Reproductive Health Essentials- Securing the Supply

Publication date: 2002

220 East 42nd Street New York, NY 10017 United States of America UNFPA World Wide Web site: http://www.unfpa.org ISBN 0-89714-626-3 E/10,000/2002 UN Sales No. E.02.III.H.3 Printed on recycled paper Reproductive Health Essentials SECURING THE SUPPLY Global Strategy for Reproductive Health Commodity Security Contents Preface. ii I. A Secure Supply of Commodities .1 II. Contraceptives for Family Planning . 9 III. The Condom Crisis and HIV/AIDS Prevention .15 IV. When Disasters and Conflicts Disrupt Supplies .18 V. How UNFPA Advances RHCS . 21 VI. The Way Forward . 27 Annexes The Global Strategy for RHCS . 29 Partners: Working together for RHCS . 30 Figures Figure 1: UNFPA commodity distribution in a typical year. 7 Figure 2: Family planning needs will grow as both population and demand increase . 10 Figure 3: Trend of reported donor support for contraceptives compared with estimated requirements . 14 Boxes Coordinated response improves supply in Nepal . 2 Categories and examples of reproductive health commodities . 6 Conference inspires action in Indonesia . 11 Commodities a constraint to family planning in Lao PDR . 12 Commodity costs for family planning and HIV prevention . 14 Commodities in crisis situations . 19 Examples of UNFPA- supported RHCS activities . 22 The United Nations Population Fund (UNFPA) is the world’s largest international source of population assistance. UNFPA helps developing countries and countries with economies in transition, at their request, to improve reproductive health and family planning services (including HIV prevention) and to formulate population policies and strategies in support of sustainable development. About a quarter of all population assistance from donor nations to developing countries is channelled through UNFPA. Since it began operations in 1969, the Fund has provided some $5.6 billion in assistance. REPRODUCTIVE HEALTH ESSENTIALS: SECURING THE SUPPLY Lot A, Eng_Text.cc 6/4/02 8:41 PM Page i ii Reliable access to contraceptives and other commodities is a fundamental requirement for repro- ductive health. Yet millions of women in developing countries go without these essentials, leaving them vulnerable to unwanted pregnancy, sexually transmitted infections including HIV/AIDS, and the risks of childbirth without basic equipment or medical supplies. The subject of reproductive health essentials is more complicated than it would seem. It is far more than a matter of “contraceptives for everybody”, although this is one aspect. Many different kinds of equipment and supplies are required for reproductive health, and a great deal must happen in order for these commodities to reach the people who need them, involving partnerships among UN agencies, national governments, nongovernmental organizations (NGOs) and others. There must be a system in place that makes equipment and supplies readily available—the right quantities of the right products in the right condition in the right place at the right time for the right price. A new global strategy for reproductive health commodity security (RHCS) provides a framework for such a system. It is described as “a call to action” and “a partnership for change”. It is the ral- lying point for numerous actions coordinated by the United Nations Population Fund (UNFPA) and carried out by partners around the world, each according to its particular area of ability or comparative advantage. For UNFPA, that advantage is long experience and a global presence. Commodities have been an integral part of UNFPA’s mission throughout its more than 30 years in the sexual and reproductive health field. During this time, the Fund has established an extensive network of partners—including donors who provide funds, officials in health departments, NGOs, manufacturers and researchers. UNFPA has an unparalleled comparative advantage in keeping track of global need and use and coordinating a worldwide system of supply and support. The success of this global strategy will mean a reduction in the amount of unmet need for family planning, fewer unwanted births, a decrease in the number of women who die of pregnancy- related causes and reduced HIV prevalence among young people. It will also mean reduced costs as a result of efficient management and accountability. All of this contributes to the global development agenda to reduce poverty and improve reproductive health. Today, the strategy is guiding efforts to achieve the ambitious goal set forth at the International Conference on Population and Development: universal access to reproductive health care by 2015. This goal, and all that it represents—such as safer childbirth, prevention of HIV/AIDS, respect for the rights of women and girls—will only be met when developing countries can count on a secure, high quality supply of reproductive health commodities. Thoraya A. Obaid UNFPA Executive Director Preface Lot A, Eng_Text.cc 6/4/02 8:41 PM Page ii I REPRODUCTIVE HEALTH ESSENTIALS: SECURING THE SUPPLY A Secure Supply of Commodities Shortages threaten life and health Pills that allow couples to plan for pregnancy. Soap, plastic sheets and razor blades to cut umbilical cords. Antiseptics and medical equipment for inserting intrauterine devices. Condoms for protection from HIV/AIDS. It’s a shopping list that saves lives. These essential items—contraceptives, condoms and medical equipment and supplies—are in high demand and short supply. Demand and population are increasing, yet contributions from donors and developing countries them- selves are not keeping pace. Each $1 million shortfall in commodity sup- port for contraceptives means an estimated: n 360,000 more unwanted pregnancies; n 150,000 additional induced abortions; n 800 maternal deaths; 1 Demand far exceeds supply, and inadequate systems of logistics and health care leave many people vulnerable to unwanted pregnancy, sexually transmitted infections including HIV/AIDS, and the risks of childbirth without basic equipment or medical supplies. (continued on page 3) Lot A, Eng_Text.cc 6/4/02 8:41 PM Page 1 Coordinated response improves supply in Nepal Nepal has a population of 24 million, nearly 90 per cent of which is rural, with high infant and maternal mortality rates and low use of reproductive health services. By 1993, weak logistics and fragmented reporting were making a bad situation worse. Stockouts and expired products further compromised the dangerously inadequate supply of contraceptives. In response, the Ministry of Health and UNFPA launched an emergency intervention. First, estimates of supply requirements were made for each of the country’s 75 districts, with help from 75 graduate students in demography. The students then packaged condoms, pills, injectables, IUDs, oral rehy- dration salts, safe delivery kits for traditional birth attendants, vitamin A and information materials for each district. A private shipping company was contracted to deliver these supplies by road, plane and helicopter and on the backs of porters. One student was assigned to each district to sign a receipt for the supplies, and to convene a meeting attended by one representative from every local health facility. The result: within 60 days, every health facility in the country had been supplied with several essential reproductive health commodities. Building on this effort, a system of supply from warehouse to storeroom to health facility was soon established. In 1998, this UNFPA-supported activity was taken over by the Government as its official commodity distribution programme. Coordination was the key to the successful response in Nepal, where a much-improved logistics system increased access to contra- ceptives and contributed to an increase in their use. Indeed, researchers documented a sharp increase in the use of contraceptives, which had remained very low for many years. Today, longer-term planning and more efficient management can be seen in the analysis of trends, the five-year forecasts of needs, cost projections, the identification of funding commitments by the Government and donors, and annual reviews. Coordination was especially effective among donors, whose commitment to an agreed-upon approach to forecasting needs was pivotal in establishing a more secure supply of commodities. 