PAI The Road from Istanbul to Addis and Beyond- Setting an Agenda for Reproductive Health Supplies

Publication date: 2011

The Road from Istanbul to Addis and Beyond setting an agenda for reproductive health supplies Elizabeth Leahy Madsen, Wendy Turnbull, Shelly Amieva, Yonas Asfaw, Jessica Bernstein, Mercedes Mas de Xaxas and Foluke Ojelabi June 2011 Population Action International INTRODUCTION In May 2001, 130 stakeholders from around the world gathered in Istanbul, Turkey, to discuss challenges related to shortages of reproductive health supplies at the global and national levels. The group outlined actions for a response and committed to moving momentum forward through coordinated initiatives and leadership.1 One of the hallmarks of the Istanbul meeting was the active participation and engagement of delegations from 10 countries,2 who met in a pre-conference session to draft a list of recommendations that were presented at the subsequent high-level meeting. This effort fostered broad participation, identified common themes and enabled an effective voice and presence for country delegates to ensure that the Istanbul Declaration included perspectives beyond international organizations and donor agencies. The Istanbul meeting and the resulting declaration have become recognized as the catalyst of the global reproductive health supplies movement and resulted in numerous successes. Still, as the tenth anniversary of the Istanbul meeting approaches, challenges remain, and a new agenda for action must be established for the coming years. This report is intended to follow the model of the Istanbul meeting by ensuring that country voices and experiences play an even stronger role in the design and implementation of the next stage of the reproductive health supplies effort. The report’s objective is to inform stakeholders at all levels of representative successes, challenges and opportunities for reproductive health supplies across a diverse subset of national experiences. The country-led contributions informed in part by this research will be a valuable foundation for activities that move the reproductive health supplies agenda forward. The findings and recommendations presented in this report are drawn directly from surveys and interviews conducted in early 2011 with 53 stakeholders in six focus countries: Bangladesh, Ethiopia, Ghana, Mexico, Nigeria and Tanzania. This research was supported by the Innovation Fund of the Reproductive Health Supplies Coalition. For further details on the research process, please see the methodology section at the end of the report. 1300 19TH STREET NW, SECOND FLOOR WASHINGTON, DC 20036 USA +1-202-557-3400 WWW.POPULATIONACTION.ORG © 2011 POPULATION ACTION INTERNATIONAL 2 KEY FINDINGS Progress has been enormous, from coordination and funding to new ways of expanding clients’ access. But like any progress, it has not been without challenges. Shortfalls remain between funds committed and allocated and between funds allocated and spent. Reproductive health supplies also compete for funding with other areas of health as well as with broader development priorities. To ensure better access to reproductive health supplies, coordination between central and local levels must continue to improve. Bureaucracy often clogs procurement and distribution, resulting in shortages and stockouts. The challenges facing reproductive health supplies are particularly acute at the lowest levels of the health system. Demand for reproductive health supplies is increasing everywhere and will continue to do so. Young people remain the primary underserved population when it comes to family planning and reproductive health services and supplies. A range of legal, regulatory and infrastructure barriers persist in limiting access and choice. Government commitment is often weak and uneven. Civil society is demanding and creating new mechanisms for improving accountability and transparency. Donor support for reproductive health supplies ebbs and flows. The ability of donors to act as catalysts for better government policies and increased investment in family planning and repro- ductive health is not fully realized. Across the board, policymakers consistently fail to recognize family planning as a fundamental socioeconomic issue. The private sector has the potential to scale up and be more active. Public-private partnerships and coordination are important to move forward. Civil society organizations have played and will continue to play a pivotal role in ensuring access for all. RECOMMENDATIONS Drawing from the progress achieved since Istanbul and their assessment of current issues, country stakeholders offer the following recommendations for the future advocacy agenda for reproductive health supplies. s Strengthen Government Commitment and Effectiveness Strengthening government commitment is often the top priority for future advocacy efforts related to reproductive health supplies at the country level. Stakeholders recommend that national and local governments: ፘ Institute budget lines for supplies with adequate allocations and develop long-term projections of need, including at lower levels and for all population groups ፘ Strengthen coordination between central and lower levels ፘ Improve logistics management information systems at all levels of the health system ፘ Improve training and human resources in health ፘ Coordinate with civil society, donors and the community ፘ Upgrade infrastructure to improve access for people in remote and underserved areas ፘ Identify and remove procurement barriers s Coordinate Across Sectors Coordination across public and private sectors, donors, NGOs and civil society is necessary to build support for reproductive health supplies. Stakeholders recommend that: ፘ Incentives, whether from international organiza- tions to governments or within governments, and accountability mechanisms are used to ensure that stated commitments to reproductive health supplies are met in funding and practice ፘ Public-private partnerships are increased and strengthened “We will have to keep up the pressure on the government regarding reproductive health supplies, especially now that we have two years’ worth of contraceptives in-hand. The government will relax a bit and advocates might, too. But we have to stay focused and continue pressuring govern- ment.” — Tanzania 3 ፘ Evidence and data are directed to and utilized by policymakers to make the case for reproductive health supplies ፘ Family planning is consistently linked with socioeconomic development ፘ Advocacy efforts reference family planning and its connections to other policy issues in outreach to government s Activate the Private Sector In addition to improved coordination with other sectors, the private sector can also increase its own engagement with reproductive health supplies. Stakeholders recommend that the private sector: ፘ Educate pharmacists and other service providers to provide information about supplies and to offer a wider array of methods ፘ Increase local production of supplies ፘ Improve transparency about the types and quantity of reproductive