Synthesis Report: UNFPA Global Programme to Enhance RHCS: Mid-Term Review (2012)

Publication date: 2012

Synthesis Report UNFPA Global Programme to Enhance Reproductive Health Commodity Security Mid-Term Review Final draft (version 2) January 11th 2012 UNFPA Authors: Adrienne Chattoe-Brown, Olivier Weil and Meg Braddock UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report 281664 JC 01 1 D Document3 05 October 2011 Synthesis Report UNFPA Global Programme to Enhance Reproductive Health Commodity Security Mid-Term Review Final draft (version 2) January 11th 2012 UNFPA Authors: Adrienne Chattoe-Brown, Olivier Weil and Meg Braddock HLSP, 10 Fleet Place, London, EC4M 7RB www.hlsp,org 281664//Synthesis report final draft V2/11th January 2012 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report The team would like to thank Commodity Security Branch in UNFPA, and other UNFPA staff in New York, the regional offices and case study countries who were so helpful with the field work and supplementary data gathering for this mid term review. This report was written by Adrienne Chattoe-Brown, Olivier Weil and Meg Braddock with Dan Whitaker, Yasmin Hadi, Derek Gunby, Jody Tate and Nicolas Avril. This document is issued for the party which commissioned it and for specific purposes connected with the above-captioned project only. It should not be relied upon by any other party or used for any other purpose. We accept no responsibility for the consequences of this document being relied upon by any other party, or being used for any other purpose, or containing any error or omission which is due to an error or omission in data supplied to us by other parties. This document contains confidential information and proprietary intellectual property. It should not be shown to other parties without consent from us and from the party which commissioned it. Acknowledgements 281664/ Synthesis report Final draft V2/ 11th January 2012 1 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report Chapter Title Page 1 Key recommendations and conclusions 4 1.1 Introduction ________________________________________________________________________ 4 1.2 The Programme approach to reproductive health commodity security ___________________________ 4 1.3 What has the GPRHCS achieved to date? ________________________________________________ 5 1.4 Are the interventions and approaches of the GPRHCS likely to lead to better RHCS? ______________ 6 1.5 The impact of Programme design on progress towards outputs and outcomes ____________________ 9 1.6 Programme contribution to achievement of outcome and goal level results at country level. _________ 10 1.7 Priority programming areas until 2013 __________________________________________________ 14 2 Introduction 16 2.1 Purpose of the review _______________________________________________________________ 16 2.2 This report ________________________________________________________________________ 16 2.3 A brief overview of the Programme _____________________________________________________ 16 2.4 Scope of the review ________________________________________________________________ 18 2.5 Methodology of the review ___________________________________________________________ 19 3 Country level findings 21 3.1 Whether the GPRHCS meets the needs of the countries ____________________________________ 21 3.2 How the GPRHCS has contributed to advancing the monitoring of national programmes ___________ 44 3.3 The efficiency of GPRHCS implementation at country level __________________________________ 47 4 Global and regional level findings 52 4.1 Introduction _______________________________________________________________________ 52 4.2 How regional and global activities of the GPRHCS have enhanced country level work _____________ 53 4.3 Awareness raising __________________________________________________________________ 58 4.4 Resource Mobilisation _______________________________________________________________ 61 4.5 The effectiveness of the bottom up approach to management and internal coordination of the GPRHCS. ________________________________________________________________________ 69 4.6 The extent to which the monitoring framework and system meets the needs of the GPRHCS ________ 72 Annex 1: Terms of Reference 76 Annex 2: Programme Monitoring Framework 85 Annex 3: Summary of Progress against the MF for Case Study Countries 88 Annex 4: Input Diagram 93 Annex 5: List of People Interviewed 94 Annex 6: Bibliography 97 Annex 7: Global Level Awareness Raising Activities 109 Contents 281664/ Synthesis report Final draft V2/ 11th January 2012 2 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report List of tables Table 1 Contraceptive prevalence rate in Stream one countries with new data __________________________ 11 Table 2 Percentage of service delivery points (SDPs) offering at least three modern methods of contraception in GPRHCS Stream 1 countries _________________________________________________________ 11 Table 3 Percentage of SDPs with five life-saving maternal/RH medicines (including three UNFPA priority medicines) available in GPRHCS Stream 1 countries ______________________________________ 12 Table 4 Percentage of SDPs reporting ‘no stock-out’ of contraceptives within the last six months in GPRHCS Stream 1 countries _________________________________________________________________ 12 Table 5 Trends in donor expenditure by commodities, 2005 – 2009, in millions of USD ___________________ 13 Table 6 Expenditure by the Programme USD ___________________________________________________ 18 Table 7 Summary of case study findings: alignment ______________________________________________ 22 Table 8 Summary of case study findings: national coordination mechanisms ___________________________ 26 Table 9 Case study commodity expenditure 2008 – 2010 __________________________________________ 31 Table 10: Summary of case study findings: capacity building activities _________________________________ 33 Table 11 Provision of contraceptives and CYP 2009 and 2010 _______________________________________ 38 Table 12 Spending on RH drugs 2009 and 2010 (USD) ____________________________________________ 42 Table 13 Summary of case study findings: monitoring of national programmes __________________________ 44 Table 14 Summary of case study findings: efficiency of GPRHCS implementation ________________________ 47 Table 15 Summary of case study findings: global and regional support to countries _______________________ 54 Table 16 Donor support and Secretariat expenses ($m) ____________________________________________ 64 Table 17 IERD budget at UNFPA headquarters level, 2007-10 _______________________________________ 65 Table 18 Travel cost for Donors’ meeting, 2008-10 ________________________________________________ 65 Table 19 Variation between GPRHCS funding and expenditure, 2007-2010 ($m) ________________________ 67 Table 20 Growth in Resource Mobilisation, various elements of UNFPA _______________________________ 67 Table 21 Global donors to reproductive health commodities ($m) _____________________________________ 68 Table 22 Summary of case study findings: experiences with the Monitoring Framework ___________________ 72 281664/ Synthesis report Final draft V2/ 11th January 2012 3 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report APRO Asia Pacific Regional Office AWP Annual work plan CCP Commodity manager CO Country office CSB Commodity Security Branch CYP Couple years of protection DHS Demographic health survey EAC East African Community EMOC Emergency obstetric care FHCI Free Health Care Initiative, Sierra Leone FP Family planning GFATM Global fund to Fight AIDS Tuberculosis and Malaria GPRHCS Global Programme to Enhance Reproductive Health Commodity Security HMIS Health management information system IGAD Inter-Governmental Authority on Development IPPF International Planned Parenthood Federation IPs Implementing partners IUD Intra-uterine device LAC Latin America and the Caribbean LMIS Logistics management information systems M&E Monitoring and evaluation MCH Maternal and child health MF Monitoring framework MHTF Maternal health thematic fund MoH Ministry of health MSI Marie Stopes International PMNCH Partnership for Maternal Neonatal and Child Health PRS Poverty reduction strategy RH Reproductive health RHB Regional Health Bureau RHC Reproductive health commodities RHCS Reproductive health commodity security RHSC Reproductive Health Supplies Coalition SRH Sexual and reproductive health SRHC Sexual and reproductive health commodities TA Technical assistance TA ToRs Terms of reference TMA Total market approach WAHO West African Health Organisation WCA West Central Africa - Regional Office Acronyms 281664/ Synthesis report Final draft V2/ 11th January 2012 4 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report 1.1 Introduction This is the final report of the mid term review of the UNFPA Global Programme to enhance Reproductive Health Commodity Security (GPRHCS). A brief overview of the Programme is provided at section 2.3. Terms of reference for the review are attached at Annex 1. The purpose of the review is to: � Assess the relevance, effectiveness and efficiency of the current strategies and approaches designed to improve RHCS, as financed by the GPRHCS � Assess the coordination, management and support from UNFPA global and regional levels to national level efforts The conclusions of this review will inform design of the programme for the next phase and should also encourage some developments within the current one. This report is a synthesis of findings from fourteen1 country case studies, interviews at global and regional level with UNFPA staff and stakeholders, and extensive literature review. It is therefore a strategic document dealing with principles of the Programme and high level design issues. The individual case studies reflect more closely on experiences and country level conclusions, in so far as their scope allows. (see also section 2.4, Scope of the review). This section of the report summarises key recommendations and conclusions and refers readers to the main report for further explanation where necessary. Section references are explained in the text or in brackets. 1.2 The Programme approach to reproductive health commodity security The GPRHCS defines reproductive health commodity security as a state in which all individuals can obtain and use affordable, quality reproductive health commodities of their choice whenever they need them. These commodities include equipment, pharmaceuticals and supplies for obstetrics and maternal care, STIs, abortion services, and contraception. The Programme aims to address both supply and demand side aspects of RHCS. This includes the supply, selection, financing and procurement of commodities, their distribution, the abilities of providers to administer them, the removal of access barriers, and the demand of current and potential users. The GPRHCS is designed to move beyond ad hoc responses to stock outs of essential RH commodities to more predictable, planned and sustainable country driven approaches for securing and using essential RH supplies. The Programme is intended to galvanise, institutionalise and facilitate coordination of national _________________________ 1 Stream One: Mongolia, Sierra Leone, Madagascar, Ethiopia, Burkina Faso, D.R. Lao and Nicaragua. Stream Two: Ghana, Zambia, Lesotho, Benin, Liberia, Nigeria and Uganda 1 Key recommendations and conclusions 281664/ Synthesis report Final draft V2/ 11th January 2012 5 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report efforts to enhance RHCS. UNFPA frequently refers to it as being a ‘catalyst to facilitate nationally driven efforts to mainstream RHCS’2 The goal of the Programme is universal access to Reproductive Health by 2015 and universal access to comprehensive HIV prevention by 2010 for improved quality of life. The Programme outcome is increased availability, access and utilization of RHCs for voluntary family planning, HIV/STI prevention and maternal health services in the GPRHCS focus countries. A more detailed overview of the Programme is at section 2.3. 1.3 What has the GPRHCS achieved to date? The Programme has successfully set up country level building blocks for reproductive health commodity security (RHCS): � Coordination committees are in place in most countries and function reasonably well, particularly on operational issues. (Table 8 and section 3.1.2.1 RHCS coordination committees ) � RHCS is embedded in key national strategies such as the health sector strategies, poverty reduction strategies (PRSs), and STI/HIV/AIDS. In several countries it is also included in gender mainstreaming strategies. (Table 7 and section 3.1.1.1 Alignment with policies and strategies) � RHCS strategies are in place in most countries, and are being implemented. (ibid) � With only three exceptions countries have made no ad hoc requests for supplies during 2010 (Annex 3: Summary of Progress against the MF for Case Study Countries � Logistics management information systems (LMIS) are being developed everywhere. (and section 3.1.4.1 Scope and focus of Programme activities) � Essential reproductive health (RH) commodities are included on essential medicines lists, with only a few commodities omitted in some countries. (Annex 3: Summary of Progress against the MF for Case Study Countries In some countries the programme has successfully advocated for increased government funding for reproductive health commodities (RHCs). (Annex 3: Summary of Progress against the MF for Case Study Countries The Programme has mobilised considerable and increasing donor funds for RHCS. (4.4.1.1 Scale of funds) Reports against the monitoring framework (MF) indicate that integration into UNFPA and the wider UN is proceeding well. (Annex 3: Summary of Progress against the MF for Case Study Countries Commodity Security Branch in New York has designed a programme which has good country reach and enough flexibility to enable many country priorities to be addressed. Programme management systems are in place, Country and Regional Offices have staff who are committed to RHCS, and a monitoring framework (MF) has been developed. At global level there is active engagement with key partners on RHCS. (4.3.2 Activities to date) _________________________ 2 Programme document: Global Programme to enhance Reproductive Health Commodity Security, United Nations Population Fund, 2008, p18. 