2 Lot A, Eng_Text.cc 6/4/02 8:41 PM Page 2 n 11,000 infant deaths; n 14,000 additional deaths of children under 5. Traditionally governments and individuals provided 60 per cent of contraceptive costs and donors 40 per cent. However, donor contributions have fallen in recent years to around 27 per cent. n The cost of quality contraceptives and condoms needed is projected to rise from $811 million to $1.8 billion between 2000 and 2015. The cost of services to deliver and provide these supplies is projected to increase from $4 billion to $9 billion over the same period—four times that of the products themselves. What is causing severe shortages? n More people of reproductive age. More than 1 billion people are between 15 and 24 years of age, entering their reproductive lives as the largest-ever generation of young people. n Increased demand for contraceptives. The number of contraceptive users is pro- jected to increase more than 40 per cent between 2000 and 2015, due to population growth and the success of family planning programmes. n Insufficient donor funding. Meeting demand requires a sustained commitment of adequate funding and close coordination among donors to avoid gaps or duplication. n Inadequate management capacity. A secure system of supply requires technical, financial and human resources that are sorely lacking in developing countries— including a full range of reproductive health information and services for effective delivery. ICPD sets plan of action Commodities are at the core of an ambitious goal: universal access to reproductive health care by 2015. To meet this goal, agreed to by 179 countries at the ICPD in 1994, developing countries need commodities they can count on. The ICPD 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”. The ICPD also called on governments to provide the methods and means to achieve reproductive health. With resources far below what is needed, the impact can easily be seen in the shortfalls affecting numerous countries. In 1999, intensified action was called for following the ICPD+5 (the five-year review of the ICPD process): “Governments should strive to ensure that by 2015 all primary health-care and family planning facilities are able to provide, directly or through referral, the widest available range of safe and effective family planning and contracep- tive methods; essential obstetric care; prevention and management of repro- ductive tract infections, including sex- ually transmitted diseases; and barrier methods, such as male and female 3 (continued from page 1) Lot A, Eng_Text.cc 6/4/02 8:41 PM Page 3 4 condoms and microbicides, if available, to prevent infection.”1 This directive came with measurable bench- marks: by 2005, 60 per cent of such facilities should be able to offer this range of services, and by 2010, 80 per cent of them should be able to offer such services. UNFPA’s role: to lead and coordinate The Fund’s involvement in commodities— especially contraceptives—is considered part of its contribution to the development process, and an integral part of its mission. From its inception, governments unable to obtain the volume of commodities required at a reasonable cost have requested UNFPA assistance. They continue to do so today. UNFPA is the largest international public sector supplier of contraceptives, condoms and other reproductive health supplies. n UNFPA purchases nearly $80 to $100 million in goods and services each year for many partners in development. The aim is to provide an adequate and secure supply and choice of quality contraceptives and other reproductive health commodities for every person who needs them. Such “security” requires not only the commodities themselves, but also the capacity to forecast, finance, procure and deliver them to the places they are needed at the times they are needed. UNFPA and its many partners endorse the slogan “No Product, No Programme”. Specific strengths enable UNFPA to fulfil its ICPD mandate to provide leadership in matters of sexual and reproductive health. The Fund’s comparative advantages include: n A strong global presence, with 110 country offices providing support to more than 140 countries; n Reproductive health/logistics management experts in nine regional teams; n A comprehensive system of forecasting, procurement and distribution that makes high-quality commodities readily available at low cost; n An extensive network of partnerships with governments, UN agencies, nongovern- mental organizations (NGOs), technical agencies and the private sector; n More than 30 years of programme experi- ence addressing sensitive issues in the area of sexual and reproductive health. By drawing on the comparative advantages of each partner, the collective response to supply challenges can be segmented—making it possible for UNFPA to better coordinate and monitor the response. Monitoring in particular contributes to accountability and effectiveness. 1 Paragraph 53, Proposals for key actions for the further implementation of the Programme of Action of the International Conference on Population and Development (E/CN.9/1999/PC/4), adopted by the twenty-first special session of the UN General Assembly in July 1999. Lot A, Eng_Text.cc 6/4/02 8:41 PM Page 4 n Global leadership by UNFPA in helping countries plan for their needs and establish a secure and steady flow of commodities; n Advocacy to build a global political commitment to supplying high-quality, affordable commodities and services; n Building national capacity to forecast, finance, procure and deliver reliable supplies and services over the long term to all who need them; n Improved sustainability, through stable financing that ensures an adequate and reliable flow of materials; n Coordination among partners to simplify procedures, minimize costs and maximize efficiency, with each partner acting accord- ing to its comparative advantage; Partnership and cooperation The challenges are too great for any one agency, and few countries have the capacity to sustain a steady and secure supply. The quest for reproductive health commodity security (RHCS) is a group effort at every level—from global support by UN agencies, to developing country governments striving to improve their national systems, to NGOs, bilateral donors, private sector supporters, contractors, suppliers and so on. UNFPA is positioned as a partner with leadership responsibilities. Cooperation, as in so many development efforts, is the key to success. A global strategy for RHCS Working together, partners at the global, national and local levels are taking action to establish secure, efficient and reliable systems to supply and deliver reproductive health commodities. This requires: 5 Mexican doctor explains different contraceptive options. (continued on page 8) M ar k Ed w ar ds /S ti ll Pi ct ur es Lot A, Eng_Text.cc 6/4/02 8:41 PM Page 5 Categories and examples of reproductive health commodities Reproductive health commodities are generally made available at the country level through an established network of manufacturers, vendors, transport and storage warehouses. UNFPA’s suppliers also maintain a stock of pre-packaged equipment and supplies for use in emergencies. Items are sometimes grouped into “kits” for more efficient organization and ordering. 1 Basic family planning commodities a) Contraceptives: male and female con- doms, diaphragms, intrauterine devices, contraceptive pills, injectables, implants and other hormonal contraceptives, and spermicidal products. b) Family planning commodities: speculums, forceps, scissors, scalpels, sutures and other items for insertion and removal of intrauter- ine devices (IUDs), vasectomy, subdermal implant insertion, mini-laparatomy, laparoscopy and tubal ligation. 2 Maternal and neonatal healthcare commodities a) General equipment: diagnostic kits, preg- nancy testing kits, rapid plasma reagin test- ing sets, HIV test sets, drugs and vaccines. b) Antenatal care: blood pressure testers, stethoscopes, gloves, tape measures, scales, thermometers, tourniquets, disinfectors, stoves, blood and urine test sets, safety and burn boxes for used syringes, nutrients, vaccines and other items. c) Delivery and post-partum care Delivery kit for use at home: bar of soap, plastic sheet (1 sq. metre), razor blade, string for umbilical cord, pictorial instruction sheet. Professional midwife kit: disinfector for boiling instruments, kidney basins, bowl, apron, catheters, plastic sheet, surgical gloves, mucus extractor, thermometers, scrub brush, cotton wool, gauze, nail clipper, scale, sutures, needles, umbilical tape, foil infant wrap, towel, blood pressure tester, stethoscope, forceps, scissors, syringes. Kits for use at primary health care facilities: Equipment and supplies as above, sterilizing equipment, lighting, delivery set, suture set, disposable supplies (as in midwife kit), drugs (antenatal care plus antiseptics, anaesthetics, feeding solutions) plus commodities for suturing vaginal and cervical tears, manage- ment of eclampsia, management of post- partum haemorrhage and retained placenta, 6 Lot A, Eng_Text.cc 6/4/02 8:42 PM Page 6 UNFPA commodity distribution in a typical year 8% services 5% vehicles 4% miscellaneous 1% audiovisuals1% pharmaceuticals 3% publishing/printing 5% office equipment and electronic data processing 8% medical equipment 65% contraceptives blood transfusion, and management of the complications of abortion. 