health services it provides to facilitate more accurate estimates about national needs ፘ Consider differentiated pricing and social insurance schemes ፘ Participate in technical working groups and other collaborative entities s Build Leadership from Civil Society Civil society organizations have played and will continue to play a pivotal role in ensuring access to reproductive health supplies for all. Stakeholders recommend that civil society: ፘ Pressure governments for more funding and resources ፘ Gather and disseminate information to policymakers ፘ Educate and inform citizens about the impor- tance of family planning and reproductive health for overall development ፘ Recruit new civil society organizations to be active on reproductive health supplies and strengthen existing networks toward a more cohesive advocacy voice ፘ Maintain current strong relationships with central governments while improving collabo- ration with lower levels of government ፘ Lead the creation and implementation of accountability mechanisms to watch governmental commitment and transparency s Catalyze Commitment from International Partners Donors and other international organizations are described as a catalyst, providing both encour- agement for better funding and policies on the part of government and strong messages and language for policy advocacy. Stakeholders recommend that donors: ፘ Fulfill their commitments to funding for reproductive health supplies ፘ Use their influence with governments to promote improved policies, funding and strategies ፘ Increase participation in working groups and other collaborative entities in order to reduce duplicative efforts ፘ Increase predictability and coordinate releases of funds with the government ፘ Continue to provide technical assistance s Build New Alliances Beyond the national level, stakeholders would like to see more regional advocacy for reproductive health supplies, with strategies shared across neigh- boring countries. Stakeholders recommend that: “It is the right of every woman to decide what, where, how and when number of children she wants to deliver. This is a fundamental right that should be enshrined in every bilateral agreement!” — Nigeria “We tend to think of government as a homogenous entity, but it’s not. There are Ministry of Health staff and the individuals that control the budget allocations. Colleagues at the Ministry of Health don’t wield much power; they can’t increase the budget or speed up procurement. We have to do more at regional and district level to bring about change and improve access.” — Tanzania 4 ፘ Lessons learned from innovative financing mechanisms for health are emulated where possible for reproductive health supplies ፘ Supplies are better included in the global HIV/ AIDS and maternal, newborn and child health care movements, and integrated into proposals to the Global Fund ፘ Outreach and education related to reproductive health supplies targets men and community leaders ፘ The United Nations and regional bodies form alliances and pressure governments to keep their commitments related to reproductive health s Keep Supplies on the Global Agenda Progress has been enormous, but reproductive health supplies must remain a priority for the global community. Stakeholders recommend that: ፘ Internationally and regionally agreed goals, such as the International Conference on Population and Development’s Programme of Action and the Maputo Plan of Action are achieved ፘ Global gatherings such as the “Setting an Agenda for Reproductive Health Supplies” and “Access for All” meetings in Addis Ababa are held to share best practices and galvanize broad participation in advocacy A complete list of recommendations offered by all interviewed stakeholders follows in Appendix 1. REVIEWING PROGRESS SINCE ISTANBUL In all countries surveyed, stakeholders have observed improvements in access to reproductive health supplies in the decade since Istanbul. Better coordi- nation among all actors and improved forecasting are cited among the most significant improvements in each country (see sidebar). These improvements are often credited to increased commitment from country governments and donors, advocacy by civil society, growth in public and private sector service availability and increased demand for reproductive health supplies. Despite these improvements, assessments are mixed about whether country governments have increased or decreased their commitments to strengthening family planning overall and to improving access to reproductive health supplies. In Bangladesh, Ethiopia, Nigeria and Tanzania, most stakeholders observe more commitment from their country governments, while in Ghana and Mexico, such commitment is perceived to have declined. In Ghana, one stakeholder explained, “There is a lot of talk about the importance of family planning to health and to national development, but actual government disbursement for contraceptives has declined in recent years.” q Government Commitment As a sign of increased commitment on the part of governments, the number of policies addressing reproductive health supplies has grown in all countries. Many existing policies have also been strengthened. New policies include roadmaps for “My greatest wish is for the populations of countries to rise up and face their governments—for people to stand up all around the world—for ordinary folks to demand access to family planning from their governments. For them to be able to tell their government that they demand these services and supplies and tell the government that they must provide them to the people.” — Ghana Most Significant Improvements in Access to Supplies Since Istanbul ፘ Better coordination ፘ Improved forecasting Other Major Improvements ፘ Access within the private sector ፘ Access among vulnerable and underserved populations ፘ Access at lower levels of the health system ፘ Higher funding from donors ፘ Broader method mix 5 repositioning family planning, contraceptive security strategies, provision of free contraceptives at public sector health facilities, policies linking reproductive health and HIV/AIDS, protocols related to specific contraceptive methods and to abortion, national health policies, and frameworks related to adolescent health. While these new and strengthened policies are viewed positively, stakeholders sometimes see a disconnect between strong commitment expressed on paper and weak implementation of funding and programming. q Funding Funding for reproductive health supplies has increased in most countries; in the case of Mexico, decentralized budgets make financial flows difficult to track. Elsewhere, much of the increased funding is attributed to donors, as increases on the part of government have often been too small to be significant. Unpredictability is a challenge with financial resources for supplies, as disbursements frequently fall short of allocations and funding flows can change dramatically from year to year. New financing mechanisms implemented over the past decade have resulted in greater attention to and integration of supplies into other areas of health and