Road-Mapping a Total Market Approach for Family Planning and Reproductive Health Commodity Security: Workshop Materials

Publication date: 2013

Road-Mapping a Total Market Approach for Family Planning and Reproductive Health Commodity Security Workshop Materials Acknowledgments These materials were developed by PATH with funding from UNFPA Eastern Europe Central Asia Regional Office and the Global Program for Reproductive Health Commodity Security. For more information about total market approaches (TMA) or these workshop materials contact: PATH MAILING ADDRESS PO Box 900922 Seattle, WA 98109 USA STREET ADDRESS 2201 Westlake Avenue Suite 200 Seattle, WA 98121 USA Tel: +1 (206) 285-3500 Fax: +1 (206) 285-6619 Janet Vail, Project Director Email: jvail@path.org Copyright © 2013, United Nations Population Fund (UNFPA) and Program for Appropriate Technology in Health (PATH). All rights reserved. The material in this document may be freely used for educational or noncommercial purposes, provided that the material is accompanied by the acknowledgment line: These materials were developed by PATH with funding from UNFPA Eastern Europe Central Asia Regional Office and the Global Program for Reproductive Health Commodity Security. Suggested citation: UNFPA and PATH. Road-Mapping a Total Market Approach for Family Planning and Reproductive Health Commodity Security: Workshop Materials. Seattle: PATH, 2013. Cover photo: PATH/Mike Wang 3 Table of contents Introduction .4 Participant materials .5 Agenda.7 Case study: Engage stakeholders .10 PolicyMaker .12 AccessRH .13 Case study: Gather and apply evidence .16 Ten steps to developing a strategic advocacy agenda .18 Participant worksheets .20 Facilitator guide .23 Workshop preparation .25 Case studies with facilitator notes .34 4 Background In Eastern Europe and Central Asia (EECA), the challenge of sustaining access to reproductive health commodity security (RHCS) is due to poor commitment of governments to invest in affordable and accessible reproductive health commodities, especially contraceptives. Progress toward RHCS is also challenged by political, economic, and structural changes including health sector reforms. Since most of the countries in the region are middle-income countries (MICs), a very limited amount of reproductive health commodities are provided by development partners. In order to introduce sustainable financing mechanisms, such as total market approaches, and to mobilize government prioritization of funding for vulnerable populations, UNFPA EECA Regional Office (EECARO) initiated activities for “road-mapping” implementation of total market approaches (TMA) in the region. After several consultations during 2012 and analysis of 2013 online survey findings, EECARO and PATH developed materials for regional workshops. These activities and workshops were funded by the UNFPA Global Program for Reproductive Health Commodity Security. Overview PATH and UNFPA conducted two regional workshops on TMA in April 2013. The first, in Sarajevo from April 17 to 19, was designed to reach English-speaking countries. Teams from eight countries participated: Albania, Bosnia and Herzegovina, Bulgaria, Kosovo, Former Yugoslav Republic of Macedonia, Romania, Serbia, and Turkey. The second workshop, held in Kyiv from April 23 to 25, was conducted for Russian speakers from twelve countries: Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, Tajikistan, Turkmenistan, Ukraine, and Uzbekistan. The Kyiv workshop was conducted with simultaneous interpretation for English and Russian. The country teams were composed of representatives from the following categories of organizations: • Family planning (FP) or reproductive health (RH) programming division of the ministry of health (MOH) • UNFPA • Financing responsibility from the MOH, ministry of finance, or national health insurance • NGOs, such as an affiliate of International Planned Parenthood Federation (IPPF) or a social marketing group Objectives • Increase awareness among country teams of TMA, which is an important tool not only for the sustainability of RHCS but also for the elimination of all existing barriers to access FP in the region. • Develop and agree upon recommendations on introducing TMA in the respective countries. Workshop content The structure for each three-day workshop is organized around three TMA implementation steps: 1. Engaging stakeholders 2. Gathering and applying evidence 3. Developing and implementing an action plan Each workshop is designed to be conducted in small groups composed of individuals from a mix of countries. The materials are based on case studies and small group discussion. Participants gather as country teams at the end of the second day to compare notes and to develop their country action plans. The expected result of each workshop is that the country teams will implement the actions in their plans with the support of UNFPA and its partners. Use of workshop materials These workshop materials are available for use by other organizations and may be downloaded and used with attribution as follows: “These materials were developed by PATH with funding from UNFPA Eastern Europe Central Asia Regional Office and the Global Program for Reproductive Health Commodity Security.” We welcome comments on the materials and their application. Introduction 5 Participant materials 6 7 Agenda Road-Mapping a Total Market Approach for Family Planning and Reproductive Health Commodity Security (Including Condom Programming) “Ensure access for all to family planning and reproductive health, with a specific focus on vulnerable populations.” Day 1: Background 8:45–9:15 Registration 9:15–10:00 Opening speech by host country, UNFPA, and PATH 10:00–10:30 Introductions, agreements, and other logistics arrangements 10:30–10:45 Meeting objectives and expected results 10:45–11:15 Break 11:15–13:00 What is a total market initiative (TMI)? • What are common elements of a definition? • How could a TMI help to achieve national FP/RH strategy and goals? • How do different stages of a country’s economy and its FP/RH program influence the total market interventions? 13:00–14:00 Lunch 14:00–14:30 Identify steps to a TMI 14:30–15:00 Step 1: Engage stakeholders Participants work in small groups to address questions about a case study 15:00–15:30 Break 15:30–16:00 Participants continue in small groups on a case study 16:00–16:30 Small groups report out to plenary 16:30–17:00 Synthesis of learning from Step 1 Each participant records next steps to engage stakeholders in their country 17:00–17:15 Wrap up and adjourn 8 Day 2: Implementation 9:00–9:30 Recap of day 1 Introduction to day 2 9:30-10:00 Access RH presentation 10:00–10:45 Step 2: Gather and apply evidence for decision-making Participants work in small groups on a case study 10:45–11:15 Break 11:15–12:00 Small groups report out at plenary Synthesis of learning Each participant records next steps to gather evidence in their country 12:00–13:00 Step 2, continued: Apply the evidence Round-robin in each small group: • Tell us about a time you observed in your country when data were applied effectively to decision-making? • What data might be effective to influence critical stakeholders in your country in future? Each small group reports out to plenary 13:00–14:00 Lunch 14:00–15:00 Step 3: Develop and implement an action plan Moderated panel discussion to present examples of TMIs from countries (i.e., different contexts and practices) and their action plans 15:00–15:30 Break 15:30–16:00 Each participant records an action plan Small groups discuss and compare plans 16:00–17:00 Participants work in country teams to compare the notes they recorded from previous steps 17:00 Wrap up 9 Day 3: Success 9:00–9:15 Recap of day 2 Introduction to day 3 9:15–9:45 Success and lessons learned • How do you define and measure success? • What are success factors from previous initiatives? • What are lessons learned and best practices? 