Policy Issues in Planning and Finance: Strengthening Contraceptive Security in Decentralized Settings

Publication date: 2006

Strengthening Contraceptive Security in Decentralized Settings � Decentralization of governmental functions brings forth many challenges and opportunities that affect a country’s ability to achieve contraceptive security. � National and subnational governments need to work together to identify complementary roles and responsibilities for strengthening contraceptive security. � Leadership, commitment, and coordination by the national government are crucial elements of achieving contraceptive security at subnational levels—even when subnational levels have a substantial degree of authority in planning for contraceptive security. Policy Issues IN PLANNING & FINANCEN O. 6 • JA N UA RY 2 0 0 6 POLICY Issues in Planning & Finance, a series of policy briefs, presents the findings and implications of POLICY-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 and HIV/AIDS program financing. Strengthening Contraceptive Security in Decentralized Settings Introduction As global demand for family planning (FP) services and supplies increases, more countries are preparing strategies for achieving contraceptive security (CS)—the point at which people are able to choose, obtain, and use high-quality contraceptives and condoms whenever they want them for family planning and HIV/AIDS/STI prevention (USAID, 2004). Many countries attempting to achieve contraceptive security operate under a decentralized healthcare or political structure,1 which gives rise to challenges and opportunities that differ from those associated with centralized initiatives. This brief is intended to help national and subnational2 governments and program managers to work together to achieve their countries’ CS goals. Even when authority and responsibility are transferred to lower levels of government, a successful CS initiative still requires the central government’s leadership, commitment, and coordination. This brief is organized into five areas that focus on issues to be addressed while aiming to achieve contraceptive security at lower levels of government: (1) policy; (2) strategic planning; (3) finance; (4) logistics, procurement, and management of human resources; and (5) community participation. In each area, the brief proposes strategies for capitalizing on the opportunities for working in a decentralized setting while addressing the associated challenges. Also included are examples of countries that have been successful in making progress toward contraceptive security in decentralized settings. However, CS initiatives do not occur in a vacuum; therefore, the recommendations proposed in this brief should be considered within the broader health and political framework. In the last two decades, health sector decentralization policies have been implemented throughout the developing world as part of a broader process of political, economic, and technical reform (Livack et al., 1998). Box 1 briefly describes the movement toward decentralization in the health sector. Several forms of decentralization may occur simultaneously in the same country, state, or sector, and decentralized functions may exist alongside largely centralized functions (Silverman, 1992). In reality, lines of accountability in decentralized structures are not often discrete. It is helpful to conceptualize decentralization as a continuum, ranging from all authority concentrated in a central government to all authority concentrated at the lowest level of government. Box 2 provides an overview of the opportunities and challenges that are common to achieving contraceptive security in a decentralized setting. 2 POLICY Issues in Planning & Finance • No. 6 This issue of POLICY Issues in Planning & Finance was prepared by Sarah Alkenbrack, with technical inputs from Mireille (Mickey) Aramati, Jay Gribble, Suneeta Sharma, Carol Shepherd, and William Winfrey and editorial assistance from Nancy McGirr, Lori Merritt, and Carol Soble. The author would like to thank Randy Bulatao, consultant, and John Akin of the University of North Carolina at Chapel Hill for serving as technical reviewers; and Elizabeth Schoenecker, Mai Hijazi, Diana Prieto, and Rose McCullough of the United States Agency for International Development (USAID) for their careful review and constructive comments. The views expressed in this document, however, do not necessarily reflect those of USAID or the U.S. government. The POLICY Project is funded by USAID under Contract No. HRN-00-00-00006-00 and implemented by the Futures Group in collaboration with the Centre for Development and Population Activities (CEDPA) and Research Triangle Institute (RTI). BOX 1. The decentralization movement In the health arena, decentralization is perceived mainly as a means of improving the coverage, quality, and efficiency of public health services to increase equity and government accountability and promote community participation at the local level (Peterson, 1997; Bossert, 1998). Many donors supported this shift to decentralization in the health sector. The 1993 World Development Report: Investing in Health emphasized decentralization of health services, and the 1994 International Conference on Population and Development supported decentralization within the health sector by recommending that countries decentralize the management of public health programs and expand the role of nongovernmental organizations (NGOs) and private providers in reproductive health programs. The shift to decentralization was viewed as a means to promote community participation in reproductive health decisionmaking. 1 Decentralization is the transfer of authority and the dispersal of authority in public planning, management, and decisionmaking from higher to lower levels of government (Mills et al., 1990). 