3 Commodities for the referral level For Caesarean sections, resuscitation of mothers and infants, intravenous and anti- biotic treatment for the complications of pregnancy and delivery, and for sexually transmitted infections. Kits include operating theatre and ward equipment and instruments, suction apparatus, resuscitation equipment, anaesthetic equipment, anatomical teaching models and drugs. 4 Commodities Related to STIsand HIV/AIDS Items for the prevention of sexually transmitted infections (STIs) and diseases including HIV/AIDS, and for the treatment of STIs, include male and female condoms, diagnostic testing equipment, plasma reagin test sets, speculums, syringes, needles, cotton wool, gloves, safe sex leaflets, posters and drugs. Figure 1 7 Lot A, Eng_Text.cc 6/4/02 8:42 PM Page 7 8 n Improved monitoring to better track and plan for the needs in each country; n Improved accountability to support good governance and help each partner carry out its work effectively and efficiently as part of an overall system. Taken together, these actions form the global strategy for RHCS that now guides the work of UNFPA and its partners. This strategy was jointly developed by UNFPA and partners including the Program for Appropriate Technology in Health. Actions at the global level focus on: advocacy, resource mobilization for global and in-country efforts, technical cooperation and coordina- tion. Actions at the country level, where most RHCS activities take place, focus on: building national capacity, advocacy, improved sustainability and coordination.2 Such a coordinated effort will save lives— as well as valuable human and financial resources. Reproductive health commodity security (RHCS) = A secure supply and choice of quality contraceptives and other reproductive health commodities to meet every person’s needs at the right time and in the right place. (continued from page 5) 2 See the strategy outline at the back of this publication. Also see two UNFPA booklets published in April 2001: Reproductive Health Commodity Security: Partnerships for Change: A Global Call to Action and Reproductive Health Commodity Security: Partnerships for Change: The UNFPA Strategy. Lot A, Eng_Text.cc 6/4/02 8:42 PM Page 8 Family planning Better reproductive health depends on being able to exercise the right to decide freely and responsibly the number and spacing of chil- dren. Commodities, especially contraceptives, are essential in helping to make this right a reality. Yet unmet need, inadequate supplies and increasing demand pose serious chal- lenges to family planning programmes. n More than 350 million women do not have access to a choice of safe and effective con- traceptive methods. n In addition, 120 million women would currently be using family planning methods if more accurate information and affordable services were easily available, and if husbands, extended families and the community were more supportive. Family planning helps individuals and couples avoid unwanted pregnancies, bring about wanted births, and determine the timing of pregnancies and the number of children in their families. It also slows the rapid popula- tion growth that contributes to poverty and environmental degradation. II REPRODUCTIVE HEALTH ESSENTIALS: SECURING THE SUPPLY Contraceptives for Family Planning 9 By helping women avoid unwanted and poorly timed pregnancies, family planning can save the lives of millions of women and infants each year. Most developing countries, especially the poorest in Africa, will continue to rely on contraceptives supplied by international donors for the foreseeable future. Lot A, Eng_Text.cc 6/4/02 8:42 PM Page 9 10 Principle 8 of the ICPD Programme of Action states: “All couples and individuals have the basic right to decide freely and responsibly the number and spacing of their children and to have the information, educa- tion and means to do so.” The Programme of Action also stipulates that family planning programmes must “make available a full range of safe and effective methods”. Contraceptive commodities for family planning include combined oestrogen- progesterone oral contraceptive pills, progesterone-only pills (mini-pills), IUDs, Norplant, injectables, male and female condoms, diaphragms, sterilization supplies, spermicidal products, emergency contracep- tion, and condoms for the prevention of STIs including HIV/AIDS. Increasing contraceptive use The quality of family planning programmes is, to a large extent, related to the level and continuity of contraceptive use—which is one more reason why a steady and reliable supply of reproductive health commodities is so important. Demand for contraceptives exceeds supplies in many countries and is increasing dramatically. n Since the mid-1960s, contraceptive use in developing countries has increased from 10 per cent of couples to almost 60 per cent, with some 9 out of 10 users relying on modern methods. n The population of reproductive-age couples in developing countries is expected to increase by 23 per cent between 2000 and 2015. Many will be more aware of reproductive health services than their parents were. 2000 2015 525 525 650 742 92 millionadditional users due to demand increase Current use 125 million additional users due to population growth Sources: United Nations Population Division, World Population Prospects: The 1998 Revision; and UNFPA draft report. Total number of women 15-49: 1.26 billion Total number of women 15-49: 1.55 billion C on tr ac ep tiv e us er s C on tr ac ep tiv e us er s Figure 2 Family planning needs will grow as both population and demand increase Projected increase in contraceptive users, 2000-2015 (millions of women aged 15-49, developing countries) Lot A, Eng_Text.cc 6/4/02 8:42 PM Page 10 Conference inspires action in Indonesia Successful family planning programmes have contributed to relatively high rates of contra- ceptive use in Indonesia, which is, with a population of 210 million, the fourth most populous country in the world. But an eco- nomic crisis starting in 1997 threatened the Government’s ability to meet the demand for contraceptives. Clinics ran out or were in short supply of contraceptives by early 1998. UNFPA and the United States Agency for International Development (USAID) provided emergency relief and launched fund-raising appeals. Since then, UNFPA and its partners have explored private sector initiatives while encouraging more accurate forecasting and directing subsidized contraceptives to the people most in need. In May 2001, a conference in Istanbul galva- nized participants from Indonesia to return home and take immediate action. The Interim Working Group, a consortium of organizations committed to RHCS, organized the event. As a result of the meeting, government represen- tatives with UNFPA and its donor partners established a Working Group on Reproductive Health Commodity Security. One of the issues discussed at the Group’s regular meeting was the need for data on existing supplies and those in the pipeline. The group also devel- oped an advocacy strategy for lobbying the national Government for increased support and identified members of the Group to speak to parliamentary committees. While meetings do not always result in direct action, events such as the Istanbul conference emphasize that the new global strategy for reproductive health commodity security is already making a difference. n The number of contraceptive users is pro- jected to increase by more than 40 per cent between 2000 and 2015 as a consequence of population growth and of an increase in the proportion of people who use contraception. Providing an appropriate variety of methods, or the right “method mix”, is an important aspect of contraceptive supply. Supporting a choice of methods is not only required to fulfil ICPD goals. Individuals have different needs and preferences when it comes to family planning; therefore methods of contraception differ greatly in order to meet the individual needs and circumstances of users. In 1999, the “key actions” of ICPD+5 instructed governments to provide “the widest available range of safe and effective family planning and contraceptive methods”. While contraceptive use is increasing, in many places access is still limited by social and cultural traditions, religious restrictions and taboos that prevent women in particular from making informed choices about their reproductive lives. To counter these obstacles, UNFPA supports women’s empowerment and encourages countries to recognize women’s rights to education, reproductive health and economic opportunity. Safe motherhood Closely related to family planning are efforts to reduce high rates of maternal mortality— from educating communities on safe mother- hood to training health care providers in emergency obstetrics and equipping health facilities with proper supplies. n More than 500,000 women die unnecessarily each year from complications of pregnancy 11 Lot A, Eng_Text.cc 6/4/02 8:42 PM Page 11 12 Commodities