9:45 – 10:45 Country teams record their action plan 10:45–11:15 Break 11:15–12:15 Country teams report out on their plan in plenary 12:15–12:30 Discussion and questions/answers 12:30–13:00 Country teams identify regional support to fulfill their commitments 13:00–14:00 Lunch 14:00–14:30 Evaluation of workshop 14:30–15:00 Closing ceremony 15:00–15:30 Farewell coffee break 10 Background D, a country of 10 million people, has a modern contraceptive prevalence rate of 45 percent. A summary of data from the reproductive health survey four years ago shows the following information for source of supply, by method. Source of supply Pill (%) IUD (%) Condom (%) Total (%) Public 19 85 3 69 Hospital 4 35 29 Women’s clinic 10 30 30 Polyclinic 5 20 3 10 Private 71 15 71 28 Hospital/clinic 1 1 2 Pharmacy 71 14 70 26 Doctor Other 10 26 3 Total 100 100 100 100 The Department of Maternal and Child Health (MCH) in the Ministry of Health (MOH) is responsible for national family planning service provision and clinical guidelines. Another department, the National AIDS Council (NAC), is responsible for HIV programming. A third department, the Reproductive Health Directorate, is responsible for national reproductive health (RH) and population policy. The regulatory department of the Ministry is responsible for which service providers can provide which services (such as abortions, injections, and oral contraception provision). In the context of health sector reform, the Ministry of Finance is exploring what programs to add into the evolving national health insurance program. At the subnational level, the two largest cities of D have MCH departments in their city health departments, and on an oblast level the RH program is being cited as a model by a Parliamentarian advocate for family planning. The United Nations Population Fund (UNFPA) procures condoms for HIV prevention and control programs. Several donor-supported nongovernmental organizations provide services in D, including a local affiliate of International Planned Parenthood Federation (IPPF). One social marketing agency promotes condoms. The for-profit commercial sector is highly fragmented. No information is available about the number of private physicians, pharmacists, clinics, or hospitals. You know from your previous work in another country that the private providers had an association of private health facilities, but it does not appear that such an association exists in D. There is one local oral contraceptive manufacturer. Most other hormonal methods are imported by two large wholesalers from multiple international manufacturers. Two international manufacturers have offices in Country D. Question for discussion 1. From the data provided in the background, please make an initial list of which stakeholders are important service providers, policymakers, and funders. Please add other stakeholders to the list who may not have been mentioned but are important to consider, based on your experience. Outreach The MOH has a goal to reach adolescents with family planning services and you would like to see if a total market approach could support this goal. The MOH is not particularly interested in this approach but does not forbid you to explore it further. You design an opinion and network analysis survey, and you choose leaders at 15 organizations to interview to assess their opinions about total market applications to reach adolescents. The survey takes about one hour to administer, and all interviews are complete in three weeks. Some of the interviewees have suggested additional stakeholders to interview which adds another week to the process, with a total of 17 organizations participating. Case study: Engage stakeholders 11 The results showed that the several actors are important for family planning programming (shown as “high power” on the position map below). At the same time, some moderately powerful actors are not mobilized concerning this issue. The strongest opponent to public-private coordination was the MCH department. You also learn from the interviews that financing is becoming more decentralized and that different oblasts have different methods of financing family planning. Also, 10 of the respondents said that engaging the private sector in policy and planning should be a priority. Stakeholders emphasized that information on ability and willingness to pay, market segmentation, products and prices in the commercial sector, and costs of providing services in the public sector were required to move forward with planning for how the total market could contribute to improve access for adolescents. Questions for discussion 2. Based on the survey results, which stakeholders are critical? How do you determine that? (Hint: look for both position and power.) 3. What steps would you propose to influence critical stakeholders in Country D? How can you influence the MCH department? 4. How might these steps to influence stakeholders (#3) differ from what you would do in your own country? 5. What might you do to bring together supporters and mobilize those with no position? 6. Is there a network of stakeholders in your own country? Does the composition of the network include all the critical stakeholders? 7. In this example for Country D, what steps would you propose to take next? 12 A stakeholder analysis and advocacy tool called PolicyMaker provides a computer-assisted guide for strategic thinking about policy reform. The software leads the user through a step-by-step analysis of the policy content, positions, and power of major players; opportunities and obstacles to policy change; and strategies for change. The software is available for free on the internet (www.polimap.com/download.html). The tool was developed by Dr. Michael Reich, Taro Takemi Professor of International Health Policy, Department of Global Health and Population, Harvard School of Public Health. He and his collaborators have applied this method for analyzing health reform issues in more than ten countries, in collaboration with national governments and international agencies, and the approach has been adopted by UNFPA as a core competency in policy analysis for their country offices. PolicyMaker This screen from their website shows an overview of the tool and its steps. 