2 The subnational level refers to any level of governance below the central level, for example, a state, province, district, or other jurisdiction that operates below the national government structure. Ensuring a Favorable Policy Environment for Contraceptive Security at All Levels A country’s policy environment affects all aspects of contraceptive security. The national government’s leadership, commitment, and coordination are crucial elements in achieving contraceptive security at lower levels of government— even when subnational levels exercise a substantial degree of authority in CS planning. For several reasons, the national government is usually best positioned to manage certain aspects of contraceptive security. For example, it can be more cost effective in performing certain functions because of its greater management and technical capacity (Kolehmainen-Aitken and Newbrander, 1997). Many argue that centralized functions should include instituting policy and regulatory procedures and managing procurement and logistics operations. In general, the national government should remain directly involved in CS programs when benefits extend to the country as a whole. Nonetheless, the national government often faces outright opposition to contraceptive security as conservative religious and political bodies attempt to undercut commitment to family planning. Such opposition also comes from local leaders who have a strong influence over whether local funding will be allocated to contraceptives and FP services. In a decentralized setting, other health and nonhealth priorities often take priority over contraceptive security, as there are limited resources to cover all programs and local leaders often do not view contraceptive security as a development issue affecting all sectors. Another concern with carrying out decentralized CS initiatives is that government officials do not always clearly understand their new roles and responsibilities. Central governments often fail to recognize the complexity of the procedures needed to ensure contraceptive security, especially when major functions (such as budgeting and logistics) have been transferred to local governments. Unless the central government clearly defines and guides the planning of efficient local management systems, CS goals will be seriously jeopardized. For example, project evaluations in the Philippines in the 1990s found that the lack of clear guidelines significantly delayed the procurement of contraceptives. Local officials required up to 40 separate signatures before allowing a purchase order to be sent to a supplier, thereby threatening the timely delivery of contraceptives (Kolehmainen-Aitken and Newbrander, 1997). To overcome the challenges that may undermine the CS policy environment in decentralized settings, decisionmakers should consider the strategies noted below. Centralize Policy and Regulatory Functions and Develop Standards The national government should take a lead role in overseeing and regulating FP functions through policy formulation and the establishment of regulatory processes. Specific procedures governing contraceptive security include, but are not limited to � policies on cost recovery of contraceptives; � approval and registration of contraceptive products, prescription requirements for contraceptives, and preparation of an essential drug list (which ideally includes contraceptives); � regulations addressing the procurement, sale, distribution, and delivery of Strengthening Contraceptive Security in Decentralized Settings 3 BOX 2. Opportunities and challenges to addressing contraceptive security at the decentralized level Opportunities � CS decisions and services more responsive to local needs � Greater accountability for program management (i.e., service delivery; logistics; supervision; and information, education, and communication) � FP services and contraceptive logistics more easily coordinated to meet consumer needs and convenience � Greater promotion of local interest and commitment to FP programs � Greater ownership over activities when the community participates in planning Challenges � Limited opportunities for cost recovery in impoverished areas � Competition with other health and nonhealth priorities, especially when local budgets lack a line item for contraceptives � Possible inequity of resources between regions due to disparities in ability to generate revenues through taxes, user fees, etc. � Fewer opportunities for economies of scale through use of national procurement and logistics systems � Difficulties meeting human resource requirements; need for training on certain FP functions (e.g., procurement, budgeting, and management) since these skills tend to be concentrated at central level � Legal and/or regulatory implications not clearly understood at lower levels contraceptives (as well as drugs and antiretrovirals for HIV/AIDS, which may be procured in conjunction with family planning commodities in some countries); and � policies and regulations governing private sector FP practices and advertising. To ensure high-quality services and supplies, national governments should also play a role in formulating standards and guidelines for FP service delivery and logistics operations in all regions. Involve Subnational Governments in the Policy Formulation Process Even though the national government is ultimately responsible for policies and regulations that provide a country’s strategic direction, policymakers should include subnational levels of government in the policy formulation process. In a decentralized setting, local government participation is crucial for ensuring that national policies reflect local priorities and can be feasibly implemented. Coordinate and Define the Roles and Responsibilities of Subnational Governments The national government is responsible for coordinating FP responsibilities among donors, between donors and government, and across various levels of government and technical agencies. Effective coordination helps avoid duplication of effort and promotes efficiency and is especially important in a newly decentralized setting in which roles and responsibilities are often not clearly defined. The national government should provide leadership to subnational officials as they implement newly decentralized procedures. Mobilize Support for Contraceptive Security Through Advocacy Mobilizing political support and leadership for contraceptive security among decisionmakers responsible for priority setting, planning, and budget allocation is essential to any successful CS strategy (POLICY Project and DELIVER, 2004). Civil society organizations3 at subnational levels can create public awareness of contraceptive security, advocate for its inclusion in plans and budgets, and ensure that commitment to contraceptive security is sustained despite political changes. The examples in Boxes 3 and 4 from the Philippines and Ukraine illustrate how civil society organizations helped mobilize support for contraceptive security among local leaders facing competing priorities. Despite successful efforts in the Philippines and Ukraine, the training of advocacy groups may be challenging. First, replicating the training process in each small unit of government is labor-intensive. Second, the cost of providing this training and the need to monitor several activities taking place simultaneously is burdensome. Furthermore, mobilization of support for contraceptive security is an ongoing process rather than just an isolated, one-time event. The challenge lies not only in gaining commitment to contraceptive security among lower level governments but also in maintaining that commitment. Thus, ongoing advocacy and leadership are required to ensure that decisionmakers remain committed to contraceptive security. 