development. These include poverty reduction strat- egies and health sector and general budget support. However, these mechanisms have also presented some obstacles. In Nigeria, some stakeholders observe that supplies have not been included in new financing policies and are therefore neglected. While reproductive health supplies must compete with other health priority areas, a stakeholder in Ghana noted that budget lines for reproductive health supplies within the health sector must also be allocated and released by multiple ministries: “A move to sector budget support by many of the development partners made Ministry of Health procurement, even with donor support, hostage to release of funds by the Ministry of Finance.” Also in Ghana, a national health insurance scheme was implemented that neglected to cover costs for contraceptive services and supplies, despite offering free maternal and child health care. It is described as a major missed opportunity. q Decentralization of the Health System Evolving financing mechanisms are often viewed positively, but decentralization of the health system has presented new challenges in access to and availability of reproductive health supplies in many countries. Decentralization of funding decisions to lower levels is welcomed in principle, but takes time to be implemented effectively. In some cases, repro- ductive health supplies have become subject to the priorities and beliefs of more government officials, some of whom choose to emphasize other health issues. Other challenges related to decentralization include inadequate projections of need at lower levels and increased costs for transportation borne by districts. Even when decentralization has success- fully resulted in more attention to reproductive health supplies at all levels, stakeholders note that serious problems of access at lower levels remain. In some countries, decentralization exists on paper but is described as ineffective in practice, with authority for procurement and funding still invested at the central level. q Stockouts and other Major Barriers Across countries surveyed, shortages and stockouts are typically described as an ongoing major barrier to improving access to reproductive health supplies. In some cases, shortages and stockouts occur at all levels of the health system; in others, they are more common at the district level and facilities or only in certain regions. Implants and injectables are the contraceptive methods most commonly affected by shortages and stockouts. Even when contra- ceptives are available, necessary consumable and infection prevention materials such as gloves may be stocked out. These shortfalls are often attributed to insufficient funding and procurement delays as well as problems with stock status information and transportation. Given their impact on shortages and stockouts, low levels of funding from country governments and procurement delays are often described as the biggest outstanding challenges in improving access to supplies. In Tanzania, for example, the procurement and logistics system often fails in practice. According to one stakeholder, “Lengthy bureaucratic processes at central level combined with cumbersome distribution processes at local level guarantee shortages and stockouts.” In Bangladesh, the lengthy procurement process can be further slowed if any party raises questions or complaints. Access problems among underserved populations, training health workers, and health 6 management information systems are often cited as important issues. In Bangladesh, Ghana and Mexico, access to supplies is described as better than in neighboring countries, while in Ethiopia, Nigeria and Tanzania, it is considered to be similar or worse. ASSESSING CURRENT ISSUES q Logistics Systems and Public Sector Commitment Stakeholders do observe signs of progress in national logistics systems, particularly in the accuracy of forecasting and quantification of need. Up-to- date stock status information in Bangladesh and procurement at the central level in Ethiopia and Nigeria are also cited as strengths. Most stakeholders rate the capacity of public sector institutions in their country as average to strong, but simultaneously rate the level of government commitment to improving access to reproductive health supplies as weak. These responses indicate that while capacity for attention to supplies exists, governments have chosen to focus their investments and attention elsewhere. q Private Sector Assessments of private sector capacity are mixed. In Bangladesh, Ghana and Mexico, private sector capacity is generally described as strong; in Ethiopia and Tanzania it is weaker; and in Nigeria, assess- ments are mixed. Even if private sector capacity is strong, collaboration with the government and other service providers is required for the private sector to fully meet its potential. Some stake- holders note limitations in the population’s access to private sector services in poor and/or rural areas and barriers with the provision of family planning services in religious institutions. q Civil Society In contrast to public and private sector capacity, stakeholders most often rate the strength of civil society advocacy for reproductive health supplies as strong, and report that civil society involvement in supplies has increased over the past 10 years. Civil society organizations have been particularly effective in raising awareness among clients and potential users, improving access to certain methods, motivating policymakers to provide more funding and working with governments to develop new policies. Some challenges were noted for civil society, including funding cuts, inexperience of some indigenous organizations, political rigidity that inhibits NGOs, and the fact that awareness-raising efforts targeting women of reproductive age are sometimes still dominated by the government. q Maternal Health Supplies and the Global Fund to Fight AIDS, Tuberculosis and Malaria Stakeholders were also surveyed about two related health areas: maternal health supplies and the Global Fund to Fight AIDS, Tuberculosis and Malaria. Maternal health supplies include medicines and equipment for safe pregnancy and delivery, such as magnesium sulfate, manual vacuum aspirators (MVAs), misoprostol and oxytocin. The biggest challenges facing access to and availability of these supplies include their lack of availability for home deliveries and at lower-level facilities. Political sensitivities, shortages of health workers, poor provider training and quality of care, and access problems among underserved populations are other challenges. One stakeholder in Tanzania summa- rized, “Policymakers at all levels don’t seem to understand the connection, the cost-effectiveness of family planning in reducing maternal mortality. Globally and nationally, there’s more emphasis on expensive interventions. We have the evidence but there is no awareness, no understanding, no action on family planning and reproductive health.” The Global Fund, which is active in all countries surveyed, has had a neutral to negative effect on access to reproductive