13 AccessRH AccessRH Deliver products and services to various economic segments Where Government and NGOs can procure commodities • Government and NGOs can procure commodities with the UNFPA’s price through: – AccessRH – direct procurement by using web-based service from UNFPA at http://www.myaccessrh.org Note: AccessRH is formerly UNFPA’s third party procurement , e.g. UNFPA CO procurement in Albania on behalf of Government What is AccessRH? AccessRH is a UNFPA-managed procurement and information service for reproductive health supplies We offer NGOs and low and middle income governments efficient access to high quality, affordable commodities and increased supply chain visibility Ministries of health Whom we serve UNFPA Country Offices Non- Governmental Organizations Other UN Organizations www.MyAccessRH.org AccessRH Product Catalog RHInterchange How to order Typical lead times by product Quality assurance policy List of quality assured suppliers Information Services Procurement Services 14 Request and review quotation Order confirmation Lead time for RH supplies Shipment Arrival at port of destination Production 1-4 weeks 2-17 weeks 1-4 weeks 1-4 weeks Total lead time 5-29 weeks depending on product specifications Stock Contraceptives Reproductive health kits Medical equipment AccessRH Online Product Catalog Pharmaceutical products 36 20 447 285 Commodity Quantity Unit of Measure Marvelon 28 144,230 cycle Male condom 53mm 3,300,000 Piece Female Condom 175,435 Piece Emergency contraceptive NorLevo 142,855 Pack Injectable contraceptive Norigynon 177,645 ampoule IUD T380 – Paper/Film Pouch 503,512 piece What you can buy for 100,000 USD* Contraceptives *Does not included freight charges or 5% handling fee Commodity Quantity Unit of Measure Marvelon 28 288.475 cycle Male condom 53mm 6,620,400 Piece Female Condom 350,875 Piece Emergency contraceptive NorLevo 285,714 Pack Injectable contraceptive Norigynon 235,295 ampoule IUD T380 – Paper/Film Pouch 1,005,025 piece What you can buy for 200,000 USD* Contraceptives *Does not included freight charges or 5% handling fee Commodity Quantity Unit of Measure Marvelon 28 1,442,447 cycle Male condom 53mm 33,103,440 Piece Female Condom 1,754,386 Piece Emergency contraceptive NorLevo 1,428,521 Pack Injectable contraceptive Norigynon 1,176,471 ampoule IUD T380 – Paper/Film Pouch 5,025,126 piece What you can buy for 1,000,000 USD* Contraceptives *Does not included freight charges or 5% handling fee Commodity Quantity Unit of Measure Misoprostol 1,724 PK of 60 tbl Oxytocin 10 l.U./ml, 1ml 2,500 Pk of 100 amp Metronidazole 200mg 9,560 Pk of 1,000 tbl Magnesium Sulphate 500 mg/ml (50%), 10 ml 6,250 Pk of 5 amp Hydralazine Hydrochloride 50 mg 714 Pk of 500 tbl Pregnancy Test Dip Strip 555,550 strip What you can buy for 50,000 USD* Maternal Health Pharmaceuticals *Does not included freight charges or 5% handling fee 15 Commodity Quantity Unit Price Ultrasound, scanner, portable, with printer 31 3,181 Anesthesia machine 15 6,451 Doppler, heart rate detector, pocket size 2,000 50 Bed, labor delivery 201 490 Vacuum extractor 590 169 Steam sterilizer, pressure type, 24 L 1,200 83 What you can buy for 100,000 USD* Medical Equipment *Does not included freight charges or 5% handling fee Message to Governments Please apply to the membership at RHSC http://www.rhsupplies.org 16 Case study: Gather and apply evidence Background The Ministry of Health Women’s Department (WMOH) in N, a country of 5 million people, would like to expand contraceptive options for women by adding female condoms to their method mix. In addition, they would like to increase use of implants. For implants, a newly signed agreement with AccessRH may enable them to purchase this product in their national program for the first time. For female condoms, new products are coming on the market which gives them an opportunity to look at this type of product. Beyond public provision, they realize that private and nongovernmental organization (NGO) provision could help to generate demand and access. The WMOH would like to obtain information about the potential size of the market for these two products, and especially to understand the composition of the private and NGO markets for these two products. In terms of existing data, they have a reproductive health survey from five years ago that provides information about contraceptive prevalence by method and urban/rural population, method mix by source of supply, and wealth quintiles of contraceptive users. It does not contain information about female condoms. Some of the key information is included in the table below. Current use of contraception by background characteristics (percent distribution). Any modern method Pill IUD Male Condom Implants Residence: Urban 35 10 15 5 5 Residence: Rural 10 2 3 3 2 Wealth quintile Lowest 20 5 5 5 5 Second 20 5 5 5 5 Middle 20 5 5 5 5 Fourth 15 4 5 4 2 Highest 25 10 8 3 4 Total 25 8 10 4 3 In terms of source of supply, the commercial sector and NGOs account for 75 percent of the sources of contraceptive supplies, with the government serving as the remaining source. In addition, the WMOH has identified the following data sources: • A market segmentation study developed eight years ago. • The social marketing project has information about the sales volume and prices of their products, and they have expressed interest in adding both products to their program. • Data about commercial sales from a retail audit company could be commissioned that would provide information about the range of products available, their prices, and sales volume by location. Questions for discussion 1. How can the stage of the contraceptive market of Country N (early, developing, or mature) inform the focus of the total market intervention and therefore the information requirements? 2. What are the specific questions the WMOH is trying to answer? 3. What information do you think they need? Are the existing data sufficient or do you think they need more? 17 Expanding the evidence The WMOH decides to focus its efforts on coordinating with the commercial sector and NGOs to increase rural access to implants. They convene a meeting of the representatives of the two implant manufacturers, the social marketing group, and the IPPF affiliate to discuss increasing implant use. Both manufacturers decline to attend the meeting but request individual meetings with them. Questions for discussion 4. What are the WMOH’s options to respond to the manufacturers’ requests for individual meetings? 