 Strategic Framework The overall strategy proposed for ensuring commodity security in the Gambia is discussed within this framework, and it is a continuous and long-term process that are linked to the different areas or components as proposed in the SPARHCS tool. 3.1 Goal The Gambia Goal for the present strategic plan as mentioned earlier is that by the end of 2010: “Reproductive health commodity security exists when clients can make an informed choice and reliably obtain and use affordable, quality contraceptives, condoms, and other essential reproductive health supplies.” The strategic objectives are aligned with the Action Plan developed for the various components in this national strategy document, which are in turn, directly linked to make the connection between “logistics” on which the emphasis is usually placed and the other components of the programme that need to be done in order that contraceptive supplies are available to clients. These include political commitment and financing, policy and advocacy, demand for services, service delivery, promoting public-private partnership, and coordination, monitoring and evaluation. Particular emphasis will be placed on the monitoring and evaluation component. This will allow for the review and/or adjustment to be made to the various programme implementation activities. In addition to these, operational objectives have been identified from the strategic objectives, based on which the activities have been similarly identified. 3.2 Operational Objectives and Activities by Component 3.2.1 Political Commitment and Financing Clearly the programme activities expected to be undertaken are all geared towards the removal of obstacles/operational barriers to ensure increased access to RH commodities, especially contraceptive products which is the initial focus of the plan by family planning clients and also contribute to resource mobilization from the Government of Gambia as well as other partners, i.e UNFPA, WHO, UNICEF, USAID civil society organisations. Operational objective 1: To develop advocacy programme activities to ensure increased government support and funding for contraceptives and other basic RH equipment. The foremost priority activity under this strategic component is the adoption and implementation of the RHCS plan. Once approved and adopted the RCH unit, and its partners will then spearhead the various tasks towards ensuring its full implementation. The RCH Unit, working together with the RCH Committee and partners, will advocate to government to ensure that DoSH budget contains a provision for the purchase of contraceptives and other basic RH equipment beginning in 2007. The main activities to be carried out includes the following: Finalise the development of the RHCS plan and identify funding gap and commitment Plan and organise eight (8) dissemination events at national and divisional levels to ensure implementation of the RHCS plan by DoSH and its partners Develop advocacy materials in support of contraceptive financing Operational objective 2. Sensitise key decision makers (Finance, Parliamentarians) to include a budget line for contraceptives in the health budget of DoSH. This will involve the organisation of advocacy events/meetings and communication activities to ensure the government of Gambia and other national stakeholders, and the development partners support the RHCS plan through resource commitment in support of financing the purchase of contraceptives and other basic RH equipment. The main activities to be carried out are: Sensitise key decision makers to include a budget line for contraceptives in the health budget Liaise with CMS, planning unit and other key partners to ensure budget request is submitted for financing Operational objective 3. Mobilise, monitor and coordinate the financing of contraceptives and basic RH equipments This will involve mobilisation and coordination of resources in support of the reproductive health programme, particularly to finance the procurement of contraceptives and other basic RH equipments. The main activities to be carried out are: Identify needs for reproductive health programme and work to obtain commitment for financing from donors. Organise roundtable meetings and discussions with partners to advocate for sustainable financing mechanism for RH contraceptives and basic RH equipment Prepare and quantify official requests to donors based on agreed commitments for roundtable meetings. 3.3.2 Policy and Advocacy Component Policy and advocacy initiatives form a critical component of the RHCS plan. They are supportive to the other programme components and the activities planned are geared towards ensuring a supportive programme environment to address in general commodity security, including contraceptive security and the provision of other basic RH equipment and supplies. Operational objective 1: Support the revision of the National RH Policy to strengthen the case for commodity security and incorporate roles and responsibilities of service providers on contraceptive technology. The review of the National RH Policy is in support of strengthening the case for contraceptive security by ensuring that the policy makes explicit statement regarding the need to address contraceptive security issues within the context of the Gambia reproductive health. The main activities to be implemented are: Revise National RH Policy to reflect commodity security issues Organise four (4) sensitisation and advocacy events to increase awareness among politicians, community and religious leaders on the need for commodity security Sensitisation of communities and “Bara” (Boat) owners to support RH activities including referrals for family planning services Conduct meetings with stakeholders to revise the RH policy and incorporate roles and responsibilities of service providers on contraceptive technology Hold consultations with CMS and National Pharmaceutical Services etc., to revise national drug policy and include contraceptives. Print 250 copies of the national RHCS plan Organise 3 days training programme for health service providers by division on sexual and reproductive health issues Organise community for a for 20 ‘Bara’ Boat owners and 80 community members to support RH activities Operational objective 2: To advocate for more male support/involvement in RH commodity security issues and dialogue The activities here will support demand and awareness creation among men about the need to support RH issues including being active partners in addressing contraceptive security challenges. Examples from other programme settings show that it is possible to change people’s perceptions of particular family planning services/methods in order to increase their acceptance especially of the under-utilised family planning methods and support their spouse in decision-making regarding the use of family planning. The main activities to be carried out include: Conduct IEC activities through mass media campaigns for greater male involvement Sensitise community base organizations on the need for greater male involvement on RH/CS issues Encourage Community Health Nurses and Community-based Organization to sensitise community on RH/CS issues Operational objective 3: To advocate for sales tax exemption on contraceptives as an Essential Drug Product Opportunities for increased private sector participation in the provision of RH commodities and services exist in the Gambia. A key issue is the need to engage the private sector in dialogue to discuss common issues, including defining their appropriate role in the procurement of contraceptives and other basic RH equipment and the provision of family planning services. The main activities to be carried