281664/ Synthesis report Final draft V2/ 11th January 2012 6 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report UNFPA has established itself as a global and country level player in RHCS 1.4 Are the interventions and approaches of the GPRHCS likely to lead to better RHCS? 1.4.1 Positive approaches In the following areas the GPRHCS interventions are likely to lead to better RHCS and should be continued: The country level building blocks outlined above are necessary elements in establishing national RHCS commitment and capability. The Programme has made good progress in these areas. Alignment with national policies and strategies is good. This implies a degree of ownership in many countries, and although there is a long way to go to achieve RHCS in most places, this is an important starting point. (3.1.1.1 Alignment with policies and strategies) Many of the capacity building activities address major health systems weaknesses that undermine RHCS. The works on integrated supply chains, procurement and forecasting is particularly important here. (3.1.4.1 Scope and focus of Programme activities) The increases in funding mobilised from donors are essential to contribute to meeting commodity needs. (4.4 Resource Mobilisation). The principle of the Programme that it is based on a country led approach enables it to respond well to developments and opportunities at country level. 1.4.2 Positive approaches which need some modification The Global level has carried out RHCS awareness activities, but more could be done to reach new supporters, and to communicate GPRHCS achievements and aspirations. (4.3 Awareness raising) More efforts are needed to encourage governments to spend their own money on commodities. Ultimately if RHCS is to be sustained countries are going to have to spend more of the resources under their own control on commodities. More systematic information on actual spending by all sectors (donors, public, private, NGO) on both contraceptives and other commodities is needed to develop better strategies at HQ and at country level and to inform advocacy efforts. The MF should be modified to include an indicator which quantifies national expenditure on commodities. This may not be possible for all commodities but it should be possible for contraceptives at least, from procurement information. (4.4.1.3 Government co- financing and the private sector) In federal countries there has been a good start at national level, but activities at sub-national level remain limited despite the important role that states play in RHC resource allocation. More focus on sub-national level is needed, and could be facilitated by HQ and the Regional Offices to ensure cross country learning. This also applies to unitary states where devolved decision making powers affect RHCS. (3.1.1.2 Alignment with structures) 281664/ Synthesis report Final draft V2/ 11th January 2012 7 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report In countries with strong governments the GPRHCS runs the risk of simply providing resources for existing programmes. This may be the most appropriate a course of action for some countries, but in others MoH plans may not represent optimal RHCS strategies for a country, and will not therefore always address key needs. (3.1.1.4 The price of alignment?) There has been insufficient work on the involvement of the non-state sector, which is essential for sustainable RHCS: the GPRHCS has been very focussed on government’s role and capacity in RHCS. There are examples of capacity building for non-government implementing partners and this has been particularly interesting where it demonstrates the potential of the non-state sector to reach segments of the market. However in general the potential role of the non-state sector has been largely unexplored by the GPRHCS at country level, although UNFPA engages with this idea at global level. The review team recommends that more stream one countries are encouraged to explore the potential of the approach. Market segmentation work should be stepped up, working with international partners who are expert in this area. (3.1.4.1 Scope and focus of Programme activities) More analysis of appropriate contraceptive method mix is needed, and country staff’s capacity to tackle this type of strategic issue needs to be strengthened. Staff need to be able to support policy making that addresses the balance between long term and short term family planning methods and the relative costs of methods and brands and which promotes the selection of financially sustainable, as well as appropriate options. The review team appreciates that suitability and acceptability varies according to country context and users, but is concerned that where considerable proportions of GPRHCS funds are spent on large quantities of expensive methods the Programme is effectively limiting access to any family planning method for large percentages of the population who fall outside the limited group who have access to those few more expensive ones. (3.1.5.2, Method mix) The GPRHCS needs to continue its emphasis on capacity building in country. Whilst the flexibility to determine the split between capacity and commodities at country level with guidance from HQ, is a sensible one, the case study countries have fallen short of this, in particular in stream 2. The split for the overall Programme has also not met this target particularly when running costs are deducted from capacity spend. Capacity building is a long term commitment and spending in this area is more difficult than procuring commodities. Countries need continued guidance and support from HQ to try to achieve this split. The review team recommends that the 60/40 guide is maintained as an encouragement to countries to invest more in capacity building. (3.1.3 Split between capacity support and provision of commodities) 1.4.3 Approaches with limited effectiveness Expenditure on commodities to date has been very largely focussed on contraceptives; spending on maternal and child health (MCH) drugs has been low in the countries studied except for Nicaragua. The rationale of UNFPA for focussing on contraceptives is that these are the items most commonly absent from country budgets and which are most reliant on donors. This would seem to be a sensible justification. This prompts the question however whether, given its relatively low level of engagement on maternal health commodities, and indeed maternal health issues (beyond family planning) in country, and the fact that maternal health is a much more high profile area for donor support and national political commitment, the Programme should continue to include non-contraceptives in its scope. The definition of RHCS used by the Programme includes maternal health (see Box 1) but it does not have to. The Programme could focus on contraceptives only which have long been a relatively neglected area. UNFPA HQ however is convinced that it should not do so, and that an integrated definition of commodities is essential to ensure 281664/ Synthesis report Final draft V2/ 11th January 2012 8 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report their security. UNFPA also maintains that the Programme has an important advocacy role in addressing all essential maternal health commodities even when Programme resources do not permit financial support. The review team believes however that based on actual practice to date, and within current resources, an attempted Programme focus on all commodities is overambitious. (3.1.5.3 Spending on other commodities). There is a similar issue with the scope of capacity building activities. The Programme has been funding some general sexual and reproductive health (SRH) and maternal health capacity building work in areas such as improving service protocols, improving infrastructure and equipment for SRH and MCH service provision, providing ambulances, training for service providers and demand creation for SRH and safe motherhood services. Many of these activities are not specific to RHCS but could be seen to be part of family planning or maternal health programmes. The justification from UNFPA for including them is that in order to achieve RHCS as defined by the Programme (in Error! Reference source not found.) it needs to address a very wide range of issues including, as discussed in section 2.3 (A brief overview of the Programme), demand as well as supply side constraints. The difficulty is that in practice, the activities funded by the GPRHCS are drops in the ocean compared to what needs to be done in all these areas in the participating countries. The review team therefore believes that the Programme outcome (increased availability, access and utilization of RHCs for voluntary family planning, HIV/STI prevention and maternal health services in the GPRHCS focus countries) will only be achievable in some very limited areas in some target countries. Moreover many of the interventions funded in general SRH capacity building work were small scale and may not have had the catalytic impact that the Programme hopes for. Country offices are expected to prioritise from the vast range of potential target areas open to them, a difficult task, which the review team was not convinced they did systematically or in a way which is sufficiently based on evidence of priority needs or which interventions might have the most impact. The recommendation of the review team is that if the programme is going to fund such a wide range of activities, then countries need much more support from HQ in analysing their environments, thinking strategically and using programme resources to really lever long term, wide ranging, and sustainable change (3.1.4.1 Scope and focus of Programme activities). The review team found some instances of general SRH activities being transferred to the GPRHCS from another funding stream. The justification from UNFPA HQ and the countries concerned is that other funds are under pressure from many demands, so it makes sense for activities to be covered by the GPRHCS in some instances where they are related to RHCS; this is seen as an organisationally integrated approach to RHCS. The review team however questions the additionality of GPRHCS resources under this arrangement. Moreover the GPRHCS does not have the resources to do all that UNFPA should be doing in other parts of its programme. 281664/ Synthesis report Final draft V2/ 11th January 2012 9 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report 1.5 The impact of Programme design on progress towards outputs and outcomes 1.5.1 Design features which impact positively The fact that the Programme is run by UNFPA ensures good country reach, building on existing relationships with government. At country level the Programme has a very flexible, non prescriptive approach to interventions which supports country level leadership and priority setting. It requires that certain things be put into place (see building blocks above) but allows great flexibility in the choice of interventions that are supported and how they are supported. Countries have to justify their proposals to the regions and the global level but this aids rigour. 1.5.2 Features which need attention The commodity availability surveys have been useful and are appreciated by some governments, but they are expensive and time consuming. Where adequate alternative information would be, or could be available from national LMIS the GPRHCS should use it, especially in stream one countries. Where LMIS cannot give this information UNFPA should still consider the added value of running these surveys in their current form versus their cost and effort. (3.2.2 Conducting surveys) There is not enough emphasis on adherence to national RHCS strategies and plans, and their monitoring. In countries where there was a strategic plan, or a situation analysis, and even just an expanded Memorandum of Understanding with focal areas outlined, the match of eventual activities to the content of these plans was very variable. Although national RHCS strategies exist the review team did not see much evidence that they were being used as a substantive guide to determine either long term or short term planning by the GPRHCS. This may be a reflection of other national priorities emerging, the age of the strategies (the older ones may be less relevant), the quality of the strategies, their failure to develop, or a lack of reference to them after they had been written. . Some of these are valid reasons for departure and it is a strength of the Programme that it enables new priorities to be met without being tied to out of date documents. There are also no regular programme mechanisms for monitoring the implementation of country strategies. (3.1.4.3 Match of activities to plans) GPRHCS needs to work within a medium-term planning framework, especially in countries where government has the capacity to do this, or is already doing it. Regional Offices can support countries in this, and ensure medium-term planning is closely linked to national RHCS strategies and implementation plans. This will necessitate some development and clarification of planning and financing systems with the Programme. (3.3.1 Planning and financial administration) The RHCS advisers in the Regional Offices play a useful role but could make a greater contribution in technical assistance (TA), capacity building and advocacy if more resources were available to them (4.2.2 Overview of support to countries). The GPRHCS sits on a world stage where competition for aid resources is fierce and it needs to be marketed so that it can compete with global funds such as the Global fund to Fight AIDS Tuberculosis and Malaria (GFATM). To do this effectively Commodity Security Branch (CSB) needs to distinguish between 281664/ Synthesis report Final draft V2/ 11th January 2012 10 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report its other on-going functions and future plans and the GPRHCS, taking a more objective view of the opportunities open to the Programme, and how they could be developed (4.3 Awareness raising). 1.5.3 Design features which impact negatively The funding arrangements and planning cycle for the Programme hold up implementation and discourage long term planning in countries. This is due to UN accounting procedures, programme management arrangements, and uncertainties over the timing of donor money which is assured but not delivered to a fixed timetable. (3.3.1 Planning and financial administration) There is poor alignment with countries’ aid coordination systems. The timing of GPRHCS planning and funds flow does not coincide with national cycles in all countries, and the UN requires separate reporting and accounting. GPRHCS commodity funding generally remains outside pooled funds, even when other donors use the pool for commodity procurement, and even in some cases when UNFPA uses it for other funding streams. (3.1.2.3 GPRHCS alignment with national aid modalities) 1.6 Programme contribution to achievement of outcome and goal level results at country level. 