Reproductive Health Commodity Security: Leading from behind to forge a global movement

Publication date: 2011

Reproductive Health Commodity Security: Leading from behind to forge a global movement julie solo PA TH /A m y M ac Iv er Copyright 2011 © The Reproductive Health Supplies Coalition. This document was produced with support from the U.S. Agency for International Development through Task Order 4 of the USAID | DELIVER PROJECT under contract no. GPO-I-00-06-00007-00, and the Reproductive Health Supplies Coalition. Contents 1 List of ACronyms 2 exeCutive summAry 3 introduCtion 5 sourCes for the story 5 A Brief history 6 Fragmented support —1970s–1997 6 A looming crisis: advocates join the cause — 1998–2001 7 Coordinated action —2002–present 10 the AChievements of A movement 12 Awareness: “Istanbul woke people up.” 12 Coordination: “We need each other.” 14 Capital: Making financing more fashionable. 15 Commodities for clients: Strengthening the chain. 17 the next ChApter of the story 20 appendix 1: List of int erv ie wee s 22 appendix 2: referenCe s 23 Contents 1 2 R E P R O D U C T I V E H E A LT H CO M M O D I T Y S E C U R I T Y: L E A D I N G F R O M B E H I N D T O F O R G E A G L O B A L M O V E M E N T List of ACronyms CARhs: Coordinated Assistance for Reproductive Health Supplies group (formerly known as the CAR, for Countries at Risk) CDC: Centers for Disease Control and Prevention CS: Contraceptive security DFID: United Kingdom Department for International Development DSW: German Foundation for World Population DTTU: Delivery Team Topping Up FP: Family planning FPLM: Family Planning Logistics Management ICOMP: International Council on Management of Population Programmes ICPD: International Conference on Population and Development IPPF: International Planned Parenthood Federation IWG: Interim Working Group on Reproductive Health Commodity Security JSI: John Snow, Inc. KfW: German Development Bank MNCH: Maternal, Newborn and Child Health PAI: Population Action International PGH: Pledge Guarantee for Health PMNCH: Partnership on Maternal, Newborn and Child Health PPD: Partners in Population and Development PPMR: Procurement Planning and Monitoring Report Project RMA: Project Resource Mobilization and Awareness RH: Reproductive Health RHI: Reproductive Health Interchange RHCS: Reproductive health commodity security SPARHCS: Strategic Pathway to Reproductive Health Commodity Security UNFPA: United Nations Population Fund USAID: United States Agency for International Development E x E C U T I V E S U M M A R Y 3 exeCutive summAry It is widely recognized today that ensuring a reliable supply of quality contraceptives is essential to reproductive health programs. The tagline ‘No product? No program’ is known, understood, and embraced by those working to support reproductive health in the developing world. But this was not always the case. This paper tells the story of how what was once seen only as a technical issue became a global movement. It also marks the tenth anniversary of a milestone conference that many credit with having given birth to that movement. This publication, then, offers an opportune moment to step back, assess what has been accomplished, and strategize for the future. As discussed in more detail in this report, contraceptive security (CS) exists when every person is able to choose, obtain, and use quality contraceptives, condoms, and other necessary reproductive health (RH) supplies for family planning and for the prevention of HIV/AIDS and other sexually transmitted infections. While this terminology only came about in 1998—drawn from an analogy to food security—the international community has been addressing contraceptive supply issues since the 1960s. There are three main periods to this history. During the 1970s–1997, there was fairly fragmented technical assistance and provision of supplies, mostly by the United Nations Population Fund (UNFPA) and the United States Agency for International Development (USAID), and supplies had a low profile within the RH community. From 1998 to 2001, advocates joined the cause and raised the profile of the issue. Lastly, since 2002, there has been greater awareness at the global level and significantly more coordinated action. The latter period was inspired in no small part by a global conference entitled “Meeting the Reproductive Health Challenge: Securing Contraceptives and Condoms for HIV/AIDS Prevention,” held in Istanbul in May 2001. More than 127 participants, including ten country delegations, represented 41 organizations and governments. With talk of the “looming crisis” of a donor funding gap, participants were galvanized to work together on four main actions: advocacy, national capacity building, donor coordination, and financing. Discussions were based on a solid evidence base, and an approach of “leading from behind,” as one organizer described it, was taken in recognition that the issue was more important than the individuals or organizations involved. This spirit continued after the conference, leading to the development of coordinating mechanisms and harmonized tools for contraceptive security. From that event, a movement was created. Like other movements, this one has been characterized by expansion, by the inclusion of a wider range of partners, and by inspiring people about the importance of contraceptive supply issues. What has this movement achieved? As in other areas of health, it is often difficult to attribute, in a direct linear way, the on-the-ground successes in contraceptive security with the movement itself. What is clear is that the movement has created momentum and an enabling environment, which, in turn, have facilitated and catalyzed achievements around the world. These achievements can be divided into four overarching areas: Awareness: “Istanbul woke people up.” The importance of ensuring a reliable supply of commodities is now accepted and acknowledged by a wider circle of people than the technical experts who were once the issues’ sole champions. This heightened awareness is evident in the more frequent inclusion of commodity security in international declarations and global conferences, and it is evident in the increased levels of program and financial support among senior-level decision- and policymakers. Coordination: “We need each other.” The establishment of new, more formalized coordinating mechanisms has allowed key players to get to know one another better, create stronger connections, and communicate more easily. Important examples of this coordination include the Reproductive Health Supplies Coalition (The Coalition), which serves as a conduit and brain trust for information; the Coordinated Assistance for Reproductive Health Supplies (CARhs) group, which averts unanticipated supply shortages through monthly conference calls; and the Reproductive Health Interchange (RHI), an online database that tracks contraceptive shipments. Capital: Making financing more fashionable. A 2009 update of the original donor funding gap analysis showed that the dire predictions of funding shortages for contraceptives projected in 2001 did not come to pass, largely because resources were mobilized. European donors have increased their support for supplies, and the Global Fund to Fight AIDS, Tuberculosis and Malaria has allocated some resources to contraceptives. More national governments are also committing their own resources to purchasing supplies: 22 of 35 developing countries used government funding for contraceptive procurement. Two newly introduced mechanisms—the Pledge Guarantee for Health and AccessRH—aim to address the volatility of 4 R E P R O D U C T I V E H E A LT H CO M M O D I T Y S E C U R I T Y: L E A D I N G F R O M B E H I N D T O F O R G E A G L O B A L M O V E M E N T funding and procurement cycles. Such innovations were only possible with the increased coordination that has developed since Istanbul. Commodities for clients: Strengthening the chain. The point of increased awareness, coordination, and financing is to make sure that commodities actually reach the clients who need them. In the last decade, we have seen increasing attention and investment in supply-chain systems, greater inclusion of contraceptives on National Essential Medicine Lists, and the gradual transition from vertical to “integrated” supply chains. Improvements in data visibility are now allowing countries to understand stockouts better and respond to them more effectively. Lastly, we are seeing greater innovation and creativity in the approaches being taken to improve supply-chain efficiency. Much has been achieved in the last decade, primarily due to the commitment of advocates, technical experts, and other key stakeholders to work together. This collaboration has resulted in the development of powerful messages that raise the profile of commodity security. It has fostered effective coordinating mechanisms, harmonized strategic tools, and increased the availability of supplies to clients. That said, the world is not a static place. What will characterize the next phase of this ongoing story? As the decade since Istanbul draws to a close, the supplies movement faces an environment markedly different from that which characterized the past ten years. As the environment changes, so do the challenges, which threaten past gains and make it harder to maintain, much less accelerate, the momentum of the past ten years. On the other hand, this changing environment also provides new opportunities to further expand the community committed to this cause, to improve supply-chain efficiencies and effectiveness, and to strategically reduce inequities in access. What has become clear is that the future of commodity security will ultimately rest with the Global South— in particular, on ownership of the issue by national governments, civil society, and the private sector. It will also rest on the ability of countries to engage effectively with the international community, including the global commercial market, and to make the most of the very real benefits this community has to offer. There is no question that much has been achieved in the last decade and that the opportunities to build on those achievements abound. The tenth anniversary of the 2001 Istanbul conference represents a symbolic opportunity to reflect on past successes. It is also a strategic moment to heighten the enthusiasm that inspired a movement to guarantee that women and men around the world could choose, obtain, and use the supplies they need to ensure their reproductive health. I N T R O D U C T I O N 5 introduCtion Logistics. Procurement. Forecasting. Distribution. These are not exciting words for most people, much less concepts to motivate a movement. And yet, the need to draw attention to the critical importance of reproductive health (RH) commodity security, which necessitates these practical steps, did inspire a movement. The ten-year anniversary of the milestone conference, “Meeting the Reproductive Health Challenge: Securing Contraceptives and Condoms for HIV/AIDS Prevention,” provides an opportune moment to step back, assess what has happened in the last decade, and strategize for the future. The story of what has been accomplished—and how—has important lessons for the RH field and beyond. sourCes for the story How do you tell the story of a movement that has involved numerous individuals around the world over an extended period of time? This account does so through the contents of a wide range of documents and data and through the words of key individuals who were involved in this process. While the respondents to our interviews are quoted anonymously, their names are listed in Appendix 1. Each one told the story somewhat differently, but there were clear themes and general agreements on critical steps and significant achievements. The protagonists who speak here can be proud. Our hope is that their achievements can motivate and inform others in the health field while further energizing those who continue the struggle to ensure that all men and women in every corner of the world are able to access the RH supplies they need. “Meeting the Reproductive Health Challenge,” Istanbul, 2001. From left to right: Carolyn Hart (JSI), Peter Piot (UNAIDS), Paul Van Look, (WHO), and Mari Simonen (UNFPA). 