Policy Issues in Planning and Finance: Policy Aspects of Achieving Contraceptive Security

Publication date: 2002

Policy Aspects of Achieving Contraceptive Security � All countries can benefit from policy attention to contraceptive security issues—whether they depend on external assistance, are transitioning to self-reliance, or are already relying on their own resources. � Enhancing the policy environment for contraceptive security requires awareness raising, advocacy, open and informed policy dialogue, and strategic planning. � A range of stakeholders from both the public and private sectors must contribute to policy dialogue and planning for contraceptive security, and each has a unique role to play in the process. Policy Issues IN PLANNING & FINANCEN O. 1 • M AY 2 0 0 2 POLICY Issues in Planning and Finance, a series of policy briefs, presents the findings and implications of POLICY Project-supported research. The series is intended to focus attention on the importance of developing a favorable policy environment that encourages appropriate and adequate FP/RH/AIDS program financing. 2 A key condition for contraceptivesecurity is a policy environmentthat enables forecasting, financing, procuring, and delivering contraceptives in a fair and equitable way to all women and men who need them. Contraceptive security exists in a country when all women and men who need and want contraceptives can obtain them. Policies can either inhibit or enhance achievement of contraceptive security. There is a dynamic relationship between the policy environment, the logistics and management functions of delivering contraceptive supplies and services, and contraceptive security. More emphasis is typically given to logistics and management issues than to policy issues in efforts to promote contraceptive security. However, the importance of a favorable policy environment as a lynchpin to contraceptive security is becoming increasingly apparent. This brief focuses on the key policy aspects of contraceptive security, and describes how policy interventions are essential to achieving contraceptive security. Political Commitment and Good Policies Are Key A policy environment conducive to contraceptive security is characterized both by sound policies and by the commitment to implement them. Commitment is most likely to be present when stakeholders within the country feel a sense of ownership of the contraceptive security agenda. Commitment is needed at the political level as well as at the bureaucratic, program, and civil society levels. Commitment at the political level provides the mandate for ministries and other bureaucratic agencies to develop and support favorable policies. Planners obtain the information necessary for formulating sound policies at both the broad policy and operational levels. Program managers implement policies and are an important source of the feedback that is necessary to the iterative process of policy refinement. Commitment at the civil society level ensures that the appropriate connections are made between policies and programs so that sound policies are created, properly implemented, and refined as needed. A Policy Framework for Contraceptive Security Four elements must be considered for strengthening the policy environment, making it conducive for achieving contraceptive security: awareness raising, advocacy, policy dialogue, and planning (Figure 1). These elements can be used in combination or independently, depending on the particular needs of a country. In addition to the four elements, two crosscutting components also contribute to strengthening the policy environment. Building an adequate information base and using it in the policy process is a critical component of evidence-based policy formulation and planning. Capacity building may be required at the policy formulation level and at the logistics and management level to improve the skill POLICY Issues in Planning & Finance • No. 1 Policy Aspects of Achieving Contraceptive Security Contraceptive Security C ap ac it y B ui ld in g Mobilize Finances Procure Commodities Conduct Forecasting Deliver Commodities & Services Commitment Favorable Policies & Plans Awareness Information Advocacy Policy Dialogue Planning FIGURE 1. A Policy Framework for Achieving Contraceptive Security This issue of POLICY Issues in Planning and Finance was prepared by Jeffrey Sine and Suneeta Sharma, with technical inputs from Kokila Agarwal, Harry Cross, Varuni Dayaratna, Jeff Jordan, and Carol Shepherd. The authors would like to thank Liz Schoenecker and Monica Kerrigan, U.S. Agency for International Development (USAID), for their careful review and constructive comments, and for their overall support during the development of the briefs. The views expressed in this document, however, do not necessarily reflect those of USAID. The POLICY Project is funded by USAID under Contract No. HRN-00-00-00006-00 and is implemented by The Futures Group International in collaboration with Research Triangle Institute (RTI) and the Centre for Development and Population Activities (CEDPA). base of stakeholders working toward contraceptive security. The following sections examine each of the four policy elements, including the crosscutting information and skills needed for the element’s application. As with all policy development, the process of strengthening the policy environment is not linear. Forecasting, financing, procuring, and delivering goods and services must occur even as