1.6.1 Programme performance at outcome level The Programme outcome is “Increased availability, access and utilization of RHCs for voluntary family planning, HIV/STI prevention and maternal health services in the GPRHCS focus countries”. The GPRHCS has made good progress in developing and measuring some useful indicators for the Programme outcome around family planning commodity availability, and uptake and availability of maternal health commodities. Programme indicators at outcome level are as follows: • Average Unmet need for FP (45 countries) • Average Contraceptive prevalence rate of modern methods (45 countries) • No. of stream 1 countries with Service Delivery Points (SDPs) offering at least three modern methods of contraceptives • No. of stream 1 countries where 5 life-saving maternal /RH medicines from UNFPA list is available in all facilities providing delivery services • No. of Stream 1 Countries with Service Delivery Points with ‘no stock outs’ of contraceptives within last 6 months • Funding available globally for contraceptives / condoms 281664/ Synthesis report Final draft V2/ 11th January 2012 11 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report For those stream one case study countries3 where new CPR figures are available since baselines have been set, some progress in CPR is evident as shown in the following table. Table 1 Contraceptive prevalence rate in Stream one countries with new data Country Baseline 2009 2010 Target Burkina Faso 8.6 (DHS 2003) 13.3 (MICS 2006) 13.3 (MICS 2006) 35% (2013) Ethiopia 13.9 (DHS 2005) 30.0 (MOHS) 32.0 (MOHS) 65% (2015) Madagascar 18.0 (DHS 2004) 29.2 (MOHS) 29.2 (DHS 2008-09) 36% (2012) Mongolia 40.0 (RHS) 52.8 (RHS 2008) 52.8 (RHS 2008) 55% (2012) Only Burkina Faso has updated figures (supplied by MoH) for unmet need4. This changed from 31.3 in 2008 to 28 in 2009, and 28.8 in 2010. Stock availability figures were as follows: Table 2 Percentage of service delivery points (SDPs) offering at least three modern methods of contraception in GPRHCS Stream 1 countries Country Baseline 2009 2010 Target Burkina Faso NA 80.4 (2009) 93.5 100 (2012) Ethiopia 60.0 (2006) 90.0 98.0 100 (2010) Laos 96.0 (2006) 91.0 93.0 100 (2012) Madagascar - 30.8 47.8 100 (2012) Mongolia 98.0 NA 93.5 100 Nicaragua 66.6 (2008) 92.0 99.5 100 Sierra Leone - 88.0* 87.2 100 Notes: * Proportion with at least two modern methods available _________________________ 3 The GPRHCS has not reported on CPR for stream two countries in 2010 although the data was gathered. No backdated data was available to the review team for comparison and reporting here. 4 Ditto for unmet need 281664/ Synthesis report Final draft V2/ 11th January 2012 12 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report Table 3 Percentage of SDPs with five life-saving maternal/RH medicines (including three UNFPA priority medicines) available in GPRHCS Stream 1 countries Country 2010* Target Burkina Faso 51.4 Y** Ethiopia 71.6 100 Laos 13 Y** Madagascar 66.6 100 Mongolia 76.8 98 Nicaragua 99.5 100 Sierra Leone 75.5 100 Notes: *Source: GPRHCS 2010 country and related sample survey reports ** National average 80%, Prov: 100%, Dist: 90% HC: 30% Table 4 Percentage of SDPs reporting ‘no stock-out’ of contraceptives within the last six months in GPRHCS Stream 1 countries Country Baseline 2009 2010*** Target Burkina Faso NA 29.2 (2009) 81.3 100 (2012) Ethiopia 60.0 (2006) 90.0 (2009) 99.2 100 (2010) Laos NA 20.0* 36.0 80.0 Madagascar 63.3 (2008) 74.4(2009) 79.6 96.0 (2012) Mongolia 100 100 97.6** 100 Nicaragua 66.6 (2008) 81.0 (2009) 99.7 92.0 Sierra Leone _ 77.0 41.4 100 Notes: * For Lao PDR, the break down were as follows in 2009; national = 20%, provincial hospitals = 50% district hospitals = 19% and health centre = 15% ** 100% in both tertiary and secondary facilities but 92 % in primary facilities ***GPRHCS 2010 country and related sample survey reports With few exceptions these indicators show good improvement, although the likelihood of reaching the individual country targets varies. It should be noted that a standardised approach to data definition and collection was introduced by UNFPA in 2010 so data before this time is not strictly comparable. Given that many of the countries’ activities are focussed on improving supply chain management, and providing commodities it is reasonable to assume a fairly direct relationship between programme inputs and these outcomes, although not all results can be attributed to the Programme. 281664/ Synthesis report Final draft V2/ 11th January 2012 13 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report With regard to Programme influence on Funding available globally for contraceptives / condoms it is difficult to see a clear link between GPRHCS activities and outcomes Although the Programme has made effective efforts to mobilise resources (see section 4.4 Resource Mobilisation) directly to its programme, its influence on mobilisation by other partners is less clear. Table 5 Trends in donor expenditure by commodities, 2005 – 2009, in millions of USD Donors 2005 2006 2007 2008 2009 USAID 68.8 62.8 80.9 68.9 87.5 UNFPA 82.6 74.4 63.9 89.3 81.1 PSI 28.8 30.6 24.9 14.1 17.9 BMZ/KFW 13.1 23.6 24.6 15.5 16.2 DFID 4.6 12.1 22.5 11.1 13.0 Others* 9.6 5.1 6.4 14.9 23.0 Total 207.5 208.6 223.2 213.7 238.8 *Includes IPPF, MSI, Japan, Netherlands and others 1.6.2 The link between Programme outputs and outcome It is difficult to see clear links between Programme output and outcome measures. Most of the countries we reviewed had achieved most of the output indicators and yet none would say that RHCS had been attained (although some would say that it had improved in some specific areas). Moreover most of the output measures focus on procurement, supply and distribution, rather than access and demand. Also there are few outputs indicators dealing specifically with HIV/STI prevention and maternal health services. The review team recommends that UNFPA gives this further attention as discussed with the Programme Coordinator, to ensure that the MF reflects the range of activities supported by the Programme. 1.6.3 Programme performance at goal level As this is a mid term review it is too early to comment on the likelihood of the Programme achieving its goal. 281664/ Synthesis report Final draft V2/ 11th January 2012 14 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report 1.7 Priority programming areas until 2013 1.7.1 Strategic issues The review has identified some strategic areas where GPRHCS needs strengthening and focusing to make a significant and lasting contribution to RHCS in participating countries. These areas of work should be given high priority in the remaining period. Strategic areas include: � Promotion of rational method mix with national ministries of health (MoHs), to ensure availability of a range of contraceptives to the maximum number of users in resource-poor settings, to reduce the vulnerability of supply, and address challenges related to supply and demand. This also needs to reach beyond MoHs to encompass other partners, and is linked to the next point. � Promotion of the total market approach (TMA) and inclusion of the NGO and for-profit private sectors whose participation will be essential for achieving sustainable RHCS, focusing efforts on appropriate market segments for each type of service provider, and ensuring that any free MoH supplies go to those who have no alternatives. � A greater focus on, and development of strategies to increase the domestic contribution to commodity provision and reduce dependence on donors. This includes increasing government contributions and potential for user fees. � Greater support to country offices to help them prioritise capacity building approaches which will ensure maximum programme impact. 1.7.2 Programmatic issues National RHCS strategies and action plans need to be placed at the heart of GPRHCS activities in country. In some countries the Programme operates less as a commonly owned RHCS initiative, and more as another on-going UNFPA programme, without that element of common ownership. The need to revise strategies in many countries as old ones come to their end, coupled with the foundation work that UNFPA has been doing, should present opportunities to increase ownership and refocus on common planning and implementation for RHCS. Engagement with the non state sector must be stepped up, particularly at country level. RHCS will not be achieved without a major increase in its contribution. The MF needs to be revisited. The current MF is a good start and elements of it serve the Programme well, but the lack of country level monitoring is a major omission. Country level monitoring needs to be based as much as possible on RHCS strategies and action plans. Strategies and action plans should be owned by countries and monitoring of them should therefore be a common undertaking. Priorities should be clearly spelt out and the GPRHCS contribution and responsibilities clearly stated, alongside those of other stakeholders. The global MF should still be retained for the GPRHCS as a whole. There should be clear links between the global MF and individual country monitoring of national strategies and plans, with a small number of common indicators, useful to both parties. The MF indicators also need to be reviewed to make sure they reflect the next stages of capacity building. Many of them have been achieved but RHCS has not been achieved. 281664/ Synthesis report Final draft V2/ 11th January 2012 15 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report There are also missing areas in the MF. Government expenditure on RHCs should be better tracked, and the private sector needs to be included. UNFPA needs to address entry, transition within and exit from the programme: � Entry strategies - Country selection for stream one and two is not systematic. The review did not address this directly, and whilst the team appreciates that initial selections were made to provide ‘proof of concept’, and that selecting one country above another is problematic in the UN context, the team believes that that more could be done to make selection criteria more transparent in the future, particularly for admission to stream one. There may also be potential for moving to some form of an application process, which could depend on evidence of commitment and guaranteed future commitment from governments, including commitments of increased funding in the future. Although the team appreciates that UNFPA does not want to raise expectations of countries unduly, opportunities have been missed to enable the GPRHCS to act as a lever. � Transition strategies – it is not clear whether countries are intended to move up the streams from 3 to 1 as their RHCS improves and then back down again as their needs decrease. � Exit strategies – UNFPA needs to be specific about what measurable and agreed conditions (agreed with countries) would enable exit. It would be easier to develop clear exit strategies if the GPRHCS goals were clearer at the start of country programmes, what this was likely to cost and how this achievement could be assessed. We understand that there is discussion between UNFPA and the donors on the targets that could be set to trigger exit and this should be further developed, and that this is being revised in the new version of the Programme document. Another alternative would be to limit the time and resources for each country, which would challenge them to achieve as much as they could within the time and funding available. Definition of individual country exit strategies from the outset would enable UNFPA to plan the entry of future countries to stream one. It would also assist with planning overall resource allocation to the Programme especially between streams. Greater investment in resource mobilisation would be worthwhile, as discussed in section 4.4, Resource Mobilisation. It is likely to yield a significant positive return in increased GPRHCS contributions. UNFPA could promote discussion on the feasibility of setting up an international fund to provide resources for very poor countries which are unlikely to be able to cover their needs for commodities however committed they are to RHCS. Capacity building of UNFPA staff, especially at country level, should be addressed more systematically, and more funding devoted to this. Lack of knowledge and confidence among these staff is affecting the efficacy of the programme. The planning and financing cycle managed by HQ should be addressed to encourage longer term planning. HQ should also engage with donors on the timing of their funding tranches. A communication strategy is needed to raise profile of the programme, communicate better with its supporters, publicise its achievements and support advocacy activities (see also 4.3, Awareness raising). The role of the regions should be strengthened to enable them to play a greater part in capacity building, provision of technical assistance, and advocacy. 281664/ Synthesis report Final draft V2/ 11th January 2012 16 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report 2.1 Purpose of the review This is the final report of the mid term review of the UNFPA Global Programme to enhance Reproductive Health Commodity Security. Terms of reference for the review are attached at Annex 1. The purpose of the review is to: � Assess the relevance, effectiveness and efficiency of the current strategies and approaches designed to improve RHCS, as financed by the GPRHCS � Assess the coordination, management and support from UNFPA global and regional levels to national level efforts The conclusions of this review will inform design of the programme for the next phase and should also encourage some developments within the current one. 2.2 This report This report is a synthesis of findings from fourteen5 country case studies, interviews at global and regional level with UNFPA staff and stakeholders, and an extensive literature review. It is therefore a strategic document dealing with principles of the Programme and high level design issues. The individual case studies reflect more closely on experiences and country level conclusions, in so far as their scope allows. (see also section 2.4, Scope of the review). 