a constraint to family planning in Lao PDR The Lao People’s Democratic Republic has a high rate of population growth, 2.3 per cent annually. Fully 80 per cent of the population of 5.4 million lives in rural areas. On aver- age, each Lao woman has 4.8 children. This rises to 5.3 children on average for women in rural areas. Sixty-two per cent of the population is under 25 years of age. Family planning services are relatively new in the Lao PDR, with demand growing across the country. The country is making steady progress towards its national population and development goals. Nevertheless, the gains are uneven. About 40 per cent of Lao couples who would like to use such services currently do not have access to them. In September 2001, the first-ever Conference on Reproductive Health Commodities and Logistics Requirements for the Lao PDR (2002-2010) examined funding and other constraints to reproductive health services. A press release from the conference warned, “Among the constraints is the fact that from next year, 2002, neither the Ministry of Health nor UNFPA alone can assure the level of contraceptive commodities required by the national programme.” The Government would like to increase family planning choices. However, the estimated cost of contraceptive supplies needed for the next five years is $6 million—much more than is available. This would provide for supplies including oral contraceptives, injectables, condoms for the prevention of unwanted pregnancy and HIV infection, and IUDs. Additional funds are needed for other methods of family planning such as steriliza- tion and to strengthen the service delivery system. Lot A, Eng_Text.cc 6/4/02 8:42 PM Page 12 the treatment of STIs. In 2001, the Netherlands pledged another $15 million and Canada added $588,000 to procure contra- ceptives, including condoms, for developing countries with the greatest needs. While last-minute contributions have helped, nothing compares to the value of steady fund- ing as a foundation for long-term planning. In the absence of large increases in financial support by donors and developing country governments, the world can expect to see a rise in death and illness related to poor reproductive health. and childbirth, almost all in developing countries, where access to services and vital equipment and supplies could save women’s lives. n Up to a third of maternal death (mortality) and injury and infection (morbidity) could be avoided if all women had access to a range of modern, safe and effective family planning services that would enable them to avoid unwanted pregnancy. The need for steady funding Neglecting family planning has enormous human, social and economic costs. Among the consequences of such neglect are unwanted pregnancies, unsafe abortions, pregnancies spaced too close together, dangerous pregnancies in women who are too old or too young, and the transmission of STIs including HIV/AIDS. Donors have stepped in when shortfalls in funding have threatened supplies. Three donor countries pledged $78.4 million as an emergency measure in 2000 to help cover a shortfall in contraceptive commodities, especially condoms: n The United Kingdom pledged $36.7 million; n The Netherlands contributed $40.8 million; n Canada pledged $846,000. The funds were used to purchase male and female condoms (a priority in the prevention of HIV/AIDS), other contraceptives, obstetric and gynaecological equipment, and drugs for 13 Participant in community-based condom distribution programme in Jamaica. E. D ui ge na n- C hr is ti an A id /S ti ll Pi ct ur es Lot A, Eng_Text.cc 6/4/02 8:42 PM Page 13 14 Figure 3 Trend of reported donor support for contraceptives compared with estimated requirements (in millions of dollars) 800 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 700 600 500 400 300 200 100 0 Donor actual support Total estimated Contraceptive CostsEstimated donor support at 40.9% 154130.8143.2137.5 172.2 143.9 118.4116.9 82.8 702 657 614 572 529 480 437 351 308 265 222 394 287.1268.7 251.1233.9216.4 196.3 178.7 Source: “Global Estimates of Contraceptive Commodities and Condoms for STI/HIV Prevention 2000-2015” (in press), UNFPA, 2002. Commodity costs for family planning and HIV prevention Costs are increasing, yet donor support is decreasing. In the early 1990s, donors provided an average of 41 per cent (1992- 1996) of the amount required each year for contraceptive commodities. That level of support fell to only 24.7 per cent in 1999. Specifically, contributions peaked in 1996 at $172.2 million, dropping to $130.8 million in 1999. Contributions in 2000 totalled $154 million. UNFPA estimates that between 2000 and 2015, commodity costs for contraceptives and condoms for STI/HIV prevention will increase as follows: n From $572 million to $1.25 billion for family planning contraceptives; n From $239 million to $557 million for con- doms to prevent STIs including HIV/AIDS; n In total, from $811 million to over $1.8 billion for family planning and HIV/AIDS commodities combined. Lot A, Eng_Text.cc 6/4/02 8:42 PM Page 14 Preventing infection The dual protection afforded by condoms— preventing both unwanted pregnancy and sexually transmitted infections (STIs) includ- ing HIV/AIDS—places condoms high on the list of commodities requested by countries. Access to male and female condoms is a matter of life and death in communities affected by HIV/AIDS. At the United Nations General Assembly special session on HIV/AIDS in June 2001, all member states called for “expanded access to essential commodities”. The gap between what is needed and what is available is so large that it can be termed a crisis. The Joint United Nations Programme on HIV/AIDS (UNAIDS) reports a relentless pace of infection: n 5 million people were newly infected with HIV/AIDS in 2001—15,000 new infections per day; III REPRODUCTIVE HEALTH ESSENTIALS: SECURING THE SUPPLY 15 “The most alarming consequences of the financial shortfall, where a condom crisis exists today, are in the area of HIV/AIDS prevention. In all of the affected countries, the supply of condoms is far short of what is needed.” — Thoraya A. Obaid, UNFPA Executive Director The Condom Crisis and HIV/AIDS Prevention Lot A, Eng_Text.cc 6/4/02 8:42 PM Page 15 n More than half of new infections in 2001 occurred in young people aged 15 to 24; n More than 330 million people acquire an STI each year, making them up to 10 times more vulnerable to HIV infection. Consistent and correct use of condoms can help slow the epidemic, providing millions of people with a simple and effective means to protect themselves and their sexual partners from infection. Access to condoms is crucial in developing countries, where 95 per cent of all people infected with HIV live. Africa, which has been hit especially hard by HIV/AIDS, depends on donors more than any other region. If donors were to strive to meet 100 per cent of the condom requirements in Africa, they would need to double their 1999 level of support. A figure that illustrates the crisis: in sub-Saharan Africa, current levels of donor support would make available an aver- age of three condoms for every man per year. Any effective prevention strategy depends on the widespread availability of male and female condoms, combined with efforts to reduce risk-taking behaviour. The ICPD Programme of Action (paragraphs 7.31-7.33) recommended prevention, training, education and coun- selling and “the promotion and reliable supply of high-quality condoms”. As part of its RHCS activities, UNFPA sup- ports the supply of male and female condoms, HIV/STI diagnostic testing kits, speculums, syringes, needles, cotton wool, gloves, safe sex leaflets, posters and drugs, among other items. Such supplies and equipment aid in efforts to prevent STIs including HIV/AIDS, especially among young people and pregnant women, through comprehensive programmes for prevention. HIV/AIDS and young people While more than half of new infections are among young people, many lack the information and services they need to protect themselves—including access to condoms. To prevent HIV/AIDS among sexually active youth, UNFPA supports programmes that make condoms available and affordable to at-risk young people aged 15 to 24. As a result of the five-year review of the ICPD process, new goals were set: 16 Cuban teacher shows how to use a condom. Young people need access to reproductive health information and services. M ar k Ed w ar ds /S ti ll Pi ct ur es Lot A, Eng_Text.cc 6/4/02 8:42 PM Page 16 n By 2005 at least 90 per cent of young people aged 15 to 24, and 95 per cent by 2010, should have access to the means to prevent and control HIV/AIDS; n HIV infection rates in persons 15 to 24 years of age should be reduced by 25 per cent in the most-affected countries by 2005, and by 25 per cent globally by 2010. To meet these global goals, UNFPA works with partners as a cosponsor of UNAIDS, a group of