4 POLICY Issues in Planning & Finance • No. 6 BOX 3. Increasing commitment to contraceptive security in the Philippines In the early 1990s, the healthcare system in the Philippines was decentralized to 1,500 local government units—leaving them to struggle with addressing family planning and other healthcare needs in the face of a 40 percent poverty rate and competing priorities for scarce resources. These pressures, coupled with the pervasive influence of the Catholic Church, contributed to an unfavorable environment for family planning. Approximately one decade later when the largest donor began phasing out its involvement in contraceptive provision, municipalities failed to allocate resources for contraceptives to replace donor-provided commodities. To increase the commitment to family planning and contraceptive security, the POLICY Project implemented a pilot project in 10 municipalities of Pangasinan Province to help position family planning on the local political leaders’ agendas and to create a local strategy for strengthening contraceptive security. POLICY trained multisectoral community-based groups, including representatives from NGOs, the private sector, and civil society organizations, in advocacy skills, networking, and advocacy plan development. The community-based groups in each municipality prepared an advocacy plan with the intention of eliciting increased local government funding for contraceptive procurement. In nine of the 10 municipalities, the advocacy activities led to the allocation of funds for contraceptive procurement in 2003–2004. The Philippines’ experience demonstrates the important role of advocacy in garnering support for contraceptive security and in overcoming religious and political opposition. 3 Civil society organizations generally include private, nonprofit organizations that pursue social welfare goals related to human rights, the environment, health, and women’s rights (POLICY and DELIVER, 2004). Strategic Planning for Contraceptive Security at Subnational Levels The challenges affecting local CS strategic planning are closely linked to the policy environment for contraceptive security and local stakeholders’ commitment to CS initiatives. When local stakeholders view contraceptive security as a priority, they are more likely to prepare, fund, and implement strategic plans that take into consideration the reproductive health interests of their communities. Strategic planning in a decentralized setting provides an opportunity to engage a multisectoral group of participants. Planning at the district or community level, for example, is often characterized by the participation of community leaders, representatives of grassroots organizations, interested individuals, and local government officials from different sectors. An important part of the strategic planning process is defining CS priorities, which requires local governments to obtain reliable information and data from clinical, epidemiological, financial, and programmatic sources. For example, data pertaining to a local area’s contraceptive prevalence rate, level of unmet need, and method mix are important for identifying groups in need of FP services and identifying sources for contraceptives. Unfortunately, at the subnational level (especially in districts), the most important data are often not available or regularly updated. Typically, the sample size of national surveys does not allow data to be disaggregated at subnational levels. The SPARHCS framework—Strategic Pathway for Achieving Reproductive Health Commodity Security—has been particularly successful in helping countries identify priorities and prepare a strategic plan for contraceptive security. SPARHCS is a comprehensive, long-term approach that can help countries build a commitment to contraceptive security and prepare a funded action plan. The SPARHCS process is flexible and can be adapted to a country’s needs. The process usually begins with an assessment of the CS environment, which helps stakeholders determine the strengths, weaknesses, opportunities, and challenges of achieving contraceptive security, and the resulting priorities to be addressed in the CS plan. The approach has been applied in both centralized and decentralized settings and has been particularly effective at the state, regional, and district levels. Steps for designing strategies using the SPARHCS framework follow. Form a Contraceptive Security Working Group to Address Local Priorities A multisectoral working group known as the Contraceptive Security Working Group usually implements a SPARHCS application. In a decentralized setting, the working group may comprise local representatives from ministries of finance, health, women’s affairs, education, youth, planning, religion, rural development, and so forth; FP and HIV/AIDS program managers; NGO representatives; public and private FP providers; representatives of commercial pharmaceutical companies; logistics managers; civil society members; religious group representatives; donors; community members; and any other individuals or groups concerned with contraceptive security. Other organizations with a more indirect interest in contraceptive security, such as the Ministry of Agriculture, may be involved in CS initiatives and participate in regular CS meetings to address contraceptive security as a development issue. Multisectoral participation ensures that the planning process reflects local priorities and that communities assume ownership of the process. Identify Local Priorities The SPARHCS framework can help local governments garner support for contraceptive security so that an adequate supply and range of high-quality contraceptives and other reproductive health commodities are available in their given jurisdiction, including condoms for HIV/AIDS prevention. Conducting an assessment using the SPARHCS framework is an important first step in the strategic planning process. The framework helps stakeholders gather information relevant to contraceptive security even when national surveys do not provide the needed data; required information is largely available as unpublished and published data and Strengthening Contraceptive Security in Decentralized Settings 5 BOX 4. Tailoring advocacy strategies to local conditions in Ukraine Following a workshop in February 2005 to identify national and subnational CS issues, the Ukrainian Network for Reproductive Health (URHN), with POLICY support, designed a diverse set of advocacy approaches appropriate to specific oblasts. In one oblast (Poltava), the advocacy plan helped secure commitment from the local administration to allocate funds for contraceptives. In other oblasts (Kharkiv, Donetsk, and Zaporozhie), the lack of awareness among youth about responsible reproductive health behavior and modern contraceptives spurred advocates to seek funds from the oblast budgets to conduct additional awareness-raising efforts. 