2.3 A brief overview of the Programme The GPRHCS is designed to move beyond ad hoc responses to stock outs of essential RH commodities to more predictable, planned and sustainable country driven approaches for securing and using essential RH supplies. The Programme is intended to galvanise, institutionalise and facilitate coordination of national efforts to enhance RHCS. UNFPA frequently refers to it as being a ‘catalyst to facilitate nationally driven efforts to mainstream RHCS’6 The goal of the Programme is universal access to Reproductive Health by 2015 and universal access to comprehensive HIV prevention by 2010 for improved quality of life. The Programme outcome is increased availability, access and utilization of RHCs for voluntary family planning, HIV/STI prevention and maternal health services in the GPRHCS focus countries. Programme outputs are as follows: � Output 1: Country RHCS strategic plans developed, co-ordinated and implemented by government with their partners � Output 2: Political and financial commitment for RHCS enhanced � Output 3: Capacity and systems strengthened for RHCS � Output 4: RHCS mainstreamed into UNFPA core business (UN reform environment) _________________________ 5 Stream One: Mongolia, Sierra Leone, Madagascar, Ethiopia, Burkina Faso, D.R. Lao and Nicaragua. Stream Two: Ghana, Zambia, Lesotho, Benin, Liberia, Nigeria and Uganda 6 Programme document: Global Programme to enhance Reproductive Health Commodity Security, United Nations Population Fund, 2008, p18. 2 Introduction 281664/ Synthesis report Final draft V2/ 11th January 2012 17 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report The Monitoring and Evaluation framework for the Programme is at Annex 2. Annex 3 shows performance of each country studied, against the MF. UNFPA uses a definition of RHCS which encompasses both supply and demand side issues and all RH commodities. See Box 1. The Programme aims to address these aspects of RHCS. This means that it potentially includes provision of all these commodities to all possible users in all participating stream one and stream two countries. This includes the selection, financing and procurement of commodities, their distribution, the abilities of providers to administer them, the removal of access barriers, and the demand of current and potential users. The Programme began in 2007 after extensive consultation with international donors in RH commodities, and other stakeholders in RHCS. The current programme phase will end in 2013. Recipient countries are grouped into three streams according to their engagement with the Programme: � 11 stream one countries receive medium term support of up to USD5m per annum, to be spent on commodity supply, developing political commitment to RHCS and capacity building of national systems that impact on RHCS. Ethiopia, Burkina Faso, Mozambique, Nicaragua and Mongolia have been receiving support since 2007; Madagascar, Laos, Niger and Haiti since 2008; and Mali and Sierra Leone since 2009. Expenditure by this group in 2010 totalled $37.2 million. � A much larger group of stream two countries (34 in 2010) receive some support for commodities and a lesser amount for capacity building. Expenditure by this group totalled $35.4 million in 2010. � Stream three funding covers emergency procurement for countries with weak capacity to plan and manage their commodity procurement. It also covers commodities in humanitarian situations. In 2010, $8,084,053 was spent on contraceptives for stream 3 countries. Expenditure by the Programme on commodity procurement and capacity development as been as follows: Box 1 Reproductive Health Commodity Security – The UNFPA GPRHCS definition Reproductive Health Commodity Security is a state in which all individuals can obtain and use affordable, quality reproductive health commodities of their choice whenever they need them. As UNFPA characterises it, this necessitates the right quantities of the right products being in the right condition in the right place at the right time for the right price. Reproductive health commodities include equipment, pharmaceuticals and supplies for: � Obstetric and maternal health care � Prevention, diagnosis and management of reproductive tract infections and STIs. � Management of complications of unsafe abortion and for comprehensive abortion services where the law permits and also � Contraceptive supplies including male and female condoms, and those for emergency contraception. 281664/ Synthesis report Final draft V2/ 11th January 2012 18 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report Table 6 Expenditure by the Programme USD 2007 2008 2009 2010 Total 07 – 10 Commodities 14,500,000 25,635,786 70,259,604 61,771,480 101,907,266 Capacity Building 3,333,000 1,591,088 16,830,201 31,780,105 53,534,394 Total 17,833,000 27,226,874 87,089,805 93,551,586 225,701,265 Note: Of the capacity development expenditure in 2009 & 2010, 75% went to countries for their activities and local running costs. The remainder included spending by regional offices and the global level, and spending on the Prequalification and Access RH projects. The key inputs to the GPRHCS are: Advocacy to build understanding of and commitment to and funding for RHCS by: � CSB to international partners � Regional offices to regional bodies � Country office to national governments, and other stakeholders / national partners Capacity building to enable better programme implementation by: � CSB for regional and country office staff � Regional offices (and partners) for country office staff, national government staff and other stakeholders / national partners � Country office staff for national government staff and other stakeholders / national partners Technical assistance to support programme implementation in countries by: � CSB through their own staff or other consultants � Regional offices through their advisers or other consultants � Country offices through their staff or other consultants Provision of commodities to support programme implementation in countries by: � CSB providing commodities as requested by country programmes. The logic of the GPRHCS is that these inputs should combine to provide improved understanding of and commitment to RHCS, the capacity to address it, and the wherewithal (in the form of commodities) to meet RH needs, which should lead to meeting the GPRHCS Outcome (Increased availability, access and utilization of RHCs for voluntary family planning, HIV/STI prevention and maternal health services in the GPRHCS focus countries ) and thus the Goal (Universal access to Reproductive Health by 2015 and universal access to comprehensive HIV prevention by 2010 for improved quality of life). The link between inputs and outputs is illustrated schematically in the diagram in Annex 4. 2.4 Scope of the review This mid term review focuses primarily on: � Whether the Programme inputs are the right ones in terms of country needs and priorities, and GPRHCS goal and outcome (relevance). � Whether these are showing signs of having a positive effect (effectiveness). The ToRs for the review are extremely wide and when these were unpacked further it was agreed between UNFPA and HLSP that full exploration of all the questions would be unmanageable within the time available. We therefore agreed on 16 questions which encompassed the key points in the ToRs. 281664/ Synthesis report Final draft V2/ 11th January 2012 19 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report Overarching questions for the review7: 1. Are the interventions and approaches that the GPRHCS is supporting likely to lead to better RHCS? 2. How has Programme design affected progress towards outputs and outcomes? 3. How has the GPRHCS advanced RHCS to date? 4. What is the Programme contribution to date to achievement of outcome and goal level results? 5. How could the GPRHCS be made more effective? 6. What are the priority programming areas for the GPRHCS as a whole until 2013? The relevance of the GPRHCS to existing country needs and approaches: 7. Does the programme address the right needs in the country? 8. How have regional and global aspects of the GPRHCS enhanced country level work? The effectiveness of selected inputs: 9. How have global level activities of the GPRHCS helped to raise awareness of RHCS? 10. How have global level activities of the GPRHCS helped to increase resources for RHCS? 11. How effective have country level interventions been in terms of achieving their objectives (referring to the four MF outputs as they apply at country level)? 12. How has the GPRHS contributed to advancing the monitoring of in-country programmes? 13. To what extent does the current M&E system and framework meet the needs of the GPRHCS? 14. How effective has been the bottom up approach to management and internal coordination of the GPRHCS? The efficiency of the Programme: 15. Have countries carried out their interventions in the most efficient way open to them? 16. Have activities been completed to time, as planned? Our assessment of efficiency is limited to qualitative appraisal. Value for money in terms of the costs of outputs and outcomes was not addressed by the original terms of reference (ToRs) and, with UNFPA’s agreement, was not addressed by the team due to resource constraints. 2.5 Methodology of the review In the ToRs UNFPA stipulated that 4 in-depth case studies should be carried out from stream one, namely Ethiopia, Madagascar, Nicaragua and Sierra Leone. Members of the review travelled to those countries to review the programmes and interview the Country Office and stakeholders. Prior to the country visits an extensive literature review was carried out. The team also agreed with UNFPA ten others which have been the subject of desk review. From stream one these are Lao, Burkina Faso and Mongolia. From stream two these are Benin, Ghana, Lesotho, Liberia, Nigeria, Uganda, and Zambia. Assessment was based on literature review and a limited number of telephone interviews. The methodology for selection was based partially on a matrix of country characteristics drawn up by HLSP and on the advice of UNFPA who were able to advise on feasibility etc. _________________________ 7 When we came to write this report it became apparent that there was very strong overlap between questions 5 and 6 so they have been reported on together. 281664/ Synthesis report Final draft V2/ 11th January 2012 20 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report Given the diverse nature of the Programme no one country can necessarily be said to be representative of the others. In our selection of countries we tried to capture the range of countries but cannot claim that the set we agreed are representative of the others i.e. it is not a sample. Fourteen individual country case studies have been produced as supplements to this report. Based on the questions agreed with UNFPA an evaluation framework was drawn up. The global and regional level assessment was carried out through a visit to UNFPA HQ, and through extensive phone interviews with CSB staff, regional RHCS advisers, and other stakeholders. A list of interviewees who helped informed the synthesis report is at Annex 5. A bibliography for the synthesis report is at Annex 6. Case study references and interviewees are listed in the respective case study documents. 281664/ Synthesis report Final draft V2/ 11th January 2012 21 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report 3.1 Whether the GPRHCS meets the needs of the countries This question, primarily about relevance of the Programme, was assessed against the following criteria: � The alignment of the GPRHCS with existing and proposed national structures and systems � The alignment of the GPRHCS with national aid coordination mechanisms � The appropriateness of the split between funding to commodities and capacity building � The appropriateness of the capacity building support provided � The appropriateness of the commodities supplied. 3 Country level findings 281664/ Synthesis report Final draft V2/ 11th January 2012 22 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report 3.1.1 Alignment with existing and proposed national structures and systems Table 7 Summary of case study findings: alignment Stream 1 Sierra Leone Madagascar Mongolia Lao Nicaragua Ethiopia Burkina Faso -Sector policy context weak -However GPRHCS integral to delivery and coordination of Free Health Services Initiative -Global Programme (GP) supports efforts to integrate supply chain -Aligned with MoH plans and strategies in SRH and with the action plan for the integration of health commodities -Annual planning for RHCS led by MoH -GPRHCS supports efforts to integrate supply chain -Strategy on RHCS consistent with Sector Strategic Plan -GPRHCS supports national integrated supply chain -RHCS regarded as sufficiently integrated such that no separate RHCS strategy developed -GPRHCS supports efforts to integrate supply chain -RHCS integrated with national SRH policies and plans. -GPRHCS supports and is integrated with national work on integrated supply chain management -RHCS regarded as sufficiently integrated such that no separate RHCS strategy developed -Limited sub- national engagement on RHCS. -GPRHCS supports national integrated supply chain management -Close alignment of GPRHCS with sector policies and strategies. -RHCS strategy in place before GPRHCS (now being further developed). -GPRHCS supports national integrated supply chain management Stream 2 Benin Zambia Liberia Nigeria Uganda Lesotho Ghana -Alignment with MoH priorities. -Leadership by MoH but high reliance on GP. -Issues with alignment of CHANNEL to other existing LMISs. -Not clear if GPRHCS supporting full integration of supply chain management -Closely aligned in terms of priority setting and leadership by MoH. -GPRHCS supporting full integration of supply chain management but possible issues of alignment of CHANNEL with other LMIS system. -Growing commitment to RHCS reflected in recent policies. -National logistics system fragmented. -UNFPA makes some use of it for storage of commodities, but otherwise supply chain vertical -RHCS strategy and activities well aligned. -GPRHCS supports national integrated supply chain management -GPRHCS consults with FMoH on state level support -Activities in line with RHCS strategic plan. -GPRHCS supports national integrated supply chain management -GPRHCS works closely with MoH. -GPRHCS supports national integrated supply chain management -The GPRHCS is closely aligned to the RHCS Strategic Plan which was developed with GPRHCS support. GPRHCS supports integrated supply chain 3.1.1.1 Alignment with policies and strategies In all countries the GPRHCS is well aligned with national policies and strategies. Inclusion of RHCS issues in PRSPs and sector strategies is good and RHCS is also represented in many HIV strategies. RHCS is less present in gender mainstreaming strategies. Clear statements of commitment to RHCS by government officials were made in several countries, and they were able to demonstrate understanding of the concept and the practical implications. Essential RH commodities appear on the essential drug lists of the case study countries with a few exceptions of individual items. In general the GPRHCS has raised the profile of commodity security and effectively placed it on the agenda for all of the countries in this review, at least on paper. 