Reproductive Health Commodity Security for Improved Maternal and Child Health

Publication date: 2003

No Product? No Program! Reproductive Health Commodity Security for Improved Maternal and Child Health The Fourth Ordinary Meeting of the West African Health Organisation (WAHO) July 14–18, 2003 Banjul, Gambia Meba Kagone Lisa Hare David O’Brien Dana Aronovich Aoua Diarra No Product? No Program! Reproductive Health Commodity Security for Improved Maternal and Child Health The countries of the Economic Community of West African States (ECOWAS) are facing a health crisis: women in West Africa are dying from complications of childbirth at rates much higher than other regions of the world.1 In response to the persistently high maternal mortality, the Health Ministers tasked the West African Health Organisation (WAHO) with developing a regional strategy to lower maternal mortality. Drawing on regional expertise, WAHO formed a strategy to reduce maternal mortality, which will be presented to the Health Ministers in July for their endorsement. To implement this strategy, ECOWAS countries must ensure a sustained supply of reproductive health commodities. This document summarizes the relationship between maternal health and commodity security, the current state of commodity security in the sub-region, and several options for strengthening commodity security to support maternal health. Relationship between Maternal Health and Reproductive Health Commodity Security It is well documented that an important part of improving maternal health is increasing the interval between births. This requires strengthening reproductive health. As figure 1 shows, when family planning use— contraceptive prevalence rate (CPR)—increases, maternal mortality improves. The difference is striking between Cape Verde, which has the highest CPR and lowest maternal mortality ratio (MMR); and Sierra Leone, which has the lowest CPR and highest MMR. To improve maternal health in the sub-region, child spacing, including access to contraceptives, must be strengthened. Figure 1. CPR Compared to Maternal Mortality Note: This document will accompany the presentation on Reproductive Health Commodity Security by the DELIVER project to the Ministers of Health of WAHO in Banjul in July 2003. WAHO requested that DELIVER make the presentation based on a concept paper jointly developed by USAID, the World Bank, and UNFPA. The maternal mortality ratio (MMR) in West Africa is 1,100/100,000 live births compared to 190/100,000 in Latin America and 280/100,000 in Asia (PRB. 2002. Women of Our World.). 1 1 The Fourth Ordinary Meeting of the West African Health Organisation In addition, strengthening family planning services will benefit infant and child health. As figure 2 illustrates, when mothers space their births at least two years apart, infant mortality is much lower. With birth intervals greater than two years, Mali reduced its infant mortality by 45 percent and Guinea by 26 percent. Figure 2. Infant Mortality by Birth Interval Although the sub-region has made progress in increasing the use of family services over the last decade— CPR doubled in a number of countries2 —the use of family planning is still low and unmet need is high (see figure 3).3 If these women were using contraception, there would be corresponding declines in maternal and infant mortality. However, to cover this expressed need, access to reproductive health services and commodities in West Africa must increase substantially. Moreover, the effect of the HIV/AIDS pandemic— which has already strained health delivery systems—will exacerbate the situation as demand for condoms to prevent HIV and other HIV/AIDS products continues to rise. Figure 3. Contraceptive Prevalence and Unmet Need for FP 2 CPR increased over the last decade in every ECOWAS country where data was available. However, CPR remains lower than other regions of the world including the rest of sub-Saharan Africa: 8% CPR compared to 13% in sub-Saharan Africa (Demographic and Health Surveys, 1990 through 2001). 3 Unmet need is defined as all women of reproductive age who wish to delay or prevent their next birth but are not currently using family planning. 