6 is often collected in interviews with local officials. The SPARHCS method of data collection is useful in identifying available information and for pointing out information gaps to address in the future. Design Contraceptive Security Strategies Designing a strategy should be characterized by participatory planning and clearly define the roles and responsibilities of FP managers. A participatory review process will ensure that stakeholders reach consensus on the final action plan. For example, following an assessment of the FP program in Uttar Pradesh, the POLICY Project and the State Innovations in Family Planning Services Project Agency (SIFPSA) held district workshops in 1998 with a wide range of stakeholders to reach consensus on district-specific strategies. Following the workshops, the governing body of SIFPSA approved the first six district action plans.4 This approach to district planning can be applied to CS planning to achieve favorable results. Although decentralized strategic planning can be especially responsive to community needs, it may be appropriate to initiate strategic planning centrally and then replicate it locally—depending on the degree of authority and expertise at the local level. In Madagascar, the USAID- funded POLICY, DELIVER, and PHRplus projects, in collaboration with the United Nations Population Fund (UNFPA) and the Ministry of Health, brought together stakeholders from different regions in a workshop to assess contraceptive security using the SPARHCS framework (POLICY Project et al., 2003). The workshop served as a model for replication in other regions. The strategies developed for each region varied considerably in view of the wide disparities between regions with respect to access to, quality of, and financial resources and demand for contraceptives. Financing for Contraceptive Security at the Local Level Fiscal constraints severely limit stakeholders’ ability to ensure that contraceptives are available to all individuals when they need them. Moreover, fiscal constraints are felt at all levels of government but tend to be magnified at subnational levels for several reasons. First, local governments, or local ministry of health offices, often depend on the central government for funding (Mills et al., 1990). Second, central governments often transfer responsibilities to local administrative levels without allocating or ensuring adequate resources to match those responsibilities (Sadasivam, 1999). Third, in low-income areas, the ability to raise tax revenues is typically limited. For these reasons, decentralization may compromise access to FP services and commodities and lead to significant inequities within countries with regional disparities in resources and wealth. Furthermore, decentralization creates a greater chance for inefficiencies because, as mentioned, some functions generally cannot be performed efficiently and cost- effectively at the subnational level. Thus, financing challenges can threaten the supply of contraceptives in public sector FP programs. The financial environment for contraceptive security is closely linked to the policy environment. When a central government disburses funds to local governments, the funding often takes the form of block grants, allowing recipients considerable discretion in use of the funds. The financing of contraceptives frequently competes with other, ostensibly more pressing, needs both within the health sector (such as HIV/AIDS and curative care) and outside the health sector (such as water sanitation projects and transportation). As a result, local decisionmakers often overlook contraceptive security as an immediate priority. After decentralization advanced in the late 1990s in Mexico, state governments assumed responsibility for financing FP programs but many failed to budget for contraceptives, which contributed to stockouts at many levels. The failure to budget for contraceptives was a function of insufficient experience in budgeting and procurement, resource demands that exceeded available funds, or the designation of family planning as a low priority. In both centralized and decentralized settings in many countries, policies mandating free provision of contraceptives restrict the public sector’s introduction of cost-recovery schemes for contraceptive commodities. These policies have the potential to “crowd out,” or discourage, consumers’ reliance on the private sector. When this occurs, people who could otherwise pay for contraceptives in the private sector tend to seek free services and supplies in the public sector, assuming that public provider quality is acceptable and contraceptives are available. Given that lower levels of government often face greater financial constraints than central governments, the need to advocate for the repeal of policies that restrict implementation of cost-recovery schemes is particularly important in decentralized settings. Finally, the complex processes required for strengthening contraceptive security can contribute to inefficiencies at the local level. For example, local procurement translates into low-volume procurement and higher unit costs for contraceptives. Furthermore, the duplication of processes, such as the establishment of standards and regulatory procedures, is not efficient when conducted across several regions versus at the national level. POLICY Issues in Planning & Finance • No. 6 4 By 2003, 38 districts were covered by approved disctrict action plans. National and subnational governments must play complementary roles in ensuring that the financing of contraceptives at the subnational level leads to meeting consumers’ contraceptive needs. Specific strategies for increasing financing for contraceptive security follow. Allocate Funding Based on Need When lower levels of government depend on centralized funding allocations, a country’s funding entity can ensure that sufficient funds for contraceptives are available by allocating resources on the basis of need. Allocation formulas for determining funding for contraceptives should consider factors such as population size, contraceptive prevalence rate, unmet need, income, education levels, total fertility rates, and expected changes in demand