6 R E P R O D U C T I V E H E A LT H CO M M O D I T Y S E C U R I T Y: L E A D I N G F R O M B E H I N D T O F O R G E A G L O B A L M O V E M E N T A Brief history As with any movement, it is difficult to pinpoint one precise beginning, one eureka moment, or even one clear linear path. It is clear that the 2001 Istanbul meeting was a critical moment. Still, much happened before the pivotal meeting, though not necessarily in a united, coordinated manner. First, it is important to define what we are talking about. Contraceptive security exists when every person is able to choose, obtain, and use high-quality contraceptives and condoms for family planning and for the prevention of HIV/AIDS and other sexually transmitted infections. The fundamentals underlying contraceptive security, of course, are equally relevant to the wider stock of supplies needed to provide the full range of RH services. These supplies include antibiotics to treat sexually transmitted infections, drugs and equipment to ensure safe delivery, and the equipment and supplies needed for all family planning methods, including long-acting and permanent methods. Indeed, most actors today in the contraceptive “supplies movement” would probably define their work as closely aligned to the broader issue of RH supplies. But the genesis of this movement, and indeed the recognition of its cross-cutting nature, was largely rooted in early efforts to ensure contraceptive supplies, including condoms. For that reason and for the sake of convenience as much as anything else, this paper will tend to favor the term contraceptive security or, on occasion, RH commodity security. Although research suggests that these terms may be understood differently by different audiences, here they will be used interchangeably unless specified otherwise. Looking back over the past 40 years, it is possible to discern at least three distinct periods in the evolution of the supplies movement. The first saw many years of intermittent technical assistance and supply provision. It was a period when the United Nations Population Fund (UNFPA) and the US Agency for International Development (USAID) shouldered most of the responsibility for sustained international support. Next, advocates and other bilaterals joined the cause and, in doing so, raised the profile of contraceptive security to heights that had not been previously seen. Finally, there emerged a period of greater awareness at the global level and more coordinated action in addressing supply issues. The story of how the issue of contraceptive supplies became a movement is, at its heart, about people getting to know each other—often strange bedfellows who were willing to work through the growing pains of new relationships. It is an illustration, for example, of the power that can come from the simple act of picking up a phone and talking. Yes, the power and persuasiveness of a strong evidence base has also been critical, especially when that evidence is translated into financial terms. But in the end, this story proves what committed people and organizations can achieve if they work together and put concerns for the “issue” ahead of concerns for themselves. fragmented support — 1970s–1997 Since the late 1960s and early 1970s, donors have supported both contraceptive supplies for developing countries and technical projects to strengthen logistics systems. While the biggest players were (and remain today) UNFPA and USAID, they were not alone in this effort. The Danish International Development Agency and other Nordic bilateral agencies were also active, particularly in strengthening central medical stores and other key links in the supply chain. An early director of USAID’s Office of Population, Ray Ravenholt, was known for emphasizing the need to “get the supplies out there.” Although the phrase “No product? No program” would not come into use until years later, he was most certainly guided by its message. This early period also saw the involvement of a number of technical assistance agencies. John Snow, Inc. (JSI), PATH, and the Centers for Disease Control and Prevention (CDC) all played critical roles in improving supply systems. JSI, through the USAID-funded Family Planning Logistics 1986 USAID-funded Family Planning Logistics Management (FPLM) project begins (1986–1990). 1990 USAID-funded FPLM project is renewed (1990–1995). A B R I E F H I S T O R Y 7 Management (FPLM) projects (1986–2000), supported efforts to improve supply chains. PATH’s emphasis was analyzing and supporting local manufacturing, quality assurance, and various access issues. In 1994, the International Conference on Population and Development (ICPD) changed the direction of international population efforts. ICPD’s Programme of Action focused on universal access to reproductive health care by 2015, and urged UNFPA to strengthen its leadership role in assisting countries “to ensure availability of reproductive health services and choices of reproductive health products, including contraceptives” (UNFPA, 2002). With an emphasis on comprehensive reproductive health care and rights, some argue that attention was taken away from family planning. It is worth noting that in the ICPD Programme of Action, contraceptive supplies actually received little attention. With the growing emphasis on HIV/AIDS, support for family planning programs began to stagnate. Even before ICPD, however, it had become clear that the convergence of increased budget constraints and growing demand for family planning would make it impossible for the world’s two leading contraceptive donors—USAID and UNFPA—to sustain the developing world’s dependence on them for these supplies. This and other factors led to the recognition that some kind of mechanism would be needed to reform health financing and expand and coordinate donor contributions. In the 1990s, UNFPA convened the Contraceptive Commodity Group (later the RH Supplies Working Group). Its aim was to bring together representatives of major donors and key developing countries and to assess, on an annual basis, any potential commodity issues that might confront them. Starting in 1993, UNFPA also launched a global donor support database with the aim of consolidating and documenting financial commitments, especially by its European and Canadian donors. In the early years, data collection proved challenging and, given the database’s retrospective nature, served more of an advocacy than a programming role. Nonetheless, the tool is still in use by UNFPA (UNFPA, 1995). Through the 1990s, supply issues remained largely the exclusive domain of highly technical and specialized experts. In spite of the central importance of contraceptive supplies to program success, it remained a low-profile issue for the RH community. But that would soon change. A looming crisis: advocates join the cause — 1998–2001 In the late 1990s, the discourse on supplies shifted to talk of contraceptive security and a looming crisis of funding shortfalls. The concept of contraceptive security—a term first coined by Carolyn Hart from JSI in 1998—came out of an analogy to food security. “If only,” she wrote, “contraceptives were thought of as an essential commodity—like food, like water—governments and donors would commit unequivocally to the availability of needed supplies and synchronize their financial, program planning, and delivery systems to secure it.” (Hart, 2003). At that time, a small group of committed and driven women began to discuss this concept and brainstorm solutions. These included Carolyn Hart from JSI, Terri Bartlett of Population Action International (PAI), Jane Hutchings from PATH, and Susan Rich from the Wallace Global Fund. As global attention began to gravitate toward RH issues with a greater emotive component, they saw concern for supplies gradually slipping off people’s radar screens. They were committed to preventing that from happening. The four met frequently, both formally and informally, and began planning. The Interim Working Group on Reproductive Health Commodity Security (IWG) was formed in January 2000 by JSI, PAI, PATH, and the Wallace Global Fund in response to a meeting of the Working Group of UNFPA’s Global Initiative on RH Commodity Management. The choice of this name was intentional and important, with “interim” highlighting the group’s catalytic potential, not the restructuring of the existing institutional landscape. The IWG was guided by beliefs in evidence and participation and a conviction that the problem of contraceptive supply could only be solved 1992 The Global Initiative on Contraceptive Requirements and Logistics Management Needs established by UNFPA. Value of family planning (FP) commodities procured by donors for developing world reaches US$73 million. 1993 UNFPA establishes contraceptive commodity database with the aim of consolidating and documenting financial commitments, especially by its European and Canadian donors. 