out include : Advocate to DoSH, and National Pharmaceutical Services etc., to encourage the Category A drug outlets on increasing access to contraceptives in the private sector, including improving the choice of contraception available. Advocate for sales tax exemption on contraceptives as an essential drug. 3.3.3 Demand For Services Component The operational objective targeted under this component of the strategy is to contribute to the reduction of unmet need for family planning among those who want to use contraceptives as outlined in the National RH Strategy and the Vision of the Gambian Road Map on Maternal and Newborn Morbidity and Mortality Reduction. The activities are supportive of the service expansion needs of the RH programme to increase the uptake of contraceptives in the Gambia and thereby reduce the high unmet need for family planning. Operational Objective 1: Contribute towards the increase in the acceptor rate of modern family planning methods Emphasis will be placed on carrying our various communication and community sensitisation events to influence behaviour change. More specifically, the activities will include the use of mass media, folk drama, community theater and other known social marketing techniques. These activities will be combined with advocacy involving both opinion, religious and community leaders to promote the use of family planning services. In support of this effort, a communication strategy will be developed based on the thorough analysis of the causes of unmet need. The main activities to implemented are: Hire consultant to undertake a desk review of socio-cultural and religious barriers to the use of FP Contribute to the development of a communication strategy to increase the use of family planning services Conduct social mobilization campaigns to counter socio-cultural and religious barriers to RH services Review and then revise/develop/print and distribute IEC/BCC materials at all levels Train multimedia professionals and traditional communicators to develop and use IEC/BCC materials on RH Develop radio and TV spots and community drama series using traditional communicators Produce and broadcast radio and TV spots Operational objective 2: Contribute to the reduction of the current high unmet need for family planning Significant unmet need currently exists for family planning in the Gambia. Recent survey findings put the number of women who approved of family planning, but not using any method of contraception at 32 percent in 1998 and 25 percent in 2001 respectively. With this high unmet need, programme efforts need to be directed at increasing access to family planning services to reduce the high unmeet need. The main activities to be carried out include: Conduct situation assessment of IEC materials in various institutions for demand creation in order to identify gaps Collaborate with health education Unit, GFPA, AOHJ, GAMCOTRAP, BAFROW and other other partners to promote the regular production of IEC and broadcast materials to increase the demand for FP services Organise six advocacy events (meetings/community forums etc) with traditional and religious leaders on importance of family planning Train service providers in the use of appropriate counselling/IEC skills 3.3.4 Service Delivery Component The activities under the service delivery component of the strategy are geared towards satisfying the demand for family planning services and are also supportive of activities outlined in the National RH Strategic plan and Vision of the Gambian Road Map on Maternal and Newborn Morbidity and Mortality Reduction. In all, four (4) operational objectives have been identified to fully meet the strategic objective specified. This is expected to improve service delivery and quality of the service. Operational objective 1: To improve the skills of service providers This refers to activities directed towards the training of a competent cadre of health service providers with the requisite skills in contraceptive technology updates and professional attitude that will facilitate the uptake on contraceptives for clients who visit the FP facilities. The main activities to implemented are: Undertake a training needs assessment to identify critical skills gap Design and conduct relevant training to update/upgrade the skills of service providers in family planning clinical skills and IPC, etc. Operational objectives 2: Ensure availability of quality contraceptives and other basic RH equipment On the basis of the concept of service quality improvement which encompasses client satisfaction with contraceptive products, clients counselling, improving basic RH equipment supply and rationalising the range of products available at the service delivery points (SDP) will all be addressed this sub-component to ensure improved access to services. The main activities to be implemented are: Update RH service manuals to strengthen the technical aspects of service delivery Strengthen the capacity of Medicines Board and other such bodies to monitor the quality of contraceptive products and services Operational objective 3: Promote the use of IUD as a cost effective and long term method. The recent assessment of the RH programme found that the use of IUD as a long-term contraceptive method is on the decline. The activities being planned will ensure that the underlying factors are studied and properly understood and recommended actions implemented to reverse the decline in the usage of IUD. The main activities are: Carry out IUCD study on low utilization of IUCD, female condom and male participation in RCH services Support of implementation of recommendations from the above study Organise radio spots to promote the use of IUD Train 60 nurse/midwives in contraceptive technology including IUD. Operational Objectives 4: Support Strengthening of Supervision for the provision of efficient FP service delivery Supervision to ensure maintenance of service standard is an essential component of the strategy for programme improvement. For example, there is a clear need to update supervision tools, and carry out other supervisory activities that will be integrated into regular divisional management team activities. The central level and other social marketing stakeholders and NGOs will also ensure supervision of the entire distribution chain based on revised guidelines and tools to be developed. The main activities are: Review existing supervisor checklist/tools and update where necessary Plan regular supervision activities Organise/conduct monthly supervision visit to service delivery points offering family planning services and management of contraceptive supplies Write supervisory reports and give feedback for service improvement 3.3.5 Logistics Component The success of any family planning programme is characterised by a growing interest in contraceptive use, which translates into an increase in the number of contraceptive users. This requires an increased supply of commodities. The Gambia population census of 2003 indicates a growing number of young people, many of who will enter the reproductive age group and will therefore require reproductive health services, including family planning. The various logistical needs have to be planned for, including procurement and management of the supply chain to ensure continuous supply of contraceptives and the other basic RH equipment already identified at the facility level. There are seven (7) operational objectives under the logistics component. Operational objective 1: Build capacity in logistic management including forecasting for the RCH unit This will entail capacity development efforts in order to strengthen the RCH unit and provide the requisite skills to forecast