for contraceptives. Ideally, this information should be readily available in a centralized statistical database that is regularly updated. As demand for family planning increases, the budget should reflect the growing need for contraceptives. However, even when national funding is allocated based on consumer needs, local politicians must make contraceptive security a priority and use the funds appropriately. Funding allocations based on both need and local politicians’ ongoing commitment to contraceptive security will promote equitable access to reproductive health services and supplies. Earmark Funding for Contraceptives Whether by introducing incentive schemes or instituting policies and regulations that earmark funds for contraceptives, central governments can hold local governments accountable for investing in family planning. In Mexico, after the state governments failed to budget for contraceptives, the national government included a line item in state budgets that earmarked funds for contraceptives, thus holding state government officials accountable for investing in contraceptives (Alkenbrack and Shepherd, 2005). Such a federal mandate may be seen as running counter to the movement toward decentralization, whereby authority and responsibility are passed down to lower levels. However, such a mandate may be necessary to ensure the availability of funding for contraceptives, especially in newly decentralized jurisdictions or in government units in which the commitment to contraceptive security is particularly weak or other priorities compete for funding. Even in a decentralized system, improper decisions affect the whole country, necessitating national government funding mandates. Advocate Change to Policies That Mandate Free Provision of Contraceptives Changes to policies mandating free provision of contraceptives can improve access to contraceptives. In many instances, if national policies encouraged consumers willing and able to pay for contraceptives to make their purchases in the private sector, local governments could direct retained resources to the poorest populations and thus improve access to and ensure the availability and quality of contraceptives at the local level. These national policies would affect contraceptive security at all levels. Local CS working groups, and especially advocacy groups, should advocate for policy changes that recognize some consumers’ ability to pay for contraceptive commodities. Mobilize Resources The repeal of policies that mandate free contraceptives would allow local governments to mobilize their own resources to finance or subsidize contraceptives. Several financing mechanisms for contraceptives include user fees, insurance premiums or copayments to the government, and purchases of subsidized social marketing products and unsubsidized products from the commercial sector. The example in Box 5 discusses the introduction of user fees for contraceptives but is not meant to Strengthening Contraceptive Security in Decentralized Settings 7 BOX 5. Introducing user fees for contraceptives in Ghana In Ghana in 1998, the Ministry of Health established modest user fees for contraceptives that previously were available at no charge. In principle, service delivery points (SDPs) retain 50 percent of the funds from the sale of contraceptives and pass along the other 50 percent to higher levels of the health system to finance resupply and improve product quality. The SDPs have used the retained funds to cover related supervisory visits, local training sessions, fuel for transport, and administrative costs (Chandani et al., 2000). Although contraceptive sales generate only modest revenues, providers use the funds to purchase supplies and improve the operation or physical appearance of the SDPs, thereby increasing quality and satisfaction. To address issues of inequity, the government of Ghana significantly increased funding for the provision of exemptions to the poor. User fees are now well established in Ghana’s healthcare system and are an important source of finance for contraceptives and improved service quality. In a decentralized setting, user fees can be effective in giving local governments discretion to use funds according to their priorities (e.g., improving service quality, starting a revolving fund for contraceptives, and so forth). 8 suggest that user fees are always a country’s best option. A detailed discussion of financing options for contraceptive security is beyond the scope of this policy brief. Another method for mobilizing resources at the local level is to obtain donor funding. Local governments have little training in mobilizing funds from donors, and many donors are still determining how to channel funds to lower levels of government. However, local governments in Latin America have been relatively successful in generating funds from donors and foundations for specific projects. Eliminate Inefficiencies Given the inefficiencies that can result when some processes are handled locally, it is important to recognize which processes can be most efficiently administered locally versus centrally (e.g., central functions include logistics, payment of salaries, procurement of contraceptives, establishment of regulatory procedures, and policy formulation). Eliminating duplication in labor and achieving high procurement volumes can help local governments realize cost savings. Define the Roles of Each Sector Decentralization provides an opportunity for all sectors to work in harmony and benefit from a well-segmented market in which the public sector, the private sector, social marketing programs, NGOs, the commercial sector, and donors serve specific populations. Market segmentation studies can help identify opportunities and challenges for each sector. Improved policies that encourage the participation of the private sector in ensuring contraceptive security can reduce the financial burden on local governments, thereby allowing local decisionmakers to focus financial resources on the most vulnerable while encouraging those who can afford to pay for contraceptives to do so in the private sector.5 Freeing up resources is important for local governments; often the hardest- to-reach groups are also the most expensive to reach. For the public and private sectors to work cooperatively, stakeholders need to collaborate and define common goals for service delivery. Public- private partnerships may be easier to forge if local governments are permitted to exercise flexibility in decisionmaking. Logistics, Procurement, and Management of Human Resources To achieve contraceptive security, key systems must synchronize their operations, with staff trained to carry out