281664/ Synthesis report Final draft V2/ 11th January 2012 23 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report In most countries studied the GPRHCS has played a key role in developing specific RHCS strategies and getting sign off although some had already had strategies in place prior to the start of the Programme (Sierra Leone, Nicaragua and Madagascar). In Laos and Ethiopia, RHCS is deemed sufficiently integral to national policy and implementation such that no separate strategies are required by government but are integrated into existing documents. UNFPA still has influence on the content of these wider strategies however when they are being revised. The Programme has made a good start in instituting RHCS in key policy and strategy documents, either alone or working with other partners such as USAID. It now faces the greater challenge of building capacity to implement them and mobilising government funds. Whilst most of the countries reviewed had budget lines set up for contraceptives, actual expenditure was a problem in many places, and where this did exist several countries were suffering from insufficient and usually static or even decreasing government funds. 3.1.1.2 Alignment with structures Alignment with structures at national level is good in terms of the integration of RHCS coordination committees with government decision making bodies. This is discussed further in section 3.1.1.2 Alignment with structures. In countries with federal structures UNFPA has aligned GPRHCS with central level structures as a first step, with only limited forays to lower levels. Nigeria seems to have had the most comprehensive coverage of its states (see Box 2) whereas in Ethiopia this has been more confined, limited to states where UNFPA has been working already. Where sub-national levels of government have important responsibilities for RHCS it will also be necessary to align the programme with policies, strategies, structures and systems at and state levels. The need to operate effectively at lower levels also applies to countries which are not federal but which have devolved decision-making. In Lesotho, for example, there is an effort by the National RHCS Coordinating Committee, supported by the GPRHCS, to build District RHCS Coordinating Committees and establish District RH Focal persons. 3.1.1.3 Supporting integrated distribution of contraceptives. Prior to the GPRHCS UNFPA’s in country distribution of commodities was largely done through vertical, parallel distribution systems, often funded by UNFPA. UNFPA has now moved away from this approach such that the GPRHCS focuses its attention and resources on building up integrated supply chains. In some countries where some donor driven vertical systems remain (Sierra Leone. Madagascar, Lao) the GPRHCS is endeavouring to work with other partners to bring distribution and LMIS into a common system. In others where that system is in place (Ethiopia, Uganda, Mongolia, Burkina Faso, Lesotho, Nicaragua) the GPRHCS tends to align its capacity building resources to support common distribution and LMIS systems. All the reviewed countries are spending a significant proportion of their capacity building funds on supply chain management. Success in this area will clearly have a positive impact on RHCS. In some countries the review team had concerns that CHANNEL was possibly being inappropriately offered as a suitable LMIS system and its recommendation by UNFPA was not always based on an objective needs analysis at country level or an understanding of the purpose and limitations of CHANNEL. The team was not in a position to objectively assess the facts in support or against this (as it would have taken detailed appraisal of the various LMIS and CHANNEL), but there were enough comments from 281664/ Synthesis report Final draft V2/ 11th January 2012 24 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report stakeholders about the issue that UNFPA should note the concern. The use of CHANNEL is further discussed in section3.1.4.2, 3.1.4.2 CHANNEL. 3.1.1.4 The price of alignment? Although it is important that the GPRHCS support the work of governments the review team has concerns that this has not always allowed sufficient space for the programme to serve the best interests of RHCS. Close alignment of the GPRHCS with national priorities may be appropriate in many cases but MoH plans do not always represent optimal strategies for a country, and will not therefore always address key needs. For example inclusion of the non-state sector in addressing RHCS has not been adequate in any country reviewed. Mongolia, Nicaragua and Madagascar are beginning to investigate a total market approach, but strategic thinking about this issue in other countries has been limited. In the short term the traditional emphasis on UNFPA providing commodities to the state sector for free delivery is narrowing the space for NGOs and the private sector to widen usage through cost recovery. In the long term this is important because the majority of countries will need more involvement of the NGOs and private sector to ensure sustainable RHCS regardless of whether a state supports free distribution of commodities. Full alignment with national structures and systems and integration of GPRHCS annual work plan (AWP) into national plans has also led to lack of focus on the objectives of the GPRHCS itself and lack of ‘space’ to challenge government requests. This has led to country offices to make initial agreement to requests which HQ has not then been willing to support 3.1.1.5 Conclusions and recommendations Alignment with national policies and strategies is good. Alignment with sub-national structures is weaker. Where sub-national levels of government have important responsibilities for RHCS, UNFPA needs to give special attention to alignment with structures and systems at regional and state levels. The GPRHCS global team should consider how they can support Country Box 2 State level activities in Federal countries In Nigeria the GPRHCS is supporting monthly review meetings for state and LGA family planning providers to review RHCS activities. The programme also funds additional quarterly monitoring and supervision visits by joint FMOH and State level teams to states, LGAs and SDPs. These assess how RHCS activities are being implemented. Additional TA is being provided to assist with data collection and compliance with procedures. In Ethiopia the GPRHCS has helped to set up several regional RHCS coordinating mechanisms. These are in the States where the UNFPA Country Programme has a regional coordinator are headed by the Regional Health Bureaus (RHBs). The strong role played by the RHBs in service delivery and financing has the potential to mobilise local partners and increase funding from RHBs for RH commodities, as already demonstrated in some regions. Advocacy and technical support at these levels is therefore crucial to long term RHCS. Ideally such a system should also be instituted at the next level down and in the remaining states. 281664/ Synthesis report Final draft V2/ 11th January 2012 25 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report Office staff in addressing this issue. This may have resource implications in terms of GPRHCS staffing in the larger countries. The GPRHCS is rightly supporting integrated supply and distribution systems but needs to take care that the over promotion of CHANNEL does not undermine this. It should be working with partners to identify the best system available for the country out of the options available (including, but not limited to CHANNEL). Although alignment with government policies and strategies is important this must not be at the expense of optimal strategies for RHCS and its priorities. The review team appreciates that the GPRHCS approach emphasises local level ownership; this is laudable. However UNFPA occupies a unique and influential position in its relationship which governments which give it an authority and license that other development agencies working in this field do not have. The team would encourage UNFPA to ensure that the GPRHCS is operating in the best interests of potential end users. 281664/ Synthesis report Final draft V2/ 11th January 2012 26 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report 3.1.2 Alignment with national aid coordination mechanisms Table 8 Summary of case study findings: national coordination mechanisms Sierra Leone Madagascar Mongolia Lao Nicaragua Ethiopia Burkina Faso -RHCS coordination committee chaired by Ministry of Health. -UNFPA active in donor coordination fora. -GPRHCS not fully aligned to 2011 Health Compact. -Separate activity and financial reporting. -GPRHCS supports national RH coordination committee -UNFPA participates in donors’ coordination fora for health and RH, and HIV. -RHCS coordinating committee reports to national steering committee on maternal and new born health -UNFPA active in donor coordination fora at strategic and technical levels. -Existing MNCH Technical Working Group coordinates GPRHCS -UNFPA involved in the high level Sector Coordination Mechanism. -Coordination committee led by MoH -UNFPA active in donor coordination fora -USD100k p.a. to health basket fund earmarked for RHCS -RHCS indicator in basket fund monitoring -Federal RHCS coordinated by family planning technical working group -UNFPA active in donor coordination fora. -GPRHCS not aligned to GoE preferred aid channels (one plan, one budget, one report). -GPRHCS continues pre- existing RHCS coordination structure. -UNFPA active in donor coordination fora. -GPRHCS funds sit outside sector pooled funds. Benin Zambia Liberia Nigeria Uganda Lesotho Ghana -National coordination not yet in place -UNFPA funding remains outside the pooled fund for commodities but may join in future. -UNFPA active in donor coordination fora. Reproductive Health Technical Committee coordinates RHCS but weak -RHCS TWG reports to National RHCS Stakeholders Committee. -UNFPA active in donor coordination fora. -GPRHCS funds outside sector pooled funds. -Reporting on MoH GPRHCS activities based on UNFPA reports, not MoH’s. -Misalignment with national planning calendar. -RHCS coordinating committee in place and merged with Condom Programming Committee. -UNFPA active in donor coordination fora. -GPRHCS funds outside sector pool. -ICC/CS in place and meets twice a year. -GPRHCS funding not included in pooled fund for budget support 3.1.2.1 RHCS coordination committees Coordination of forecasting, planning, procurement and distribution is crucial for addressing RHCS. The absence of this coordination has been an evident cause of stock outs, over supply, and many other failings in commodity security. It has therefore been one of the key standard activities of the GPRHCS in all its countries, both stream 1 and 2, to try to institute functional coordination mechanisms. It should be noted however that the number of stakeholders to be coordinated and the scope for doing so is much more limited in some places than others. In Sierra Leone UNFPA is the sole provider of contraceptives, whereas in Nigeria USAID, CIDA and DFID also contribute funds. In Madagascar the fact that most donors cannot deal directly with the Government makes coordination of all stakeholders involved in RHCS difficult. 281664/ Synthesis report Final draft V2/ 11th January 2012 27 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report RHCS coordination bodies are in place for all of the countries studied. Either separate coordination entities have been formed focussing only on RHCS, or RHCS coordination activities have been assumed by other coordination mechanisms focussing more broadly on FP or RH (Ethiopia, Lao). All are chaired by MoH personnel of varying degrees of seniority. Some report directly into the MoH and some operate as sub- groups of other MoH led committees. UNFPA participates in (and is a significant player in) all the RHCS committees. The committees usually include donors as well as operational organizations such as MoH and NGOs. Although the GPRHCS regards the coordination committees as a national aid coordination mechanism, the ownership of the committees (ie the ‘national’ element of this term) varies greatly from place to place, partly dependent on commitment but very dependent on capacity. In several countries the mechanism would not exist without the GPRHCS, and in some of those it may not survive beyond the life of the Programme. The committees do however seek to coordinate RHCS activities that are much wider than just those carried out by the GPRHCS, and UNFPA is flexible in its approach to the support it offers and how it thinks the committees should function and be organised. As a consequence there is considerable potential for the committees to be truly national and aligned to other aid coordination arrangements. The effectiveness of the coordination mechanisms varies. Several of them e.g. in Lesotho, Uganda and Zambia, are very dependent on the GPRHCS staff to encourage regular meetings and facilitate their functioning. In several cases (Lesotho, Mongolia, Ghana) the GPRHCS has been used to meet operational costs of the RHCS Coordination Committees, sometimes including travel and accommodation costs for monitoring visits and sometimes meeting the cost of buying a vehicle (Ghana). On the whole the coordination committees are most effective at addressing operational issues such as coordination (or at least exchange of information about availability) of short term funding and technical assistance, facilitating participation in forecasting exercises, encouraging information exchange about campaigns and other activities, and generally improving communication between partners. Given that in most cases funds allocation and programme management are still carried out by each separate donor or organisation the influence of the committees on what each partner should do is generally limited and based more on encouragement than government leadership. However in Ethiopia clear statements of government strategy mobilise support from donor partners and in Nicaragua the committee also has a strong political and technical leadership function. In Sierra Leone and Liberia, the leadership role of the committee is much weaker. The committees are generally not very effective at formulating long term strategy for commodity security beyond the role of the state sector. Nor do they engage in a meaningful way with non-state partners beyond some narrow operational concerns (although the Burkina Faso committee does manage to involve NGOs and address strategic issues). This may be attributable to the obstacle presented to many organisations by MoH providing free contraceptives in all countries. This limits full coordination with donors and other organizations who have their own distribution channels and charge for family planning services and other SRH services (e.g. social marketing organizations, service provision NGOs, etc.). Overall however, in the short term they have improved and formalised coordination with all partners and helped to address some fundamental issues around shipment scheduling and which methods are being procured by whom. The Programme has been right to adopt this approach. The challenge in the next phase is to further institutionalise the capacity to lead the committees, ensure their better functioning, and effectively widen their remit into addressing more strategic issues. 