Safeguarding contraceptive security in Latin America and the Caribbean

Publication date: 2008

For decades, donors such as the United States Agency for International Development (USAID) have promoted contraceptive security in Latin America and the Caribbean (LAC) by donating contraceptives to the region’s governments and nongovernmental organizations. However, beginning in the 1990s— with the use of modern family planning (FP) methods increasing in the region and the urgent need for contraceptive support growing in other parts of the world—donors began phasing out these donations. Recognizing the need to help LAC countries assume the financial and logistical responsibilities for meeting the rising demand for contraceptives, USAID’s LAC Bureau launched the Regional Initiative on Contraceptive Security for Latin America and the Caribbean (LAC CS Initiative) in 2003. Jointly implemented by the USAID | Health Policy Initiative, Task Order 1, and the USAID | DELIVER Project, the initiative focuses on identifying common, priority CS- related issues and designing and implementing regional- and country-level interventions to help achieve CS in an efficient and equitable manner. Achieving contraceptive security requires political commitment from national governments, strong supply chains, adequate country financing to procure commodities, private sector involvement, the ability to plan for the longer term, and the local capacity to develop and implement CS strategies. To fulfill these requirements, USAID assistance emphasizes the implementation of country action plans and regional strategies in four key areas: procurement and pricing, logistics systems, market segmentation, and political commitment and leadership. The LAC CS Initiative has targeted activities in eight focus countries: Bolivia, Dominican Republic, El Salvador, Guatemala, Honduras, Nicaragua, Paraguay, and Peru. The initiative was launched in Managua, Nicaragua, with a gathering of more than 70 representatives from nine countries. Participants came together to foster south-south collaboration and identify effective strategies to achieve contraceptive security. They also facilitated the formation of national CS committees to spearhead and coordinate local efforts to achieve CS. Over the next five years, three additional regional meetings were held to (1) facilitate the creation of country action plans and regional strategies for achieving CS (Peru, 2004); (2) provide training on advocacy and action plan development (Guatemala, 2006); and (3) address CS and the logistics cycle (Dominican Republic, 2007). Key ApproAches And Activities In support of the LAC CS Initiative, the Health Policy Initiative has employed six key approaches in implementing its activities to date: Contraceptive security (CS) is achieved when individuals have the ability to choose, obtain, and use high-quality contraceptives, including condoms, whenever they need them. sAFeGUArdinG contrAceptive secUrity in LAtin AMericA And the cAriBBeAn October 2008 Forming and strengthening the capacity of national cs committees. The Health Policy Initiative helped to establish and strengthen multisectoral CS committees in seven countries: Bolivia, Dominican Republic, El Salvador, Guatemala, Honduras, Nicaragua, and Paraguay. Comprising representatives of the ministries of health, social security institutions, NGOs, and international agencies, CS committees function as catalysts for advocacy and action on CS issues. Over the past five years, they have been instrumental in achieving progress toward CS goals in the LAC region by raising awareness about the importance of CS, advocating for policy improvements, and developing and implementing action plans to improve CS. They have helped governments, donors, and NGOs analyze FP markets and demand, forecast contraceptive needs, improve logistics systems, develop CS strategies, carry out policy analyses, and advocate for policy change and greater political commitment—all of which contribute to contraceptive security. promoting supportive policies and sustainable financing mechanisms. Ensuring funding for family planning through the establishment of sustainable financing mechanisms is essential in achieving CS. As a result of the joint efforts of the Health Policy Initiative and CS committees, several countries have instituted policies that safeguard funding for FP. Some countries have created earmarked taxes and protected budget line items for contraceptives; expanded social security systems and other health insurance schemes to include FP in their benefits packages; or designed strategies that target FP resources toward the poorest, most underserved populations. providing data for decisionmaking. Accurate, relevant data are the underpinnings of successful advocacy and policy planning. To support the efforts of CS committees and national governments, the Health Policy Initiative provided tools for data analysis, as well as training in the collection and use of data. Strategic Pathway to Reproductive Health Commodity Security (SPARHCS) assessments helped countries identify their priority CS issues. Market