logistics, procurement, and management functions. Procurement systems and human resource management processes are two of the most complex functions in FP programs (Kolehmainen-Aitken and Newbrander, 1997) and CS planning. Decentralizing logistics functions offers some advantages. For example, logistics decisions can reflect local needs; local requirements can drive forecasts and procurements; and local decisionmakers can exercise control over shipping and reordering commodities. However, the disadvantages of decentralizing logistics functions almost always outweigh the advantages. For example, product selection is not necessarily based on treatment guidelines and medical criteria; replicating logistics and forecasting processes increases the need for labor and the potential for errors; staff and transportation resources are usually in short supply; quality control is not effectively enforced; and supervisory systems are often weak (DELIVER, 2004). Furthermore, decentralizing logistics functions can result in missed opportunities to attain economies of scale through high- volume procurements, thereby jeopardizing the supply of contraceptives or making products more expensive (IWG, 2001)— whether the end-user is the consumer or the government. Not only is it difficult to procure at low volumes, but the procurement process also requires long-term planning of contraceptive needs. As a result, local governments must forecast their needs and ensure the availability of funds before beginning the procurement process. To some extent, most local governments depend on central government fund transfers and cannot predict either the timing or amount of disbursements. Consequently, local governments often have no choice but to procure in small quantities from local venders when funding is available. Such an approach not only increases unit costs and makes commodities less affordable to consumers, but it also leads to more frequent disbursements—all of which increase the risk that processes (forecasting commodity needs, financing, procurement, and delivery) will not function in synchronization and potentially lead to stockouts. When stockouts occur, consumers do not receive the contraceptives they need. Many stakeholders at the subnational level also lack an understanding of procurement procedures, which traditionally have been set and managed by national governments and donors. For example, in Romania, the national government approved a policy for local procurement of contraceptives that was funded initially through federal funds released to each district government. District health authorities used the seed monies to purchase contraceptives but because of a limited understanding of market, procurement, and logistics POLICY Issues in Planning & Finance • No. 6 5 Nos. 4 and 5 in the POLICY Issues in Planning & Finance series outline strategies for improving public/private partnerships and the use of government resources. systems, they purchased several types of contraceptives and limited quantities of the more expensive brands, resulting in the inefficient use of scarce government resources. This example illustrates the need to make training a key component of the decentralization process, so that staff at the local level have the capacity to carry out operations needed to achieve contraceptive security. In some countries, decentralizing human resources procedures, such as paying salaries, recruiting staff, and providing training and technical assistance, can result in inefficiencies. Salaries constitute a substantial proportion of the FP budget. In decentralized settings, where local governments face competing priorities for funds, they sometimes reduce employee benefits and salaries, affecting the quality of FP services. Following the decentralization of financial management in the Philippines and Zambia, a decline in health workers’ salaries and benefits corresponded with a decrease in the quality of care (Nanda, 2000). A decrease in quality of health services ultimately affects FP services and contraceptive supply. Strategies that ensure that procurement and human resources are handled most effectively and efficiently in a decentralized environment are described below. Identify Roles for Central and Local Governments in Managing Human Resources Whether human resources management (such as paying salaries, recruiting staff, and providing training) is more effective at the national or local level varies from case to case. The central government does not always handle human resource activities better than local governments, but often it commands the knowledge, skills, and resources needed to carry out these activities more efficiently and effectively. Ensuring the adequacy of human resources at lower levels of government is a major challenge of decentralization that is not unique to reproductive health programs. Identifying mutually beneficial strategies for handling human resources operations is an important aspect of any decentralized CS strategy. Provide Local Capacity Building and Training If decentralization of logistics occurs, it is essential to train subnational staff on logistics operations (such as budgeting, forecasting, or procurement) and to build a strong supervisory structure to ensure that all aspects of an FP program operate smoothly. Centralized training can promote quality and uniformity of skills among FP managers across regions; however, some lower level governments have succeeded in their efforts to train each other in CS functions. For example, training logistics operations managers in Indonesia relied on district-to-district assistance as described in Box 6. This approach appears to be effective in both building capacity and increasing efficiency, suggesting that training can succeed without the national government’s support. However, uniform training must be conducted in all districts to promote equity, which can be expensive and time consuming. Introduce Coordinated Procurements Many governments have introduced coordinated procurements, whereby the central government procures contraceptives on behalf of local governments. Centralized procurement enables government to capitalize on scale economies and benefit from the expertise of the entity engaged in procurement. Box 7 describes how Mexico’s coordinated procurement helped states procure contraceptives after decentralization occurred. Strengthening Contraceptive Security in Decentralized Settings 9 BOX 6. Building district capacity for CS planning and implementation in Indonesia One successful application of the SPARHCS framework occurred in Indonesia at the district level. The national FP program, BKKBN, had been highly centralized for 30 years before