UN agencies that was created in 1996 to strengthen and better coordinate the UN system’s response to HIV/AIDS.3 The group mobilizes international action and resources and shares best practices worldwide. Although most people become sexually active between 15 and 24 years of age, cultural and political issues sometimes make the provision of condoms to young people a sensitive topic. UNFPA has addressed such issues in many ways during decades of work in sexual and reproductive health, always taking into account user needs and perspectives and responding within the unique sociocultural context of different countries. Youth-friendly services are being integrated throughout UNFPA-supported activities. Condom programming The prevention of STIs, especially among young people, has become an even higher priority since the advent of HIV/AIDS. One fundamental aspect of STI and HIV preven- tion is a strategic approach known as condom programming. As a sub-component of RHCS, it combines various activities into a coherent framework—elements including condom promotion, communication for behaviour change, market research, the logistics of sup- ply, and forms of support such as advocacy and coordinated management. Depending on local conditions, condom programming might include social marketing, community-based distribution and campaigns to promote the value of condoms for dual protection against infections and unwanted pregnancy. It is driven by demand and requires a well-coordinated approach by all of the partners involved. Condom programming is one aspect of an overall prevention strategy that also supports interventions that promote safe sexual behav- iour among young people (including absti- nence and delaying sexual activity) and that help prevent HIV infection among pregnant women and its transmission to children and to HIV-negative partners. Female condoms The female condom is the only currently available method that women can initiate, and in some ways control, which provides protec- tion from both unwanted pregnancy and STIs including HIV/AIDS. An innovative public- private partnership brokered by UNAIDS has made more than 19 million female condoms available at reduced cost in over 70 countries in Africa, Asia and Latin America. It is gain- ing acceptance as an important choice for women and is included in UNFPA supplies of reproductive health commodities. 17 3 UNAIDS cosponsors include UNICEF, UNDP, UNFPA, UNDCP, ILO, UNESCO, WHO and the World Bank. Lot A, Eng_Text.cc 6/4/02 8:42 PM Page 17 obstacle to reproductive health in emergen- cies. Transportation routes may be cut off, distribution networks dissolved and health facilities destroyed. Existing supplies may fall far short of demand when large numbers of people move into a safer location. Supplies, equipment and medicine are orga- nized and stored by UNFPA for immediate distribution when an earthquake, flood, violent conflict or other crisis arises. n In 2000, UNFPA dispatched 35 shipments of emergency reproductive health equip- ment and supplies to 20 countries and territories; IV REPRODUCTIVE HEALTH ESSENTIALS: SECURING THE SUPPLY When Disasters and Conflicts Disrupt Supplies Providing emergency supplies Crisis conditions caused by conflicts and nat- ural disasters are present in as many as 40 per cent of the most needy countries assisted by UNFPA, creating demand for reproductive health services in places where distribution and health care systems have broken down. UNFPA works closely with its humanitarian relief partners to support early and effective action to meet the reproductive health needs of refugees, internally displaced persons and others caught in crisis situations. Supply shortages compound health risks in already dangerous situations and are a major “UNFPA recognizes that all refugees and persons in emergency situations have the same vital human rights, including the right to reproductive health, as people in any community.” — Thoraya A. Obaid, UNFPA Executive Director 18 Lot A, Eng_Text.cc 6/4/02 8:42 PM Page 18 n A rapid-response fund enables UNFPA to mount a quick response to emergencies, especially in the initial stages. Supplies are packaged in 12 different emergency reproductive health kits. Once an emergency situation stabilizes, the procurement of reproductive health materials becomes a regular part of a more comprehensive health care programme. Condom distribution in emergencies Free condoms are among the first reproductive health supplies to reach people caught in a crisis situation. They are in demand to prevent both unwanted pregnancy and STIs including HIV/AIDS, and are the first step towards restoring family planning services. Once a situation stabilizes, condom distribution and Commodities in crisis situations UNFPA launched its largest-ever humanitarian operation in September 2001 when hundreds of thousands of Afghans fled their homes to escape armed conflict. Thousands of preg- nant women were among the civilians massed along the country’s borders with Pakistan and Iran. UNFPA pre-positioned emergency relief supplies including clean delivery supplies, support for border-area hospitals receiving referrals with pregnancy and childbirth complications, and counselling for victims of trauma. The initial operation was supported with donor contributions from Italy, Luxembourg, the Netherlands, Norway and the United States. Even before the exodus, maternal and infant mortality in Afghanistan were among the highest in the world. Three earthquakes struck El Salvador in early 2001, killing thousands, destroying hospitals and leaving an estimated 1.2 million people without shelter. UNFPA sent supplies, equip- ment and medicine so that health workers in makeshift clinics could provide urgently needed care to pregnant women and new mothers. In addition to items required to perform clean and safe deliveries, UNFPA supplied health centre delivery equipment to stabilize convulsions and bleeding and, for hospitals or clinics handling referred cases, instruments for Caesarean sections, resuscitation and other complications. The supplies also included tools for HIV prevention and safe blood transfusion. When thousands fled Kosovo for Albania and Macedonia in 1999, UNFPA directed support to NGOs and national health sys- tems so they could better respond to the needs of the refugees. UNFPA also sent equipment and supplies to help make childbirth safer and to treat victims of rape. Antibiotics, sutures and other supplies pro- vided material support while training for counsellors addressed psychosocial needs. Two earthquakes struck Turkey in 1999, the massive first quake killing more than 17,000 people and destroying the homes of 400,000. UNFPA immediately sent emergency reproductive health supplies and equipment and participated in a rapid needs assessment. Ongoing efforts continued to rebuild local health services. 19 Lot A, Eng_Text.cc 6/4/02 8:42 PM Page 19 20 n Equipment and supplies for assisted deliv- eries at a health facility also include stetho- scopes, thermometers, plastic aprons, latex gloves, syringes, sutures, sterile gauze pads, an intravenous infusion set, cotton wool, burn boxes for safe needle disposal, amoxi- cillin and other drugs. n Equipment and supplies are also provided for resuscitation, suturing tears, disinfec- tion and surgery. Comprehensive services for antenatal, delivery, post-partum care and breastfeeding support are organized as soon as the worst of the crisis is past. Planning ahead for crisis response Requests for help in emergency situations are expected to increase. Given the events of recent decades, the world is likely to see large and even increasing populations of refugees, returnees, internally displaced persons and others affected by emergency situations. Young people will be among the most vulner- able, especially when the risk-taking behav- iour common in displaced youth exposes them to HIV infection and unwanted pregnancy. With an expanding capacity for emergency response, UNFPA works closely with increas- ingly well-coordinated partnerships. Even when UNFPA plays a limited role, the Fund contributes its expertise in reproductive health, which is of particular use when such issues are complicated and sensitive and are being overlooked. Ultimately, the aim of any intervention is to support the restoration or creation of national systems for reproductive health services and commodities. coverage need to be coordinated among government suppliers, the private sector and possibly social marketing programmes. UNFPA provides condoms—male and female—along with many other kinds of reproductive health equipment and supplies. This helps to fulfil the Minimum Initial Service Package that is administered in co- operation with partner agencies and that specifically calls for condom distribution in emergencies. The package was developed by the Inter-Agency Working Group for Reproductive Health in Refugee Situations, of which UNFPA is a founding member. Contraceptives for family planning Access to a secure supply of contraceptives is difficult enough in normal times in many countries; when disaster strikes, couples may not be able to obtain the supplies they need. This raises the risk of pregnancy that is unwanted, poorly timed or dangerous. Once an emergency situation is stabilized, UNFPA conducts rapid assessments to determine family planning needs, and supports efforts to make a wide range of modern methods available so that couples can maintain consistent and cor- rect use of the contraceptive of their choice. Supplies for safe motherhood In situations of conflict and natural disaster, UNFPA sends emergency reproductive health equipment and supplies that help make child- birth safer. n Supplies for clean home deliveries include soap, plastic sheeting, razor blades, string, gloves and pictorial instruction sheets. Lot A, Eng_Text.cc 6/4/02 8:42 PM Page 20 The “six rights” The UNFPA approach to reproductive health commodity security can be summarized in a simple statement: the right quantities of the right products in the right condition in the right place at the right time for the right price. Below is a breakdown of this statement. 