segmentation analyses revealed inequities in service provision and provided evidence to help CS committees match providers with contraceptive users by income group. A regional study examining the legal and regulatory environment for contraceptive procurement and the price structure of commodities provided CS committees with information to assist in using alternative procurement options to obtain the best prices for commodities. exploring alternative procurement options. For LAC countries that are or will soon have to procure contraceptives with government funds, identifying alternative sources for procuring high-quality commodities at appropriate prices is critical. The Health Policy Initiative assessed various procurement strategies and mechanisms, providing CS committees and governments with clear guidance on commodity requirements and steps for initiating procurement, maximizing its efficiency, and obtaining optimal prices. As a result, countries have made important advances in procurement, including establishing formal mechanisms to procure contraceptives through the United Nations Population Fund (UNFPA) and employing innovative options, such as partnering with private international suppliers or procuring jointly with the ministries of health and social security. engaging civil society. The formation of multisectoral CS committees has brought civil society groups—including FP associations, NGOs, and other stakeholders—into the heart of the FP policymaking process. Their participation has provided policymakers with a more comprehensive view of the public’s FP needs and priorities, fostered critical momentum for achieving CS goals, and kept the needs of the poor and marginalized communities high on the policy agenda. “In spite of the number of transitions within the Ministry of Health, the commitment of the CS committee has continued. I believe in part because of the impulse USAID has given to the issue.” - NGO Representative Rural health leaders and midwives view contraceptive methods during a reproductive health workshop in the rural village of Hormiguero, Nicaragua. © Katie Richey, Courtesy of Photoshare. Addressing cs in the context of health sector reform. Many countries in Latin America are reforming their health systems through decentralization. To sustain progress toward contraceptive security, it is essential to consider how the reform process will affect CS-related interventions and mechanisms. The Health Policy Initiative has helped decentralizing countries to assess the logistics cycle and identify key CS issues. In addition, the project has created a practical guide that equips policymakers with the information and tools necessary to ensure that CS interventions are closely coordinated with and incorporated into decentralization processes and systems. Key oUtcoMes to dAte As a co-implementer of the LAC CS Initiative, the Health Policy Initiative has contributed to the design and implementation of country-specific CS strategies and helped to advance CS efforts throughout the region. Notable achievements include the following:  The formation of highly active, country- level multisectoral CS committees in seven countries and the design and implementation of country-level advocacy plans, resulting in major advances toward contraceptive security:  In El Salvador, the government signed an agreement with USAID in 2007 to assume increased responsibility for contraceptive financing. Additionally, the MOH and the Social Security Institute gained savings on contraceptive commodities by signing an agreement allowing them to jointly purchase contraceptives through UNFPA.  Honduras established its first budget line item for contraceptives in 2004, and the government is paying for an increasing share of its contraceptive supplies each year.  In 2006, Paraguay passed Law 2907, which stipulates that the Ministry of Public Health and Social Welfare (MSPBS) must pay for all contraceptives and delivery kits required in the country. The MSPBS allocated US$261,753 to purchase contraceptives in 2006 and allocated nearly double that amount in 2007—US$551,000. The government also passed Resolution 598, establishing free provision of all MSPBS-procured contraceptives in public facilities.  In July 2007, the President of the Dominican Republic signed a comprehensive decree establishing the CS committee as the lead government body for contraceptive security and guaranteeing financing for the procurement of all publicly provided contraceptives.  In 2005, the government of Bolivia expanded SUMI—which provides universal, comprehensive, and free services to cover pregnancy-related care—to include FP and reproductive healthcare.  In 2006 and 2007, the CS committee in Nicaragua successfully advocated for government allocations of US$110,000 to purchase contraceptives through UNFPA.  The establishment of an increased number of funded budget line items to finance contraceptives as donations are phased out.  The increased use of UNFPA and other procurement options to overcome local procurement constraints and obtain high- quality contraceptives at competitive prices.  