health supplies. Some stakeholders are concerned that the Global Fund’s activities have diverted attention away from family planning and reproductive health. Increased funding of condoms through the Fund is welcome, but these are sometimes considered designated for HIV prevention and not as a family planning option, a real or perceived separation that seems too artificial at service delivery points. In Bangladesh, free, socially marketed condoms supported by the Global Fund may diffuse interest in branded condoms available through other sources. A stakeholder there explained, “The Global Fund has, to some extent, diluted the focus on repro- ductive health or maternal and child health services across the country. Since many of the government initiatives and private, national and international non-governmental organizations became involved 7 with Global Fund-related activities, it affected the access to reproductive health supplies as overall budget in the reproductive health sector decreased in trying to incorporate the focus on HIV, malaria and tuberculosis.” Stakeholders surveyed for this report believe that integration of family planning into proposals to the Fund is important and should be pursued, but some institutions working with the Global Fund are characterized as resistant to such integration. LOOKING FORWARD q Growing Demand for Reproductive Health Supplies In all countries, stakeholders agree that demand for reproductive health supplies will increase in the future and in many cases is already growing. Increases in demand will be driven by population growth, especially among youth entering their reproductive years. Increased awareness of family planning and increased education and desire for an improved quality of life will also play a role. A stakeholder in Bangladesh noted, “The ongoing and continuous efforts by the government, private sectors, NGOs and other stakeholders mean that more people will be accepting and adhere to family planning methods, furthering demand/need for reproductive health supplies.” An Ethiopian stake- holder explained that a “few years back there were reproductive supplies which were staying in the store for a longer period of time, compared to frequent stockout[s] now because of the increase in demand for services.” q Inadequate Supplies There is also widespread consensus that given the status quo in each country, supplies will be inade- quate to meet growing demand. Many countries have relied on donor support to fill gaps, but in the future, government commitment will be the linchpin of success. Governments have often become more active in family planning and repro- ductive health in recent years, but there are some doubts about whether this will extend over the long term. Although long-term forecasting and multi- year projections should help ensure adequate supply, unexpected shortages and problems with specific methods still occur. Donors should continue to provide support, but also motivate the government to strengthen its role. According to one stakeholder in Ethiopia, “Unless there is an increased commitment from the government to allocate enough budgets for repro- ductive health supplies and also increased funding from donors, with the current pace I doubt that the reproductive health supplies would be adequate to meet the demand.” In Ghana, a stakeholder explained, “There needs to be concerted effort to get the government to increase its commitment and to have family planning supported in all socio- economic development strategies and policies—in every component. Family planning is an economic issue as well as a health issue. Donors are important but governments must completely own this respon- sibility.” In Nigeria, a stakeholder noted that existing warehouse storage capacities are inadequate for the quantity of supplies that would be needed to meet demand. q Decentralization and Donor Phase-Out Mexico faces a unique situation among the countries surveyed because of its independence from donor funding for reproductive health supplies and the degree of decentralization within its health system. These experiences may provide guidance and lessons learned as other countries prepare for donor phase-out and/or health sector reforms. The country’s successes have, paradoxically, produced some challenges. Mexico no longer experiences international pressure to maintain its commitments to reproductive health or supplies, and changes in demographic indicators such as the lower fertility rate have weakened the once-strong culture for family planning. Meanwhile, decentralization has resulted in difficulties in calculating accurate national forecasts of need, lack of clarity among multiple financing mechanisms that cross state and federal levels, and no enforcement power in cases of state governments that do not prioritize reproductive health supplies. A stakeholder noted, “A large portion of the supplies are no longer acquired by the national government; this responsibility has been decen- tralized and now each of the 32 states decide what and how many to purchase. The large majority of the states prefer to allocate the resources available for health to other issues. And the problem is that the federal government has not made any effort to improve this situation.” 8 SUMMARY In the decade since the Istanbul meeting, the accomplishments are many. Reproductive health supplies is now an international cause that is championed by a diverse and growing coalition. Coordination at the global level is vastly improved and having an impact on the ground. At national level, meaningful policy changes and financial commitments are well underway in many countries, serving as guideposts to neighbors in the region. As our movement takes stock of the significant progress made, we acknowledge that much technical and advocacy work lies ahead. Several underlying challenges and barriers to reproductive health supplies identified in Istanbul are alive and well, as evidenced by the country level responses reflected in this report. Shortages and stockouts persist in many places due to any combination of factors outlined here. Low government funding and heavy dependence on donors for reproductive health supplies remain chief concerns across all sectors. Simultaneously, new opportunities await repro- ductive health supplies; innovative financing mecha- nisms; a growing middle class and private sector presence; strong political will for and investment in maternal health; and community-based access and advocacy, among others. A coordinated and focused multi-sector approach is essential to capitalizing on these opportunities, as well as to continue resolving the long-standing barriers to reproductive health supplies. METHODOLOGY In August 2010, Population Action International (PAI) was awarded a grant from the Innovation Fund of the Reproductive Health Supplies Coalition (RHSC) for a yearlong project to reconvene country teams at a meeting commemo- rating the tenth anniversary of the 2001 Istanbul conference. The objectives of the gathering are to assess progress, share lessons learned and identify the