commodities in support of the service delivery needs of the unit. The main activities are: Train two (2) RCH staff in logistics management Procure needed equipment and materials for record keeping system at RCH central management stores Hire one support staff to maintain stock and provide general cleaning of central store Procure one computer with accessories for the RCH central stores management Operational objective 2: Integrate RH logistic management into curricula of health training institutions The RCH unit will ensure the sustainability of logistic management being established under this plan. RCH will therefore support in institutionalization of RH logistic management in the training curricula of local health training institutions in support of capacity development need of the programme. The main activities are: Hire one consultant to conduct lead curriculum development process for max of 20 days Organise meetings with health training institutions and other stakeholders to revise and incorporate RH logistics management issues in training Organise one validation meeting with health training institutions and other stakeholders to finalise curriculum. Operational objective 3: Improve the provision of basic RH equipment at all health institutions (primary, secondary, and tertiary) levels These are basic supportive equipments that are needed to support the efficient delivery of family planning services. They include BP machines, bathroom scales, pregnancy test kits, heamoglobin metres, IUCD kits, etc. The main activities are: Carry out annual quantification exercise for contraceptive and other basic RH equipment needs Procure and distribute basic RH equipment for public health facilities based on quantification Operational objective 4: Develop a procedure manual for contraceptive and other RH drug management The activities under this component will support the development of procedure manual and management tool to ensure efficient management of logistics. The main activities are: Develop draft procedure manual and supervision guide for contraceptive and other RH drugs Organise five (5) days consensus meeting with stakeholders on the manual and management tools Validate procedure manual for contraceptive and other RH drugs Organise TOT for 20 staff from division and private sector in the use of the new procedure manual and management tools Organise 3 days training for 50 store keepers and officer –in-charge at divisional and facility level on procedure manual and management tools Print and distribute 100 copies of the new procedure manual and management tools. Operational objective 5: Strengthen the Logistic Management Information system This refers to need to operationalise the new procedure manual and management tool and ensure their consistent use in data capture and subsequent analysis in support of planning and decision-making. In support of the efficient management of the process, various training of trainers workshops will be organised for logistic/store keepers in the use of the new management tool. The staff will be from divisional and facility levels as well as the private sector. The main activities are: Organise two days training per division for all store keepers and officer in charge responsible for managing RCH supplies in the use of new management tool (stock cards, transaction book) at the divisional level and facility level Print and distribute management tool at all levels Initiate and follow up with data collection exercise with the new management tool Analyze data to inform decision making RCH unit conduct quarterly supervisory visit to divisional stores Store keepers/Pharmacist Assistant from Divisional level conduct monthly supervisory visit to facility level Operational objective 6: Establish functional laboratory services at all (primary, secondary and tertiary) levels Routine laboratory services play an essential supportive role in the delivery of RH/FP services. The activities specified under this strategic component are intended to support the expanded service delivery objectives for the provision of RH/FP services that have been clearly laid out in this plan. The main activities are: Procure and distribute basic laboratory equipment, materials and services as identified in the inventory/assessment. Identify and train 50 laboratory technicians Operational objective 7: To ensure reliable and effective transport system at all levels This is another supportive logistic and supervisory function that will contribute towards timely delivery of products from central stores to the divisional stores etc., and overall, lead to functional fleet management system. The main activities are: Estimate needs for transport fleet/fuel requirements at all levels (motorbikes, boasts, horse cart) etc to identify gaps Procure/provide transport equipment including two (2) motor bikes and two (2) vehicles in support of contraceptive and other RH equipment distribution and supervision to strengthen fleet management 3.3.6 Coordination and Monitoring and Evaluation The strategic objective under this component is to develop a national capacity to monitor implementation of the RHCS plan, and monitor achievements of the results indictors identified. The RCH unit working in collaboration with the Central Medical Stores will take the leadership role in monitoring the activities of the reproductive health commodity security plan. The RCH Unit will serve as the coordinating agency/unit for the execution of activities under this plan. It will monitor progress of implementation and report to DoSH through the Director of Medical Services and to the partners. In carrying out its central M & E functions, the RCH unit will seek technical assistance from AWARE-RH when required. Individual organizations, development partners and the other private sector partners, including NGOs will be responsible for implementing their own assigned activities and shall report to the RCH unit/DoSH and the RCH Committee. The RCH unit will reproduce quarterly reports on progress in respect of the implementation of the activities according to the agreed timelines stipulated herein. Operational objective 1: Develop national capacity to monitor implementation of the RHCS plan, and monitor the achievement of targets. The RCH Unit will carry out its M & E functions in close collaboration with the other parters and will design uniform reporting formats to facilitate this process. As already indicated, it will monitor progress of implementation and report to DoSH through the Director of Medical Services and to the partners. The main activities are: Conduct two joint meetings and invite selected community and religious leaders to the planning meetings with RCH unit. Develop and launch monitoring plan for all stakeholders Write quarterly reports and present to National RCH Committee and DoSH Conduct quarterly National RCH Committee meetings at National level Conduct regular/quarterly monitoring of commodity stock to ensure replenishment at all levels Partnerships The strategic objective is to expand RH programme output through partnership and a well co-ordinated use of meagre resources. The RCH unit will work to strengthen coordination mechanism with its partners and programme implementers, including the private sector. It is envisioned that the RCH coordination role will be expanded, especially in formalizing opportunities for private sector active participation in provision of RH commodities and services. Specifically, the RCH unit will work closely with the UNFPA to develop the new country programme for the Gambia and ensure that it reflects the need for commodity security and financing to help implement this plan. Operational objective 1: Strengthen