5. What are key agenda items for the group meeting about implants? For female condoms, the WMOH wants to target free provision of the product to women at high risk of HIV and HIV+ women. However, the department does not have information about the size of this group, and contacts the National AIDS Commission (NAC) for more information and possible collaboration. The NAC provides them with requested data and also informs them that it can only afford to provide male condoms for free and that it cannot manage the addition of female condoms. Therefore, the WMOH meets with the social marketing group to explore collaboration. Question for discussion 6. What are key agenda items for the meeting with the social marketing group about female condoms? Next steps As a result of the meetings, the WMOH determines that the main information needs are about their own service provision requirement for implants, such as the cost of providing services, developing clinical practice guidelines, and training service providers. They also want to find a way to provide subsidized female condoms to adolescents. Question for discussion 7. What do you recommend as the next steps for the WMOH? 18 Ten steps to developing a strategic advocacy agenda Step 1: Establish a process for assessing and understanding the challenges and needs of the target population. r�$POEVDU�PS�VTF�EBUB�BMSFBEZ�DPMMFDUFE�GSPN�B�OFFET�BTTFTTNFOU�PG�UIF�BĒFDUFE�QPQVMBUJPO�� r� %FWFMPQ�B�QSPDFTT�GPS�PO�HPJOH�GFFECBDL�BOE�JOQVU�GSPN�UIF�UBSHFU�QPQVMBUJPO��� Step 2: Identify policy changes that would address the needs of the target population. r� *ODSFBTFE�SFTPVSDFT r� /FX�MBXT �SFHVMBUJPOT �BOE�QPMJDJFT r� $IBOHFT�UP�MBXT �SFHVMBUJPOT�BOE�QPMJDJFT r� &OGPSDFNFOU�PG�MBXT �SFHVMBUJPOT�BOE�QPMJDJFT Step 3: Identify decision-maker(s) who have the power and influence to change policy to address the needs. r� 1PMJUJDJBOT� FMFDUFE���BQQPJOUFE�PēDJBMT r� 4PDJBM�MFBEFST r� (PWFSONFOU�BHFODJFT r� *OUFSOBUJPOBM�CPEJFT Step 4: Determine why decision-makers have not implemented the desired change. r�5PP�FYQFOTJWF r� /PU�B�QSJPSJUZ r� -BDL�PG�VOEFSTUBOEJOH r� -BDL�PG�DPNNVOJUZ�EFNBOE Step 5: Identify opposition to the policy change and the reasons for their opposition. r�8IP�JT�UIF�PQQPTJUJPO r� 8IBU�BSF�UIFJS�LFZ�BSHVNFOUT � r� 8IP�EP�UIFZ�IBWF�JOëVFODF�XJUI Step 6: Assess your institution’s strengths and weaknesses in advocating for the policy change. r� &YQFSUJTF r� 4QPLFTQFPQMF r� 3FMBUJPOTIJQT�JOëVFODF r� 6OJRVF�OJDIF 5FO�TUFQT�UP�EFWFMPQJOH�B�TUSBUFHJD�BEWPDBDZ�BHFOEB "EWPDBDZ�JT�PѫFO�B�IFMQGVM�UPPM�JO�BDIJFWJOH�QVCMJD�IFBMUI�HPBMT�UISPVHI�QPMJDZ�DIBOHF��(JWFO�UIF�NBOZ�EJĒFSFOU� NFUIPET�UP�JOëVFODF�QPMJDJFT�BOE�UIF�MJNJUFE�SFTPVSDFT�VTVBMMZ�BWBJMBCMF�UP�EP�TP �JU�JT�JNQPSUBOU�UP�BTTFTT�ZPVS� PQUJPOT�BOE�UBDUJDT�TUSBUFHJDBMMZ��#FMPX�BSF�UFO�TUFQT�UIBU�ZPV�NBZ�êOE�IFMQGVM�BT�ZPV�EFUFSNJOF�ZPVS�QSPHSBN�T� BEWPDBDZ�HPBMT�BOE�BDUJWJUJFT��� Conduct a policy scan: r��5SBDL�HPWFSONFOU�GVOEJOH�IJTUPSJFT� r��3FTFBSDI�FYJTUJOH�MBXT �SFHVMBUJPOT�BOE� QPMJDJFT�SFMBUFE�UP�ZPVS�JTTVF�� 19 Step 7: Identify others who have a similar interest in addressing the problem. r� 1BUJFOU�DPBMJUJPO r� 1SPGFTTJPOBM�PSHBOJ[BUJPO r� 'BJUI�CBTFE�PSHBOJ[BUJPO r� "DUJWJTU�BEWPDBDZ�PSHBOJ[BUJPO Step 8: Identify advocacy activities and messengers that could influence those in power. "DUJWJUJFT r��.FFUJOH�XJUI�EFDJTJPO�NBLFST r��1VCMJD�FWFOU r��1FUJUJPO .FTTFOHFST r��.FEJB r��$FMFCSJUJFT r��1BUJFOUT r��&YQFSUT r��1FFST r��%POPST Step 9: Assess current and future resources that could be accessed to pursue the change. r� 'JOBODJBM r� )VNBO r� *OUFMMFDUVBM� r� /FUXPSLJOH Step 10: Determine how to evaluate progress and success. 0VUQVUT�NFBTVSF�XIFUIFS�UIF�BEWPDBDZ�BDUJWJUJFT�IBWF�CFFO�DBSSJFE�PVU�TVDDFTTGVMMZ��� 0VUDPNFT�NFBTVSF�UIF�FĒFDUJWFOFTT�PG�UIF�BEWPDBDZ�BDUJWJUJFT�JO�BDIJFWJOH�JEFOUJêFE�HPBMT� 0VUQVUT r� 1VCMJD�TUBUFNFOU�PG�TVQQPSU�GSPN�EFDJTJPO�NBLFS r� /VNCFS�PG�TJHOBUVSFT�PO�QFUJUJPO r� /VNCFS�PG�BUUFOEFFT�BU�B�SBMMZ 0VUDPNFT r� /FX�SFTPVSDFT�BMMPDBUFE r� -BX�QBTTFE�DIBOHFE r� 3FHVMBUJPO�JNQMFNFOUFE�DIBOHFE Be strategic! *EFOUJGZ�B�TFU�PG�DSJUFSJB�UP�BTTFTT�BOE�TFMFDU�BNPOH� FBDI�PG�ZPVS�PQUJPOT�� $POTJEFS�VTJOH�UIF�GPMMPXJOH�DSJUFSJB�� r��-FWFM�PG�JOëVFODF�UIF�BDUJWJUZ�XPVME�IBWF�PO� EFDJTJPO�NBLFST� r��3FTPVSDFT�UIBU�XPVME�CF�OFFEFE� r��-FWFM�PG�SJTL�UP�ZPVS�QSPHSBN�JOTUJUVUJPO�JO� QVSTVJOH�UIF�BDUJWJUZ� r��"DDFTT�UP�FĒFDUJWF�NFTTFOHFST� December 2007 Hint! *ODMVEF�UIPTF�XIP�DPVME�CF�QBSUOFST �CVU�BSF�OPU� DVSSFOUMZ��'PS�FYBNQMF �ZPV�NBZ�XBOU�UP�SFBDI�PVU� UP�CVTJOFTTFT�PS�PUIFST�XJUI�QPMJUJDBM�JOëVFODF�UIBU� DPVME�CF�BĒFDUFE‡EJSFDUMZ�PS�JOEJSFDUMZ‡CZ�UIF� QPMJDZ�DIBOHF �CVU�IBWF�OPU�� ZFU�CFFO�BDUJWFMZ�FOHBHFE�JO�UIF�JTTVF� ����.BTTBDIVTFUUT�"WF�/8 4VJUF����� Washington, DC 2000� Contact: Rachel Wilson 202-822-0033 info@path.org www.path.org 20 Participant worksheets Baseline: Choosing whether to implement a total market initiative 1. What is the overall situation with family planning/reproductive health in your country (situation analysis information such as can be obtained from reproductive health surveys and strategies, for example, CPR or unmet need)? 2. What are the family planning/reproductive health program goals and strategies in your country? 3. What components of these goals and strategies could be addressed with total market activities? Step one: Engage Stakeholders 4. Who are the relevant stakeholders in your country? (include important service providers, policymakers, beneficiaries and funders) 5. Is there an existing network of stakeholders in your own country? If so, does the network include all the critical stakeholders? 6. What steps would you want to take to determine what stakeholders are critical to a total market initiative? 7. What steps would you propose to influence critical stakeholders in your country? 21 8. What might you do to bring together supporters and mobilize those with no position? 9. What do you see as the immediate next steps in your country to engaging stakeholders in a total market initiative? Step two: Gather and apply evidence for decision-making 10. What information and data do you need to identify your priorities for a total market initiative? 11. Is existing data sufficient in your country or would more information be required? If more is required, make a list here of what additional evidence needs to be collected: 12. How can you work with the stakeholders you have already engaged to use the data to develop priorities for future action? 13. Based on these priorities, who are additional stakeholders who may need to be engaged? 14. What is the one action that you want each of them to take to support the priorities? 