8 R E P R O D U C T I V E H E A LT H CO M M O D I T Y S E C U R I T Y: L E A D I N G F R O M B E H I N D T O F O R G E A G L O B A L M O V E M E N T “with a full understanding of the issues involved and with the input, participation and commitment of the principal stakeholders in the process” (IWG, 2001). One activity widely seen as having heightened awareness of the new concept of commodity security was the launch, seven months later, of what would eventually become the Critical Issues Seminar series on Contraceptive Security. With funding from USAID through the Deliver Project, the event brought together representatives from USAID and other Washington, DC–based agencies, exposing many of them for the first time to concepts such as the supply chain and the importance of logistics. Another important step in building momentum around the issue of contraceptive security was the systematic collection of evidence. First, it was necessary to convince players that this step was even necessary. While USAID, UNFPA, International Planned Parenthood Federation (IPPF), and others had confronted global supply crises for many years, their collective experience still did not add up to a coherent or systematic view of the supplies landscape. There had been anecdotal stories such as stockouts of pills in Mexico or condoms in Thailand and increases in emergency requests to USAID. But missing were the full picture and data necessary to support appropriate action. One person described the situation as a Catch-22: “How can we look into it if we don’t know it’s a problem; but how can we know it’s a problem if we don’t look into it?” And yet, even this process of gathering information was important, because “. . . it made people pay attention.” In May 2001, just one month after the publication of UNFPA’s report Reproductive Health Commodity Security: Partnerships for Change, A Global Call to Action, the IWG hosted the conference “Meeting the Reproductive Health Challenge: Securing Contraceptives and Condoms for HIV/AIDS Prevention” with support from the Bill & Melinda Gates Foundation, the David and Lucile Packard Foundation, the William and Flora Hewlett Foundation, the UN Foundation, the Wallace Global Fund, USAID, UNFPA, and others. In attendance were more than 127 participants, including ten developing country delegations, representing 41 organizations and governments. The well-organized and thought-out program carried the motto “Advocacy, Action, Access.” The meeting focused on contraceptives rather than the broader category of RH supplies for two key reasons: a lack of consensus on an essential list of RH supplies and little information on donor contributions for non-contraceptive RH commodities. The primary message of the conference, which would become the focus of future advocacy efforts, was the “donor funding gap,” shorthand for narrowing the looming discrepancy between donor support and the growing need for commodities. Throughout the conference’s background documents, the language focused on this “looming crisis.” “Meeting the Reproductive Health Challenge” was a response to that perceived crisis and called for immediate action. Its core message was conveyed powerfully through a graph (Figure 1) that illustrated the increase in financing needed to meet the supply needs of 87 developing countries (IWG, 2001). Two scenarios for donor financing suggested that the shortfall could reach as high as US$210 million annually. Many people have acknowledged that the success of the conference was attributable, in no small part, to the salience of the financing-shortfalls message. When asked what made people interested in the issue, one technical expert admitted that “. . . the advocates get [the] credit. They wanted to make it about the resource gap. I wanted it to be about the supply chain. They were right. The big scary gap. That was the attention-getter.” “Meeting the Challenge” was, of course, about more than just the “donor gap.” To the organizers and many who attended, the meeting’s success was equally attributable to its thorough evidence base, its involvement of country teams, and, perhaps most important of all, its neutrality with regards to institutional affiliation. In this way, “Meeting the Challenge” created an atmosphere that encouraged open communication. In the words of one observer; “There was a lot more free flow than usually happens at global meetings.” 1994 International Conference on Population and Development (ICPD) inspires a rights-based and people-centered perspective on sexual and reproductive health, sustainable development, the environment, HIV and AIDS, gender equality, and migration. 1995 USAID-funded FPLM project is renewed. Value of FP commodities procured by donors for developing world reaches US$130 million. A B R I E F H I S T O R Y 9 Another key to success was the careful consideration of participants, particularly the breadth of geographic representation and the level of institutional leaders. As one participant recounted, it was a “pretty potent” guest list. UNFPA and USAID tapped into their own extensive country connections, and UNFPA was especially influential in securing high-level representation, such as that of Thoraya Obaid, UNFPA’s executive director, and Peter Piot, executive director of UNAIDS. Once these participants were signed on, it was like dominoes, with more than 100 people wanting to attend. “What made the meeting effective was that we had representatives from key countries around the world,” said one participant/organizer. “All came with different problems and ways to address them. This really showed that it was not just a northern initiative but a global one.” While Istanbul is widely recognized within the supply movement as a key transformational event, its exact role is perceived differently by different actors. In looking back at the meeting, people have called it such things as a “breakthrough moment in reproductive health,” “a turning point,” “a milestone,” and “a pretty powerful, intense meeting.” Others saw its contribution more in terms of laying the foundation for what was to come. They praised the meeting’s final action statement, which synthesized key themes, left people with a shared understanding of what had been discussed and agreed upon, and identified three main action areas: advocacy to build political commitment; national capacity building to forecast, finance, procure, and deliver supplies and services; and donor coordination and financing to secure the necessary resource base. 1990 1995 2000 2005 2010 2015 400 350 300 250 200 150 100 50 0 M ill io ns o f d ol la rs Donor Financing for Commodities Compared with Projected Need Past �nancing Projected cost of subsidized contraceptives 3% growth in �nancing Constant donor �nancing $24 million gap $140 million gap $210 million gap 5.3% annual increase required figure 1: the donor gap, 2001 (adapted from IWG, 2001) 1998 Term “contraceptive security” is coined and later published in FPLM’s Programs that Deliver (2000). 1999 Fifth-year review of ICPD in the Hague reaffirms the relationship of family planning to larger issues of health, population, and development. Total value of FP commodities procured by donor community for developing countries drops to US$115 million. 10 R E P R O D U C T I V E H E A LT H CO M M O D I T Y S E C U R I T Y: L E A D I N G F R O M B E H I N D T O F O R G E A G L O B A L M O V E M E N T Soon after the conference, a follow-up meeting was held in Washington, DC. The IWG became the International Initiative on Reproductive Health Supplies with a focus on ensuring implementation of the Istanbul action plan. Other partners soon joined: International Council on Management of Population Programmes (ICOMP), IPPF Africa Region, Partners in Population and Development (PPD), and Profamilia Colombia (MSI, 2002). The stage was set for an effective division of labor, and an action plan was created to implement and finance the conference’s recommendations. Istanbul focused attention on supplies, an issue whose profile had rarely stood out on the global development agenda. And while some did question the wisdom of focusing on products rather than on services or rights, advocates saw it as an opportunity to bring to life what was often viewed as an arcane technical area and, in so doing, revitalize interest in RH more broadly. The meeting in Istanbul brought people together. The next challenge would be to sustain that spirit of camaraderie and turn it into action. Coordinated action — 2002–present A major theme of the Istanbul conference was the acknowledgement that no agency or donor acting alone could ever meet the supply challenge and that coordination was necessary. In the years since the conference, many more players have become involved, more coordinating mechanisms have been put into place, and an increasing number of tools have been developed. UNFPA and USAID still remain the largest international donors, but they are today joined by European bilaterals. Many developing country governments are committing their own resources for supplies as well. Coordination in the supplies arena has also become much more inclusive and far less tied to the activities of any single organization. This has made it possible for institutions, including governments, multilaterals, and NGOs, to keep working together despite the growing ideological sensitivities that have attached themselves to RH, especially family planning, throughout much of the last decade. In January 2003, this move toward greater coordination took a leap forward with the establishment of a new partnership— the Supply Initiative. Hosted jointly by DSW, PAI, JSI, and PATH, the Supply Initiative had three main areas of focus: advocacy and communications, web-based tracking of contraceptive shipments (which eventually became the RHInterchange), and engagement of operational- and policy-level decision-makers. At around the same time, a “task team” was created to look into the feasibility of an RH commodity fund. While circumstances beyond the team’s control ultimately prevented the application of their What made the Istanbul conference successful? A solid evidence base. Discussions were based on evidence generated through extensive background preparation (see Appendix 2 for a list of the nine background documents). Advocacy efforts were built on sound information about the gap between global demand and supply. Premeeting with country teams. A two-day meeting with country groups held before the main conference helped country representatives from diverse settings to coalesce around key issues and then bring them to the floor more powerfully. “Leading from behind.” The conference was not identified with a specific agency, but rather with the IWG. People gave up their institutional identities and put “the issue” ahead of their own organizational interests. 