linkages/coordination between Government, donors and NGO partnership on RH commodities. The RCH unit will work to strengthen coordination mechanism with its partners and programme implementers, including the private sector. It is envisioned that the RCH coordination role will be expanded, especially in formalizing opportunities for private sector active participation in supply of contraceptives and other basic RH equipment and the provision of family planning services. In addition, the RCH unit will work closely with the UNFPA to develop the new country programme for the Gambia and ensure that it reflects the need for contraceptive security and financing to help implement this plan. The main activities are: Establish Inter-agency Coordinating Committee for contraceptive security with members drawn from government, donors, NGOs and the private sector. RCH Unit will work closely with UNFPA in the development of the new country programme for the Gambia to ensure it reflects need for commodity security, especially the financing of contraceptives. Operational objective 2: Formalize and expand role of private sector in the import and provision of RH commodities and services A recent private sector assessment for RH commodity security and service provision in the Gambia noted that while the private sector had reported increased involvement in the provision of RH commodities with improved access to both oral and injectable contraceptives and condoms, the arrangements for harnessing their participation is still generally ah-hoc, and mostly limited to a few pack of oral contraceptives and condoms. More over, the private sector focus is still on the provision of commodities and less on providing services. Strengthening partnership will ensure that the sector shifts from its current passive role as a RH commodity provider to a more prominent and participatory role as a key stakeholder. The main activities are: Develop framework/MOU for strengthened private sector involvement in RH commodity provision and services Undertake market segmentation and price rationalisation study (ability to pay) Implement recommendations from study above 4.0 Action Plan: Reproductive Health Contraceptive Security Components 4.1 Political Commitment and Financing Component Strategic objectives: To advocate for higher political commitment by government, NGOs, partners (UNFPA, WHO, UNICEF, USAID etc) and civil society organizations for improved RH commodity security, and To promote the provision of secure and permanent financial support for contraceptives among government, non-governmental and private sector organisation and individuals Mobilise, monitor and coordinate the financing of contraceptives and basic RH equipment Key assumptions: Favourable political environment Availability of financial resources Political stability Operational objectives and Activities Responsible Agencies Time frame Estimated Budget Process Indicators Results Indicators Develop advocacy programmes to ensure increased government support and funding for contraceptives and other basic RH equipment Sensitise key decision makers (Finance, Parliamentarians) to include a budget line for contraceptives in the health budget of DoSH RCH Unit, RCH Committee 2006-2008 # of advocacy materials developed to sensitize government leaders, parliamentarians etc. # of sensitization events carried out by RCH committee at various levels to key decision makers RHCS plan adopted and fully implemented and funding mechanism outlined DoSH budget contains provision for purchase of contraceptives beginning in Jan. 2007 Basic RH equipment need identified and funds mobilized to provide them Activities Finalise RHCS plan and organize eight (8) dissemination events to ensure adoption of plan for implementation at national and divisional level RCH, CMS, GSMMP, GFPA, RCH Committee, UNFPA 3rd – 4th quarter, 2006 TA AWARE RH for plan D250,000 (to support dissemination) RHCS plan finalized and adopted by DoSH and partners Develop and produce 100 advocacy materials in support of contraceptive financing. DPI, RCH CMS, GFPA (GSMMP), UNFPA 1st Quarter 2006 and 1st Quarter 2007. D10,000 RHCS advocacy materials developed to ensure sustainable financing of commodities Hold two (2) advocacy events (meetings/briefing sessions) to sensitise 25 key decision makers to include a budget line for contraceptives in the health budget (DoSH, Finance, Parliamentarians) DPI, RCH CMS, GFPA (GSMMP) 3st Quarter 2006 and 1st Quarter 2007 D100,000 # of decision makers sensitized Mobilise, monitor and coordinate the financing of contraceptives and basic RH equipment DoSH/RCH, GFPA, CMS, RCH Committee, donors 4th quarter 2006 and 2007 # of meetings/events held to mobilize resources Identify needs for reproductive health programme and work to obtain commitment for financing from donors RCH, RCH committee, GFPA, CMS, 3rd Quarter 2006 and 1st quarter, 2007 Regular programme budget Report on needs assessment of and quantification for financing Organise round table meetings/discussions with partners to advocate for sustainable financing mechanism for RH commodities DoSH/RCH, GFPA, CMS, RCH Committee, donors, private sector 1st to 3rd quarter, 2007 D15,000 x 3 45,000 Three (3) roundtable meetings held with donors, private stakeholders geared towards mobilization of external resources for purchase of contraceptives Prepare and quantify official requests to donors based on agreed commitments RCH, RCH committee, GFPA, CMS, UNFPA 3rd Quarter 2006 and 1st quarter, 2007 Regular programme budget Official request sent to donors in support of funding Total (Political Commitment & Financing D405,000 4.2 Policy and Advocacy Component Strategic objective: To advocate for the revision of the RH policy to strengthen the case for commodity security Advocate for more male involvement in issues regarding contraceptive security To advocate for sales tax exemption on contraceptives as an essential drug in support of active private sector involvement Key assumptions: Favourable political environment Availability of financial resources Political stability Support from development partners Willingness of community and religious leaders and other community groups Operational objectives and Activities Responsible Agencies Time frame Estimated Budget (Dalasi) Process Indicators Results Indicators To advocate for the revision of the RH policy to strengthen the case for commodity security RCH, RCH Committee, GFPA, CMS 2nd Quarter 2007 Improved policy and programme environment for commodity security made manifest in revised RH policy that reflects case for commodity security Activities Revise RH policy to reflect commodity security issues RCH, GFPA, RCH Committee, DHT, UNFPA, WHO 1st Quarter, 2007 D100,000 Minutes of consultative meetings conducted on revision of the RH policy. Organize four (4) sensitization events and advocacy events to increase awareness among politicians, community and religious leaders on the need for contraceptive security RCH Unit, DHTs, GFPA, CMS, RCH Committee 2rd Quarter, 2007 D100,000 # of advocacy events organized local level officials, community and religious leaders Liaise with appropriate partner agencies to explore the feasibility of revising the National drug Policy to include contraceptives RCH/DoSH, Medicines Board, CMS, National Pharmaceutical Service etc 2006-2007 Regular programme budget # of meetings held to discuss and revise national drug policy Print 250 copies of the national RHCS plan RCH Unit, CMS, CMS, GFPA GSMMP 3rd & Fourth Quarter 2006 D62,500 250 copies of the RHCS plan produced and disseminated Organise 3 days training of health service providers by division (120) on sexual reproductive health issues RCH