22 Co un tr y: _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Ba se lin e an d ta rg et : __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ Ac tiv ity b y O bj ec tiv e Re sp on si bl e Pa rt y/ Pa rt ne rs 20 13 20 14 20 15 20 16 Bu dg et / Su pp or t Re so ur ce s So ug ht M ea ns o f Ve rifi ca tio n (In di ca to rs ) Se co nd ha lf Fi rs t ha lf Se co nd ha lf Fi rs t ha lf Se co nd ha lf Fi rs t ha lf Se co nd ha lf O bj ec tiv e 1 Ac tiv ity 1 .1 Ac tiv ity 1 .2 O bj ec tiv e 2 Ac tiv ity 2 .1 Ac tiv ity 2 .2 Ac tiv ity 2 .3 O bj ec tiv e 3 Ac tiv ity 3 .1 Ac tiv ity 3 .2 Ac tiv ity 3 .3 St ep th re e: D ev el op in g an d im pl em en tin g an a ct io n pl an 23 Facilitator guide 24 25 Workshop preparation Supplies and Room Set-up General supplies • Name tents or name tags • Binder with tab dividers for each participant (tabs organized by TMI Steps 1–3) • Copies of all workshop materials: agenda, workshop agreements, presentations, case studies, worksheets, resource documents, evaluation • Colored dots (for country details exercise, see details below) • Sticky wall and adhesive spray • Large notecards or half sheets of paper for use with sticky wall • Flip charts (one per table) and two flip chart easels • Markers for writing on cards and flip charts • Flash drives with all workshop materials for each participant (distributed at end of day 3) • One flower per country team for day 3 country presentations Equipment • Laptop • LCD projector for hookup to laptop • Projection screen • Extension cords • Microphones • Interpretation equipment (if needed) • Camera Room set-up and preparation required • Registration table outside workshop room where participants sign-in and pick up their binder and name tag • Room set up with participants sitting at tables of 8 to 10 people • Speakers table at front of room • Flip charts on easels at front of room • Sticky wall set up on one wall of the room with space for participants to stand in front of it • One piece of flip chart paper labeled “Parking Lot” • Markers and notecards on each table 26 • Meeting objectives and expected results prepared in PowerPoint • Proposed workshop agreements in participant binders with additions written out on flip-chart paper Country details exercise • Country details relevant to total market interventions will be described in a matrix that is written on a flip chart with the names of each country in the first column. It is recommended to print the matrix on large format paper in advance of the workshop. The matrix should be posted in the workshop room at the start of day 1. • Colored dots ready to give a representative of each country as they arrive (e.g., first person from each country to register on day 1) TMI Steps 1–3 Print outs (in very large font—one step per page, poster size) of each of the steps in a TMI covered in the workshop • Engage stakeholders • Gather and apply evidence for decision-making • Develop and implement an action plan Country name Country population Country income Modern contraceptive prevalence rate Focus on condom programming for HIV prevention? Public/private source mix for contraceptive provision <7 Million 7-20 Million >20 million L: $1,025 or less LM: $1,026 to $4,035 UM: $4,036 to $12,475 H: $12,476 or more <25% 25-54% >54% Yes No >70% public 30-70% public <30% public Country A Country B Proposed workshop agreements • Turn off all distractions (PDAs, phones, laptops), and check/return calls/send emails during breaks • Treat each other with respect • No side conversations • One person speaking at a time • Promptly return from breaks and be ready to start at agreed times • Allow differences of opinion and park topics as necessary to move discussions forward • It is acceptable to “pass” or “pass for now” if you do not wish to speak or need more time to reflect • Confidentiality: personal stories shared at the workshop stay at the workshop 27 Day 1: Background Time Event Notes 8:45–9:15 Registration As participants arrive, give each country team a set of five stickers and ask them to place the stickers on the matrix of country details relevant to total market initiatives. This can be done at the workshop registration table, with the first person to register from each country receiving a set of stickers. A workshop facilitator should be in the workshop room to provide instructions for placing the stickers on the matrix. 9:15–10:00 Opening of meeting A. Opening speech by host country. i. Talking points are on country priorities on RH and family planning. B. Opening speech by UNFPA. i. Talking points are on importance of TMA and this workshop. C. Opening speech by PATH. i. Talking points are on our role in the workshop as UNFPA’s strategic partner. 10:00–10:30 Introductions, agreements and logistics arrangements Introductions A. Ask participants to introduce themselves at their tables. i. Ask participants to take turns speaking, going around the circle clockwise. ii. Let participants know that they will have a moment to reflect before the first person will begin speaking. iii. Ask participants to say their name, organization, and country, and briefly (taking no more than one breath) share a personal or professional highlight from the past week. iv. Ask participants to go around the circle in the other direction and share a personal experience or story that makes them feel enthusiastic about the possibilities of total market approaches for family planning/RHCS. Remind participants that they will have a moment to reflect before the first person begins speaking. B. Ask participants to introduce themselves to the larger room. i. Ask participants to go around the large room and introduce themselves with their name, organization, country, and one or two words that describe how they are feeling about being at this workshop. Agreements A. Review proposed list of agreements in participant binder. (You may want to ask a participant to volunteer to read them out loud.) B. Ask participants whether there are any additions or modifications they would like to make to the proposed workshop agreements and make modifications as needed, writing these on a flip chart. C. Ask participants to agree to the list. D. Highlight concept of “parking lot” for ideas that require further or deeper discussion. Logistic arrangements A. Briefly review structure of agenda. B. Share details of when breaks will take place and mention location of restrooms. 10:30–10:45 Meeting objectives and expected results A. Review meeting objectives and describe expected results (show in a PowerPoint slide). B. Brief PowerPoint slide describing survey results and how the workshop addresses participant feedback. 10:45–11:15 Break 28 Time Event Notes 11:15–13:00 What is a total market initiative (TMI)? Definition of TMI A. Ask participants to write the core elements of a definition of a total market initiative onto cards—one thought per card. B. Ask each table to discuss the cards, synthesize the perspectives at their table, and agree on the five cards that their table will bring to the sticky wall. C. Ask each table to send a representative to bring up their table’s five cards and place them on the sticky wall. D. The facilitator can ask for volunteers to help organize common themes that emerge into various components of the definition on the sticky wall. E. Facilitator reviews the cards on the sticky wall with the group in plenary. F. Facilitator synthesizes core components of the definition of a total market initiative. Benefits of a TMI G. Ask each participant to write their top two goals for their country’s FP/RH program on their worksheet called “baseline.” H. Ask participants to briefly share their country’s FP/RH program goals at their tables. I. Ask participants to each write two elements of a total market initiative that could help them obtain these goals. J. Ask participants to share their thoughts at their tables. K. In plenary, ask each table to share key insights that emerged from their discussion of the elements of a total market initiative that could help them to obtain their program’s goals. How stages of a country’s economy influence the TMI L. Facilitator gives a brief overall synthesis of TMI. M. If space permits, ask participants to walk to the matrix of country details relevant to total market initiatives. N. Ask participants to reflect on any insights about what they observe in the matrix of countries represented at the workshop. 