1. The right quantities UNFPA supports needs assessment and fore- casting to predict the quantity and type of commodity needed and when it will be needed. Drawing upon its unique database on donor support for contraceptives and logistics, UNFPA can help forecast potential shortfalls in reproductive health commodities, including the supply of condoms. 2. Of the right products Needs are different in every country. With good specifications based on solid market research, UNFPA helps ensure that the com- modities provided are the ones that people want and need. Research enables UNFPA and its partners to understand the use of commodities and to identify opportunities to increase demand. 3. In the right condition Quality assurance, storage and warehousing are fundamental aspects of RHCS, ensuring V REPRODUCTIVE HEALTH ESSENTIALS: SECURING THE SUPPLY How UNFPA Advances RHCS 21 The UNFPA leadership and coordination role is mandated by ICPD and has been endorsed by governments, donors and other partners. UNFPA has an unparalleled comparative advantage in tracking global need and use and coordinating a worldwide system of supply and support. (continued on page 24) Lot A, Eng_Text.cc 6/4/02 8:42 PM Page 21 Examples of UNFPA-supported RHCS activities Raising awareness about RHCS A series of technical and regional meetings has been scheduled with governments, key donors, NGOs and other partners to discuss the demand for reproductive health com- modities, planning, procurement and pro- gramming. In May 2001, participants from 10 countries at a conference in Istanbul, Turkey, agreed that concrete and immediate actions are needed to meet the challenge of securing reproductive health supplies. One objective of the conference was to encour- age participants to adopt the global RHCS strategy and to use it as a basis for develop- ing complementary strategies. Participants pledged to take action at national and global levels in the areas of advocacy, national capacity building, financing and donor coordination. They noted the need for UNFPA leadership and the urgent need to build awareness of and generate action on this crisis. It was recommended that response strategies be country-specific, designed and led by governments with the involvement of civil society, and flexibly supported by donors. Strategies and budgets should give high priority to preventing unwanted preg- nancies and STIs including HIV/AIDS. They concluded that effective implementation demands clearly defined roles, responsibilities and accountability for all partners. This conference was organized by the Interim Working Group on Reproductive Health Commodity Security with funds from the Bill & Melinda Gates Foundation. Additional conferences are planned in Latin America, Africa, Central and Eastern Europe and Central Asia. Private Sector Initiative Close cooperation with the private sector can provide substantial benefits to public sector efforts to supply reproductive health commodities, especially contraceptives, in a cost-effective manner. The involvement of commercial interests can make products more affordable, which means that fewer people depend on subsidized supplies and the public sector is able to direct its limited resources to the people most in need. The commercial sector is expected to reduce prices in exchange for a bigger share of the market and certain benefits from the govern- ment such as reduced tariffs, easier import policies and free airtime for campaigns. The UNFPA Private Sector Initiative was pilot-tested in nine countries starting in 1998 and largely concluding in 2001. 22 Lot A, Eng_Text.cc 6/4/02 8:42 PM Page 22 In these and other countries, public-private collaboration may result in a “win-win” situation that ultimately improves the sustainability of reproductive health pro- grammes and brings about greater security in the supply of reproductive health commodities. Social marketing Social marketing may take many forms as it tries to reach different target audiences. In the following examples, marketing tech- niques promote the use of condoms among sexually active young people as protection from unwanted pregnancy and HIV infec- tion. In Albania, trained peer educators reached more than 1,500 young men and women aged 15 to 24 as part of a UNFPA- supported project in 2000 that also sold 1.3 million condoms. In China, students marked World AIDS Day with a concert in Beijing featuring famous Chinese pop-stars while, in a separate project, a high-quality condom brand was developed and marketed in more than 300 outlets in Beijing and Shanghai, including shops, drugstores, clinics, news- paper stands, cigarette stores, and vending machines located on university campuses. In Sri Lanka, teachers, midwives and mem- bers of youth clubs were selected to act as mediators to help create a more youth- friendly environment for young people seeking access to counselling and repro- ductive health services. In India, with a population of 1 billion, greater private sector involvement is being sought in order to increase the rate of con- traceptive use (CPR) from 46.5 per cent in 1998 to 60 per cent by 2011. The UNFPA India office helped form working groups with representatives from the Government, manu- facturers, donors and social marketing orga- nizations. The groups have recommended ways to rationalize government financing, increase contraceptive access and quality, and launch a national promotional campaign for short-term methods. In Egypt, a promising market for hormonal contraceptives (both pills and injectables) has attracted private sector interest in an expanded role. A working group of govern- mental and private sector representatives identified areas for action including a broader method mix; better pricing; demand creation for products through information, education and communication campaigns; and a new national market segmentation study to form the basis for future activities. In the Philippines, the rate of use of modern contraceptives is low, only 28 per cent. A series of workshops was planned to implement initiatives that involved the private sector as well as the public sector in logistics and supply drawing on a USAID-funded project in Commercial Market Strategies. UNFPA appointed a programme officer to manage the coordination of private and public sector collaboration in which UNFPA serves as a “broker” in negotiations between the Government and commercial interests. 23 Lot A, Eng_Text.cc 6/4/02 8:42 PM Page 23 that the commodities people count on are of good quality with maximum shelf life. 4. In the right place On a daily basis, UNFPA helps national programmes ensure that supplies move from manufacturer to warehouse to distributor to individual user. Distribution systems must be reliable, efficient and able to reach people in distant locations and under difficult conditions. 5. At the right time Lead times, consumption patterns and trans- portation determine whether supplies are available when they are needed. Long-term planning offers a measure of control, antici- pating needs far in advance. For example, suppliers need up to six months to produce and deliver commodities, market researchers need time to gather data, and funding sources need time to budget for future deliveries. To increase speed and efficiency, UNFPA has expanded its own capacity and taken the lead in coordinating partners at all steps of the process. 