policies and plans continue to evolve. Awareness Raising and the National Policy Agenda Before change can take place, policymakers must recognize that a problem or a potential problem exists and must understand the implications of the problem for contraceptive security. Broadening the base of awareness beyond policymakers in a country can accelerate the decision-making process and often improves the quality of decisions made. For instance, awareness- raising activities may target legislators in an effort to increase political support for bureaucratic action. Activities may also target civil society organizations, including commercial groups, to stimulate them to call for political action. In all cases, targets of awareness-raising activities are chosen on the basis of their clear and apparent stake in contraceptive security issues, and their ability to influence the decision- making and policymaking processes (see Box 1). Awareness raising draws attention to contraceptive security and sets the stage for policy dialogue and advocacy. It creates access to critical information on which to base decisions (policymakers) or advocacy (NGOs). Innovative use of analytic methods such as market segmen- tation and forecasting analysis can help stakeholders understand the following: � the size of the market for contraceptives; � who is supplying contraceptives to whom (public/private market shares, target populations, and equity); � who is not being served (unmet need); � how the market is expected to grow in five to ten years; � the degree to which public and private systems have the capacity to meet expected growth in demand; and � strategies to ensure contraceptive supplies match current and expected needs. The most important outcomes of awareness-raising activities are that key stakeholders understand contraceptive security, that the issue is on the country’s policy agenda, and that stakeholders within a country have a sense of ownership of the issue and are ready to engage in policy dialogue and planning. Box 2 provides examples of statements used to raise awareness about contraceptive security issues. Policy Aspects of Achieving Contraceptive Security 3 Audience Influence Ministry of Health (MOH)/Family Responsible for contraceptive supplies Planning (FP) Division Ministry of Finance (MOF) Responsible for resource allocation MOH Primary Care Division Needs the supplies for its facility network Women Legislators Likely to advocate for secure supplies Nongovernmental Organizations Can advocate for appropriate policy actions (NGOs) Pharmaceutical firms Opportunities for new and expanded markets Donors Vested interest in country-level policies Consumers Can exert pressure on political leaders BOX 1. Target audiences for awareness-raising activities � USAID has announced its intentions to phase out its health sector assistance over the next eight years in Egypt. � Condom stocks in Turkey’s MOH warehouse are depleted, and they cannot keep service delivery sites supplied. � Demand for contraceptives in Nepal has grown by an average of more than one percentage point per year over the past decade and we are reaching the limits of donor support for contraceptive supplies. � In Romania in 2000, the existing supply of free contraceptives was sufficient to meet only 15 percent of the needs of one designated target group. � Kenya’s condom supply is vulnerable to stockouts as a result of a fragmented and crisis-driven supply system. BOX 2. Awareness-raising statements draw attention to contraceptive security issues Sources: Khalifa et al., 2001; POLICY Project, 2001; Agarwal, 1998; Dayaratna et al., 2001 4 Advocacy Supports Awareness-Raising Activities and Keeps Policy and Planning Processes on Track Advocacy is a set of systematic, targeted actions directed at specific stakeholders and decision makers to promote attention to a policy issue and to influence policy decisions, funding streams, or programs. As a natural complement to awareness-raising activities, advocacy moves contraceptive security issues onto the national policy agenda. Advocates are often leaders of public sector agencies and are frequently referred to as policy champions. They seek to influence their public sector colleagues and superiors to garner support for decisions, policies, and resources that promote secure contraceptive supplies (see Box 3). NGOs also play a major role in advocating for contraceptive security. Armed with information, they act as watchdogs over decision-making and policymaking processes, ensuring that the issue stays high on the policy agenda. They track bureaucratic action and nudge the process along when the process encounters roadblocks or when momentum wanes. They assess the quality of decisions and engage decision makers when decisions fall short of meeting contraceptive security needs. They hold governments accountable for fairness and equity in using public resources. Though it is preferable that advocates work together with public sector reproductive health program leaders, NGO advocates are able to adopt a more adversarial role when policymakers fail to take necessary action and when collaborative approaches fall short. Regardless of whether advocates work within public sector agencies or outside them, they require a constant flow of information about the market for contraceptives and about the progress of policymaking. They often also need training in leadership and advocacy skills, as well as support for planning and executing