Unit 1st quarter 2007 D200,000 # of health service providers trained to provide youth friendly services Organise six (6) community fora for 20 “Bara” (Boat) owners and 80 community members to support RH activities including referrals for FP services RCH, DHT, Divisional Authorities, UNFPA, 2006-2008 D100,000 # of community sensitization events held with ‘Bora’ Boat owners Incorporate roles and responsibilities of service providers on contraceptive technology into the RH policy RCH, GFPA, RCH Committee, DHT, UNFPA, WHO 1st quarter, 2007 Roles and responsibilities for SP clearly defined in revised RH policy Activities Conduct two (2) meetings with stakeholders to revise the RH policy and incorporate roles and responsibilities of service providers on contraceptive technology DoSH/Stakeholders – (UNFPA, UNIECF, WHO, GFPA, private sector) RCH committee 2nd quarter 2007 D150,000 # of consultative meetings held to discuss and finalize the RH policy document. Advocate for more male involvement in RH contraceptive issues, including CS issues RCH, DHT, GFPA, RCH Committee, GSMMP etc 2006-2010 # of advocacy events organize to reach male specific targets/audiences Increased male participation and support for RH, including CS issues and activities Activities Contribute to IEC activities through mass media for greater male participation RCH/DHTs 2006-2010 D100,000 annually # of IEC conducted through mass media for greater male participation. Organise two fora per division (12) for community base organisation on the need for greater male involvement on RH/CS issues RCH, DHT, GFPA, RCH Committee, GSMMP etc 2006-2008 D125,000 # of community base organisation sensitized on the need for greater male involvement on RH issues Organise 12 meetings (one in each division) CHN and CBO to sensitize the community on RH/CS issues DHT/RCH 2006-2010 D150,000 # meetings held with CHN and CB0 in communities To advocate for sales tax exemption on contraceptives as an essential drug product RCH, DHT, GFPA, RCH Committee, GSMMP, private sector partners etc. 2006-2008 Sales tax exemption on contraceptives granted to enhance private sector participation in CS. Activities Hold two meetings with 20 policy makers to advocate for sales tax exemption on contraceptives as an essential drug. RCH/DHTs 2006-2008 D50,000 # of advocacy events held targeting high level DoSH policy makers and Parliament on removal of sales tax on contraceptives Hold two meetings with Category A drug outlets on increasing access to contraceptives in the private sector, including improving the choice of contraceptive methods RCH, DHT, GFPA, private sector partners 2006-2008 D25,000 # of advocacy events organize with private sector partners CMS and senior DoSH policy makers Total (Policy & Advocacy) D1,162,500 4.3 Demand for Services Component Strategic objective: Create increased demand for family planning services and thereby reduce high unmet need for FP Key Assumptions of the Demand of services component Social cultural and religious barriers identified and addressed Funding commitment Funds availability Political stability Support of partners in development Participation of communities Operational objectives and Activities Responsible Agency(ies) Time frame Estimated Budget (Dalasi) Process Indicators Results Indicators Contribute towards the Increase in the acceptor rate of modern FP methods Contribute towards reduction of the current high unmet need for FP DOSH/RCH Unit, partners, GFPA, media and communication practitioners 200-2010 Percent of sexually active women using modern FP methods Percent of unmet need for FP met Activities Hire consultant to undertake a desk review of socio-cultural and religious barriers to the use of FP RCH unit, BAFROW, GAMCOTRAP 4th quarter 2006 D27,000 Document on the socio-cultural and religious barriers available and use to inform development of communication strategy Contribute to the development of communication strategy of DoSH increase use of family planning services RCH Unit, HEU, GFPA etc 4th quarter 2006 Regular programme budget Communication strategy developed Conduct six per division (36) social mobilization campaigns to counter socio cultural and religious barriers on RH services RCH Unit, GFPA BAFROW GAMCOTRAP AOHJ HEU 2006-2008 D75,600 # of social mobilization campaigns conducted Carry out desk review of IEC materials in various institutions to identify gaps DOSH/RCH Unit, HEU 2006-2010 D27,000 Needs assessment reports available. Develop/print and distribute IEC/BCC materials at all levels DOSH/RCH Unit, HEU, GPFA 2006-2010 D24,000 # of IEC/BCC materials developed and printed for distribution. Train 50 multimedia professionals and Traditional Communicators, on the development and use of IEC/BCC materials on RH RCH Unit, GFPA BAFROW GAMCOTRAP AOHJ HEU 2006- 2007 D45,000 # of media professionals and Traditional Communicators trained. Develop radio and TV spots, drama series, Press Articles and advertisement on FP. RCH Unit, GFPA BAFROW GAMCOTRAP AOHJ HEU 2006- 2007 D120,000 # of radio and TV spots, drama series, Press Articles and advertisement on FP developed. Broadcast radio and TV spots and Community drama series using the Traditional Communicators. RCH Unit, GFPA BAFROW GAMCOTRAP AOHJ HEU 2006- 2008 D40,000 # of TV, radio spots and community drama series broadcasted by year, by month on the national and private channels and in communities Collaborate with Health Education Unit, GFPA, AOHJ, GAMCOTRAP, BAFROW & other partners to promote the regular production of IEC materials, broadcast and publication of FP materials. RCH Unit, GFPA BAFROW GAMCOTAP AOHJ HEU 2006-2010 D16,000 # of meetings with reports held with Health Education Unit & other partners Organise six (6) advocacy activities with Traditional and Religious Leaders on the importance of FP. RCH Unit, GFPA, HEU 2006- 2010 D25,000 # of advocacy activities with Traditional and Religious Leaders organised Train service providers on appropriate counselling/BCC skills DOSH/RCH 1st quarter 2007 D25,000 # of service providers trained to provide appropriate counselling and BCC services Total demand component D424,600 4.4 Service Delivery Component Strategic objective: To increase the availability, affordability and accessibility of quality RH services Key Assumptions: Availability of qualified personnel at health training courses Government commitment Availability of funds and Qualified Trainers Political stability Support from the Development partners Commitment of local authority Readiness of communities to accept and utilize RH services to maximum Operational objectives and Activities Responsible Agencies Time frame Estimated Budget Process Indicators Results Indicators To improve the skills of service providers RCH Unit, GFPA, ISTU, training institutions 2006-2010 Service providers sufficiently trained to provide efficient FP services to clients # of health training courses that offer quality FP services according to guidelines Activities Carry out training need assessment during supervisory visit RCH, DHTs, ISTU, Training Institutions 3rd quarter of 2006) Regular programme budget Report of Training needs assessment Conduct relevant trainings for service providers to maintain service standards RCH, DHTs, ISTU, Training Institutions 2006-2010 D750,000 Training reports # of each cadre of staff trained Ensure availability of quality contraceptives and other basic RH equipment as support to access for quality services RCH, DHTs, GFPA 2006-2010 Increased Access to FP services in poor and underserved areas improved Activities Update RH service manuals to strengthen the technical aspects of service delivery (e.g. contraceptive technology). RCH, DHTs, ISTU, Training Institutions 