responsibility for managing and implementing reproductive health programs was transferred to more than 420 districts and municipalities (Thompson, 2004). To begin CS planning in a new, decentralized environment, BKKBN, with support from the USAID-funded DELIVER Project, partnered with a CS team and adapted the SPARHCS framework for use at the local level. The district stakeholders were trained to use SPARHCS to collect data related to service delivery, policy, financing, logistics, and supply in their respective districts. Following data collection, three-day workshops focused on a review of the data, the definition of priorities, and the design of CS strategies. The process raised awareness about CS; identified strengths, weaknesses, opportunities, and challenges associated with achieving CS; and trained stakeholders in strategic planning. It also initiated a process whereby districts began supporting one another through district-to-district technical assistance and capacity building. Selected districts trained neighboring districts to carry out logistics operations. The experience in Indonesia demonstrates that local governments can assist each other in building capacity required for contraceptive security. 10 Community Participation Community participation is one of the greatest strengths of decentralization. When community members participate in defining CS priorities, they help ensure that strategies and programs respond to local reproductive health needs. Moreover, citizen participation fosters a sense of community ownership over program design and implementation. Community participation also promotes innovation in designing approaches to contraceptive security and ensures that communities hold local governments responsible for reaching their CS goals. In addition, community participation can spark demand for contraceptives among hard-to-reach populations. Without broad participation of all community groups, a CS effort often reflects only the needs of the most vocal groups. Disadvantaged and/or marginalized groups’ perspectives may go unheard (Brinkerhoff, 2000). In many countries, men occupy most positions of authority and, therefore, identify local priorities that may not reflect the needs of women and children (Hardee and Smith, 2000). Some strategies for enhancing broad community participation in CS planning follow. Promote a Multisectoral Participatory Planning Approach The need for multisectoral participation in all aspects of contraceptive security has already been mentioned but cannot be overemphasized. At the subnational level, it is important to establish effective working relationships among government health and population staff and key stakeholders and community members. Multisectoral participation can help identify mutually beneficial strategies, operationalize policies, monitor and evaluate programs, and provide feedback necessary for the iterative process of policy refinement. Engage Policy Champions to Increase Community Awareness of Family Planning Community participation can increase demand for contraceptives when local influential leaders are involved in the CS effort. For example, in Uttar Pradesh, the POLICY Project worked with religious leaders and village heads, who serve as policy champions, to elicit their support and involvement in the implementation of the FP program. Religious leaders participated in extensive training and received materials about the benefits of family planning (POLICY Project, 1999). Initially, the religious leaders resisted the training but, over time, came to voice their support for family planning and began preparing strategies for disseminating positive views on family planning and sponsoring FP events. The various activities resulted in an increase in the number of new contraceptive users and a stronger commitment to family planning. Raise Awareness of Policies and Laws Governing Decisionmaking It is important that local governments, advocacy groups, and communities are aware of all laws, policies, and responsibilities related to contraceptive security, especially in newly decentralized environments. Box 8 describes a process in which civil society groups and municipal governments helped operationalize laws that encouraged community participation in decentralized reproductive health planning. The lessons have specific application to CS initiatives. POLICY Issues in Planning & Finance • No. 6 BOX 7. Coordinating contraceptive procurements in Mexico Decentralization in Mexico coincided with the phaseout of USAID support for family planning, leaving states responsible for procuring their own contraceptives. The state governments, however, were ill-equipped to handle procurement procedures and worked with little assistance from the national government. In addition, they were required to procure domestically in compliance with national regulations, but they lacked an understanding of these regulations. As a result of low-volume procurements, the states incurred high unit costs and could not meet consumer demand. Some states did not procure at all. Thus, in 2000, the Secretariat of Health (SSA) and UNFPA began working with the national government to initiate coordinated procurement, with the SSA procuring contraceptives on behalf of all states. The result was increased volumes and the negotiation of lower unit costs. The SSA had extensive procurement experience and already understood the loopholes and negotiation procedures involved with procurement. Today, most states in Mexico procure through a pooled procurement system, making contraceptives more affordable and decreasing the likelihood of stockouts. The system has enhanced states’ efforts to strengthen contraceptive security (Alkenbrack and Shepherd, 2005). Conclusion Achieving contraceptive security is an iterative process that requires patience, flexibility, a long-term perspective, and a supportive policy environment at all government levels. As local governments work to overcome the challenges to contraceptive security in a decentralized setting, it becomes increasingly important that central governments exercise a stewardship role in helping their countries achieve CS goals. The central government has a responsibility to assist lower levels of government in defining new roles and responsibilities and ensuring the appropriate transfer of technical skills and resources. Local governments planning for contraceptive security need to ensure that the design and implementation of any CS strategy is driven by community participation involving a wide range of stakeholders. Strong support by locally elected leaders and broad participation by policy champions can help mobilize community support so that the