2000 UNFPA initiates global strategy for reproductive health commodity security. Interim Working Group (IWG) formed by JSI, PAI, PATH, and Wallace Global Fund. FPLM launches Critical Issues Seminar series on Contraceptive Security, Washington, DC. Millennium Development Goals (MDG) established. USAID-funded Deliver Project launched (2000–2007). A B R I E F H I S T O R Y 11 findings, the relationships they forged over the course of 2003 convinced them of the possibilities to be derived from the establishment of an “RH Supplies Partnership,” which would have a specific focus and terms of reference. UNFPA Executive Director Thoraya Obaid attended the task team’s final meeting and, in her closing remarks, pledged her support for the new initiative. In April 2004, the first meeting of the RH Supplies Partnership was held at the World Bank in Washington, DC. At that meeting, the word Partnership was dropped in favor of Coalition. The openness and common sense of purpose that characterized the meeting was a continuation of the atmosphere created in Istanbul and would set the tone for the Coalition and its operational style from that point on. Donors chaired the Coalition from the beginning, an important approach since “if they chair it, they buy into it and own it.” And so the Reproductive Health Supplies Coalition was born. Early on, three working groups were established that would, over time, become the motors driving the organization forward: (1) market development approaches, (2) resource mobilization and awareness, and (3) systems strengthening. By 2006, funding for a Brussels-based Secretariat was made possible through a grant to PATH from the Bill & Melinda Gates Foundation. The ideas of “leading from behind” and “putting the issue before the organization” that characterized Istanbul continued with the Coalition. With the adoption of new policies on membership and governance in 2007, the Coalition rapidly grew in size from fewer than 20 institutional members to more than 130 by the end of 2010. Today, this rapid growth is recognized by most people as having been a positive move, drawing in a wide range of stakeholders—from pharmaceutical companies to foundations—and giving everyone a platform. Bringing together advocates with technical experts created powerful partnerships, though the transition from watchdog to partner-in-arms was not without its challenges. The same was true with other involved groups—procurers and manufacturers, for example—who were probably more accustomed to staring across the negotiating table than sitting as neighbors around it. Equally critical in forging the new movement was the buy-in of the donor community, particularly regarding the governance of the Coalition. In its short history, the Coalition has had four chairs, each of whom has brought to the position skills and abilities that met the spirit and needs of the time. The first chair, Elizabeth Lule, from the World Bank, brought not only a vision of what the Coalition could achieve, but also the discipline and sense of purpose critical to the growth and survival of the new partnership. Her successors, co-chairs Margret Verwijk, from the Netherlands Ministry of Foreign Affairs, and Wolfgang Bichmann, from KfW German Development Bank, were similarly matched to the occasion, which entailed a very different set of needs. Their arrival coincided with the establishment of the Secretariat and a very real need for systems and policies that would guide the Coalition in the years to come. These systems included the Strategic Plan, new membership and governance policies, and a long-term agenda to ensure a diverse long-term funding base. By 2009, the Coalition’s membership had multiplied, its finances were secure, and its reputation was squarely on the global radar screen. Julia Bunting, from the UK’s Department for International Development (DFID), the Coalition’s fourth chair, saw this firm footing as an opportunity to take the Coalition to new levels by opening the eyes of its members to the potential that comes from size, strong member commitment, and an evolving, more favorable environment for supplies and family planning in general. Throughout its history and leadership, the Coalition has remained true to the spirit of “leading from behind.” While the contributions of its chairs, governing body, and other institutions are undeniable, its real movers have always been, and remain, its member institutions, more than a third of which are from the Global South. It is they who generate new knowledge, strengthen systems, lobby key decision- makers, and/or sustain the needed resource base. And it is this ownership that has fueled the energy that underlies what we call the global supply movement. But what exactly is that movement? And what difference has it made? 2001 Meeting the Challenge conference (Istanbul) convenes 127 participants from around the world and introduces the Donor Gap analysis. WHO establishes Prequalification Programme for HIV/AIDS, malaria, and tuberculosis medicines. 2002 USAID creates a team dedicated solely to contraceptive security. SPARHCS analyses in three countries: Nigeria, Ghana, Jordan. 12 R E P R O D U C T I V E H E A LT H CO M M O D I T Y S E C U R I T Y: L E A D I N G F R O M B E H I N D T O F O R G E A G L O B A L M O V E M E N T the AChievements of A movement The dictionary defines a movement as a group of people working together to advance shared ideas, and it is this idea of working together that is most important in understanding the supplies movement and its impact. One of the organizers of the Istanbul conference described the vision as “a radical movement for something vital for women’s health,” with a strong emphasis on action. Like other movements, this one has been characterized by expansion—bringing in a broader array of partners and inspiring a wider range of people about the importance of supply issues. By all accounts, the movement begun in Istanbul has made a significant difference in numerous ways, both globally and at the country level. There is much greater awareness today about contraceptive security and much greater coordination among partners working to achieve it. Coordinating bodies are increasingly characterized by inclusion and ownership. Efforts are guided by evidence, which has strengthened advocacy and interventions. And interactions among technical experts have enabled the movement to bypass politics at critical moments. Many of the recent successes in family planning at the country level have been directly attributable to these improvements in the supply situation. Between 2004 and 2005, USAID’s Repositioning Family Planning initiative examined a number of factors contributing to the success of family planning efforts. In Ghana, Malawi, and Zambia, contraceptive security was singled out as a primary contributor to increased contraceptive use (The ACQUIRE Project, 2005). This demonstrates how the issue has moved from its original, narrow technical niche to more widespread resonance. Clearly, the movement has created momentum and an enabling environment, which, in turn, has facilitated and catalyzed achievements around the world. One of the first products to come out of the Istanbul conference—and an excellent example of this catalytic effect—was the Strategic Pathway to Reproductive Health Commodity Security (SPARHCS). This common approach to operationalizing contraceptive security was developed under the leadership of UNFPA and USAID and has been adapted and applied in more than 50 countries to date. Structured around seven interrelated concepts of commodity security, SPARHCS provides a useful framework for analyzing and addressing the critical issues affecting commodity security. Borrowing, at least in part, from the language of SPARHCS, these achievements can be divided into four overarching areas: awareness, coordination, capital, and commodities for clients. Awareness: “istanbul woke people up.” One of the biggest changes in commodity security over the last decade is the increasing awareness of the issue itself. As noted earlier, with the exception of technocrats, it did not have broad appeal. Findings from focus group discussions presented in one of the Istanbul conference’s background documents showed that almost none of the 25 focus group discussion participants had any awareness of impending shortages of contraceptive supplies (IWG, 2001). After the conference, however, supplies were talked about as being essential. Today, “logistics is brought in at an earlier point and at a higher level than ever before,” explained one interviewee, who added that it was “such a coup for advocacy,” creating a “lasting impact.” Peter Piot was struck by the data presented at the conference about condom shortages, stating strongly, “No one should die for want of a three-cent condom.” (Countdown 2015 Europe). Why did the message of supply shortages resonate so strongly? “Shock factor and shame,” explained one person. The Istanbul conference report noted the striking reaction of one donor when presented with global evidence of the impending donor gap: “This is very humbling. Where have we been?” (IWG, 2001). 2003 Supply Initiative formed (2003–2006). SPARHCS analyses in Madagascar, Bolivia, Indonesia, Nepal, Peru. 2004 Reproductive Health Supplies Coalition established. RHInterchange created to provide access to up-to-date data on contraceptive supply shipments. T H E A C H I E V E M E N T S O F A M O V E M E N T 13 Contraceptive security has also come to be seen as a powerful entry point for the general goal of improving RH, perhaps due to its tangible nature. As one person said, “When you talk about empty shelves in a clinic, people really get it.” This issue can have more traction with certain audiences than sexual and reproductive health and rights, which is more difficult to define and demonstrate that concrete progress has been made. Today’s greater awareness of contraceptive security did not happen solely because of one conference. It was the product, at least in part, of a strong, sustained advocacy effort—one that took root in the Supply Initiative, but came to fruition under the umbrella of the Reproductive Health Supplies Coalition, specifically through the activities of its Resource Mobilization and Awareness Working Group (RMA). It was that working group that inspired the development of the Coalition’s Advocacy Toolkit. It was also that group that secured funding from the Bill & Melinda Gates Foundation to launch Project Resource Mobilization and Awareness (Project RMA), a three-year effort to sustain advocacy for RH commodity security at global, regional, and country levels. Between 2006 and 2009, Project RMA played a pivotal role in raising the profile of the supplies issue by improving supply-related policies, increasing funding for RH supplies, and building an evidence base for RH supplies advocacy through research and the support of advocacy champions ranging from district health officials, to global and regional NGO networks, to parliamentarians. With the support provided through a small-grants fund managed by the Coalition, called the Innovation Fund, PAI and the RMA Working Group produced the award-winning film, Empty Handed, which successfully put a human face on contraceptive security. The consequences of this sustained advocacy and awareness are evident across the RH field and particularly in the more frequent inclusion of commodity security in international declarations, policy statements, and events. As noted earlier, this greater visibility stands in sharp contrast to the previous decade where references to supplies—even in the ICPD Programme of Action—were sparse. Units devoted to “contraceptive security” are now a part of UNFPA and USAID’s organigrams, and the subject is now commonplace on the agendas of international conferences. Contraceptive security, for example, figured prominently at the International Conference on Family Planning: Research and Best Practices, held in Kampala, Uganda, in 2009. It was also a recurrent theme at the 2010 gathering of the Commission on Population and Development, at the Women Deliver Conference, and many other meetings. Supplies also now figure much more prominently in policy statements and key documents, including the following: • The African Union’s Maputo Plan of Action for the Operationalisation of the Continental Policy Framework for Sexual and Reproductive Health and Rights 2007–2010. • Addis Call to Urgent Action for Maternal Health. • Accelerating progress towards the attainment of international reproductive health goals: A framework for implementing the WHO Global Reproductive Health Strategy. • Better Health for Women and Families: The World Bank’s Reproductive Health Action Plan 2010–2015. Advocacy efforts have also increased awareness of the importance of supplies in other health areas. One donor called it “leading from family planning.” The Partnership on Maternal, Newborn and Child Health (PMNCH), for example, has called upon the Coalition to help it address commodity security issues in a strategic and coherent way. In October 2009, representatives of the PMNCH, Coalition partners, and several other agencies met in New York to reflect upon the Partnership’s Priority Action #3, which relates to commodity management. Participants agreed on the need for a short list of high-impact MNCH commodities that could serve as an evidence base for identifying commodity management issues and determining appropriate follow-on actions, including collaboration with partners. More people are now aware of and talking about supplies. But what has been the impact of this awareness? “Strategic Pathway to RHCS” (SPARHCS) published. Analyses carried out in Burkina Faso, Egypt, Ghana, Bangladesh, Honduras, Nicaragua, Paraguay, LAC Region, Georgia, Ukraine. 