2 The Fourth Ordinary Meeting of the West African Health Organisation These combined factors demand that there be a focus on increasing access to a sustained supply of reproductive health (RH) commodities now—before it becomes an even greater crisis in the sub-region— particularly if WAHO’s safe motherhood initiative is to succeed. Reproductive Health Commodity Security in West Africa Commodity security is the coordination of effective systems to ensure that every person is able to choose, obtain, and use quality contraceptives and reproductive health products whenever he/she needs them. The DELIVER project has developed a model (figure 4) that graphically illustrates the interplay of the many factors that affect reproductive health commodity security (RHCS). To ensure that people can choose, obtain, and use the RH commodities they need, there are a number of strategies and process improvements that must take place (see figure 4). Cross-cutting issues, including policies and resource mobilization, impact both the strategies and processes, and they must be included in any effort to enhance RHCS. As the cross-cutting issues are addressed, and the strategies and process improvements implemented, financing and product availability (outputs) will increase, which will lead to commodity security (outcome). All efforts must reflect the social, economic, and health realities in which the systems operate (context). Using this framework to better understand the state of RHCS in West Africa, DELIVER found that many countries have made progress in improving RHCS in recent years, although several significant challenges remain. Figure 4. DELIVER’s Model for Health Commodity Security 3 The Fourth Ordinary Meeting of the West African Health Organisation Implications of Increasing Population and Contraceptive Use As the population in the sub-region grows, the number of users of reproductive health services and products will increase (see figures 5 and 6). The steep increase in projected contraceptive users reflects the large youth cohorts that will be entering their reproductive years in the near future. Figure 5. Projected Growth of WRA, 2002–2020 Figure 6. Projected Numbers of Contraceptive Users 4 The Fourth Ordinary Meeting of the West African Health Organisation When the number of clients is converted into the quantity of commodities required to meet their needs, the urgency of securing the availability of commodities is clear. Financial Implications of Growth The growth in the number of users has important financial implications as well. As use increases, the cost of the commodities also increases. It is estimated that the funding required will more than double over the next fifteen years. This funding will need to come from a combination of governments, donors, and clients. Unfortunately, while the amount of funding required to finance these services and commodities will increase, donor funding, which has not been stable in recent years, does not appear likely to keep pace with the funding requirements. Figure 7 reveals that if current trends in donor support are maintained, in the next ten years the funding shortfall will be enormous. Figure 7. Donor Financing for Contraceptives Compared to Projected Needs: West Africa Policies and RHCS Subsequent to the Cairo and Beijing conferences, most countries adopted policies that support family planning and women’s rights, and have lifted most restrictions affecting family planning service providers and prescribing practices. However, budget allocations for RH services and commodities remain insufficient. Tariffs, taxes, and duties remain prohibitively high in some countries, and some legislative restrictions remain. 5 The Fourth Ordinary Meeting of the West African Health Organisation Logistics and RHCS RHCS requires a logistics system that is effective and efficient at— • Forecasting the required commodities. • Procuring high-quality products at the lowest available price. • Storing commodities in the right conditions. • Delivering commodities, when needed, in good condition. • Monitoring the commodity flow from the client up the supply chain, and using that information to make key decisions. Although many countries in the sub-region have systems in place, the effectiveness of these systems varies. Assessments have revealed weaknesses in human resources, data management, warehousing, and transportation.4 Moreover, integration of product lines and decentralization are posing new obstacles to effective supply chain management. The systems will be further strained as they respond to the HIV/AIDS pandemic. These weaknesses in the logistics systems lead to stockouts at service delivery points, as shown by the results of product availability assessments in several African countries (see figure 8). Stockouts occur when product is not available. As illustrated by figure 8, low product availability rates are not limited to ECOWAS countries. Ethiopia experiences similar problems. Kenya, in contrast, demonstrates that it is possible to have a highly performing program with sufficient resources and sustained efforts. Figure 8. Percentage of Service Delivery Points with Contraceptives Continuously Available during a Six- Month Period5 4 DELIVER, Logistics System Assessment Survey Results: Mali, Nigeria, Ethiopia, Kenya (2001–2002). 