principal challenges and opportunities toward improving access to reproductive health supplies. The cornerstone of the project is the assembly of country team delegates to develop and present key recommendations at the 2011 “Access for All” high-level meeting on reproductive health supplies organized by the RHSC. These recommendations are intended to be informed by research into the successes, outstanding barriers and next steps for reproductive health supplies in each country, the findings of which are detailed in this report. The research process began with a pool of 19 countries comprised of those whose delegations attended the 2001 Istanbul meeting and the focus countries of the RHSC. Five initial focus countries (Bangladesh, Ethiopia, Ghana, Mexico and Tanzania) were selected due to their diversity in four factors: change in unmet need for family planning; level of donor funding for contraceptives and condoms; existence of a budget line item for contraceptives; and inclusion of family planning, reproductive health and contraceptives in poverty reduction strategies. These selection criteria were vetted by the Istanbul+10 Task Force established by the RHSC. Nigeria was later added as a sixth focus country in order to align with contraceptive funding analysis conducted by the Health Policy Project. The countries selected, with their geographic and thematic diversity, represent a broad array of policy, funding and advocacy issues related to reproductive health supplies. q Country Selection Indicators3 Between January and May 2011, PAI contacted and distributed surveys to 81 organizations or individuals representing national governments, international organizations, civil society organiza- tions and the private sector across the six focus countries. Contacts were identified through PAI’s existing network of partner organizations as well 9 as through suggestions from other members of the RHSC. A total of 53 responses were received to the survey, which was conducted in English. Approximately half of the respondents were then asked to answer a series of additional questions in an interview format and invited by PAI to participate in the June 2011 “Setting an Agenda for Repro- ductive Health Supplies” meeting in Addis Ababa. The surveys and interviews were structured chrono- logically to cover past, present and future issues related to reproductive health supplies. The text of the survey and interview questions is included in Appendix 3 of this report. Since this report is intended to serve as a starting point for further discussion and the refinement of policy recommendations, the respondents’ answers to the survey and interview questions were not verified against existing policies or published country data. In some cases, respondents did not respond to questions they could not answer; in others, they may have answered based on their impressions or distinct perspective. While the results of this research cannot be used for statis- tical purposes, they do provide a solid framework of information based on the extensive experience of individuals and institutions with several years of experience working directly on reproductive health supplies issues. q Note on Terminology “Reproductive health supplies” is a broad concept that can encompass an array of commodities and equipment.8 Historically, the community of practi- tioners and advocates working on this issue has focused on contraceptives and condoms for family planning, due in large part to the lack of available data on other reproductive health supplies. This narrower interpretation is reflected in the survey and interview questions used in this report. The surveys also asked one question each about supplies for safe pregnancy and delivery and about activities of the Global Fund to Fight AIDS, Tuberculosis and Malaria, which often funds condoms for HIV/ AIDS prevention. The Global Fund is increasingly becoming an important donor for reproductive health supplies and in recent years, maternal health supplies have been an emerging focus of the Reproductive Health Supplies Coalition. TEN-YEAR CHANGE IN UNMET NEED FOR FAMILY PLANNING4 DONOR FUNDING FOR REPRODUCTIVE HEALTH SUPPLIES, 20095 FAMILY PLANNING/ REPRODUCTIVE HEALTH PRIORITIZED IN PRSP6 CONTRACEPTIVE SECURITY INCLUDED IN PRSP7 Bangladesh +2 percentage points $10.4 million Yes No Ethiopia -2 percentage points $25.2 million Yes Yes Ghana +12 percentage points $3.4 million Yes No Mexico No change $0.4 million Yes No Nigeria +2 percentage points $12.5 million No No Tanzania -2 percentage points $9.6 million Yes No ENDNOTES 1 For more details on the Istanbul meeting, see: Interim Working Group on Reproductive Health Commodity Security. 2001. Meeting the Reproductive Health Challenge: Securing Contraceptives, and Condoms for HIV/AIDS Prevention. Istanbul, Turkey, 3-5 May 2001. Report on the Meeting. Washington, DC: Population Action International. 2 The 10 countries were Bangladesh, Ethiopia, Indonesia, Mexico, Kenya, Nepal, Nigeria, Turkey, Vietnam and Zambia. 3 Information compiled in October 2010; Nigeria compiled in May 2011. 4 Source: Demographic and Health Surveys; United Nations Population Division where DHS unavailable. 5 Source: RHInterchange. In Tanzania, the Ministry of Health funded an additional $3.2 million. 6 Source: USAID Contraceptive Security Indicators 2010; individual country PRSPs. 7 Source: USAID Contraceptive Security Indicators 2010; individual country PRSPs. 8 The Reproductive Health Supplies Coalition defines the term as “any material or consumable needed to provide reproductive health services. This includes, but is not necessarily limited to contraceptives for family planning, drugs to treat sexually transmitted infections, and equipment such as that used for safe delivery.” http://www.rhsupplies.org/about-rh-supplies/what-are-rh-supplies.html 10 q governments ፘ Strengthen political commitment for reproductive health supplies ፘ Allocate and disburse sufficient financial resources for reproductive health supplies in the government budget ፘ Improve logistics management information systems ፘ Establish a buffer stock of reproductive health supplies to prevent shortages/stockouts ፘ Coordinate with other sectors ፘ Increase local production of reproductive health supplies ፘ Link reproductive health to overall development efforts and policies ፘ Strengthen human resources for health, including service provider retention and training ፘ Improve community-level awareness of and access to reproductive health supplies ፘ Strengthen service delivery and supplies at lowest levels of the health system ፘ Ensure adequate funding from donors ፘ Update policies and use reproductive health supplies as a monitoring indicator ፘ Translate reproductive health supplies policies and strategies into practical action ፘ Liberalize reproductive health services within the private sector ፘ Institute innovative financing mechanisms, such as social insurance ፘ Remove barriers to procurement and continue to utilize technical assistance ፘ Improve method mix and choice ፘ Use data collection to identify gaps in service and supplies