2005 CARhs begins monthly teleconferences to avert or resolve pending stockouts. SPARHCS analyses carried out in nine countries/regions: Angola, Cameroon, Dominican Republic, Ecuador, Eritrea, Fiji, Namibia, Papua New Guinea, Rwanda. 14 R E P R O D U C T I V E H E A LT H CO M M O D I T Y S E C U R I T Y: L E A D I N G F R O M B E H I N D T O F O R G E A G L O B A L M O V E M E N T Coordination: “we need each other.” Possibly one of the clearest cases of impact is the area of coordination. Interviewees often remarked about the partnerships forged following the Istanbul conference, which fostered stronger connections, trust, and easier communication. While it is difficult to quantify this change, the difference is palpable. As people get to know each other better, trust increases, tensions are eased, and there is greater understanding of each person’s (and their organization’s) strengths and constraints. “You can do so much more through closeness than formal means,” explained one respondent. It has become much easier to pick up the phone and talk when there is a problem, for example, be it a delayed shipment or the need for a more efficient solution. The Reproductive Health Supplies Coalition itself has played an important role in bringing diverse players together and in keeping them apprised of problems and activities. It is, said an interviewee, “a conduit, the glue that binds a lot of disparate organizations together, bringing together A and B to get a better result.” Two of the most important outcomes of greater coordination include the Coordinated Assistance for Reproductive Health Supplies (CARhs), which seeks to avert unanticipated supply shortages (see box, next page) and the RHInterchange (RHI). RHI is the first online database to track shipments of supplies. Previously, donors did not usually know how much others were giving to specific countries. “The idea was to have transparency in a very literal way,” explained one respondent. RHI has greatly aided coordination and the ability to be more transparent. The Coalition’s extended membership has also served as a solid base for reaching out to the broader RH community. In 2010, the Coalition’s governing body—its Executive Committee—called upon the Secretariat to help rally the support of the family planning community behind the UN Secretary General’s Global Strategy for Women’s and Children’s Health. Working together with a wide array of partners—from advocates, to demographers, to communications specialists, the Coalition launched its HANDtoHAND Campaign, which aims to reduce the unmet need for family planning by 100 million additional users by 2015. Reaching this goal will meet the family planning needs of 80 percent of women in low- and middle-income countries. It will mean 96 million fewer unintended pregnancies, 54 million fewer abortions, 110,000 fewer mothers dying in pregnancy and childbirth, and 1.4 million fewer infant deaths. In pursuing its HANDtoHAND Campaign, the Coalition has thus far secured pledges of financial, program and policy support from across the public and private sectors. And at the September 2010 Millennium Development Goals Summit in New York, AusAID, the Bill & Melinda Gates Foundation, DFID, and USAID adopted the 100 million metric as a cornerstone of their newly launched Alliance on Reproductive, Maternal and Newborn Health. The Coalition also continues its role as an important and credible source of information. It serves as a “brain trust,” building on a strong evidence base, identifying needs, and developing new tools and approaches. Like any Coalition, it must steer a careful course, ensuring that it adds value to the work of its members and does not duplicate or compete with them. The decade since Istanbul has also seen considerable improvement in coordination at country level, particularly with the establishment of commodity security committees. In a compilation of contraceptive security indicators put together by the USAID | DELIVER PROJECT (2010), 31 of 36 countries reported having a contraceptive security committee (or a group that works on contraceptive security issues). There is no question such committees can make a difference. The Logistics Committee in Rwanda, for example, played an important role in meeting the rapidly increasing needs as the contraceptive prevalence rate rose from 10 to 27 percent between 2005 and 2008 (USAID | DELIVER PROJECT, 2009). Finally, no account of partner coordination would be complete without acknowledging the growing involvement of the commercial manufacturing sector in RH commodity security discussions and initiatives. Again, it is difficult to attribute this convergence to any single event, but it is 2006 UNFPA launches the Global Programme to Enhance Reproductive Health Commodity Security. Coalition opens full-time Secretariat in Brussels. Project RMA launched (2006–2009). USAID | DELIVER PROJECT begins (2006–2014). WHO publishes The interagency list of essential medicines for reproductive health. PATH in collaboration with WHO and UNFPA publishes Essential medicines for reproductive health. T H E A C H I E V E M E N T S O F A M O V E M E N T 15 probably not coincidental that changes to the Coalition’s membership policy in 2007 opened the doors to direct participation by this sector, which, until that point, had not been fully engaged. Today the manufacturing and commercial sector make up nearly a fifth of the Coalition’s membership and their voice is an important addition. Some manufacturers, for example, have forged new partnerships with donors, making available low-cost commodities in exchange for financial support toward marketing and promotional costs. Other partnerships have led to the development, and, in some cases, commercialization, of new technologies—implants, female condoms, injectable contraception, and emergency contraception, to name but a few. There has also been growing interest on the part of manufacturers to make use of the Coalition’s convening power as a neutral, but effective, conduit to reach out to the supplies community to address a broad range of procurement issues. Capital: making financing more fashionable. The 2001 donor gap analysis presented in Istanbul provided the international community with a meaningful goal that was both ambitious and within reach. It argued that if left unchecked, annual shortfalls for supplies could reach US$140–200 million and it called upon donors to increase funding by 5.3 percent annually. Though growing demand for family planning will forever drive a wedge between supply and demand, the last ten years have shown that the donor gap can at least be kept at bay. Total funding since 2003 has averaged just above US$200 million. And if one looks to 1990, which the original 2001 donor gap analysis took as its benchmark, annual donor contributions have almost tripled, rising from just under US$80 million a year to more than US$220 million in 2007. This represents an annual increase of 6.3 percent in current dollars (Ross et al., 2009). The CARhs: “A shining example of what coordination can bring.” Even the most effective supply chains can and occasionally do break down. Beginning in early 2005, the CARhs (Coordinated Assistance for Reproductive Health Supplies, formally known as Countries at Risk group) initiated monthly conference calls as part of a coordinated donor effort to prevent and alleviate unexpected supply shortages. Participants have included KfW, DFID, Marie Stopes International, the Coalition Secretariat, UNFPA, USAID, World Bank, the USAID | DELIVER PROJECT, and others. This mechanism led, in 2007, to the development of the Procurement Planning and Monitoring Report (PPMR), a monthly contraceptive stock-status report that today provides standardized information about RH supplies in 23 countries to prevent or mitigate stock imbalances. Between October 2009 and September 2010, the CARhs addressed 184 separate supply crises—the highest number of cases since it was established. In 65 percent of the 40 instances where stock levels had dropped below minimal requirements, the CARhs successfully averted full stockouts by issuing new shipments, expediting existing shipments, or by providing policy advice. In 2010, such remedial efforts drove the procurement of more than US$8.7 million in RH commodities. Coalition recommends procurement of only supplies approved by WHO Prequalification Programme or other Stringent Regulatory Authorities. SPARHCS analyses carried out in 18 countries/regions: Azerbaijan, Benin, Botswana, Cambodia, Gabon, Guatemala, Guyana, Kazakhstan, Malawi, Mozambique, Nepal, Niger, Rwanda, Senegal, Sierra Leone, Somalia, Togo, West Africa Region. Total value of FP commodities procured by donor community for developing countries reaches US$212 million. 