5 DELIVER, Logistics Indicator Assessment Survey Results: Mali, Nigeria, Ethiopia, Kenya (2001–2002). 6 The Fourth Ordinary Meeting of the West African Health Organisation Coordination and RHCS Since resources are limited, a premium is placed on effective coordination between government, donors, lenders, and implementing agencies to minimize overlap and mobilize additional resources. WAHO is in a strong position to enable this effective coordination. Further, there are many good examples of stakeholder coordination at the country level within the ECOWAS community. Ghana, Mali, and Nigeria have all used a multisectoral approach for assessing RHCS, planning specific improvements, and, in some cases, implementing national reproductive health commodity strategies. Nonetheless, regional efforts can be strengthened by engaging a broader range of stakeholders, including other ministries (Finance, Planning, Education), private sector retailers and manufacturers, physician and nursing associations, and civil society organizations (religious institutions, and community-based agricultural and micro-finance institutions). Potential Regional Options As the earlier discussion highlights, the sub-region is facing a number of constraints that limit its ability to increase sustained availability of RH commodities and, therefore, to implement its strategy to improve maternal health. To enhance RHCS, the sub-region needs to— • Increase funding for commodities from donors, governments, individuals, and the private sector. • Lower unit cost of commodities, and make better use of resources. • Strengthen systems for delivering products. • Revise policies to reduce restrictions on financing and delivery. • Improve coordination among member countries, donors, etc. Although there are a wide assortment of potential activities to undertake to achieve this, DELIVER will highlight just a few for this particular session: Pooled Procurement: There is considerable experience in pooled procurement and financing of medicines and vaccines.6 This experience demonstrates that pooled procurement can increase access to commodities, ensure a high level of product quality, and lower unit costs. For example, the pooled procurement systems reviewed experienced between a 7 percent and 56 percent decrease in the cost of the medicine and vaccines they purchased. This potential also exists for West Africa. A quick analysis of the condom, pill, and injectable price for individual ECOWAS country orders compared to the price of the same commodities, if purchased in bulk, indicates a potential savings ranging from 45 percent for condoms to 28 percent for injectables. Implementing effective pooled procurement and finance systems is not easily achieved. Each system reviewed was unique, reflecting the differences in their operating environment and objectives. However, each has some similar requirements that indicate what would be needed in a West African pooled procurement initiative. These include significant start-up capital, strong administrative mechanisms, and political commitment from member countries, including their agreement to purchase primarily through the pooled procurement system (sole source). The ability to provide timely and accurate forecasts of commodity needs is also critical; products must be ordered in bulk and cover the needs of the region. Systems of pooled procurement and finance reviewed include the Eastern Caribbean Drug Service, Pan-American Health Organization Revolving Fund for Vaccines, African Association of Central Medical Stores for Generic Essential Drugs, Maghreb Commission for Bulk Purchasing, Gulf Cooperative Council, and the Global Vaccine Initiative and Global Fund Against Malaria, Tuberculosis and HIV/AIDS. 7 6 The Fourth Ordinary Meeting of the West African Health Organisation Pooled Finance: Many pooled procurement systems include an element of pooled financing. Pooled financing can mobilize resources by increasing member government contributions through annual commitments from both internally generated income and use of SWAp, basket funding, and World Bank loans, and by leveraging additional donor funding through demonstrated government commitments and simplified mechanisms. Pooled finance requires strong government commitment to funding RH commodities, increased advocacy of key decision makers and donors, and increased donor coordination. Logistics Capacity Building: The logistics systems in West Africa must be strengthened to ensure that the supplies required to implement the maternal health strategy are available where and when they are needed. Building regional logistics capacity would improve country-level logistics systems through the transfer of regional best practices and expertise. This would maximize the benefits of pooled procurement and