13:00–14:00 Lunch Clean sticky wall—put up posters of the three TMI steps 14:00–14:30 Identify steps to a TMI A. Show steps of the total market initiative on the sticky wall (using the large pieces of paper with one step per page). B. Ask participants if there are any context-specific steps that they would suggest adding. If so, write each one on a card and add to the sticky wall. C. Divide participants up into small groups that are not their country teams (approximately 5-6 participants per group). D. Let participants know that they will be working in these groups for the afternoon. They can take their personal items and move to a new table with their new group. 14:30–15:00 Step 1: Engage stakeholders A. See Case study 1: Engage stakeholders. B. Ask participants to read the case study, discuss it at their tables, and to answer the questions. C. Be available to answer participant questions as they work. 15:00–15:30 Break 29 Time Event Notes 15:30–16:00 Participants continue in small groups on a case study 16:00–16:30 Small groups report out to plenary D. Ask each table to report out a plenary summary of their discussions in response to the designated questions. Divide the case study questions among the groups so that each group reports out on one question. 16:30–17:00 Synthesis of learning from Step 1 A. Facilitator synthesizes core components of engaging stakeholders. Also refer to resources in participant binder. B. Allow time for clarifications and/or questions and follow-up discussion. C. Ask each participant to fill in Step 1 on their worksheets describing next steps to engage stakeholders in their country. Tell them this is part of their roadmap and the meeting outcome. 17:00–17:15 Wrap up and adjourn • Brief recap of the day. • Cover any open issues or questions from the “parking lot” and ask if there is anything to add. • Advise participants to return to the same tables tomorrow morning. • Remind participants of the start-time for day 2. 30 Day 2: Implementation Time Event Notes 9:00–9:30 Recap of day 1 Introduction to day 2 A. Make sure participants are at the same tables from yesterday. B. Ask participants what they learned from the first day. i. Ask each participant to go around their table and to share what was a key take away message from the first day of the workshop. ii. Ask tables to bring core components of what was shared to a brief plenary discussion. C. Ask participants for any needed adjustments to agenda. D. Cover any open issues or questions from the “parking lot” and ask if there is anything to add. E. Briefly go over the agenda for the day. F. Review workshop agreements (if needed). 9:30–10:00 Access RH presentation 10:00–10:45 Step 2: Gather and apply evidence for decision- making A. See Case study 2: Gather evidence for decision-making. B. Give overview and explain wealth quintiles. C. Ask participants to read the case study, discuss it at their tables, and answer the questions. Divide the case study questions among the groups so that each group reports out on one question. D. Be available to answer participant questions as they work. 10:45–11:15 Break 11:15–12:00 Small groups report out at plenary Synthesis of learning A. Ask each table to bring core insights from designated questions from their discussion to a plenary summary. B. Facilitator synthesizes and presents core components of gathering evidence for decision-making. C. Ask each participant to fill in Step 2 on their worksheets describing next steps for gathering evidence for decision-making in their country. 12:00–13:00 Step 2 continued: Apply the evidence A. Ask each participant to share at their table the story of a time when they saw data effectively used for decision-making. B. Ask each participant to respond to the question: What data would be effective for influencing/advocating to stakeholders in your country and how could it be used? C. Ask each table to bring one example from each of their discussions to a plenary summary. D. Ask participants to look at the Ten steps to developing a strategic advocacy agenda document in their binder. Mention advocacy resources from other organizations such as International Planned Parenthood Federation. E. Ask each participant to fill in Step 3 on their worksheets describing how they will begin developing a strategic advocacy agenda for their total market initiative. 13:00–14:00 Lunch 31 Time Event Notes 14:00–15:00 Step 3: Develop and implement an action plan Panel of three 10-minute presentations from counties that have implemented total market approaches already. 14:00–14:02: Facilitator will introduce the panel topic and moderator. 14:01–14:07: The moderator will give opening remarks and introduce each of the speakers. 14:10–14:40: The moderator will then call upon each speaker in turn to present (10 minutes each). 14:40–15:00: After all the speakers are finished, the moderator will facilitate questions and answers (as time allows). 15:00–15:30 Break 15:30–16:00 Each participant records an action plan A. See binder for action plan template. Project a sample completed plan on a screen. B. Participants individually fill in the template with the outline of an action plan for their country. C. Participants discuss their proposed plans at their tables: i. Compare similarities and differences ii. Discuss surprises 16:00–17:00 Country team synthesis A. Ask participants to find their country teams and move to a new table where they can work together. B. Ask country teams to compare their individual worksheets and begin to come to consensus on a single country proposal for an action plan. 17:00 Wrap up • Brief recap of the day. • Cover any open issues or questions from the “parking lot” and ask if there is anything to add. • Tell participants to that they will be working in their country teams tomorrow. • Remind participants of the start-time for day 3. Reminder: Purchase flowers for day 3 country presentations. 32 Day 3: Success Time Event Notes 9:00–9:15 Recap of day 2 Introduction to day 3 A. Make sure participants are seated in their country teams. B. Ask participants what was their key learning from the second day. i. Ask each participant to go around their table and to share this. ii. Ask tables to bring core components of what was shared to a brief plenary discussion. C. Cover any open issues or questions from the “parking lot” and ask if there is anything to add. D. Briefly go over the agenda for the day. E. Review workshop agreements (if needed). 