availability ፘ Clarify the obligations of lower levels of government to fund reproductive health supplies within a decentralized budget ፘ Create a national regulatory entity with oversight powers to ensure accountability within government for reproductive health supplies ፘ Ensure coordination of forecasting and procurement within all levels of government and across sectors ፘ Align policies related to reproductive health supplies between national and lower levels of government ፘ Ensure that reproductive health supplies are included in new health programs, such as insurance schemes and on all medical supplies lists q private sector ፘ Coordinate with the public sector and NGOs in service delivery and to improve logistics ፘ Improve access to affordable commercial products, including at community level ፘ Increase local production and marketing of reproductive health supplies ፘ Engage in social franchising/social marketing of reproductive health supplies ፘ Participate in technical working groups and other collaborative entities ፘ Deliver services through innovative financing mechanisms, such as cost sharing and social insurance ፘ Provide funding and develop specific budgets for reproductive health supplies ፘ Share information about services provided in order to improve national estimates of need for reproductive health supplies ፘ Educate private sector service providers to offer information about and access to a wider array of methods q civil society ፘ Be vocal champions with a cohesive message for reproductive health supplies ፘ Mobilize resources for reproductive health supplies ፘ Track supplies throughout the distribution system and share that information with facilities ፘ Call attention to shortages/stockouts and other supplies problems ፘ Maintain strong relationships with government and build relationships at lower levels ፘ Increase community-based care and supplies distribution ፘ Work with government on policy and program development and implementation ፘ Educate and inform the population about the benefits of family planning and reproductive health, with a focus on young people ፘ Provide services as an alternative and complement to the public sector Appendix 1. Complete List of Recommendations 11 ፘ Integrate family planning with HIV/AIDS programs ፘ Facilitate collaboration within and across civil society organizations to share experiences and influence policies ፘ Link improved family planning and reproductive health to improved health overall ፘ Build capacity of service providers to improve the quality of care ፘ Monitor the distribution and funding of reproductive health supplies q donors and international organizations ፘ Fulfill commitments to allocate funding for reproductive health supplies ፘ Use influence to motivate and incentivize governments to include reproductive health supplies in budgets, including long-term planning for donor phaseout ፘ Increase participation in meetings with governments and other donors and coordinate mutual efforts ፘ Coordinate release of funds with governments ፘ Increase contribution of supplies for emergency/ buffer stocks ፘ Develop plans with governments to improve procurement ፘ Develop policies related to reproductive health supplies with governments ፘ Continue to provide technical support ፘ Engage in research, evaluation and documen- tation related to the health system ፘ Promote integration of family planning and HIV/AIDS ፘ Support local production of supplies within the private sector ፘ Strengthen the financial and technical capacity of civil society organizations, including language and messaging used for policy advocacy ፘ Engage in global advocacy to improve access to reproductive health supplies ፘ Increase funding to the NGO sector ፘ Recognize the benefits of family planning and reproductive health for development overall ፘ Regain political will from international organizations that are not currently leaders in reproductive health supplies q global advocacy for reproductive health supplies ፘ Work at the national, regional and global levels to raise awareness and commitment to reproductive health supplies ፘ Continue funding and technical assistance for supplies to developing countries ፘ Make the reproductive health supplies agenda central to the development agenda, including integration with other development issues such as climate change ፘ Create a global funding mechanism for supplies ፘ Strengthen global coalitions and networks of organizations working on reproductive health supplies, including through international meetings to exchange lessons learned, impacts and best practices in advocacy and programming ፘ Create country and regional Reproductive Health Supplies Coalitions ፘ Advocate within the Global Fund and the maternal health community for integrated programming that includes reproductive health supplies ፘ Create regional development and poverty reduction strategies that emphasize population ፘ Implement regional and international agreements, such as the International Conference on Population and Development Programme of Action and the Maputo Plan of Action ፘ Ensure national level policymakers are aware of relevant international initiatives ፘ Monitor national budgets ፘ Ensure supplies are available in emergency situations ፘ Integrate family planning services with other health services ፘ Improve supply chain management ፘ Develop new contraceptive technologies ፘ Address the linkage between population growth and need for family planning ፘ Ensure supplies are included in health insurance schemes ፘ Support research of new and underused contra- ceptive technologies ፘ Expand protocols for provision of certain methods by additional cadres of service providers ፘ Involve men to empower women through education at the grassroots ፘ Initiate micro-level strategies to provide education inside homes 12 q bangladesh Marcos Arevalo, United States Agency for International Development (USAID) Debabrata Bandyopadhyay, MSD/Merck Abu Jamil Faisel, EngenderHealth Zubayer Hussain, Management Sciences for Health Jawher Lal Das, United Nations Population Fund (UNFPA) Tanvir Naher, Pathfinder International Shabnam Shahnaz Gias Uddin, Family Planning Association of Bangladesh Reena Yasmin, Marie Stopes Bangladesh q ethiopia Sufyan Abdulber, Ministry of Health Tigest Alemu, UNFPA Mengistu Asnake, Pathfinder International Premila Bartlett, USAID Abebe Bekele, Christian Relief and Development Association Holie Folie, Consortium of Reproductive Health Associations Fisseha Mekonnen Alemu, Family Guidance Association of Ethiopia Woinshet Nigatu, John Snow, Inc./USAID | DELIVER Andrew Piller, DKT Francesca Stuer, Family Health International Frans van Birgelen, MSD/Merck q ghana Freda Maame Bartels Mensah, Ministry of Health Egbert Bruce, John Snow, Inc./ USAID | DELIVER Sebastian Eliason, University of Cape Coast Koma Jehu-Appiah, Ipas Joana Nerquaye-Tetteh Nana Amma Oforiwaa Sam, Planned Parenthood Association of Ghana Vicky Okine, Alliance for Reproductive Health Rights Gloria Quansah-Asare, Ghana Health Service Placide Tapsoba, Population Council Frans van Birgelen, MSD/Merck Susan Wright, USAID q mexico