3rd Quarter 2007 D500,000 # of appropriate tools and guidelines revised to ensure effective service delivery Strengthen the capacity of Medicines Board & other bodies to monitor the quality of contraceptive products and services RCH, CMS, DHTs, Training institutions, etc 2006-2010 D150,000 # of meetings with regulatory bodies and reports of meetings Promote the use of IUD as a cost effective long-term method RCH, DHT, CMS, GFPA 2006-2007 Conduct IUCD study on its low utilization, female condom and male participation in RCH services RCH, DHT, CMS, GFPA 2nd & 3rd quarter 2006 In process IUCD study report with recommendations Support implementation of recommendations from IUCD study RCH, DHT, CMS, GFPA, private sector 4th quarter 2006 and 1st quarter 2007 D100,000 Strategy for implementation of of IUCD findings outlined Organise four (48) radio spots per year to promote the use of IUCD RCH, DHT, CMS, GFPA 2006-2010 D500,000 IUCD study report with recommendations Train 60 midwives in contraceptive technology including IUCD RCH, ISTU, GFPA 2nd quarter 2007 D500,000 Training reports 4. Strengthen Supervision for provision of efficient FP services RCH, DHT, UNFPA, DoSH 2006-2010 Efficient supervisory services with tools, guidelines and checklists developed Activities Review existing supervisory checklist/tools. DHTs, RCH, UNFPA, AWARE-RH, DoSH 1st quarter of 2007 D10,000 Review report of supervisory checklist Conduct quarterly supervision visits to service delivery points offering FP services and management/storage of contraceptive products DHTs, RCH, UNFPA, AWARE-RH, DoSH 2006-2010 D67,480 # of supervisory visits scheduled and conducted Write supervisory reports and give feedback DHTs, RCH, UNFPA, AWARE-RH, DoSH 2006-2010 Regular programme budget Supervisory visit reports Total Service Delivery Component D2,427,480 4.5 Logistics Component Strategic objectives: To strengthen the logistic management system of the RCH Unit to ensure the uninterrupted supply of contraceptives and other basic RH equipments at all levels, improve storage conditions, establish/improve functional laboratory services at all major facilities, and improve transport for supervisory visits at national, divisional and community levels. In total, there are seven sub-components for strengthening logistic, i.e build capacity in logistic management, integrate RH logistic management into curricula of health training institutions, improved the provision of basic RH equipment, develop a procedure manual for contraceptive and other RH drug management, strengthen the logistic management information system, and laboratory and transport support services. Key Assumptions for the logistics component: Availability of forecasting tools Availability of competent human resources Functional cost recovery system Creation of a coordination mechanism for needs planning RCH Unit mobilized adequate resources Operational objectives and Activities Responsible Agency(ies) Time frame Estimated Budget (Dalasi) Process Indicators Results Indicators Build capacity in logistic management including forecasting for RCH unit RCH, CMS, DHT, AWARE RH 2006-2008 National experts trained and available to manage logistic system Activities Train two (2) RCH staff in logistic management DOSH/RCH 2nd and 3rd quarters 2006 D108,000 per staff Two RCH staff trained in logistic management Procure needed equipment and materials (stationery, filing cabinet etc) for record keeping system at RCH central management stores DOSH/RCH, CMS 3st quarter 2006 D20,000 Record keeping and storage condition at central store improved Hire one support staff to maintain stock and provide general cleaning of central store DOSH/RCH Unit 1st quarter 2007 Regular programme budget One staff recruited to man central store Procure one computer with accessories for the RH central stores management RCH, AWARE RH 3rd quarter 2006 D58,000 One computer purchased Integrate RH logistic management into curricula of health training institutions and stakeholders (RCH, CMS, in-service training Unit, UNFPA, DHT) RCH, DHTs, health training institutions 2006-2010 Hire consultant to conduct curriculum development process for max of 20 working days RCH unit, consultant 2006-2007 D75,000 Curriculum development and integration process outlined Organise four meetings with health training institutions and stakeholders to revise and incorporate RH logistic management issues into training. (RCH, CMS, in-service training Unit, UNFPA, DHT) RCH, DHTs, health training institutions 2006-2007 D75,000 # of meetings held and minutes of meetings Organise one validation meeting with stakeholders and training institutions to finalise curriculum RCH, consultant, training institutions 2006-2007 D50,000 Curriculum finalized and adopted by training institutions Sub-Total 1 Improve provision of basic RH equipment at all health intuitions (primary, Secondary & Tertiary levels) (RCH, CMS, in-service training Unit, UNFPA, DHT) RCH, DHTs, 2006-2010 # of basic RH equipment (Eg. BP machines, bathroom scales, pregnancy test kits, haemoglobin metres, IUCD kits etc Activities Conduct an annual inventory/assessment of RH equipment including laboratory equipment for public and private sector health facilities DOSH/RCH, CMS, partners, UNFPA 2006-2009 D30,000 # of various RH commodities at both central/DHMT and health facility stores at all levels Carry out annual quantification exercise for contraceptive and basic RH equipment needs DOSH/RCH, CMS, and partners 2006-2010 D150,000 Result of quantification exercise document and share with partners Procure and distribute basic RH equipment for public health facilities based on quantification DOSH/RCH, CMS, and partners 2006-2010 See estimate table Record of RH equipment procured and supplied to public facilities station Sub-Total 2 4. Develop procedure manual and supervision guide for contraceptive and other RH drug management DOSH-RCH,CMS, DPI, DHT, AWARE RH 2006-2007 New procedure manual and management tool developed and distributed for use at all facilities. Activities Develop draft procedure manual and supervision guide for contraceptive and other RH drugs DOSH-RCH,CMS, DPI, DHT, AWARE RH 4rd quarter 2006 Regular programme budget Draft procedure manual and supervision guide developed for review by stakeholders Organise five days consensus meeting with stakeholders on the procedural manual and management tools. RCH/DoSH, CMS, divisional heads 2006 - 2007 D160,000 Workshop report and revised procedure manual Validate procedure manual for contraceptive and other RH drugs DOSH-RCH, CMS, divisional managers 2006 -2007 D45,000 Report of validation meeting with revised procedure manual Organise 5 days TOT for 20 staff (2 per division, 5 central level and 3 private sector) on procedural manual and management tool RCH, CMS, divisional managers By end of 2007 D150,000 Training report Organize 3 days training for 50 store keepers and officer in charge at divisional and facility level on procedure manual and management tool DOSH-RCH, CMS, divisional managers 2007-2008 D50,000 # of store keepers and officer in charge trained Print and distribute 100 procedure manual and management tool (log cards etc) DOSH-RCH, CMS, divisional managers 2006-2007 D25,000 # of facilities/stores using revised procedure manual and management tool Su-Total 4 5. Strengthen the logistic management information system (LMIS) RCH Unit, CMS, DHT, GFPA 2006-2007 Improved LMIS instituted and use to inform decision-making for RCH programme Activities Organise two days training per division for all storekeepers and officer in charge to adopt new tool for data collection according to new manual DoSH-RCH, CMS, divisional managers, private sector partners 2rd