9:15–9:45 Success and lessons learned A. Facilitator gives a brief recap of the big picture, and then gives a presentation on the definition and measurement of success in total market approaches (and the difficulties associated with this), success factors, and lessons learned from previous initiatives. Also see other resources in binder. B. Each participant reflects on the presentation and makes notes on their worksheet about indicators they will consider in their own countries. This should be reflected in their action plans. 9:45–10:45 Country team synthesis continued Country teams combine their individual thinking into the action plan template that synthesizes their country’s total market plans and next steps. Each country prepares a five-minute presentation to report in plenary describing next steps, timeline, responsible organization, requests their team has for support from other countries and global organizations, and measurement indicators. 10:45–11:15 Break 11:15–12:15 Country teams report out on their plan in plenary A. Each country team shares its five-minute presentation of their action plan. B. Use a timekeeper to help keep country teams to the allotted five minutes. (One way of doing this is to have the timekeeper give the presenter a flower when there is one minute remaining in their presentation. If they close within the five minutes, they keep the flower; if they go over the five minutes, the timekeeper retrieves the flower.) 12:15–12:30 Discussion and questions/ answers 12:30–13:00 Country teams identify regional support to fulfill their commitments A. Country teams brainstorm types of support needed regionally in order to fulfill their action plans. B. Engage UNFPA representatives in discussion. 13:00–14:00 Lunch Time Event Notes 14:00–14:30 Evaluation of workshop Ask participants to fill out the workshop evaluation form. Collect them or have a box for them. 14:30–15:00 Closing ceremony A. Closing speech by UNFPA. i. Talking points are on importance of working together moving forward. B. Closing speech by PATH. i. Talking points are on our role as a continued resource and supporter. C. Present certificates of participation and flash drive with all the presentations and final participants list. 15:00–15:30 Farewell break 34 Case study 1: Engage stakeholders, facilitator version Background D, a country of 10 million people, has a modern contraceptive prevalence rate of 45 percent. A summary of data from the reproductive health survey four years ago shows the following information for source of supply, by method. Source of supply Pill (%) IUD (%) Condom (%) Total (%) Public 19 85 3 69 Hospital 4 35 29 Women’s clinic 10 30 30 Polyclinic 5 20 3 10 Private 71 15 71 28 Hospital/clinic 1 1 2 Pharmacy 71 14 70 26 Doctor Other 10 26 3 Total 100 100 100 100 The Department of Maternal and Child Health (MCH) in the Ministry of Health (MOH) is responsible for national family planning service provision and clinical guidelines. Another department, the National AIDS Council (NAC), is responsible for HIV programming. A third department, the Reproductive Health Directorate, is responsible for national reproductive health (RH) and population policy. The regulatory department of the MOH is responsible for which service providers can provide which services (such as abortions, injections, and oral contraception provision). In the context of health sector reform, the Ministry of Finance is exploring what programs to add into the evolving national health insurance program. At the subnational level, the two largest cities of Country D have MCH departments in their city health departments, and on an oblast level the RH program is being cited as a model by a Parliamentarian advocate for family planning. The United Nations Population Fund (UNFPA) procures condoms for HIV prevention and control programs. Several donor-supported nongovernmental organizations provide services in Country D, including a local affiliate of International Planned Parenthood Federation (IPPF). One social marketing agency promotes condoms. The for-profit commercial sector is highly fragmented. No information is available about the number of private physicians, pharmacists, clinics, or hospitals. You know from your previous work in another country that the private providers had an association of private health facilities, but it does not appear that such an association exists in D. There is one local oral contraceptive manufacturer. Most other hormonal methods are imported by two large wholesalers from multiple international manufacturers. Two international manufacturers have offices in Country D. Question for discussion: • From the data provided in the background, please make an initial list of which stakeholders are important service providers, policymakers, and funders. Please add other stakeholders to the list who may not have been mentioned but are important to consider, based on your experience. To discuss: consider the functional categories of stakeholders, such as government (programming, finance, subnational); donors; providers; distributors (public and private); media; professional organizations, research/technical agencies; mass organizations; and professional associations. Important to have youth organizations. Case studies with facilitator notes 35 Outreach The MOH has a goal to reach adolescents with family planning services and you would like to see if a total market approach could support this goal. The MOH is not particularly interested in this approach but does not forbid you to explore it further. You design an opinion and network analysis survey, and you choose leaders at 15 organizations to interview to assess their opinions about total market applications to reach adolescents. The survey takes about one hour to administer, and all interviews are complete in three weeks. Some of the interviewees have suggested additional stakeholders to interview, which adds another week to the process, with a total of 17 organizations participating. The results showed that several actors are important for family planning programming (shown as “high power” on the position map below). At the same time, some moderately powerful actors are not mobilized concerning this issue. The strongest opponent to public-private coordination was the MCH department. You also learn from the interviews that financing is becoming more decentralized and that different oblasts have different methods of financing family planning. Also, ten of the respondents said that engaging the private sector in policy and planning should be a priority. Stakeholders emphasized that information on ability and willingness to pay, market segmentation, products and prices in the commercial sector, and costs of providing services in the public sector were required to move forward with planning for how the total market could contribute to improve access for adolescents. Questions for discussion: • Based on the survey results, which stakeholders are critical? How do you determine that? Hint: Look for both position and power—will need to