281664/ Synthesis report Final draft V2/ 11th January 2012 28 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report 3.1.2.2 The impact of GPRHCS on UNFPA’s engagement with the wider aid environment In all the countries where this issue was examined, UNFPA senior staff were actively engaged in donor coordination outside RHCS. In many cases this evidently enhanced the work of the Programme, aligning it better to national priorities and ensuring its integration with broad sectoral issues such as improving integrated supply and distribution beyond just contraceptives. UNFPA as an agency was also reported to operate better in the aid environment, because the considerable level of funding, especially in stream one countries, made it a bigger ‘player’, and the flexibility of the funding enabled UNFPA to respond quickly and appropriately to emerging needs. Sierra Leone demonstrates how the GPRHCS has both contributed to and benefited from UNFPA’s profile in aid coordination. 3.1.2.3 GPRHCS alignment with national aid modalities On the whole this is poor in terms of how funds are planned, disbursed and reported on. In the countries where some form of pooled funding exists, GPRHCS funding sits outside these arrangements. The exception is Nicaragua where USD100,000 per year is channelled through the basket fund and earmarked for RHCS (see Box ). Box 3 GPRHCS raising the sector profile of UNFPA In Sierra Leone the President launched the Free Health Care Initiative (FHCI) in April 2010 for pregnant women, lactating mothers, and children under 5, in order to address maternal and child health. This included provision of free drugs. UNFPA took the opportunity to position itself, through the GPRHCS, as a key source of support for FHCI. The Programme has addressed the priority areas of structural rehabilitation of district medical stores, supply chain management, provided contraceptives and some maternal health drugs, installed CHANNEL for all commodities and trained staff in LMIS. UNFPA sits on various coordination fora and technical working groups and has the opportunity to influence its implementation and associated government policy. 281664/ Synthesis report Final draft V2/ 11th January 2012 29 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report In Ethiopia in contrast where the government places great emphasis on ‘one plan, one budget, one report’, the GPRHCS does not use either of the preferred funding channels. And yet the MHTF does, paying USD1m per year into the ‘MDG Fund’ which supports sector priorities and gaps. Moreover it is currently used mostly for international procurement of essential health commodities such as contraceptives. The logic for this inconsistent approach with pooled funding is not clear. There is an argument to say that RHCS is a goal-focused supply-side concept which requires specific activities aimed at covering short-term needs for commodities and medium-term activities to build national capacity and that contributing to a basket fund does not guarantee that these activities or expenditure on commodities will happen. However the extent of the surety offered by a pooled fund depends on how it is designed, how well it functions and how donors engage with it. Certainly pooled funds are used successfully in many places for procurement of commodities. It was not within the scope of this review to assess individual country choices about whether to use the pool or not. But on the whole there seemed to be a reluctance at country level to challenge the perceived design of the Programme, even though there does not seem to be a distinct message coming from CSB against using pooled funds. However the approach of the Programme clearly emphasises that some things need to happen to assure RHCS e.g. coordination committees sent up, strategic plans developed etc, so that maintaining control of funds may seem to countries to be the best way of ensuring these things happen. This may be an appropriate approach for capacity building activities in countries where government capacity is low. However for those countries where effective pooled fund mechanisms are in place, which are already used for commodity procurement by other donors (and even UNFPA) it is inconsistent for the GPRHCS not to use them for commodities and potentially sends out contradictory messages about UNFPA’s faith in the systems they are building up. In terms of reporting on activities and expenditure, all the country programmes require UNFPA standard monitoring reports (ie not specific to GPRHCS) from governments on any activities they carry out with GPRHCS money (except for pooled funds). This places a considerable burden on both the UNFPA office and the recipient government and results in delays to release of funds for subsequent activities. Planning cycles are also determined by UNFPA and are not adjusted to meet national needs. Several of the countries reviewed operated on a July - June cycle whereas UNFPA operates on January – December. As a result there is only a six month window in which financial and activity planning align. These issues are further discussed in 3.3.1 Planning and financial administration. Box 4 Basket funding for RHCS in Nicaragua UNFPA has participated in the basket fund since it started in 2005, but its contribution of US$100,000 p.a. is now being paid by the GPRHCS. This has been used to raise the profile of RHCS with MoH as well as with the other participating donors. The basket fund is significant in Nicaragua as 58% of all donor contributions to MoH are channelled through it. The only earmarked contributions are those of UNFPA which are specifically tied to GPRHCS interventions such as strengthening LMIS. Through involvement in the basket UNFPA has supported inclusion of a specific RHCS indicator (% of health units offering at least 3 modern contraceptive methods) in the MoH reports to the donors. Membership of the basket has been an effective, low cost way to have a voice in a key sector forum and support mainstreaming of RHCS in MoH policy. 281664/ Synthesis report Final draft V2/ 11th January 2012 30 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report 3.1.2.4 Conclusions and recommendations RHCS coordination committees have improved country level coordination on public sector operational matters. Attention now needs to be given to how they can better address more strategic issues, and better engage with other stakeholders. Alignment with national aid modalities is poor in terms of how funds are planned, disbursed and reported on. The GPRHCS needs to consider the use of pooled funds for commodity procurement in some countries, especially those where it is using the pool already. It also needs to review its reporting and planning processes to improve alignment (further discussed in section 3.3.1) 3.1.3 Split between capacity support and provision of commodities The fundamental rationale of the Programme is that provision of commodities contributes to meeting supply needs whilst capacity building has potential for providing more medium term and sustainable solutions. The original Programme document anticipated that the split for stream one and stream two countries would be between 60-40% in favour of either capacity building or commodities. Countries would identify their needs with the support of HQ and the regions, but would be encouraged to aim for this split so that the overall Programme funding was similarly distributed. This estimation does not seem to have been made on the basis of any hard data, but UNFPA did have experience with previous RHCS trust funds where much smaller percentages were spent on capacity building, and it was evident that these needed to increase, whilst at the same time ensuring funds for commodities. The following table shows the split between capacity and commodity expenditure from 2008 – 2010 for the case study countries. The actual range achieved in fact varies widely with expenditure on commodities ranging from 53% to 82% in stream one, and from 71% to 95% in stream 2. The overall commodity expenditure for all stream one countries was 70%, and 85% for stream two. Only four case study countries in the years since 2008 were able to achieve a split between 40 – 60% (Burkina Faso, Nicaragua and Sierra Leone in 2010 and Lesotho in 2009 - 10) although Liberia has come close since 2009, as did Mongolia in 2008. With the exception of Lao in 2010 more than 60% has been spent on commodities by the other countries. However the trend in eight of the countries (Burkina Faso, Lao, Nicaragua, Sierra Leone, Benin, Lesotho,Nigeria and Zambia) has been for the proportion of spending on commodities to be decreasing, ie getting closer to the target 60 - 40%. 281664/ Synthesis report Final draft V2/ 11th January 2012 31 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report Table 9 Case study commodity expenditure 2008 – 2010 COUNTRY 2008 2009 2010 COMMODITY TOTAL Stream 1: Burkina Faso 77% 62% 41% 53% Ethiopia 77% 83% 80% 81% Lao 100% 71% 20% 51% Madagascar 82% 82% 78% 80% Mongolia 67% 72% 75% 73% Nicaragua 95% 88% 51% 82% Sierra Leone 100% 93% 50% 58% Stream 1 Total 74% Stream 2: Benin 100% 94% 78% 88% Ghana 100% 78% 84% 89% Lesotho 100% 60% 56% 71% Liberia 100% 63% 67% 79% Nigeria 100% 100% 81% 86% Uganda 100% 92% 92% 95% Zambia 0% 97% 87% 94% Stream 2 Total 90% Source: data from UNFPA, and from 2010 Progress Report It is easier to spend money on commodities than develop effective capacity building initiatives, which takes time. This can be seen in the way that some stream 2 plans for 2010 and 2011 showed much stronger capacity building elements than previously An appropriate split and resource allocation between the two inputs depends on the conditions in each country, the relative need for short and medium-term support (and an estimation of the costs of each), and on strategic analysis of the sustainability of different approaches to RHCS. 3.1.3.1 Establishing a longer term planning horizon The impression gained is that the eventual split arrived at for each country was acceptable to UNFPA and partner governments at the time. However the assessment of need usually seemed to be a short term decision worked out on the basis of the requirements for the coming year. None of the countries had agreed RHCS plans with budgets for the whole period of funding, and indeed those that had indicative overall sums in their MoUs knew that funding would only become available year on year and that the total amount planned might not materialise. In some countries there was strong leadership from government and long term capacity building e.g. in Ethiopia for procurement and distribution, but the GPRHCS still planned its activities annually. The exception was in Latin America where the regional office had started working with Country Offices in multi-year planning for GPRHCS. Also in Nicaragua the MoH has now 281664/ Synthesis report Final draft V2/ 11th January 2012 32 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report started multi-year planning so the new strategic RHCS plan drawn up by the coordinating committee has done the same. However in most countries short term planning prevailed. It is appropriate that the countries take the lead in specifying the split, but HQ needs to support them to think more strategically. Considerations to be taken into account when thinking strategically about GPRHCS funding to commodities include future commitments from governments, the potential for expanding the role of the private sector, method mix, other sources of funding and the exit strategy of the Programme. These are all difficult issues but the presence of GPRHCS funds for commodities could act as a potential lever for governments to think more strategically about these issues. A good start has been made by the GPRHCS where the Programme has built up forecasting capacity and coordination but more emphasis now needs to be placed on longer term and wider issues. Considerations to be taken into account when thinking strategically about GPRHCS funding to capacity building include the priority needs of the country, the feasibility of the long term strategy for the area (will GPRHCS contributions make sufficient difference?), the country teams’ technical strengths and weaknesses, absorptive capacity, the potential to catalyse other commitments from donors and government, and again the exit strategy of the Programme. Country Offices do seem to think about these issues but only in a short term way and many seem to be stuck on how to move forward. The evidence for this is shown in the lack of long term plans, and some disparate activities which are only funded for a year before being dropped by the Programme. Taking into account these longer term issues may not alter the balance between the two but it will help countries and UNFPA Country Offices make the decision on a strategic basis rather than a short term one. A presentation to the donors in November 2010 proposed a revised split for stream 2 of 30% for capacity building rather than 40-60%. Looking at the evidence above this is closer to current reality but still will push countries to spend more on capacity than they do at the moment. It was suggested that the split remain unchanged for stream 1 which is probably wise 3.1.3.2 Conclusions and recommendations The flexibility to determine the split between capacity and commodities at country level, with guidance from HQ, is a sensible one. This guidance is probably needed in most countries to prevent commodity needs driving out capacity building activities. UNFPA has proposed that there be a new split of 70% (commodities) and 30% (capacity) for stream 2. This favours commodities more than the current split of 60/40 and is closer to actual current spending at least in case study countries. However the review team would recommend that the 60/40 split remains as an encouragement to countries to invest more in capacity building. Capacity building is a long term commitment. At country level the balance between the two needs to be informed by longer term thinking about long term need for both commodities and capacity. 