Esperanza Delgado, Mexicam Family Planning Association (MEXFAM) Samah El Din Aly El Saghir Ramos, MSD/Merck Javier Domínguez, UNFPA Marco Antonio Olaya Vargas, Ministry of Health Diego Palacios, UNFPA José Luis Palma, INSAD Maria-Eugenia Romero, Equidad de Género Raffaela Schiavon, Ipas Marieke Van Dijk, Population Council q nigeria Aliyu Ahmed, Futures Group Nigeria Uwem Eshiet, Action Health Incorporated Elizabeth Igharo, John Snow, Inc./USAID | DELIVER Project Greg Izuwa, Ministry of Health Samuel Molokwu, Planned Parenthood Federation of Nigeria Sola Oridami, Association for Reproductive and Family Health q tanzania Felister Bwana, UNFPA Steven Chimile, Chama Cha Uzazi na Malezi Bora Tanzania (UMATI) Justine Coulson, Marie Stopes Tanzania Ousmane Dia, John Snow, Inc./USAID | DELIVER Project Joseph Kanama, EngenderHealth Mustafa Kudrati, Pathfinder International Maurice Hiza, Ministry of Health and Social Welfare Tim Manchester, USAID Gilbert Mworia, German Foundation for World Population (DSW) Halima Shariff, Advance Family Planning Frans van Birgelen, MSD/Merck q additional acknowledgements This research and the “Setting an Agenda for Reproductive Health Supplies” meeting are supported by the Innovation Fund of the Reproductive Health Supplies Coalition. Assistance and facilitation of the research was provided by: Brian Briscombe, Gloria Castany, Susan Collins, Priya Emmart, Francis Fix, Lorena Santos, Frank Roijmans. At PAI, thanks to: Allie Doody, Elisha Dunn-Georgiou, Suzanne Ehlers, Roberto Hinojosa, Carolyn Vogel and Danielle Zielinski. APPENDIX 2. ACKNOWLEDGEMENTS AND SURVEY PARTICIPANTS PAI gratefully acknowledges the time and insights provided by the individuals below who completed surveys and/or interviews about their perspectives related to reproductive health supplies. 13 q reproductive health supplies survey Part 1 Reviewing progress since Istanbul (2001) 1. What have been the most important improvements in access to reproductive health supplies in your country in the past 10 years? (If you choose more than one answer, please rank the answers from most important [1] to least important.) __ Higher funding from donors __ Higher funding from government __ Improvements at lower levels of health system __ Broader method mix __ Fewer shortages/stockouts __ Better forecasting of need __ Better procurement systems __ Better prices __ Better quality of care to users __ Improved access among vulnerable/underserved population groups __ More health workers available __ Better training of health workers __ More health facilities available __ Less wastage __ Expanded access within private sector __ Better coordination among country stakeholders __ Other: _______________________________________ 2. What were the reasons for these improvements? (Please rank your answers if possible.) __ Increased commitment from government __ Increased commitment from donor(s) __ Advocacy by civil society __ Expanded service availability by government __ Expanded service availability by private sector __ Expanded service availability by NGOs __ Technical assistance __ Infrastructure improvements __ Improved economy/development __ Increased demand from clients/users __ Other: _______________________________________ 3a. How would you describe your government’s overall commitment to strengthening family planning today, relative to 10 years ago? __ More commitment __ Less commitment __ Same level of commitment 3b. How is this demonstrated? __ Allocation of funding from government sources for family planning __ Disbursement of government funds __ Statements in support of family planning by government leaders and officials __ Policies related to family planning __ Relationship with donor(s) __ Integration of family planning with other health areas __ Other: _______________________________________ 4a. How would you describe your government’s commitment to improving access to reproductive health supplies, today, relative to 10 years ago? __ More commitment __ Less commitment __ Same level of commitment 4b. How is this demonstrated? __ Allocation of funding from government sources for reproductive health supplies __ Disbursement of government funds __ Statements in support of reproductive health supplies by government leaders and officials __ Policies related to reproductive health supplies __ Relationship with donor(s) __ Better supply chain management __ Other: _______________________________________ 5. How have policies related to reproductive health supplies in your country changed in the past 10 years? __ New policies developed (Which ones?) __ Existing policies strengthened (Which ones?) __ Policies weakened (Which ones?) __ Policies out of date (Which ones?) __ Other: _______________________________________ 6a. How has total funding for reproductive health supplies in your country changed in the past 10 years? __ Increased __ Decreased __ Stayed the same 6b. Has funding for reproductive health supplies in your country been affected by the global financial crisis since 2008? __ Less funding from government __ Less funding from other sources (Which ones?) __ No effect 7a. How would you describe donor funding for reproductive health supplies relative to 10 years ago? __ More donor funding __ Less donor funding __ Same level of donor funding 7b. Is there a difference between the amount of funds allocated by donors and the amount spent (disbursed)? __ Donor disbursements match allocations __ Funds disbursed are less than funds allocated __ Funds disbursed are greater than funds allocated 8a. How would you describe government funding for reproductive health supplies relative to 10 years ago? __ More government funding __ Less government funding __ Same level of government funding 8b. Is there a difference between the amount of funds allocated by the government and the amount spent (disbursed)? __ Government disbursements match allocations __ Funds disbursed are less than funds allocated __ Funds disbursed are greater than funds allocated APPENDIX 3. SURVEY INSTRUMENT AND INTERVIEW QUESTIONS 14 9. Have funding instruments such as Poverty Reduction Strategies or health sector plans changed funding for reproductive health supplies in the past 10 years? How? __ Reproductive health supplies more likely to be included in PRS, SWAp, etc. __ Funding for reproductive health supplies has increased because of PRS, SWAp, etc. __ Reproductive health supplies more integrated with other health/development issues in PRS, SWAp, etc. __ Reproductive health supplies neglected because not included in PRS, SWAp, etc. __ Other: _______________________________________ 10. Has decentralization affected access to reproductive health supplies in your country? How? __ Central level gives less attention/funding to reproductive health supplies __ District/lower levels give more attention/funding to repro- ductive health supplies __ All levels give more attention/funding to reproductive health supplies __ All levels give less attention/funding to reproductive health supplies __ Overall improvement in access to reproductive health supplies __ Overall declines in access to