strengthen stakeholder coordination. It requires the commitment of member countries to fund and staff their logistics functions in order to implement improvements and to develop an appropriate mechanism for effective south- to-south exchange, such as a resource center or training center. Private Sector Expansion: Private sector provision of RH commodities could be increased by expanding the private sector’s potential market, making it more attractive for the private sector’s participation. This could benefit the sub-region by potentially reducing the price of commercially available products, segmenting the market to better target public resources, and increasing access through private providers. Additionally, increased demand and a regional market may promote local marketing of products, leading to lower costs. Realizing the private sector’s potential requires reducing trade barriers for RH imports, regional production, and distribution capacity; coordinating public and private sectors; and attracting the interest and investment of the private sector. Conclusion The options discussed in this paper have the potential to improve RHCS within the sub-region and contribute to improving maternal health. However, before undertaking any of the options, further in-depth investigation is required to more specifically determine the costs and benefits, the details of how to tailor the particular option for West Africa, and the feasibility of their implementation. 8 The Fourth Ordinary Meeting of the West African Health Organisation References African Association of Central Medical Stores for Generic Essential Drugs in collaboration with the WHO Regional Office for Africa. 1999. “Report of a Study Tour to the Secretariats of Bulk Purchasing Systems in the Maghreb and Gulf States.” vi + 15 pages. Burnett, Francis. 2001. The OECS Pharmaceutical Procurement Service: Reducing the Cost of Pharmaceuticals through Multi-state Pooled Procurement. Published for the 13th Commonwealth Health Ministers' Meeting, 25–29 November 2001, New Zealand, by OECS Pharmaceutical Procurement Service. Castries, St. Lucia. DELIVER. Contraceptive Procurement Tables for Burkina Faso, Cote d’Ivoire, Ghana, Guinea, Mali, Nigeria, Senegal, and Togo. 2002. Arlington, Va.: John Snow, Inc./DELIVER, for USAID. DELIVER. Logistics Indicator Assessment Survey Results, Ethiopia. 2001. Arlington, Va.: John Snow, Inc./DELIVER, for USAID. DELIVER. Logistics Indicator Assessment Survey Results, Kenya. 2001. Arlington, Va.: John Snow, Inc./DELIVER, for USAID. DELIVER. Logistics Indicator Assessment Survey Results, Mali. 2001. Arlington, Va.: John Snow, Inc./DELIVER, for USAID. DELIVER. Logistics Indicator Assessment Survey Results, Nigeria. 2002. Arlington, Va.: John Snow, Inc./DELIVER, for USAID. Huff-Rouselle, Maggie, and Francis Burnett. 1996. “Cost Containment through Pharmaceutical Procurement: A Caribbean Case Study.” International Journal of Health Planning and Management. 11: 135–157. Martin, J-F, and J. Marshall. 2003. “New Tendencies and Strategies in International Immunization.” GAVI and The Vaccine Fund. Vaccine. 21: 587–592. ORC Macro International Inc. Demographic and Health Surveys (multiple countries and years). Calverton, Md.: ORC Macro International Inc. Pascal, Coffi. Joint Bulk Purchasing of Essential Drugs, presented by Mr. Coffi Pascal. HESSOU: ACAME President. Population Reference Bureau (PRB). 2002. 2002 Women of Our World. Washington, DC: PRB. Population Reference Bureau (PRB). 2002. 2002 World Population Data Sheet. Washington DC: PRB. Regional Committee. Intercountry Cooperation in the Supply of Essential Drugs. 25 June 1999. Regional Committee, Fifty-second session, Provisional Agenda Item 11, SEA/R 52/6. N.p. Ross, John, John Stover, and Amy Willard. Profiles for Family Planning and Reproductive Health Programs, 116 Countries. 2000. Glastonbury, Ct: The Futures Group International. The Global Fund to Fight AIDS, Tuberculosis and Malaria. N.d. The Framework Document of the Global Fund to Fight AIDS, Tuberculosis and Malaria. N.p. UNFPA website. Prices paid by country for contraceptives received. 2002 price schedule for contraceptives procured through UNFPA. United Nations Population Fund (UNFPA). 1999. Donor Support for Contraceptives and Logistics 1999. New York: UNFPA. USAID Africa Bureau and Global Bureau for Health. 2002. “Status and Trends of Family Planning in Sub-Saharan Africa.” Presentation by USAID Africa Bureau and Global Bureau for Health. October 2002. WAHO, USAID, UNFPA, and the World Bank. N.d. “West Africa Regional Initiative for Reproductive Health Commodity Security.” A concept paper developed based on discussions between WAHO, USAID, UNFPA, and the World Bank. N.p. 9

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