281664/ Synthesis report Final draft V2/ 11th January 2012 33 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report 3.1.4 Provision of appropriate capacity support to government, partners and systems The following table summarises capacity building activities in each of the 14 case study countries. Table 10: Summary of case study findings: capacity building activities Sierra Leone Madagascar Mongolia Lao Nicaragua Ethiopia Burkina Faso -Focus on logistics, demand creation, service provision, and country commodity manager (CCP). -Also cervical cancer screening (of questionable relevance) -Focus on strategic planning, logistics management, & promotion of long term methods -Beginnings of a total market approach. -Also supports regular RHCS activities in MoH -Support focussed on forecasting, procurement, stock control, and monitoring. -Beginnings of a total market approach. -Equipment for emergency obstetric care (EmOC) procured. -Focus on surveys, assessment and operational research, LMIS, and attendance at international advocacy events. -Also demand creation, community empowerment, long term methods scale up, and service delivery. -Focus on developing strategy and budget line, coordination, mainstreaming of RHCS, and LMIS. -GPRHCS funds 4 national staff for LMIS design and programme monitoring. -Initiative to provide capacity building in procurement for an NGO -Focus on supply chain management, scale up of long terms methods, demand creation, repositioning family planning, advocacy and policy, & HMIS. -Activities broadly address coordination, policy and finance, FP service delivery, LM and LMIS, demand creation, M&E; also EmOC -Technical expert in MoH Benin Zambia Liberia Nigeria Uganda Lesotho Ghana -Capacity building focuses on CHANNEL, FP provider training, reducing cultural barriers, community level awareness raising. -Technical expert based in MoH. -No private sector involvement in RHCS -Focus on strategic planning, coordination, information systems and supply chain. However activities increasingly disparate. -Focus on strengthening coordination, country RH supervisors, training service providers, advocacy. -Capacity work dependent on UNFPA RHCS coordinator in MoH. -2010 focus on CCP. 2011 funds to be spent mostly on training FP providers. Also forecasting, logistics & CLMIS training, -Support to procurement, forecasting, and advocacy to increase public spending and to parliamentaria- ns. -RHCS coordinator in MoH. -Focus on RHCS strategy coordination, LMIS, forecasting -Activities in family planning, female condom promotion, Global Fund grant preparation. Implementatio- n of CHANNEL is planned. -Focus on training of family planning providers, forecasting and quantification, logistics systems strengthening, monitoring, coordination and advocacy with politicians and communities. 3.1.4.1 Scope and focus of Programme activities The review team endeavoured to get from each country, expenditure against activities so that they could be grouped and the relative focus on the different areas could be assessed across the board. This proved impossible to do consistently for a variety of reasons so the following statements are based on information from interviews and narrative reports. 281664/ Synthesis report Final draft V2/ 11th January 2012 34 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report A lot of effort in all countries, in terms of time and focus, seems to have been made in the area of supply chain management, including strengthening of central and district stores, equipment purchase, and development of LMIS, often through CHANNEL. This has largely been at national level though some countries are training people further down the system (Burkina Faso, Sierra Leone) and this is expected to expand in some places. UNFPA staff take an active part in forecasting exercises where they exist and in some places have endeavoured to build national capacity to carry this out (Ethiopia, Mongolia). Capacity building in procurement has also taken place (Mongolia, Uganda, Zambia, Burkina Faso). Where possible these activities have generally take place in support of integrated systems as discussed above. All countries have supported or tried to support the development or continuation of RHCS coordination committees as discussed above and several have supported policy and strategy reform pertaining to RHCS. Advocacy for increased national funding has also been a common theme. The review team was convinced that these are key capacity building areas for the GPRHCS and are in line with the MF. The efficacy of individual country approaches is detailed in the case studies. In some countries GPRHCS funds have been used to finance salaries of RHCS advisers or specialists in the MoH. All of these are likely to contribute to RHCS and its medium-term sustainability, although salary payments for technical staff will not be sustainable post-GPRHCS unless the MoH funds these posts itself in the future. In some countries RHCS capacity building has been exclusively directed to government. There are examples of capacity building for non-government implementing partners and this has been particularly interesting where it demonstrates the potential of the non-state sector to reach segments of the market. However in general the potential role of the non-state sector has been largely unexplored by the GPRHCS at country level, although UNFPA engages with this idea at global level. There are examples of total market approaches in Nicaragua and Madagascar, and these could be further rolled out to other countries. Some of the Focal Points were keen to learn more about it and could see potential in their countries, but felt they did not have the experience to raise the issue with government effectively. The team was rather unconvinced that some of the general SRH capacity building work in areas such as improving service protocols, capacity building in adolescent SRH work, improving infrastructure and providing equipment for SRH and MCH service provision (including ambulances and midwifery teaching aids and provision of maternity waiting houses in rural areas), training for service providers and demand creation for SRH and safe motherhood services is the most appropriate form of RHCS capacity building at this stage. Many of these activities are not specific to RHCS but could be seen to be part of family planning or maternal health programmes. The justification from UNFPA for including them is that in order to achieve RHCS as defined by the Programme (in Error! Reference source not found.) it needs to address a very wide range of issues including, as discussed in section 2.3 (A brief overview of the Programme), demand as well as supply side constraints. The difficulty is that in practice, the activities funded by the GPRHCS are drops in the ocean compared to what needs to be done in all these areas in the participating countries. The review team therefore believes that the Programme outcome (increased availability, access and utilization of RHCs for voluntary family planning, HIV/STI prevention and maternal health services in the GPRHCS focus countries) will only be achievable in some very limited areas in some target countries. 281664/ Synthesis report Final draft V2/ 11th January 2012 35 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report Moreover many of the interventions funded in general SRH capacity building work were small scale and may not have had the catalytic impact that the Programme hopes for. Country offices are expected to prioritise from the vast range of potential target areas open to them, a difficult task, which the review team was not convinced they did systematically or in a way which is sufficiently based on evidence of priority needs or which interventions might have the most impact. The recommendation of the review team is that if the programme is going to fund such a wide range of activities, then countries need much more support from HQ in analysing their environments, thinking strategically and using programme resources to really lever long term, wide ranging, and sustainable change. The review team found some instances of general SRH activities being transferred to the GPRHCS from another funding stream. The justification from UNFPA HQ and the countries concerned is that other funds are under pressure from many demands, so it makes sense for activities to be covered by the GPRHCS in some instances where they are related to RHCS; this is seen as an organisationally integrated approach to RHCS. The review team however questions the additionality of GPRHCS resources under this arrangement. Moreover the GPRHCS does not have the resources to do all that UNFPA should be doing in other parts of its programme. 3.1.4.2 CHANNEL In most countries LMIS work has involved installation of CHANNEL and training in its use, although some countries have opted for or already had alternative software systems which suit their needs better. GPRHCS funds have been used to purchase computers for CHANNEL, though they are not exclusively used for the software. In many places where CHANNEL has been installed it is a “work-in-progress”, as the computer system is still used in parallel with manual records and reporting systems. In general CHANNEL is being used only piecemeal for stock control, management decision-making on stock levels, ordering and distribution. One reason for this is that CHANNEL is often incompatible with the software used by central stores, which need invoicing and other financial features which are not included in CHANNEL (e.g. Burkina Faso), and this has caused opposition to the software in some countries. Interface software is currently being developed to solve this problem. Computerisation of the stock control system down to health unit level is not feasible in countries where health units do not have electricity supply (especially common in rural areas). The potential for using mobile phone technology for stock management is being investigated in some countries. If CHANNEL is to make a significant contribution to supply chain strengthening, Country Offices will have to follow-up installation with considerable technical assistance to adapt the programme to country needs where necessary, ensure that it is compatible with existing software systems, that it can be used down to health unit level, and that staff at operational level as well as supply chain managers know how to use the system properly to meet their needs for information and for decision-making on stock levels, distribution, and supply. In some countries UNFPA have embarked on this undertaking. In Sierra Leone for example future supervision of CHANNEL implementation has been promised as part of UNFPA contribution to the development of a new Autonomous Pharmaceutical Procurement and Supply Agency. An important first step in this process will be a more detailed diagnostic of the use and potential of CHANNEL overall and in different countries, and a training programme to ensure that Country Office staff themselves fully understand the software’s functions and potential, and know how it should be used for better management and decision-making on supply chain and stock control issues. This training can then be replicated with national partners including the MoH. A better understanding of the potential and 281664/ Synthesis report Final draft V2/ 11th January 2012 36 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report limitations of CHANNEL may help to address the concerns noted previously in section 3.1.1.3 Supporting integrated distribution of contraceptives. that CHANNEL may have been offered inappropriately in some countries. 3.1.4.3 Match of activities to plans Overall it is worth noting that in countries where there was a strategic plan, or a situation analysis, and even just an expanded Memorandum of Understanding with focal areas outlined, the match of eventual activities to the content of these plans was very variable. This may be a reflection of national priorities emerging, the age of the strategies (the older ones may be less relevant), the quality of the strategies in the first place, their failure to develop, or a lack of reference to them after they had been written. Some of these are valid reasons for departure and it is a strength of the Programme that it enables new priorities to evolve without being tied to out of date documents. However there is no system in place in the GPRHCS to monitor implementation of countries’ strategic plans8 or to encourage review before a new one is due. Nor is there necessarily any alignment between the strategic plans (even the relevant) and the GPRHCS MF. 3.1.4.4 Match of activities to the MF The match between the MF and activities was also variable. Some countries were carrying out activities that they admitted contributed directly to outcome level SRH indicators rather than to RHCS-related outputs and some countries justified many of their activities under the systems strengthening output in a fairly broad way, especially for general SRH systems strengthening. This issue is further discussed in section 4.6. 3.1.4.5 Conclusions and recommendations Many of the activities that the Programme is supporting are appropriate for building capacity in RHCS within the wide definition used by the GPRHCS. However the review team recommend that countries need more support from HQ to analyse their environments, think strategically and use programme resources to really lever long term, wide ranging, sustainable change in RHCS ; i.e. to ensure that Programme interventions are truly catalytic for improved RHCS and not just ‘business as usual’. Several countries’ RHCS strategic plans are due for renewal and this would be an obvious point at which to initiate this exercise, going through a process of situation analysis beforehand (probably best done through SPARCHS). HQ and regional advisors should then include in their support to planning (as discussed in section 4.5 The effectiveness of the bottom up approach to management and internal coordination of the GPRHCS.), reference to the agreed plans to encourage continued strategic thinking. Investment needs to be made by the Programme in ensuring that GPRHCS staff understand the potential and limitations of CHANNEL. This will help it to be offered appropriately. The match of implementation activities to original country strategies and plans is variable. Country Offices need to ensure that these strategies and plans still have stakeholder buy in, and that the GPRHSC supports their implementation. They also need to be properly monitored with the support of, or by the country office. _________________________ 8 In recognition of this the regional office in Johannesburg has recently carried out a review of implementation of strategic plans of those countries within its area. 281664/ Synthesis report Final draft V2/ 11th January 2012 37 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report The match of activities to the MF is also variable. Again this is further discussed in section 4.6. 