quarter 2007 D150,000 New data collection tool reviewed and updated to manage logistic stock at facility and divisional level Print and distribute management tool at all levels DOSH-RCH, CMS, divisional managers, private sector partners 3st quarter 2007 D25,000 Management tool printed and distributed to all central stores and all divisional and facility level Initiate and follow up with data collection exercise with the new management tool (done jointly during supervisory visits) Same 2006-2010 Regularly programme budget Inventory records/system developed Analyze data to inform decision making RCH UNIT, CMS, DHT 2006-2009 Regular programme budget Stocks in place based on established guidelines RCH unit conduct quarterly supervision visit to divisional stores RCH, CMS 2006-2009 D100,000 # of reports on supervisory visits Store keepers/Pharmacist Assistant from Divisional level conduct monthly supervisory visit to facility level RCH, Divisional store keepers and Pharmacist 2006-2009 D20,000 # of reports on supervisory visits produced at divisional level Sub-Total 5 6. Establish functional laboratory services at all levels (primary, secondary tertiary levels) RCH, CMS, DHT 2006-2010 Strengthened laboratory services in place Activities Procure/provide basic laboratory equipment & materials and supply as identified in the inventory/assessment Gambia Government, USAID, AWARE-RH, Government of Taiwan, UNFPA, WHO, WAHO, UNICEF, UNDP July 2007 – January 2008 D Availability of the required materials e.g. test kits at all levels Identify and train 50 laboratory technicians Gambia Government, USAID, AWARE-RH, Government of Taiwan, UNFPA, WHO, WAHO, UNICEF, UNDP July 2007 – January 2008 D50,000 # of Laboratory Technicians trained Sub-Total 6 Operational objectives and Activities Responsible Institution Target Date Budget (FCFA) Process Indicators Results Indicators 7 To ensure reliable and effective transport system at all levels RCH/DoSH, CMS, DHT 2006-2010 Improved efficiency of transport fleet reflected in timely delivery of contraceptive supplies Activities Estimate needs for transport fleet/fuel requirements at all levels (motorbikes, boats, horse cart) to identify gaps Gambia Government, UNFPA, UNICEF, USAID, AWARE-RH, WHO, WB, ADB, IDB, Republic of China on Taiwan 2006-2007 D50,000 Reports of the need assessment of the transport fleet and fuel requirement Procure/provide transport equipment including two motor bikes and two vehicles in support of contraceptive and other RH equipment distribution and supervision Gambia Government, UNFPA, UNICEF, USAID, AWARE-RH, WHO, WB, ADB, IDB, Republic of China on Taiwan 2006-2007 D2,000,000 Spare parts D600,000 # of vehicles and motobikes available to support distribution of supplies and for supervision Sub-Total 7 Total Logistics D3,991,000 Procurement of contraceptives Total Logistics Component 4.6 Coordination and M & E The Strategic objective is to develop national capacity to monitor implementation of the RHCS plan, and monitor the achievement of its targets. The RCH unit working in collaboration with the Central Medical Stores will take the leadership role in monitoring the activities of the reproductive health contraceptive security plan and will report on progress of implementation to DoSH through the Director of Medical Services and to the partners. In carrying out its central M & E functions, the RCH unit will seek technical assistance from AWARE-RH when required. Individual organizations, development partners and the other private sector partners, including NGOs will be responsible for implementing their own assigned activities and will report to the RCH unit/DoSH. Key Assumptions for Coordination and M & E: Received government commitment to fund purchase of contraceptive Strong collaboration exist between public and private sector partnership for contraceptive security Logistical indicators in place (stock outs, min/max levels etc) High unmet need for FP reduced Operational objectives and Activities Responsible Institution Target Date Budget (FCFA) Process Indicators Results Indicators Develop national capacity to coordinate and monitor implementation of RHCS plan RCH/DoSH, CMS, RCH Committee, GFPA, partners 4th quarter, 2007 National coordination and monitoring plan on RHCS developed and implemented Activities Conduct two joint meetings and invite selected community and religious leaders to the planning meetings with RCH unit RCH, DHTs Donors, CMS, GFPA 2006-2010 D100,000 # of community and religious leaders in the annual planning meetings Develop and launch monitoring plan for all stakeholders DPI, RCH, CMS, GFPA, GSMMP, UNFPA 4th quarter 06-2nd quarter 07 Regular programme budget RHCS monitoring plan developed and disseminated Write quarterly reports and present to National RCH committee and DoSH RCH/DoSH, CMS etc 2006-2010 Regular programme budget Quarterly reports written on implementation of RHCS plan Conduct quarterly National RCH Committee meetings at the National level RCH UNIT, RCH Committee, GFPA, CMS etc 2006-2010 D680,000 # of quarterly meetings held and reports of meetings Conduct regular/quarterly monitoring of commodity stock to ensure replenishment at all levels RCH UNIT, RCH Committee, GFPA, CMS etc 2006-2010 D100,000 # of quarterly monitoring visits and report on findings Total Coordination and M & E D880,000 4.7 Partnerships The strategic objective is to expand the RH programme output through partnership and a well co-ordinated use of meagre resources. The RCH unit will work to strengthen coordination mechanism with its partners and programme implementers, including the private sector. It is envisioned that the RCH coordination role will be expanded, especially in formalizing opportunities for private sector active participation in provision of RH commodities and services. In addition, the RCH unit will work closely with the UNFPA to develop the new country programme for the Gambia and ensure that it reflects the need for contraceptive security and financing to help implement this plan. Key Assumptions for Coordination and M & E: Sales tax exemption granted for contraceptives as an essential drug to enhance private sector participation Expanded coordination and collaboration exist between RCH/DoSH and UNFPA in support of contraceptive security. Inter-agency coordinating committee for contraceptive security established and meets regularly Operational objectives and Activities Responsible Institution Target Date Budget (FCFA) Process Indicators Results Indicators Strengthen linkages/coordination between Government, donors and NGO partnership on RH commodities. RCH/DoSH, CMS, RCH Committee, GFPA, UNFPA partners 2006-2007 Inter-agency coordinating committee on contraceptive security with private sector partners established and chaired by DoSH Activities Establish Inter-agency Coordinating Committee for contraceptive security with members drawn from government, donors, NGOs and the private sector. DoSH/RCH, CMS, GFPA, GSMMP, UNFPA, other donors private partners by 4st quarter 2007 D150,000 per annum (4 meetings held) D600,000 # of consultative meetings and dialogue held between DoSH and partners to constitute ICC/CS RCH Unit to work closely with UNFPA in the development of the new country programme for the Gambia to ensure it reflects need for CS and financing. RCH/DoSH, UNFPA, CMS, GFPA 2006-2007 Regular programme budget New UNFPA country programme reflects CS issues Formalize and expand role of private sector in the import and provision of RH commodities and services RCH/DoSH, CMS, GFPA, Private partners, Medicines Board, Pharmacists etc 2006-2010 Develop framework/ MOU for collaboration and get approval Activities Develop draft framework/MOU for