reduce high-power opponents, and can also mobilize those with high power who are neutral. • What steps would you propose to influence critical stakeholders in D? How can you influence the MCH department? Advocacy—what is the source of MCH opposition and what would they need to change their position? • How might these steps to influence stakeholders (#3) differ from what you would do in your own country? • What might you do to bring together supporters and mobilize those with no position? • Is there a network of stakeholders in your own country? Does the composition of the network include all the critical stakeholders? • In this example for Country D, what steps would you propose to take next? Case study 2: Gather and apply evidence for decision-making, facilitator version Background The Ministry of Health Women’s Department (WMOH) in N, a country of 5 million people, would like to expand contraceptive options for women by adding female condoms to their method mix. In addition, they would like to increase the use of implants. For implants, a newly signed agreement with AccessRH may enable them to purchase this product in their national program for the first time. For female condoms, new products are coming on the market, which gives them an opportunity to look at this type of product. Beyond public provision, they realize that private and nongovernmental organization (NGO) provision could help to generate demand and access. The WMOH would like to obtain information about the potential size of the market for these two products, and especially to understand the composition of the private and NGO markets for these two products. In terms of existing data, they have a reproductive health survey from five years ago that provides information about contraceptive prevalence by method and urban/rural population, method mix by source of supply, and wealth quintiles of contraceptive users. It does not contain information about female condoms. Some of the key information is included in the table below. Current use of contraception by background characteristics (percent distribution). Any modern method Pill IUD Male Condom Implants Residence: Urban 35 10 15 5 5 Residence: Rural 10 2 3 3 2 Wealth quintile Lowest 20 5 5 5 5 Second 20 5 5 5 5 Middle 20 5 5 5 5 Fourth 15 4 5 4 2 Highest 25 10 8 3 4 Total 25 8 10 4 3 In terms of source of supply, the commercial sector and NGOs account for 75 percent of the sources of contraceptive supplies, with the government serving as the remaining source. In addition, the WMOH has identified the following data sources: • A market segmentation study developed eight years ago. • The social marketing project has information about the sales volume and prices of their products, and they have expressed interest in adding both products to their program. • Data about commercial sales from a retail audit company could be commissioned that would provide information about the range of products available, their prices, and sales volume by location. Questions for discussion: 1. What are the specific questions the WMOH is trying to answer? Some answers: What implants are provided now and by what service providers in what volumes? Do the providers have information about their users? What are the prices charged by providers? Does the WMOH know its own cost to provide implants—not just the product cost but the entire cost of service delivery? For FC, what products are already registered in the country and sold on private markets at what prices? For both methods, is there a particular population that the WMOH wants to reach (for example, rural women, adolescents)? If so, how can they identify and estimate the size of that target population (by place of residence/ID card)? What can that target population afford to pay? Which sectors are best placed to reach that target population? 37 2. What information do you think they need? Are the existing data sufficient or do you think they need more? Some answers: May need data on ability to pay (depending on what data are included in the market segmentation study and what providers cite as barriers), or wealth quintile by source of supply for implants. For FC: Existing sales trend data; size of population of women at risk or HIV+ by wealth status; and size of sexually active adolescent population. Identify any previous studies of FC in the country or region about introduction issues. Policy information from AIDS programming dept. Information about provider perspectives on FC (knowledge, capacity, and perceptions). Expanding the evidence The WMOH decides to focus its efforts on coordinating with the commercial sector and NGOs to increase rural access to implants. They convene a meeting of the representatives of the two implant manufacturers, the social marketing group, and the IPPF affiliate to discuss increasing implant use. Both manufacturers decline to attend the meeting but request individual meetings with them. Questions for discussion: 3. What are the WMOH’s options to respond to the manufacturers’ requests for individual meetings? 4. What are key agenda items for the group meeting about implants? Possible topics: Provide information on data now available, policy directions of WMOH, barriers and opportunities for implant provision in terms of provider perspectives, financing, supply constraints, rural access issues, next steps, possible roles/strengths of each group. For female condoms, the WMOH wants to target free provision of the product to women at high risk of HIV and HIV+ women. However, the department does not have information about the size of this group, and contacts the National AIDS Commission (NAC) for more information and possible collaboration. The NAC provides them with requested data and also informs them that it can only afford to provide male condoms for free and that it cannot manage the addition of female condoms. Therefore, the WMOH meets with the social marketing group to explore collaboration. Questions for discussion: 5. What are key agenda items for the meeting with the social marketing group about female condoms? Possible answers: What does the social marketing group think they could contribute? What other potential user groups for FC should be considered, such as adolescents or young women? Does that target group have a known preference for where to access methods? Are donors available to procure this method? If so, do the donors want to target a specific audience? What would that audience be able to pay for the method? What is the level of social marketing interest and to reach which audience? Next steps As a result of the meetings, the WMOH determines that the main information needs are about their own service provision requirement for implants, such as the cost of providing services, developing clinical practice guidelines, and training service providers. They also want to find a way to provide subsidized female condoms to adolescents. Question for discussion: 6. What do you recommend as the next steps for the WMOH? 38 39

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