16 R E P R O D U C T I V E H E A LT H CO M M O D I T Y S E C U R I T Y: L E A D I N G F R O M B E H I N D T O F O R G E A G L O B A L M O V E M E N T Focus group discussions conducted before the Istanbul conference revealed that many donors—Europeans particularly—saw commodity security as “unfashionable” or, at best, a pre-ICPD relic. Not all shared this view, of course. DFID, KfW, and the Netherlands had, for many years, invested significantly in contraceptive security through the design, funding, and implementation/management of their own programs. DFID and the Netherlands still contribute the largest share to the UNFPA’s Global Programme to Enhance Reproductive Health Commodity Security. And yet in the years following Istanbul, the skepticism over supplies began to fade. The conference made it clear that modern contraceptives, however mundane, are a basic requirement of any RH program. “Without that, much of the rest becomes an exercise in futility,” said one respondent. Today, no fewer than six other European donors have joined with the Dutch and British in supporting the UNFPA Global Programme, while others have moved to basket funding or SWAps (Sector Wide Approaches). The IPPF European Network-led Countdown 2015 Europe consortium was also instrumental in bringing about an upturn in financial and political commitments from European donors. Between July 2007 and December 2009, 15 European countries committed an additional €400 million to reproductive health, with a portion of this going toward supplies (Gates Foundation, personal communication). Another recent achievement has been the ability to leverage financing for contraceptives from the Global Fund to Fight AIDS, Tuberculosis and Malaria. Rwanda was the first country to include contraceptives in its Global Fund proposal and, in 2008, secured a three-year commitment of more than US$2.4 million of Round 7 funds for that purpose. Due to the efforts of Coalition partners in the Mobilizing for RH/HIV Integration Project (PAI, IPPF, Interact Worldwide) and the Advance Family Planning Program, Global Fund proposals from Zambia, Ghana, Nigeria, and Uganda have also included RH commodities other than condoms. The past decade has also seen more developing countries take on greater responsibility for their own commodity security. There are encouraging signs of increased commitment as reflected in the development of national contraceptive security strategies, the inclusion of contraceptives on National Essential Medicines Lists, and the inclusion of contraceptive security concepts in the Poverty Reduction Strategy Papers. Such national-level commitment is especially important in the current environment of increased budget and sector support. While contraceptive security need not necessarily imply complete donor independence, greater self-sufficiency does indeed signal greater national commitment. One way to measure that commitment is to follow the money. According to the 2009 Contraceptive Security Indicators Survey, 22 out of 35 countries used at least some government funding (be it internally generated funds, World Bank credits, or basket funds) for contraceptive procurement. As a percentage of total spending, the amount varied from 4 percent in Madagascar to 100 percent in India. It is also encouraging to note that 20 of the 35 countries had in place a national budget line for contraceptive procurement. This is, of course, only the first step in a long process since budget lines alone do not guarantee that money will actually be spent. Few countries actually report on budget line expenditures, which is probably a good indication that shortfalls are widespread. What little data do exist suggests considerable variability. On the one hand, there are countries such as Uganda, where spending shortfalls grew from 63 percent in fiscal year 2005/6 to 94 percent in 2007/8. But there are also many other countries that have fully met their contraceptive requirements. The resource base for commodities, however, is not just about more money; it is also about the disbursement and flow of money. Volatility and unpredictability of funding have long been significant problems for procurement. Effective collaboration among Coalition members has made possible two mechanisms that address what is often referred to as the non-alignment of funding and procurement cycles—in other words, situations where the need for supplies may be acute, but the lack of available financing yields poor procurement terms, such as higher prices and longer lead times. 2007 Universal access to reproductive health added to MDG5. Procurement Planning and Monitoring Report (PPMR) launched to support work of CARhs. Countdown 2015 Europe launched. The Coalition adopts Strategic Plan and revises policies on membership and governance. SPARHCS analyses carried out in 17 countries/regions: Angola, Burundi, Central African Republic, Côte d’Ivoire, DRC, Guinea Conakry, Guinea Bissau, Haiti, Lesotho, Liberia, Republic of Congo, Rwanda, Sao Tome and Principe, Southern Sudan, Sudan, Swaziland, Tanzania, Yemen. T H E A C H I E V E M E N T S O F A M O V E M E N T 17 One such mechanism is the Pledge Guarantee for Health (PGH). Managed by the United Nations Foundation, the PGH was designed to ensure that development-assistance funds are available when needed, not just when the donors can disburse them. The PGH achieves this by allowing governments and nongovernmental agencies to convert their unrealized aid commitments into bankable donor pledges, which they can then use to obtain short-term, low-cost commercial credit. In this way, the PGH increases the efficiency of existing resources, leverages existing market-based mechanisms, and enhances country ownership. The other mechanism, AccessRH, aims to improve access to high-quality, affordable RH commodities and enhance delivery performance by providing stock held on its behalf by prequalified suppliers to government and NGO clients. It also offers accurate, up-to-date information on contraceptive orders and shipments for more than 100 countries through the incorporation of RHI. AccessRH was developed under the auspices of the Reproductive Health Supplies Coalition and is being implemented by UNFPA with support from the European Union, the German Federal Ministry for Economic Cooperation and Development, and USAID. Commodities for clients: strengthening the chain. The point of increased awareness, coordination, and financing is to make sure that commodities actually make it into providers’ and ultimately clients’ hands—a seemingly simple task on the surface, but one that belies tremendous complexity. And what better an illustration of that complexity than the iconic image of Kenya’s public-health logistics landscape (Figure 2). While many factors influence RH commodity security, the functionality and efficiency of in-country supply chains is essential. In the last decade, we have seen increasing attention and investment in key elements of supply- chain systems—strengthening the policy environment, encouraging meaningful integration, improving data visibility, and fostering innovation. The policy environment: One of the first steps in securing contraceptive security, of course, is the acknowledgement by national governments that contraceptive commodities are indeed essential, because it is that classification as an “essential medicine” that helps ensure products will have a place in the public-sector commodity supply chain. On that front, the last decade has seen considerable progress. In 2003, relatively few countries included contraceptives on their National Essential Medicines Lists (WHO 2003). Six years later, that had changed dramatically. In a 2009 survey of 35 countries conducted by USAID | DELIVER PROJECT (2010), 33 (94 percent) had at least one of eight possible contraceptive methods* on their lists. The average number of methods per country was five. Integration: Over the past decade, there has been a noticeable transition from vertical to “integrated” supply chains where commodities from multiple programs are largely procured, stored, and distributed together. Historically, donors have tended to invest in supply chains linked to their commodity and/or programmatic priorities such as HIV/AIDS, malaria, or family planning. The result has been a proliferation of vertical supply chains leading to redundancy and inefficiency. The labyrinth illustrated in Figure 2 highlights this point. Today, as a result of broader systems strengthening efforts, most ministries of health manage contraceptives and other RH commodities as part of the national supply chain for all essential medicines. In this new context, the emphasis is on strengthening the essential medicines supply chains and systems as a whole, while simultaneously supporting the “vertical” or specialized attributes of RH programs and supplies (such as financing and product selection). For example, in Rwanda, Malawi, and Tanzania, many of the supply-chain functions are integrated, with products stored and distributed together. However, certain functions remain predominantly vertical. In all three countries, there *Methods in the analysis included combined oral pills, progestin-only pills, injectables, implants, intrauterine devices, male condoms, female condoms, and emergency contraceptives. 2008 Rwanda becomes first country to use funds from the Global Fund to Fight AIDS, Tuberculosis and Malaria to procure contraceptives. Original Donor Gap Analysis (2001) updated by Futures Institute. Dalberg publishes first major technical report on future AccessRH and Pledge Guarantee for Health. Coalition launches Caucus on New and Underused RH Technologies and the online Supplies Information Database. SPARHCS analyses carried out in four countries: Chad, Mauritania, Nigeria, Uganda. 18 R E P R O D U C T I V E H E A LT H CO M M O D I T Y S E C U R I T Y: L E A D I N G F R O M B E H I N D T O F O R G E A G L O B A L M O V E M E N T is a coordination body focused on RH commodity security issues. And in Rwanda, where family planning is a priority, the government maintains a separate logistics reporting and information system for contraceptive use. It is important to remember that in an “integrated” supply chain, some commodities have unique characteristics that require special considerations and treatment. An integrated supply chain does not mean “one size fits all.” Data visibility: Another trend evident over the past decade is the recognition that decision-makers need timely data to make supply-chain and programmatic decisions. “Ten years ago, we assumed there were stockouts,” said one respondent. “Now we know there are stockouts.” Thanks to improvements in data visibility, many countries now have a better understanding of where stockouts are in the supply chain and thus can identify ways to respond. To improve data visibility, countries and partners have applied new technologies to collect, analyze, and share data. They have established forums for sharing data for decision-making. Three initiatives developed over the past decade have responded to the need for more data: the CARhs group, the Procurement Planning and Monitoring Report (PPMR), and RHI. As a result of these resources, donors and governments have the data they need to inform decisions and drive actions and responses to emergency orders, shipment timing and quantities, and funding commitments. Innovative solutions: One of the key strategic functions of the Reproductive Health Supplies Coalition is to assemble critical and credible expertise in the supplies field and ensure that the knowledge and experience they bring can benefit the supplies community as a whole. This role is possible only because of the volume of innovative work now underway. The last decade has seen a dramatic increase in efforts to increase the reach of national supply chains. In Zimbabwe, the government adopted and applied commercial best figure 2: the donor map: public health commodity supply chain in kenya (Aronovich and Kinzett, 2001) 2009 New Obama administration embraces importance of reproductive health. The Coalition’s membership tops 100. The Coalition issues first grants under Innovation Fund. SPARHCS analyses carried out in Ethiopia, Mali, and Zambia. T H E A C H I E V E M E N T S O F A M O V E M E N T 19 practices to ensure contraceptives were available at the client level, despite the country’s economic, social, and political upheaval (see box). In countries such as Malawi, Pakistan, and Ethiopia, partners have recognized the role of community-based workers to increase access to