6. For the right price Costs are kept down through good planning and coordination, competitive bidding, inno- vative attempts to rationalize expenses, track- ing, monitoring and accountability. Also, as the largest international public sector procur- er of these reproductive health commodities, UNFPA is able to purchase in bulk to keep prices down. UNFPA’s Procurement Unit has established a worldwide network of suppliers and offers high-quality products at the most competitive pricing, while at the same time supporting emerging industries. For those countries able to purchase their own supplies, the aim is to provide access to the lowest possible prices. 24 (continued from page 21) Poster in Burkina Faso encourages the use of condoms for HIV/AIDS prevention. M ar k Ed w ar ds /S ti ll Pi ct ur es Lot A, Eng_Text.cc 6/4/02 8:42 PM Page 24 Expanding organizational capacity A well-established internal structure and expanding capacity enable UNFPA to function effectively. Complementing this structure are ongoing activities including technical workshops where UNFPA staff and international experts help national counter- parts develop strategies for specific countries. Ultimately, the effectiveness of these activities depends on the many valuable partnerships forged at the global, national and local levels. UNFPA is enhancing its capacity at head- quarters and in developing countries by: n Adding staff and resources to its Commodity Management and Procurement Units; n Expanding its reproductive health commodities database; n Organizing team-building exercises for nationals, UNFPA country offices and the Country Technical Services Teams (CSTs); n Developing technical and operational guidelines to ensure that RHCS is integrated into all UNFPA country programmes; n Organizing a round of meetings with partners to introduce and implement the RHCS strategy. Activities to advance RHCS are carried out within the UNFPA structure as follows: UNFPA country offices: The most important commodity work takes place at the country level, in the overall context of UNFPA sup- port to reproductive health programmes (including services focusing on family plan- ning, maternal care and the prevention of sexually transmitted infections including HIV/AIDS). As always, attention is given to quality of care and cultural sensitivity. UNFPA offices in 110 countries are integrat- ing RHCS strategies into their ongoing pro- grammes. This presence in countries enables UNFPA to stay in touch with the evolving needs and priorities of people who live there. UNFPA works with country counterparts to develop strategies to strengthen population policies, mobilize resources, build national capacity, coordinate work with partners and achieve long-term sustainability. Country Technical Services Teams: Nine regional, multi-disciplinary teams include advisers in the logistics and management of reproductive health commodities, reproduc- tive and sexual health, gender, advocacy, HIV/AIDS and other technical disciplines. They are based in Addis Ababa, Amman, Bangkok, Bratislava, Dakar, Harare, Kathmandu, Mexico City and Suva. Commodity Management Unit: For more than 10 years, the Commodity Management Unit has conducted in-depth studies of contraceptive requirements and logistics management needs in more than 20 countries. Originally known as the Global Initiative, the Unit has issued reports to guide national policies and programmes on topics such as strategies for financing; policy issues; short- term and long-term needs; service delivery roles for public, private and NGO bodies; and the impact of HIV/AIDS. Beginning in 1999, the Unit expanded its focus to embrace all aspects of reproductive health commodity security including advocacy and resource mobilization, coordination and sustainability. UNFPA has maintained a database since 1990 on the contraceptive commodities provided 25 Lot A, Eng_Text.cc 6/4/02 8:42 PM Page 25 by donors, making it possible to identify potential shortfalls and track trends in each country. The database will be expanded in 2002 to include the “demand” dimension. In addition, a new database on technical resources such as institutions, training materials and publications is being developed. n Drawing on the database is an annual publication, Donor Support for Contraceptives and Logistics, which helps donor agencies plan their responses to country needs. Procurement Unit: UNFPA specializes in the supply of contraceptives and other reproductive health commodities and offers a complete “best value” procurement service. For purchases in support of the public sector, UNFPA offers a number of advantages: com- petitive pricing, low overhead costs, fixed fees, impartial expert advice, a transparent procurement process, accelerated delivery, assured quality, products delivered with maximum shelf-life, long-term partnerships with suppliers and pre-packaged equipment and supplies for emergency situations. Global Contraceptive Commodity Programme: This revolving fund helps UNFPA maintain buffer stocks of essential commodities to permit quick responses to urgent requests from countries in emergency situations. It is managed by the Commodity Management Unit in cooperation with the Procurement Unit. 26 Lot A, Eng_Text.cc 6/4/02 8:42 PM Page 26 Adopting the global strategy Commodities are an important part of UNFPA support for reproductive health, required in nearly every area of program- ming. An inadequate or erratic supply can slow or set back progress towards develop- ment goals. At a time of growing demand and declining resources, the challenges are many to establishing a secure supply of contracep- tives, condoms and other reproductive health commodities. To bring about a more secure supply in the future, UNFPA advocates the adoption by all partners of the global strategy for RHCS.4 Building commitment to RHCS In November 2001, UNFPA organized the first of a series of regional workshops to introduce and implement the RHCS global strategy in country programmes. The Consultative Meeting on Reproductive Health Commodity Security was held in Mombasa, Kenya. Fourteen sub-Saharan countries were represented by 40 participants from government ministries, UN and technical agencies and NGOs. Government-led working groups were proposed for each country to continue discussions on how to strengthen advocacy, resource mobilization, national REPRODUCTIVE HEALTH ESSENTIALS: SECURING THE SUPPLY 27 VI The Way Forward “Meeting reproductive health supply needs is a key element of the global effort to save the lives of women and men by protecting their reproductive health.” — Thoraya A. Obaid, UNFPA Executive Director 4 See the summary of the global strategy for RHCS at the back of this publication. More detailed information is available at www.unfpa.org/tpd/globalinitiative. Lot A, Eng_Text.cc 6/4/02 8:42 PM Page 27 UNFPA is working to develop inventories, resource guides, models for forecasting and estimating commodity needs, and a system to qualify and monitor manufacturers of repro- ductive health supplies. The Fund is also identifying countries where there is potential for early successes in improving commodity sustainability, undertaking country assess- ments and developing country-level RHCS coordinating mechanisms. Other partners are encouraged to develop their own RHCS strategies, work plans and budgets for their specific contribution to the global effort. Such actions are part of the global commit- ment to achieving the goals of the ICPD. The role of commodities in reproductive health, while sometimes overlooked, is among the most basic requirements for success. capacity building, coordination and sustainability. Taking action at many levels For UNFPA, immediate actions include pro- moting RHCS through conferences, technical workshops and publications; attracting addi- tional funding; integrating RHCS strategy within its country programmes; developing work plans and budgets to expand the role of RHCS; and developing a list of essential reproductive health commodities. Working with partners, UNFPA works to strengthen national capacity, putting in place commodity management information systems and, where needed, procurement systems with monitoring and planning. Additionally, 28 Pregnant Afghan refugee in Pakistan hospital where UNFPA provides essential supplies. W ill ia m A . R ya n/ U N FP A Lot A, Eng_Text.cc 6/4/02 8:42 PM Page 28 A global strategy for reproductive health commodity security was articulated in 2000 by UNFPA and its partners. It calls on all partners to use their comparative advantages in a coordi- nated and systematic joint effort. Actions at the GLOBAL level 1. Advocacy—to build a global political commitment to supplying adequate quantities of high-quality, affordable commodities and services. Advocacy takes many forms, including meetings, training, public relations, Goodwill Ambassadors, study tours, publications, newsletters, Web sites and other means for sharing information and building networks. Partners should make RHCS a top priority within their organizations, and develop strategies, policies and procedures that promote a cooperative and coordinated global effort. Advocacy raises awareness of the growing gap between needs in developing countries and available resources. 