strengthened private sector involvement in RH commodity provision and service and organize one stakeholder meeting to validate and adopt MOU RCH/DoSH, CMS, GFPA, Private partners, Medicines Board, Pharmacists etc 2006-2007 D150,000 # of meetings held to draft framework and/or MOU Undertake market segmentation and price rationalization study (ability to pay) RCH unit, GFPA, CMS UNFPA, consultant 2006-2007 D200,000 Study report with recommendations for action Organize validation meeting to gain consensus on study recommendations RCH By 4th quarter 2008 D150,000 # of consultative meetings held with partners to ensure implementation of study findings Total Partnership D650,000 References ANNEX 1: Gambia Estimated funding Requirements for Contraceptive Commodities, 2005-2015 The table shows the estimated “bottom line” funding requirements for contraceptive commodities for 2005-2015. For each year, the lowest and highest estimates are shown considering all nine projections for modern methods. The commodities are male condoms, oral pills, 3-month injectables, vaginal foaming tablets (VFTs), and IUDs. The condom estimates do not include condoms for HIV prevention. The estimates are inclusive of freight and procurement fees. Year Estimated Contraceptive Costs Low Estimate ($US) High Estimate ($US) 2005 139,000 172,000 2010 178,000 268,000 2015 224,000 390,000 Source: Alan H. Bornbusch AWARE RH: Estimating Future Contraceptive Requirements for The Gambia (2005-2015). ANNEX 2: Estimating Future Contraceptive Requirements for The Gambia (2005-2015) Nine projections were used to estimate contraceptive commodity requirements for The Gambia to 2015. These are demographic projections. They are for the country as a whole, regardless of where users obtain their method (public, NGO, social marketing, commercial). Each projection makes assumptions about future trends in contraceptive use. Each estimates the volume of commodities needed to supply future prevalence rates. The commodities are male condoms, oral pills, 3-month injectables, vaginal foaming tablets (VFTs), and IUDs. The condom estimates do not include condoms for HIV prevention. Commodity requirements are translated into financing requirements by multiplying the number of commodities by unit price. Unit prices are approximate 2005 prices obtained by UNFPA (for all except pills), or 2005 price obtained by USAID (for pills): Table 1: FP Commodities and Unit Prices Commodity Unit price ($US) Male condom 0.028 Oral pills 0.23 Injectable 1.0 VFT 0.091 IUD 0.65 An additional 15 percent and five percent are added to allow for freight and procurement fees, respectively. It is important to note that the estimates used here do not take into account supplies for male and female sterilization. More broadly, they do not account for service delivery costs, including procedures for IUD insertion and sterilization. All nine projections estimate growth in the number of women of reproductive age according to UN medium variant estimates (http://esa.un.org/unpp/). The nine projections make different assumptions about future trends in overall contraceptive use (contraceptive prevalence rate, CPR) and method mix. Because The Gambian programme is in its early stages, and that there is little data to discern recent trends, it is difficult to know how the programme will evolve over the next ten years. The 2001 National Survey on Maternal, Perinatal, Neonatal, and Infant Mortality and Contraceptive Prevalence Survey was used as the baseline for each projection. There is no more recent national data, though a 2006 Demographic and Health Survey is planned. From the 2001 baseline, the CPR can increase more or less rapidly. For this exercise, three trends in CPR were used, all increasing CPR by a set amount annually: Table 2: Projected Annual Increase in CPR Annual increase Contraceptive Prevalence Rate (CPR) 2001 2005 2010 2015 0.5 17.5 19.5 22.0 24.5 1.0 17.5 21.5 26.5 31.5 1.5 17.5 23.5 31.0 38.5 From the 2001 baseline, the method mix can stay relatively constant, shift to more use of modern short-term methods, or shift to more use of long term and permanent methods. Three trends in method mix were used: (A) Method mix remains constant from the 2001 mix. (B) Method mix shifts to more use of modern methods, with greater increases for short term methods (pills, injectables). (C) Method mix shifts to more use of modern methods, with greater increases for long term and permanent methods (IUDs, female sterilization). The differences between these are illustrated using projections based on a 1.0 annual increase in CPR: Table 3: Method mix and Prevalence, 2001-2015 Method Prevalence 2001 2015 (A) (B) (C) Total 17.5 31.5 31.5 31.5 Modern methods 13.4 24.0 27.0 27.0 Male condom 0.5 0.9 1.1 1.0 Oral pills 6.8 12.2 13.8 12.4 Injectable 3.7 6.6 7.4 6.7 VFT 0.1 0.2 0.0 0.0 IUD 1.5 2.6 3.0 4.5 Female sterilization 0.7 1.3 1.5 2.3 Male sterilization 0.1 0.2 0.2 0.2 Traditional 4.2 7.5 4.5 4.5 Trends (B) and (C) both indicate a shift in modern methods, from 77 per cent of total CPR in 2001 to 86 per cent in 2015. (B) suggest the shift will be concentrated in short-term methods, so that by 2015 pills and injectables account for 67 per cent of total use. IUD use and sterilization would account for 15 per cent. (C) suggest greater increases in long term and permanent method use, accounting for 22 per cent of total use by 2015. Together, the three CPR trends and the three trends in method mix define the nine projections: Table 4: Projection Scanarios Projection CPR Method Mix 1 0.5 increase per year (A) Method mix remains constant 2 0.5 increase per year (B) Shift to short term methods 3 0.5 increase per year (C) Shift to long term, permanent methods 4 1.0 increase per year (A) Method mix remains constant 5 1.0 increase per year (B) Shift to short term methods 6 1.0 increase per year (C) Shift to long term, permanent methods 7 1.5 increase per year (A) Method mix remains constant 8 1.5 increase per year (B) Shift to short term methods 9 1.5 increase per year (C) Shift to long term, permanent methods Other scenarios can be constructed. However, they would likely be no more or less valid than the ones used here. Further, the nine used here probably give a reasonable picture of the upper and lower estimates for what The Gambia will need. They should, though, be revisited and refined based on results of the 2006 demographic and health survey. These estimates (see annex 1) are meant to be used for long term planning purposes. They are NOT appropriate for shorter term procurement planning. The commodity projections are not forecasts per se. Further, the projections project total contraceptive use, regardless of source. In The Gambia, contraceptive sources now include the public sector, social marketing, NGOs, and probably least of all the commercial sector. Year-to-year financial allocations and procurements planning will require yearly, programme-specific forecasts based on consumption trends, stock balances, desired balances, and other data. National Reproductive Health Commodity Security Plan for the Gambia: 2006-2010 Situation Analysis Getting consensus on Priority Areas Develop the RHCS plan Advocacy to raise awareness and mobilize resources to fill contraceptive gap Implement the RHCS plan and monitor and evaluate results OF THE GAMBIA THE REPUBLIC � The SPARHCS (Strategic Pathway to Reproductive Health Commodity Security), strategic approach for reproductive health commodity security is intended to help countries face their contraceptive commodity supply problems, to develop and implement strategies for reproductive health commodity security (RHCS). PAGE 12

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