advocacy campaigns, particularly in countries with little precedent for bureaucrats to act as policy champions. Advocacy also plays an important role throughout the policy dialogue and planning process. Policy Dialogue Develops Consensus Necessary for Contraceptive Security Decision Making Policy dialogue is the process of bringing together groups of stakeholders to reach consensus for taking action to improve contraceptive security and to define and debate the merits of policies that emerge from the process. Policy dialogue is a mechanism to build consensus, ownership, and commitment within an MOH, more broadly within government, and even more broadly within society, including the private sector. The private sector must play a pivotal role in order to successfully address contraceptive security needs, while civil society acts as a watchdog to ensure that commitment is sustained. It is particularly useful to engage the commercial sector as a full partner in dialogue and planning. Their participation is one means for government policymakers to become aware of issues and policies that affect the commercial sector’s ability to provide high-quality services to clients. Box 4 provides examples of forums for policy dialogue on contraceptive security that have worked well in various countries. National symposiums are useful for achieving broad consensus among public, private, and NGO representatives that contraceptive security belongs high on the national health policy agenda. Commonly, senior public officials pronounce support for contraceptive security at national symposiums, and participants generally find it easy to agree on a broad vision about public and private sector roles, including how best to use public subsidies. However, it is critical that these large gatherings be followed by more targeted policy dialogue sessions so that sensitive issues can be more openly discussed. Separating stakeholders into smaller, more uniform groups is one means for addressing sensitive issues. Interministerial working groups bring MOH leaders together with decision makers from other government agencies, such as the MOF and planning agencies. POLICY Issues in Planning & Finance • No. 1 � KIDOG, Turkey — national women’s rights network of NGOs met with the country’s president in 1999 to seek a directive to the MOH that funds be allocated for contraceptive procurement. � Multisectoral group, Kenya — advocacy efforts of a group including donors and other stakeholders led to major commitment of resources from the Kenyan government. � Policy champions and NGOs, Romania — advocacy efforts resulted in high-level support for a contraceptive security initiative. In August 2000, the prime minister signed a government order that mandated the first-ever budget allocation for contraceptive commodities in Romania � POPCOM and the Department of Health, Philippines — helped mobilize public and private organizations that supported deployment of resources for the FP/RH program and implementation of a Local Advocacy Project (LAP). BOX 3. Examples of advocacy actors and actions Source: POLICY Project, 2001 They are important mechanisms for creating a common governmental platform on issues such as targeting public services, financing, and private sector participation in the contraceptive security planning process. Internal working groups assemble key leaders from different departments of an MOH. They are useful for building an understanding that contraceptive security is a shared health sector goal that is important to the FP/RH unit as well as to the primary and preventive care units. They can also address and resolve concerns of other organizational units within the MOH that are often not expressed in public meetings. Workshops and consultative meetings at various levels can occur simultaneously with other forums. They bring the perspective of subnational leaders into the policy dialogue process. They are especially important in countries that have decentralized decision-making authority. One challenge is to ensure that all levels of policy dialogue feed into a common national framework for addressing contraceptive security. This is accomplished in part by ensuring that the outcomes of internal, government policy dialogue reaches the broader public forums where they can be vetted for their responsiveness to community needs, appropriateness, and acceptability. Planning and Policy Formulation Turns Commitment into Concrete, Actionable Strategies Planning is the iterative process of assessing a situation; setting short-, medium-, and long-term goals; identifying priorities; understanding the feasibility of options; knowing the resource requirements of each; and developing strategies and policies. Policy formulation moves the process from dialogue to action by either revising current policies or writing new ones. The result is a set of broad policies that define the country’s strategy, and a set of operational policies that defines norms, guidelines, and implementation plans to translate policy into action. Effective use of reliable, up-to-date information and analysis is an important element of all aspects of the policy process, including awareness raising, advocacy, policy dialogue, and planning. At the planning stage, the same information is used to ensure that resulting policies are well conceived and have a reasonable chance of producing the intended effect. Information and analysis needs include market segmentation, unmet need, expenditure (public and private) on family planning products and services, projected commodity needs, current and potential market niches for the public and private sectors, financing options, legal and regulatory analysis, and client willingness to pay. This information helps planners and policymakers understand the Policy Aspects of Achieving Contraceptive Security 5 Policy Dialogue Forum Participants Expected Outcomes National Symposium Public, private, and NGO leaders � Broad awareness � Commitment � Planning framework Interministerial Working Groups Health, finance, planning ministry � Contraceptive security parameters leaders � Planning process � Planning partners Internal Working Groups MOH leaders from FP/RH, primary � Consensus on goals and responsibilities care, and preventive services units � Development of operational policies and guidelines Workshops and Consultative Health sector and administrative � Broad awareness Meetings leaders; women’s groups; NGOs; � Commitment to national plan legislators; health care personnel; � Planning process for local response development officers � Consensus regarding the need for new resource allocation and targeting systems BOX 4. Policy dialogue forums 6 prevailing situation, identify positive and negative factors contributing to the current situation, assess strategic alternatives, and craft policies to resolve existing and potential problems. A comprehensive set of policies for contraceptive security should include the following: � Specification of the roles and responsibilities of the public, NGO, and commercial sectors based on their current and potential market niches, recognizing that the commercial sector responds to market opportunities and incentives and its role cannot entirely be prescribed; � Targeting policies that promote equity, including designation of priority groups to receive subsidized services, exemption criteria from public sector user fees, and mechanisms of means testing (see Box 5); � Current and future family planning commodity and service requirements; � Potential sources of financing including government, donors, the private sector, and alternative financing mechanisms such as user fees, health insurance, and revolving funds; supportive and controlling legal and regulatory mechanisms, and incentive structures; � Mechanisms for encouraging efficient use of existing resources; and � Operational policies and guidelines for addressing barriers and for implementing financing and regulatory mechanisms, targeting strategies, and so forth. Summary: All Countries Can Benefit from a Focus on the Policy Aspects of Contraceptive Security This brief has shown how policy interventions work to improve prospects for contraceptive security and the importance of a true sense of ownership and commitment to the contraceptive security agenda across sectors in a country. All countries can benefit from these interventions, whether they are dependent on external assistance for contraceptive supplies, transitioning to self-reliance, or already reliant on their own resources (see Box 6). Even when a country is fully self-reliant, contraceptive security is not reached until supplies and services are assured presently as well as into the future. Policy challenges and opportunities vary with the stage and the policy environment of a particular country. The challenges are more obvious in countries facing imminent phaseout of external support for contraceptive supplies. They are less obvious and often overlooked in countries that are likely to remain dependent on donated supplies for the near future. Long-run contra- ceptive security prospects can, however, be enhanced by attention early on. As countries dependent on external sources of support work to improve their logistics and management systems, they can also begin to work on policies that will expedite the eventual transition to contraceptive independence. Ensuring that publicly provided supplies go to those most in need (targeting) is perhaps one of the most useful policy actions governments can take. Creating a policy environment conducive to full private sector partnership in delivering contra- ceptive supplies is another challenge that need not wait until donor phaseout has begun. A multifaceted process that includes stakeholders from all sectors is required to POLICY Issues in Planning & Finance • No. 1 Romania To promote equity, students, the unemployed, and low-income persons are explicitly designated as eligible to receive free contraceptives at public sector clinics. All others are expected to pay for contraceptives. Obtaining sufficient financing to back the policy will be a challenge. Indonesia A family planning self-reliance campaign sought to instill a sense of personal responsibility among contraceptive users to pay for contraceptive supplies with household resources. The campaign contributed to a stronger private sector role in delivering contraceptive supplies and greater cost recovery for public services. Defining consistent operational policies is a continuing challenge. Turkey Introduction of a system of targeted donations at public sector clinics encourages clients who are not poor to consider private sector alternatives for their contraceptive supplies. The policy has been successfully pilot tested. Nationwide extension of the system is underway. Ecuador The NGO CEMOPLAF charges higher prices for services at clinics located in non-poor areas, ensuring that greater subsidies go to clients using