voices of all affected groups are represented and an ongoing commitment to contraceptive security is maintained in decentralized settings. Balancing the central government’s leadership, commitment, and coordination with the local level’s authority, flexibility, skills, and resources is crucial to any successful CS initiative. � Strengthening Contraceptive Security in Decentralized Settings 11 BOX 8. Mobilizing communities to participate in reproductive health planning in Bolivia In 1994 and 1995, the government of Bolivia passed the Popular Participation Law (PPL) and the Administrative Decentralization Law (ADL), mandating participation of local communities in the public policy process. However, even after passage of the laws, locally elected political leaders dominated decisionmaking, monitoring and evaluation, and program implementation, with little input from the community. Advocacy groups and community members were unfamiliar with the new laws and unaware of the rights granted to them, and there were very few policy champions to advocate for the inclusion of reproductive health in municipal development plans (MDPs). Moreover, community members lacked the necessary skills for participating in the policy process and did not view reproductive health as a priority. With support from the POLICY Project, the Vice Ministry of Popular Participation conducted training workshops to inform more than 450 citizens of their rights and obligations under the new PPL and ADL and to encourage their participation in the decentralization process. Following the workshops, POLICY and the Population Policy Unit of the Ministry of Sustainable Development assisted six municipalities in creating MDPs that outlined reproductive health needs. One-day workshops held with prospective participants in the municipal planning process provided information and raised awareness about reproductive healthcare issues. As a result of these efforts, the MDPs for the six municipalities included—for the first time—programs and funding for reproductive healthcare; the municipal and central governments began actively supporting reproductive healthcare; civil society groups learned how to overcome the challenges to participating in decentralized decisionmaking; and advocates gained the skills and commitment to keep reproductive healthcare on local agendas. In contrast, the municipalities that did not receive assistance in participatory planning did not include or make reference to reproductive health in their MDPs (Hardee et al., 2000). 12 POLICY Issues in Planning & Finance • No. 6 References Alkenbrack, S., and C. Shepherd. 2005. Lessons Learned from Phaseout of Donor Support in a National Family Planning Program: The Case of Mexico. Washington, DC: POLICY Project. Bossert, T. 1998. “Analyzing the Decentralization of Health Systems in Developing Countries: Decision Space, Innovation, and Performance.” Social Science and Medicine 47 (10): 1513–1527. Brinkerhoff, Derick W. 2000. “Democratic Governance and Sectoral Policy Reform: Tracing Linkages and Exploring Synergies.” World Development 28 (4): 601–615. Chandani, Y., K. Crowley, J. Durgavich, R. Lunt, P. Nersesian, N. Pehe, and T. Rosch. 2000. Ghana: Implications of Health Sector Reform for Family Planning Logistics. Arlington, VA: Family Planning Logistics Management/John Snow, Inc., for the U.S. Agency for International Development (USAID). DELIVER Project, John Snow Institute. 2004. “Strategic Decentralization: Centralizing Logistics.” Presentation at American Public Health Association Annual Conference, Washington, DC. Hardee, K., M. Bronfman, T. Valenzuela, and W. McGreevey. 2000. “Promoting Partnership and Participation in the Context of Decentralization to Improve Sexual and Reproductive Health in Latin America and the Caribbean.” Pp. 1–10 in Health Reform, Decentralization, and Participation in Latin America: Protecting Sexual and Reproductive Health, edited by POLICY Project. Washington, DC: POLICY Project. Hardee, K., and J. Smith. 2000. “Implementing Reproductive Health in the Era of Health Sector Reform.” POLICY Occasional Paper No. 4. Washington, DC: POLICY Project. Interim Working Group (IWG) on Reproductive Health Commodity Security. 2001. Meeting the Challenge: Securing Supplies for Reproductive Health. Arlington, VA: John Snow, Inc., Population Action International, PATH, and Wallace Global Fund. Kolehmainen-Aitken, R., and W. Newbrander. 1997. Lessons from MSH: Decentralizing the Management of Health and Family Planning Programs. Boston: Management Sciences for Health. Livack, J., J. Ahmed, and R. Bird. 1998. Rethinking Decentralization in Developing Countries. Washington, DC: World Bank. Mills, A., J.P. Vaughan, D.L. Smith, and I. Tabibzadeh. 1990. Health System Decentralization: Concepts, Issues, and Country Experience. Geneva: World Health Organization. Nanda, P. 2000. Health Sector Reforms in Zambia. Implications for Reproductive Health and Rights. Takoma Park, MD: Center for Health and Gender Equity. Peterson, G. 1997. Decentralization in Latin America: Learning Through Experience. Washington, DC: World Bank Latin American and Caribbean Studies Viewpoint Series. POLICY Project. 1999. Making It Happen. New Delhi: POLICY Project, Futures Group. POLICY Project. 2000. “Implications of Decentralization for Reproductive Health Planning in Senegal.” POLICY Matters No. 3. Washington, DC: POLICY Project. POLICY Project and DELIVER Project. 2004. Regional Contraceptive Security Report: Latin America and the Caribbean. Findings and Recommendations. Washington, DC: POLICY Project. POLICY Project, DELIVER Project, and PHR Plus. 2003. “An Assessment of Reproductive Health Commodity Security in Madagascar.” Unpublished. Sadasivam, B. 1999. Risks, Rights and Reforms. A 50-Country Survey Assessing Government Actions Five Years After the International Conference on Population and Development. New York: Women’s Environment and Development Organization. Silverman, J. 1992. “Public Sector Decentralization. Economic Policy and Sector Investment Programs.” World Bank Technical Paper No. 188. Washington, DC: World Bank. Thompson, D. 2004. District Planning Tool for Contraceptive Security. STARH, BKKBN, and DELIVER. Unpublished. USAID Bureau for Global Health, Office of Population and Reproductive Health. 2004. “Contraceptive Security-Ready Lessons Overview.” Washington, DC: USAID. For more information, please contact: Director, POLICY Project c/o Futures Group One Thomas Circle, NW, Suite 200 Washington, DC 20005 Tel: (202) 775-9680 Fax: (202) 775-9694 e-mail: policyinfo@futuresgroup.com Internet: www.policyproject.com; www.futuresgroup.com

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