contraceptives. In Pakistan, “lady health workers” are a major source of contraceptives, supplying 26 percent of oral contraceptives, 13 percent of injectables, and 11 percent of condoms (Pakistan DHS, 2007). The last decade of investments in the supply chain and RH commodities has clearly paid high dividends, and few countries can match the returns seen in Rwanda. Between 2000 and 2007/8, the country’s contraceptive prevalence rate jumped from 4 percent to a remarkable 27.4 percent. Rwanda’s success was built on a strong government commitment to family planning, investment in needed systems—including supply-chain enhancements—diversified and coordinated financing, and strong partnerships. Between 2004 and 2006, the proportion of facilities without oral contraceptives decreased from 33 to 13 percent. It dropped from 21 to 8 percent in the case of injectables and from 61 percent to 18 percent with regard to implants (USAID | DELIVER PROJECT, 2009). Many countries could testify to the dramatic progress in strengthening supply chains, but the fact remains that many other countries continue to experience contraceptive stockouts. And stockouts or other supply-chain issues are really only one facet of contraceptive security; the effective lack of demand in some places is an even more important consideration. Worldwide, more than 215 million people have an unmet need for family planning. Even among users, huge inequities exist among subsections of the population. Innovative solutions to grow demand are needed—and robust supply systems must be ready to meet that greater demand. While integrated supply chains may, in the long run, lead to greater efficiencies and more sustainable supply chains, integration may negatively affect contraceptive security if contraceptives get “lost” in the system and are not prioritized. Amidst these concerns, however, it is still important to on occasion take a “glass half-full outlook,” as one donor described it. “Why don’t people write about the ‘daily miracle’ of having products, not just stockouts,” the donor asked. Acknowledging the “daily miracle” does not imply complacency about the ongoing needs. Stockouts do remain a problem, which is why the movement continues. 2010 UK government identifies family planning and maternal health as development priorities. AccessRH and Pledge Guarantee for Health begin operations. Bill & Melinda Gates Foundation pledges $1.5 billion for maternal and reproductive health. The Coalition launches HANDtoHAND Campaign with goal of reducing unmet need for modern family planning by 100 million by 2015. Reproductive, Maternal and Newborn Health Alliance launched by USAID, DFID, AusAID, and the Bill & Melinda Gates Foundation at the “Every Woman, Every Child” conference. SPARHCS analyses carried out in Ethiopia and Gambia. Innovative solutions: Zimbabwe The tremendous economic, social, and political disruptions facing Zimbabwe have prompted its Ministry of Health to adopt a strategy more typical of the commercial sector in order to get products to the people who need them. Called “Delivery Team Topping Up,” or DTTU for short, this approach authorizes the supplier of goods to ensure that the right quantities are supplied, in this case, to the service delivery facility. This approach reduces delivery time and shifts the burden of reporting and calculating supply needs from the facility to the supplier, leaving the facilities with more time to serve their customers. The results have been impressive. In the two provinces involved in the DTTU pilot initiative, condom stockout rates dropped from 20 percent to only 2 percent of facilities (USAID | DELIVER PROJECT, 2008). Building on this success, the DTTU has been expanded to include other commodities, and the country is considering the approach for all primary health commodities. 20 R E P R O D U C T I V E H E A LT H CO M M O D I T Y S E C U R I T Y: L E A D I N G F R O M B E H I N D T O F O R G E A G L O B A L M O V E M E N T the next ChApter of the story The prospects for choosing, obtaining, and using RH supplies have changed markedly in the last 20 years and even more so in the decade since Istanbul. The commitment of advocates, technical experts, and other key stakeholders has raised the profile of commodity security, fostered effective coordinating mechanisms, harmonized strategic tools, and increased the availability of supplies to clients. What will characterize the next phase of this ongoing story? As we have seen, the resource base for reproductive health has improved. Governments that may have once been indifferent are now championing the cause of commodity security along with many institutions in the philanthropic community. Even today’s economic crisis is making itself felt, because when financial belts are tightened, only the most cost-effective programs can be sustained—and few, if any, programs can match the cost-effectiveness of family planning. Whether this “alignment of the stars” will last is impossible to know. What is clear is that the future of commodity security will ultimately rest on ownership of the issue by national governments, civil society and the private sector in the Global South. It will also rest on the ability of countries to effectively engage with the international community and make the most of the very real benefits this community has to offer. Funding, of course, is never far from most people’s minds. But international collaboration around commodity security has also yielded a host of promising tools that, ten years ago, were a pipe-dream at best: mechanisms to align financing and procurement cycles, tools for effective advocacy, programs to assure product quality, information systems to track commodity movements, and frameworks, such as SPARHCS, for operationalizing contraceptive security. While the achievements highlighted in these pages testify to the successes of the supplies movement, they should not be allowed to obscure the very real challenges that lie ahead. Yes, the donor gap has been kept at bay at least temporarily. But increases in the number of contraceptive users—especially younger users—coupled with the growing demand for condoms for HIV/AIDS means that by the year 2020, an estimated US$424 million will be required in commodity support to satisfy all demand for contraceptives in donor-dependent countries. Even if donor funding were to remain at or near current levels, the shortfall would be almost US$200 million annually, with a cumulative shortfall of about US$1.4 billion over the 2008–2020 period. These challenges do indeed threaten past gains and make it still harder to maintain, much less accelerate, the momentum of the past ten years. The evolution of the supplies movement can, in some respects, be seen as a prelude to the many challenges ahead. If the last decade has taught us anything, it is that no “quick fix” will address the multiple threats facing contraceptive security. It is not just about money, it is not just about systems, and it is not just about coordination. And yet, as one respondent noted, many of us in the field “. . . have a sprint . . . rather than a marathon mentality. This [will be] . . . a journey of 26 miles rather than 20 meters.” In marking ten years since Istanbul, we acknowledge the “daily miracle” that happens for so many women. But we also recognize that much is left to be done. In conducting the interviews that shaped this report, respondents were unanimous on the need to innovate, apply best practices, develop new technologies, and think and act strategically. There was also growing consensus on selected priorities that should help shape the future of the supplies movement. The list is not exhaustive, but it does provide insight into the thinking of those who will help shape the future. Taking responsibility at country level from the first mile to the last. The future of commodity security will increasingly rest at country level, from the first mile to the last. Country ownership means strengthening government commitment, not just among ministries of health, but also by ministries of finance where key decisions are made on budget allocations, tax legislation, and other areas of critical importance to commodity security. It means strengthening the total market and forging linkages across all sectors— public, private, and nongovernmental. It means getting civil society to care about RH commodity security and to use evidence-based advocacy to target critical pressure points. And it means putting in place the systems needed for better supply-chain management, from procurement to warehousing to distribution. In the words of the film Empty Handed, “Commodity security is everyone’s responsibility.” Building local capacity. Ultimately, supply chains are nothing more or less than the people who run them. Yet their management is one of the most under-recognized disciplines within public health. Of the four action areas identified after Istanbul (advocacy, national capacity-building, donor coordination, and financing), building a strong supply- chain workforce has possibly been the most challenging. Many of the people who manage supply chains, be they in medical stores or warehouses, “have responsibility, but no standing,” with limited powers (or even incentives) to deal with problems directly and efficiently. Recognizing this challenge, the Systems Strengthening Working Group of the Coalition has launched a new workstream designed to T H E N E x T C H A P T E R O F T H E S T O R Y 21 address capacity building and professionalize supply-chain management. The People that Deliver initiative is a global alliance of institutions and countries committed to creating strong, sustainable supply-chain workforces. Exploring engagement with maternal health. The critical lessons learned from contraceptive security need to be shared. Nowhere is this need greater or more relevant than in the area of maternal health. Just four products—oxytocin, magnesium sulfate, misoprostol, and manual vacuum aspiration—have the potential to more than halve maternal deaths. Family planning is unquestionably the most cost- effective strategy for reducing maternal mortality. The synergies with maternal health are undisputable and the opportunities for change are unparalleled. Already efforts are underway by PAI, PMNCH, and other Coalition partners to broaden dialogue with the maternal health community and explore barriers to access maternal health supplies. Facilitating market development. In Latin America and Asia, at least two-thirds of all contraceptive supplies are provided through the private sector. In sub-Saharan Africa, the figure averages only around 20 percent. In both regions, however, women and men with the ability to pay are accessing low-cost public-sector services that could otherwise be meeting the needs of those with little, if any ability to pay. There are many advantages to be derived from a more optimal mix and better alignment of the public, private, and non-commercial sectors. Some have even argued that market dynamics hold out greater potential than logistics to improve contraceptive security. Research carried out by the Market Development Approaches Working Group in Honduras and Madagascar has