reproductive health supplies __ Other: _______________________________________ 11. How has the involvement of civil society organizations in repro- ductive health supplies advocacy changed in the past 10 years? __ Increased ___ Decreased ___Stayed the same 12. What are some of the most important actions civil society organizations have taken related to reproductive health supplies in the past 10 years? __ Motivated government to give more funding to reproductive health supplies __ Improved access to certain reproductive health supplies/ methods (Which ones?) __ Worked with government to develop new policies for repro- ductive health supplies __ Raised awareness among clients and potential users of repro- ductive health supplies __ Other: _______________________________________ Part 2 Assessing current issues 13. What are the most important outstanding challenges or barriers to improving access to reproductive health supplies in your country? (Please rank your answers if possible.) __ Low funding from donors __ Low funding from government __ Problems in access at lower levels of health system __ Small method mix __ Shortages/stockouts __ Problems in forecasting of need __ Problems in procurement systems __ High prices __ Problems in quality of care to users __ Problems in access among vulnerable/underserved population groups __ Few health workers available __ Problems in training of health workers __ Few health facilities available __ Wastage __ Problems in access within private sector __ Problems with coordination among key stakeholders __ Problems with health management information systems __ Other: _______________________________________ 14a. Does your country currently experience stockouts or shortages of reproductive health supplies? __ Yes: stockouts __ Yes: shortages __ No stockouts or shortages 14b. If yes, which supplies? __ Oral contraceptives __ Injectables __ Implants __ IUDs __ Condoms __ Equipment for vasectomy/tubal ligation __ Other: _______________________________________ 14c. Why do the stockouts or shortages occur? (Please rank your answers if possible.) __ Type of products ordered do not match demand __ Procurement delays at central level __ Delays receiving shipments of supplies __ Delivery delays from central or district levels __ Insufficient funding to meet need __ Forecasting/quantities ordered do not match need __ Problems with stock status information __ Facility problems in ordering __ Transportation problems __ Human resources: too few workers or inadequately trained __ Theft/corruption __ Wastage/expiry __ Other: _______________________________________ 14d. Where do stockouts or shortages occur? __ Central level __ District level __ Sub-district level __ Facility level __ Certain regions (Which ones?) __ Other: _______________________________________ 15. Is there a difference in availability of reproductive health supplies within your country? __ Central level/warehouse has good supply, but facilities do not __ Higher level facilities have good supply, but lower level facilities do not __ All facilities usually have good supply __ Availability of supply changes, but does not fit a pattern __ Certain regions have problems with supply (Which ones?) __ Other: ________________________________________ 15 16. What is the biggest strength in forecasting, procuring or distrib- uting reproductive health supplies in your country? __ Accurate forecasting/quantification of need __ Procurement at central level __ Sufficient funding __ Up-to-date stock status information __ Distribution to lower levels and facilities __ Transportation network __ Strong human resources __ Other: _______________________________________ 17. How would you describe your government’s level of commitment to improving access to reproductive health supplies? __ Very strong __ Strong __Average __ Weak __ Very weak __ Other: _______________________________________ 18. How would you describe the capacity of public sector institutions in your country’s health system to improve access to reproductive health supplies? __ Very strong __ Strong __Average __ Weak __ Very weak __ Other: _______________________________________ 19. How would you describe the capacity of private sector institutions in your country’s health system to improve access to reproductive health supplies? __ Very strong __ Strong __Average __ Weak __ Very weak __ Other: _______________________________________ 20. How would you describe the strength of advocacy among your country’s civil society and NGOs to improve access to reproductive health supplies, relative to other countries in your region? __ Very strong __ Strong __Average __ Weak __ Very weak __ Other: _______________________________________ 21. How does access to reproductive health supplies in your country compare to other countries in your region? __ Access is better in my country than in neighboring countries __ About the same __ Access is worse in my country than in neighboring countries __ Other: ________________________________________ 22. Thinking about supplies for safe pregnancy and delivery (for example, oxytocin, misoprostol, magnesium sulfate, MVA), what are the main barriers to accessing these supplies in your country? (Please rank your answers if possible.) __ Not available at hospitals __ Not available at lower-level facilities __ Not available for deliveries at home __ Few health workers available __ Providers not trained __ Restricted to administration by high-level providers __ Policies/political sensitivities __ Low funding from donors __ Low funding from government __ Problems in forecasting of need __ Problems in procurement systems __ High prices __ Problems in quality of care to users __ Problems in access among vulnerable/underserved population groups __ Wastage __ Problems in access within private sector __ Other: _______________________________________ q interview questions Looking ahead: What next for reproductive health supplies? 1. Do you anticipate that need/demand for reproductive health supplies in your country will increase, decrease, or stay the same in the next 10 years? Why? 2. Do you anticipate that the supply of reproductive health commodities, especially contraceptives and condoms, will be adequate to meet need in your country in the next 10 years? Why or why not? 3. What are the most important strategies for advocacy for repro- ductive health supplies in your country in the next 10 years? 4. The next question has to do with four different sectors. What are the most important actions that should be taken to improve access to reproductive health supplies in your country in the next 10 years: ፘ By your country government? ፘ By the private sector? ፘ By civil society organizations? ፘ By donors and other international organizations? 5. Outside of your country, what do you think are the most important strategies for advocacy for reproductive health supplies globally in the next 10 years? 6. How has the Global Fund to Fight AIDS, Tuberculosis and Malaria affected access to reproductive health supplies in your country?

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