2. Resource mobilization—to ensure an ongoing flow of materials, raising funds at the global level to help finance commodity pro- curement and national capacity building. RHCS requires full and sustained financing and cost sharing between donors and developing countries. Within countries, it requires the involvement of the public, nongovernmental and pri- vate commercial sectors. Imbalances must be addressed: currently, almost two thirds of all donated contraceptive support is provided to only 10 countries. Each financing source should be used to its best advantage, and funds must be more efficiently applied. 3. Technical cooperation—to develop tools and provide guidance for achieving RHCS. Among the technical resources to be developed at the global level are the following: a technical resource database; policy, opera- tional and technical guidelines; publications; standards, norms and protocols; collections of good practices and lessons learned. 4. Coordination—to address RHCS as an overall strategy and a joint effort in good management by governments, UN agencies, NGOs and many other partners. Partners at all levels pledge their commitment to the principle of working together in a joint effort. Global coordination requires advocacy, resource mobilization and technical cooperation. Specific mechanisms include consultative meetings, expanded databases, publication and Web sites for information-sharing and networking. Actions at the COUNTRY level 5. Building national capacity—to forecast, finance, procure and deliver adequate supplies and services to all who need them. At the national level, security in reproductive health supplies requires the capacity to forecast, finance, procure and deliver high- quality and reliable supplies and services over the long term. A country’s ability to monitor activities and promote accountability will help sustain a well-managed system. Many countries need technical and financial assistance to achieve this. Strategies, train- ing and technical assistance should be tailored to the situation in each country, providing knowledge, skills and experience. 6. Advocacy—to improve the environment for partnerships and financing by raising awareness and removing policy and procedural barriers to RHCS. Advocacy at the national level builds political commitment and mobilizes resources needed to ensure an adequate, consistent and appropriate supply of reproductive health products. Policy-makers and planners should develop consumer-centred approaches to identifying the needs of their populations and an innovative vari- ety of funding sources. Activities include the development of polit- ical support, policy analysis and interventions that improve regulations related to reproductive health, price controls, advertis- ing and promotion. 7. Improved sustainability—to find innovative approaches to strengthening national health systems, especially through stable financing. Stronger national capacity ensures sustainability. Other measures can also enhance RHCS, especially when they help strengthen national health systems overall. Beyond donor support, innovative approaches may increase self-reliance. Cost recovery schemes ask users to pay fees, social marketing schemes sell subsidized brand- ed products through existing commercial outlets, and private sec- tor schemes encourage greater use of products from affordable commercial sources. Better management can reduce the cost of products and services by improving efficiency. Better distribution planning, based on market segmentation studies, can ensure that scarce resources are directed to the most needy populations. 8. Coordination—to simplify procedures, minimize cost and maxi- mize usefulness of the partner’s work. The aim is to address RHCS in a coordinated way within national reproductive health programmes. Countries should take the lead in coordinating the efforts of all partners. Led by governments with assistance from UNFPA and other partners, national-level working groups should organize in order to gather and analyse RHCS data, generate consensus, segment the market and monitor the activities of each partner. These working groups should meet regularly to discuss progress and problems and, generally, hold each partner accountable. For donors, better coordination means greater consistency and coherence in their policies and practices, as demonstrated in flexible and simplified procedures and the timeliness of their assistance. 29 The Global Strategy for RHCS ANNEXES Lot A, Eng_Text.cc 6/4/02 8:42 PM Page 29 The roles of key partners are outlined below. Developing country governments: Governments assess demand, forecast, finance, procure and deliver reproductive health com- modities. Strengthening their capacity to do so is an important objective of UNFPA support. Governments have the closest links to users and their needs and know local conditions. United Nations organizations and agencies: Partners in the UN provide coordination, technical information and guidance, and standards and quality assurance. In the area of reproductive health commodities, UNFPA often works closely with the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS). NGOs (international and local), inter-governmental organizations and contractors: These partners help national governments with advocacy, technical training, developing models, delivering services and exchanging information. The Interim Working Group on Reproductive Health Commodity Security (IWG) is an example of NGO cooperation. The IWG is a collaborative effort of John Snow Inc., Population Action International, the Program for Appropriate Technology in Health (PATH) and the Wallace Global Fund. The IWG furthers the goals of the ICPD Programme of Action by contributing to efforts to secure essential supplies for the delivery of reproductive health care. It was formed following a meeting convened by UNFPA in January 2000, in response to a call for the participation of a wide variety of stakeholders to address contraceptive shortfalls around the world. Major NGO partners include, among others: Commercial Market Strategies (of the United States Agency for International Development), EURONGOs, Family Health International, International Council on Management of Population Programmes, the Futures Group, International Planned Parenthood Federation, International Projects Assistance Services, John Snow, Inc. (the prime contractor for DELIVER, a global technical assistance contract funded by USAID), Management Sciences for Health (a private non-profit), Marie Stopes International, Partners in Population and Development, Population Action International, Population Concern, the Population Council, Program for Appropriate Technology in Health, the Swedish Association for Sexual Education (RFSU) and Väestöliitto (the Family Federation of Finland). Bilateral donors: Donor countries such as Canada, Germany, the Netherlands, the United Kingdom and the United States supply financial and technical support. They also collect data and conduct analyses that help UNFPA and its partners to understand com- modity requirements. Better coordination among donors could create a more reliable flow of funds that support long-term planning. The World Bank and regional development banks: These financial institutions promote sector-wide approaches and are restructuring the way governments organize services and allocate resources, so their collaboration ensures an ongoing focus on RCHS goals. Foundations: Foundations can provide flexible and long-term grants as required. Major donors include the Bill & Melinda Gates Foundation, the David and Lucille Packard Foundation, the United Nations Foundations and the Wallace Global Fund. Commercial private sector: Half or more of the commodities used in some countries are provided by the commercial private sector. They make products and services more attractive and accessible to users who can pay commercial prices, and are central to sustainable programmes. Private individuals: Individual people drive the demand side of the equation, and their private purchases of commodities can reduce the burden on public-sector programmes. 30 Partners: Working Together for RHCS Cover photo: Afghan women wait to see doctor at refugee camp health centre. The need for reproductive health essentials is growing as the largest-ever young generation comes of age. Credit: William A. Ryan/UNFPA Lot A, Eng_Text.cc 6/4/02 8:42 PM Page 30 220 East 42nd Street New York, NY 10017 United States of America UNFPA World Wide Web site: http://www.unfpa.org ISBN 0-89714-626-3 E/10,000/2002 UN Sales No. E.02.III.H.3 Printed on recycled paper Reproductive Health Essentials SECURING THE SUPPLY Global Strategy for Reproductive Health Commodity Security

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