demonstrated the potential for facilitating overall market growth, ensuring greater equity, and strengthening government stewardship. Assuring product quality. Many essential RH medicines and devices are now off-patent and being manufactured by suppliers throughout the world. These suppliers, including manufacturers of lower-priced generic versions of name brand medicines, have an important role to play in meeting the need for RH supplies. But as one respondent noted, “Genericizing is a trend of great possibility and risk.” All products, irrespective of origin, should meet international norms and standards for quality, efficacy, and safety. But for many generic manufacturers, navigating the requirements of a stringent regulatory authority (SRA) can be a serious obstacle with consequences at both the global and country levels. Failing to secure SRA approval can either deprive the marketplace of affordable, potentially high-quality products, or it can encourage the circumvention of international standards and allow products whose quality cannot be ascertained into the global marketplace. In recent years, the world has seen a number of large research and development manufacturers turn their backs on the production of contraceptives for developing markets. If this trend continues, we may soon find ourselves in a race against time. International efforts, such as the WHO Prequalification Programme, are already underway to address this dilemma, and the Coalition and its members are solidly behind them. But at the same time, countries themselves must prioritize the need for quality and develop and maintain systems that can assure product quality in both the public and private sectors. Many countries still remain deficient in this important stewardship role. Humanizing the supply issue. In the end, what matters most is the client. Is she able to choose, obtain, and use the products she wants and needs? As one donor pointed out, “We can’t say we’re successful because we have a supply chain that works. It’s whether women get what they want.” As obvious as this message may seem, the reality is that our discourse does not always match what we know to be true. Few in the supplies movement—perhaps few in the RH community—have not heard the slogan, “No product, no program.” That alone is a significant achievement. It shows the value to be derived from a clever turn of phrase and is a testament to the emergence of the issue on the development scene. But to some observers, the focus on “program” also says a great deal about the supplies movement. Ten or 20 years on, we are still not fully equipped to document the human, rather than programmatic consequences of failing to meet our goals, to quantify the unwanted pregnancies, maternal deaths, and unsafe abortions that result from leaving a health facility empty- handed. The production of the film, Empty Handed, was a critical step in putting a human face on supplies. In the eyes of many, it is essential that this spirit be pursued. There is no question that much has been achieved in the last decade and that the opportunities to build on those achievements abound. In June 2011, partners from around the world will gather in Addis Ababa, Ethiopia to commemorate the tenth anniversary of the Istanbul conference. That event, “Access for All: Supplying a new decade for reproductive health,” will offer an unparalleled opportunity to reflect on the achievements of the past, learn from their lessons, and identify strategies for taking forward those lessons into the coming decade. If the past truly is prologue, then “Access for All” promises to take to a new level the enthusiasm that inspired a powerful movement—a movement to ensure that women and men around the world can choose, obtain, and use the supplies they need to ensure their reproductive health. 22 R E P R O D U C T I V E H E A LT H CO M M O D I T Y S E C U R I T Y: L E A D I N G F R O M B E H I N D T O F O R G E A G L O B A L M O V E M E N T appendix 1 List of interviewees Jagdish Upadhyay, United Nations Population Fund (UNFPA) David Smith, UNFPA/Procurement Services Branch Patrick Friel, Consultant Mark Rilling, United States Agency for International Development (USAID) Alan Bornbusch, USAID Susan Rich, Bill & Melinda Gates Foundation Monica Kerrigan, Bill & Melinda Gates Foundation Joerg Maas, Consultant Steve Sinding, Consultant Carolyn Hart, John Snow, Inc. (JSI) Leslie Patykewich, JSI Sally Ethelston, Program for Appropriate Technology in Health (PATH) Jane Hutchings, PATH Duff Gillespie, The Gates Institute for Population and Reproductive Health, Johns Hopkins Bloomberg School of Public Health Elizabeth Lule, World Bank Sangeeta Raja, World Bank Carolyn Vogel, Population Action International (PAI) Margaret Neuse, Consultant Elly Leemhuis, Ministry of Foreign Affairs of the Netherlands John Worley, International Planned Parenthood Federation (IPPF) John Skibiak, Reproductive Health Supplies Coalition A P P E N D I C E S 23 appendix 2 referenCes 1 The ACQUIRE Project. Moving family planning programs forward: Learning from success in Zambia, Malawi, and Ghana. New York: The ACQUIRE Project/EngenderHealth; 2005. 2 Aronovich DG, Kinzett S. Kenya: Assessment of the Health Commodity Supply Chains and the Role of KEMSA. Arlington, VA: DELIVER/John Snow, Inc., for the US Agency for International Development (USAID); 2001. 3 Ashford L. Securing Future Supplies for Family Planning and HIV/AIDS Prevention. Policy Brief. MEASURE Communication. Population Reference Bureau; 2002. 4 Bartlett T. Setting the Scene for the Reproductive Health Supplies Issue: History and Progress. PowerPoint presentation at Asia Pacific Alliance. Bangkok, Thailand: PAI; November 16, 2006. 5 Bornbusch A. Contraceptive Security. PowerPoint presentation for Health Communication Partnership brown bag. 2004. 6 Countdown 2015 Europe. Available at: http://www. 7 Family Planning Logistics Management/John Snow, Inc. Programs That Deliver Logistics’ Contributions to Better Health in Developing Countries. Published for USAID. Arlington, VA: Family Planning Logistics Management/John Snow, Inc.; 2000. 8 Hare L, Hart C, Scribner S, Shepherd C, Pandit T (ed.), Bornbusch, A (ed.). SPARHCS: Strategic Pathway to Reproductive Health Commodity Security. A Tool for Assessment, Planning, and Implementation. Baltimore, MD: Information and Knowledge for Optimal Health (INFO) Project/ Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health; 2004. 9 Hart C. The Strategic Pathway to RHCS v.7. (Section drafted but ultimately not included in final SPARHCS published version). April 14, 2003. 10 The Interim Working Group on Reproductive Health Commodity Security (IWG). Meeting the Reproductive Health Challenge: Securing Contraceptives, and Condoms for HIV/AIDS Prevention. Istanbul, Turkey, 3–5 May 2001. Report on the Meeting. 2001. 11 IWG. 2001. Packet of background materials for Istanbul meeting: a Overview: The Need for Security in Reproductive Health Supplies b Contraceptive Projections and the Donor Gap c Contraceptive Security: Toward a Framework for a Global Assessment d Country Perspectives on the Future of Contraceptive Supplies e Defining Reproductive Health Supplies: A Survey of International Programs f Issue Profiles: Lessons Learned from Five Countries g Donor Funding for Reproductive Health Supplies: A Crisis in the Making h Financing Contraceptive Supplies in Developing Countries: Summary of Issues, Options and Experience i Gauging Awareness, Assessing Concern: Focus Group Findings on Reactions to Contraceptive Supply Shortages 10 Leahy E. Reproductive Health Supplies in Six Countries: themes and entry points in policies, systems and financing. Population Action International; 2009. 11 Marie Stopes International (MSI). Reproductive health supplies security. Position Paper No. 3; 2002. 12 PATH, the World Health Organization, the United Nations Population Fund. Essential Medicines for Reproductive Health: Guiding Principles for Their Inclusion on National Medicines Lists. Seattle, WA: PATH; 2006. 13 Rao R; Olson N, Bornbusch A (ed.), Pilz K (ed.). The SPARHCS Process Guide: A Planning Resource to Improve Reproductive Health Commodity Security. Baltimore, MD: Information and Knowledge for Optimal Health (INFO) Project/Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health; 2008. 14 Reproductive Health Supplies Coalition. Monitoring Report (2007–2009). 2009. 15 Ross J, Weissman E, Stover J. Contraceptive Projections and the Donor Gap. Reproductive Health Supplies Coalition; 2009. 16 Sarley D, Rao R, Hart C, et al. Contraceptive Security: Practical Experience in Improving Global, Regional, National, and Local Product Availability. Arlington, VA: DELIVER PROJECT for USAID; October 2006. 17 Solo J. Family Planning in Rwanda: how a taboo topic became priority number one. IntraHealth International; 2008. 18 United Nations Population Fund (UNFPA). Addis Call to Urgent Action for Maternal Health. 2009. Available at: http://www. addis_call_action.pdf 19 UNFPA. Reproductive Health Essentials: Securing the Supply. Global Strategy for Reproductive Health Commodity Security. 2002. 20 UNFPA. Programme Effectiveness: Contraceptive Requirements and Logistics Management Needs. 1998. Available at : 21 UNFPA. Donor Support for Contraceptive Commodities. Technical Report No. 32. 1995. 22 USAID | DELIVER PROJECT. Measuring Contraceptive Security Indicators in 36 Countries. Arlington, VA: USAID | DELIVER PROJECT, Task Order 1. 2010. 23 USAID | DELIVER PROJECT. The Procurement Planning and Monitoring Report: Reducing Contraceptive Stockouts Through Data and Partnerships. 2010. 24 USAID | DELIVER PROJECT. The Strategic Pathway to Reproductive Health Commodity Security: Five years & 50 countries later: What have we learned? PowerPoint presentation. 2009. 24 R E P R O D U C T I V E H E A LT H CO M M O D I T Y S E C U R I T Y: L E A D I N G F R O M B E H I N D T O F O R G E A G L O B A L M O V E M E N T 25 USAID | DELIVER PROJECT. A Strong Supply Chain Responds to Increased Demand for Contraceptives in Rwanda. Success Story. January 2009. 26 USAID | DELIVER PROJECT. Delivery Team Topping Up: Bringing About Reliable Distribution in Difficult Environments. Success Story. December 2008. 27 USAID. Contraceptive Security: Ready Lessons. Available at: 28 USAID. Contraceptive Security: Ready Lessons II. Contraceptive Security in a Changing Global Health Environment. 29 World Bank. Better Health for Women and Families: The World Bank’s Reproductive Health Action Plan. 2010–2015. 2010. Available at: Resources/376374-1261312056980/RHAP_Pub_8-23-10web.pdf. 30 World Health Organization (WHO). Accelerating progress towards the attainment of international reproductive health goals. 2006. Available at: WHO_RHR_06.3_eng.pdf. 31 WHO. Reproductive Health Medicines in National Essential Medicines List: A Research Report. Background discussion paper No. 3 for the Interagency Consultation on the Selection and Delivery of Essential Medicines and Commodities for Reproductive Health. Geneva; November 2003. Reproductive Health Supplies Coalition Coalition Secretariat Rue Marie-Thérèse 21 1000 Brussels Belgium + JulieSolo

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