The identification of country-specific priorities for logistics system improvements in collaboration with local partners. MovinG ForwArd While there is still much work to be done, the activities of the Health Policy Initiative have already contributed to the emergence of a more favorable policy environment for CS in the LAC region, particularly for poor and underserved populations. Moving forward, safeguarding contraceptive security will require additional focus on several areas:  Maintaining CS advances in decentralized and integrated settings  Meeting the FP/RH needs of the poor CS Committee El Salvador, during swearing in ceremony with Minister of Health. © 2007 El Salvador Ministry of Health. English only.  Increasing private sector involvement  Overcoming ongoing political challenges  Obtaining adequate and sustainable financing for the purchase of contraceptives  Sustaining the CS committees To support countries as they t a mobile health continue to refine their strategies productive health for achieving contraceptive security, rs of marginalized in the Dominican the Health Policy Initiative, elen Hawkings, share. the POLICY Project, and the DELIVER Project prepared a series of publications on CS topics to serve as resources. A full list of resources is available on CD-ROM from the Health Policy Initiative. recoMMended resoUrces Documents are available in both English and Spanish unless otherwise noted. health policy initiative Available at  Mobilizing Political Support and Resources for Family Planning in a Decentralized Setting: Guidelines for Latin American Countries. Available in English and Spanish.  Exploring Longer-Term Options for Sustainable and Efficient Contraceptive Procurement in Central America. Forthcoming.  Contraceptive Procurement in Peru: Diversifying Suppliers. Forthcoming.  Achieving the MDGs: The Contribution of Family Planning: Bolivia, Dominican Republic, El Salvador, Guatemala, Honduras, Nicaragua, Peru. 2007.  Using Data and Information to Advance Contraceptive Security in Latin America and the Caribbean. 2007.  How Data and Information Contribute to Contraceptive Security (Summary Brief). 2007.  Contraceptive Security Committees: Their Role in Latin America and the Caribbean. 2007.  The Challenge of Family Planning Supplies in Latin America: How Contraceptive Security Committees Are Making a Difference (Summary Brief). 2007.  Approaches that Work: Health Equity. 2007.  Making Family Planning Part of the PRSP Process: A Guide for Incorporating Family Planning Programs into Poverty Reduction Strategy Papers. 2007. Available in English and French only.  Increasing Access to Family Planning Among the Poor in Peru: Building on Strengthening Financing Mechanisms for the Poor. 2008. Available in  A Multi-tiered Approach to Meeting Family Planning Needs of the Poor in Peru (Summary Brief). 2008. Available in English only. poLicy project Available at  SPARHCS—Strategic Pathway to Reproductive Health Commodity Security. INFO Project, Center for Communications Programs, Johns Hopkins Bloomberg School of Public Health. 2004.  Lessons Learned From Phaseout of Donor Support in a National Family Planning Program: The Case of Mexico. 2005. Available in English only.  The Procurement Options Study: Contraceptive Procurement in Costa Rica. 2008. Available in English only.  The Procurement Options Study: Contraceptive Procurement in Mexico. 2008. Available in English only. health policy initiative and deLiver Available at  Options for Contraceptive Procurement: Lessons Learned from Latin America and the Caribbean. 2006.  Contraceptive Procurement Policies, Practices, and Options. 2006.  Country reports available for Peru, Bolivia, Paraguay, Nicaragua, Honduras, Dominican Republic. Reports for Guatemala, Ecuador, and El Salvador available in Spanish only. poLicy project and deLiver Available at  Regional Contraceptive Security Report: Latin America and the Caribbean. 2004.  Contraceptive Security in Paraguay: Assessing Strengths and Weaknesses. 2004.  Country reports are also available for Nicaragua, Honduras, Peru (2003), and Bolivia (2003). A young family visi clinic that offers re services to membe rural communities Republic. © 2006 H Courtesy of Photo For more information, please contact: USAID | Health Policy Initiative, Task Order 1 Futures Group International One Thomas Circle, NW, Suite 200 Washington, DC 20005 This brief was produced for review by the U.S. Agency for International Development. It was prepared by staff of the Health Policy Initiative, Task Order 1. The views expressed in this publication do not necessarily reflect the views of USAID or the U.S. government. The USAID | Health Policy Initiative, Task Order 1, is funded by the U.S. Agency for International Development under Contract No. GPO- I-01-05-00040-00, beginning September 30, 2005. Task Order 1 is implemented by Futures Group International (formerly Constella Futures), in collaboration with the Centre for Development and Population Activities (CEDPA), White Ribbon Alliance for Safe Motherhood (WRA), Futures Institute, and Religions for Peace.

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