clinics located in poor areas. Identifying appropriate pricing policies that balance cost recovery needs with clients’ ability to pay is an ongoing challenge. BOX 5. Countries that adopt targeting policies promote contraceptive security Sources: Tatar et al., 2001; Cakir et al., 1997; Sharma et al., 2001 accomplish policy goals that promote contraceptive security. The approach calls for � mobilizing information; � advocating for change; � debating policy options; � promoting broad participation in identifying needs for policy creation and reform; � institutionalizing technical and policymaking skills (important aspects of setting the policy stage for achieving contraceptive security); and � monitoring operational implementation of policies. It is important to note that the policy process is iterative. Valuable policy insights are gained as forecasters, procurement specialists, supply managers, and service delivery personnel implement policies. To achieve contraceptive security in a fair and equitable way, a system must be in place to capture these insights and feed them back into policy dialogue and planning. Actions that promote contraceptive security help set a country on the path to reproductive health program sustainability. Working to achieve contraceptive security and reproductive health program sustainability are interdependent and complementary processes that share a common goal of ensuring access to commodities and to high-quality services for all who need and want them. � Policy Aspects of Achieving Contraceptive Security 7 Context Major Challenges Externally dependent � Ensuring the availability of adequate resources to meet demand � Promoting targeted use of donated contraceptives � Integrating FP and other RH services � Designing policy interventions to encourage private sector participation � Donor coordination by government to ensure efficient use of all resources Transition � Sustaining the FP/RH program � Committing new national resources � Formulating and implementing targeting policies and strategies � Removing operational policy barriers to logistics and management systems � Identifying and removing impediments to private sector growth � Donor coordination to support country efforts to achieve self-reliance Self-reliant � Maintaining ability to meet demand � Defining alternative approaches to financing contraceptives � Maximizing private sector participation BOX 6. Three types of national contexts shape needs for contraceptive security policy intervention 8 POLICY Issues in Planning & Finance • No. 1 For more information, please contact: Director, POLICY Project The Futures Group International 1050 17th Street, NW, Suite 1000 Washington, DC 20036 Tel: (202) 775-9680 Fax: (202 775-9694 E-mail: policyinfo@tfgi.com Internet: www.policyproject.com Selected References Agarwal, K. 1998. “Reproductive Health Case Study: Nepal.” Country Report. Washington, D.C.: POLICY Project, The Futures Group International. Cakir, V., and J. Sine. 1997. “Segmentation in Turkey’s Family Planning Market.” Washington, D.C.: POLICY Project, The Futures Group International. Cross, H., K. Hardee, and N. Jewell. 2001. Reforming Operational Policies: A Pathway to Improving Reproductive Health Programs. POLICY Occasional Paper No. 7. Washington, D.C.: POLICY Project, The Futures Group International. Dayaratna, V., I. Zosa-Feranil, A. Stanescu, L. Marcu, and C. Butu. 2001. “Operational Barriers to Implementing Contraceptive Security Policies in Romania.” Washington D.C.: POLICY Project, The Futures Group International. Khalifa, M., S. Sharma, and S. Moreland. 2001. “Issues and Strategies for Sustainability of Family Planning Service in Egypt: A Background Analysis Paper.” Cairo, Egypt.: POLICY Project, The Futures Group International. Mallari, E., M. Sherman, and W. Winfrey. 1999. “Commercial Contraceptive Marketing in the Philippines.” Washington D.C.: OPTIONS Project, The Futures Group International. Mras, D.B. and A.C. Nielsen. 1998. “Segmentation of Family Planning Market in India.” New Delhi, India: POLICY Project, The Futures Group International. POLICY Project. 1998. “Contraceptive Market Analysis in Uttar Pradesh: A Synthesis and Summary of Recent Research.” New Delhi, India: POLICY Project, The Futures Group International. POLICY Project. 1999. Networking for Policy Change: An Advocacy Training Manual. Washington, D.C.: POLICY Project, The Futures Group International. POLICY Project. 2001. “POLICY I Project: September 1, 1995 to December 31, 2000. Final Report-Cumulative Project Results by Country.” Washington D.C.: POLICY Project, The Futures Group International. Sharma, S., W. Winfrey, and M. Marin. 2001. “A Family Planning Market Segmentation Analysis: A First Step in Operationalizing Contraceptive Policies in Romania.” Washington D.C.: POLICY Project, The Futures Group International. Sine, J. 1999. “Case Study of Contraceptive Self-Reliance Efforts in Turkey: Prospects and Lessons Learned.” Washington D.C.: POLICY Project, The Futures Group International. Tatar, F. and J. Sine. 2001. “Client Donations for Contraceptives: An Innovative Approach to Sustainable Financing in Turkey.” Washington D.C.: POLICY Project, The Futures Group International. Winfrey, W. and L. Heaton. 1996. “Market Segmentation Analysis of the Indonesian Family Planning Market: Consumer, Provider, and Product Market.” Washington D.C.: OPTIONS Project, The Futures Group International.

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