3.1.5 Provision of appropriate commodities In principle the GPRHCS provides for both contraceptives and other SRH commodities such as emergency obstetric drugs and equipment. In practice in the countries we visited, the vast majority of commodities supplied were contraceptives. The next table shows the provision of contraceptives to the fourteen case studies in 2009 and 2010 by proportion of funds spent, and the CYPs generated. Only Sierra Leone, Madagascar, Mongolia, Nicaragua and Ethiopia (to support implant insertion) supplied other items and with the exception of Nicaragua, these were in small volumes. The rationale of UNFPA HQ for focussing on contraceptives is that these are the items most commonly absent from country budgets and which are most reliant on donors. For stream one countries priority is given to contraceptives, then maternal health drugs and finally equipment. Table 11 Provision of contraceptives and CYP 2009 and 2010 Contraceptives provided 2009 & 2010 Male condoms Female condoms Injectables (2 and 3 month) IUDs OCPs Implants spend CYP spend CYP spend CYP spend CYP spend CYP spend CYP total spend total dollars per % % % % % % % % % % % % $ CYPs CYP Burkina Faso 6 9 0 0.00 16 21% 0.20 6 23 20 55 43% 2,995,940.55 649,128 $ 4.62 Ethiopia 1 2 0 0.00 0 0% 0.00 0 5 6 94 92% 13,848,000.00 2,358,333 $ 5.87 Laos 3 4 0 0.00 69 78% 0.00 0 28 18 0 0% 837,601.92 220,834 $ 3.79 Madagascar 0 0 0 0.00 53 62% 0.18 5 24 18 23 15% 9,417,157.62 2,374,970 $ 3.97 Mongolia 40 27 0 0.00 22 12% 3.70 48 34 13 0 0% 405,896.00 210,283 $1.93 Nicaragua 9 12 0 0.00 41 46% 0.23 6 49 36 0 0% 1,020,660.00 272,042 $ 3.75 Sierra Leone 11 17 11 0.69 14 18% 0.55 16 25 20 38 28% 2,536,810.79 574,744 $ 4.41 Benin 25 39 12 0.78 11 7% 0.46 14 7 6 45% 34% 1,609,405.04 354,867 $ 4.54 Ghana 25 35 3 0.14 51 47% 0.13 3 6 4 15% 10% 2,355,800.00 589,500 $ 4.00 Lesotho 7 11 12 0.79 62 72% 0.00 0 19 16 0% 0% 520,452.66 114,469 $ 4.55 Liberia 0 0 12 0.82 26 37% 0.37 12 57 47 4% 3% 476,550.00 100,017 $ 4.76 Nigeria 39 51 6 0.29 44 24% 0.67 17 4 3 7% 5% 2,230,900.00 586,769 $ 3.80 Uganda 22 27 3 0.13 24 25% 0.79 18 15 10 35% 20% 4,341,344.44 1,253,074 $ 3.46 Zambia 6 15 28 2.92 21 17% 0.17 9 20 25 25% 31% 4,334,928.93 584,917 $ 7.41 Total, stream 1 & 2 12% 18% 7% 0.41% 37% 40% 0.39% 11% 20% 15% 23% 16% 30,087,507.40 7,236,485 $ 4.16 Source: UNFPA The table shows quantities approved by year. Shipment dates may fall into subsequent years. 281664/ Synthesis report Final draft V2/ 11th January 2012 39 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report 3.1.5.1 Overview of expenditure on contraceptives In total, in 2009 and ’10, the GPRHCS spent over USD30m on contraceptives in the fourteen case study countries. Overall, the largest percentage of expenditure in the 14 countries has been on two and three month injectables (14%). Laos (69% of its expenditure) and Lesotho (62%) have been particularly big spenders on this method. This has generated 40% of the total CYP for all countries. The least expenditure overall has been on intra-uterine devices (IUDs): less than one percent of the total has gone to this method despite its very low cost per CYP. All countries, with the exception of Mongolia, spent less than 1% or none of their budget on this method. Several countries have spent on the female condom, in Zambia as much as 28% of total expenditure. However the cost is high per CYP, and in several countries including Benin there are issues with acceptability of the method for the general population. However several country offices (Zambia, Lesotho) have been supporting NGOs to promote the method because of the dual protection it offers. The Ethiopia GPRHCS has been a major supplier of implants to the country, spending 94% of its USD13.8m budget on this method over the two years. Burkina Faso (55%) and Benin (45%) have also spent significant proportions of their budgets on this method. In terms of cost per CYP Mongolia has used its budget most efficiently, spending USD1.93 per CYP. In contrast Ethiopia has spent USD7.41 per CYP. The difference can be explained by Zambia spending 28% of its budget on female condoms, and 25% on implants, but Mongolia generating 48% of its CYP through IUDs, on which it only spent 3.7% of its budget. 3.1.5.2 Method mix It has been difficult to asses whether the mix of methods supplied by the GPRHCS has been appropriate to each country. It was not possible to obtain consistent and comparable information across all countries on current and projected total need, the strategic plan for method mix and how the GPRHCS and other partners have met this need. We have therefore had to rely on non-quantifiable data to draw conclusions in this report Positive indications are that estimates of supplies have usually been reached as a result of a coordinated forecasting exercise involving appropriate partners and with varying degrees of leadership by government. Government is at least nominally in the driving seat even if the reality is, in some places, that its capacity to lead on forecasting is very limited (Sierra Leone, Lesotho). As discussed in section 3.1.2.1 above, forecasting and planning the timing of procurements and shipments between partners have been some of the areas where the RHCS coordination committees have functioned reasonably well. Some UNFPA country offices have reported that the process of forecasting and coordination for contraceptives and other commodities has improved (Sierra Leone, Ethiopia, Lesotho). The review team did however have concerns that the GPRHCS should be doing more to encourage long term strategic thinking in the choice of commodities, in particular the balance between long term and short term and the relative costs of methods. See Box 5. 281664/ Synthesis report Final draft V2/ 11th January 2012 40 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report In several countries (Burkina Faso, Ethiopia, Sierra Leone, Benin, Uganda) a large proportion of GPRHCS funds have been spent on implants. This makes sense in the context of their weak supply chains and the small contribution of the private sector to selling contraceptives. The brand currently supplied, Implanon, is still expensive relative to others on the market despite a recent price drop negotiated by UNFPA and the Supplies Coalition; however cheaper options are not yet available to UNFPA to buy until they are approved by a Stringent Drug Regulatory Authority and / or are pre-qualified by WHO. The limitations placed on UNFPA in terms of the manufacturers from which it can procure protects end users. However this does place a burden on governments and makes it more difficult for them to fund the commodities themselves - this was reported to the review team in one of the case study countries, This implies that UNFPA needs to continue its work with WHO and the Supplies Coalition on pre-qualification and look for other strategies to bring about price decreases. In some of the case study countries UNFPA could also have provided more rigorous analysis to enable governments to plan strategically for long term method mix. UNFPA estimates Implanon to cost USD20 per implant whereas IUDs are estimated to cost 50 cents each for longer protection. Whilst there are insertion and removal costs to be taken into account for each of these methods, and suitability and acceptability varies according to country context and users, and there are many service delivery implications for each, more far reaching analysis of the potential sustainability of a different method mix (both in terms of cost and other factors), in line with existing and future resources, would be of assistance to countries. Box 5 Strategic considerations for method mix Short-term v long-term contraceptive methods In countries with little participation by the private sector and NGOs, governments control procurement and supply chains. With few if any alternative channels the supply system is vulnerable to delays and stock-outs. In these circumstances a rational response to improve contraceptive security for users would be a focus on long-term methods. In countries where alternative supply channels exist (e.g. through the private sector or social marketing), promotion of short-term methods by government presents less risk for some end users who could have access to other sources of supply if the government system fails. Relative costs of different methods and brands To be sustainable, the range of choice and method mix offered to end users must be within the country’s capacity to pay, particularly when family planning services are free in the public sector. It is important to offer users some choice of methods, but it does not make sense in economic or social justice terms to spend a large proportion of scarce financial resources on expensive methods or brands. 281664/ Synthesis report Final draft V2/ 11th January 2012 41 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report The review team is concerned that where GPRHCS funds are spent on Implanon rather than larger quantities of cheaper methods, GPRHCS is effectively supporting the government in limiting access to any family planning method for large percentages of the population who fall outside the relatively small group who have access to Implanon9. Purchase of Implanon has been justified on the basis of offering women the choice of a complete range of family planning methods, but this argument is not valid if free choice for one woman means that as a result others have no choice at all. The GPRHCS should analyse the equity and social justice of requests from government, as well as the feasibility of governments sustaining purchase of expensive methods with their own resources in the future. The aim should be to raise awareness of alternative ways of satisfying the family planning needs of a larger group. As well as ensuring governments are aware of the strategic implications of different method mixes, GPRHCS can support practical steps to promote a more rational mix, such as demonstration projects in some countries (e.g. promotion of IUDs by Marie Stopes International and the International Planned Parenthood Federation affiliate in Burkina Faso, and MSI Madagascar). In some countries IUDs are not promoted because service providers do not know how to insert them, although they are a much cheaper alternative with some important advantages such as rapid return to fertility on removal10. Many other reasons are given for lack of IUD promotion, but demonstration projects have shown that these can be overcome, the principal problem often being service provider bias. GPRHCS should further promote the results of these projects to governments as part of a strategic analysis of contraceptive method mix. It is UNFPA policy to promote a wide range of method choice for women, and this is sometimes interpreted by Country Offices as the need to ensure that all methods are offered to all potential users. However in practice financial and logistical considerations also need to be taken into account. UNFPA needs to take a realistic look at method mix to see how women’s right to a choice of methods can be maintained whilst ensuring that completely free choice for the lucky few does not mean that many others have no access at all, taking into account the need for sustainability in method supply in resource-poor countries. 3.1.5.3 Spending on other commodities In addition to contraceptives, GPRHCS funds have been used to procure a range of other commodities including SRH supplies, MCH supplies, midwifery and obstetric kits and essential medicines (Sierra Leone, Madagascar, Mongolia, Nicaragua and Ethiopia). It has been difficult to obtain clear information on the level and breakdown of spending on these items for the countries studied so we focus here on maternal health drugs, information on which was obtainable from UNFPA HQ. Expenditure on RH drugs for 2009 and 2010 is shown in table 12. _________________________ 9 In 2010 the GPRHCS spent 35% of its total commodity resources on implants which bought only 16% of its CYPs. 10 Creinin, M.D. (1996) Interuterine devices: separating fact from fallacy. Mescape General Medicine 1996:1 (1) Soeprono, R. Return to fertility after discontinuation of copper IUD use. Advances in contraception Vol 4, Num 95-107, pp 95-107 281664/ Synthesis report Final draft V2/ 11th January 2012 42 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report Table 12 Spending on RH drugs 2009 and 2010 (USD) 2009 ($) 2010 ($) Total ($) Stream 1 Burkina Faso 145 145 Ethiopia 120,343 120,343 Madagascar 93,040 93,040 Mongolia 72,075 35,510 107,585 Nicaragua 1,991,493 1,991,493 Sierra Leone 91,325 86,000 177,325 Stream 1 total 2,368,420 121,510 2,489,930 Stream 2 Benin Liberia 51,170 51,170 Niger 21,678 21,678 Stream 2 total 72,848 - 72,848 Stream 1 and 2 total 2,441,268 121,510 2,562,778 Source; UNFPA commodity security branch This total figure of USD2.56m is small in comparison to the USD30.08m spent by the programme on contraceptives in case study countries: it represents about 7.5% of total commodity expenditure11. In some places such as Ethiopia this is because the presence of the MHTF enables a concentration by the GPRHCS on contraceptives. In other countries RH drugs are funded alongside other essential drugs through pooled fund arrangements and / or by other donors and government, motivated by an effort to meet MDG 5. For example the GPRHCS in Mongolia is not continuing its funding of RH drugs in 2011 because the government is taking this on. The review team had concerns that in some countries some GPRHCS funds have been spent on essential medicines which are not solely related to RHCS, although they may be used in MCH and some STI services. For example in Nicaragua a high proportion of spending on drugs has been on essential medicines which are relevant to SRH but are not exclusively used in sexual and reproductive health care, such as amoxicillin. These drug purchases are responses to direct requests from MoH, and are not planned on the basis of the need to ensure commodity security for SRH. The concern of the team is not that a particular UNFPA-supplied drug might be used to treat something other than an RH condition, but whether the total volume of drugs delivered by the GPRHCS means that that an equivalent volume is additionally available for RH treatment on top of what was already available in country. _________________________ 11 The team was unable to get a breakdown of Programme expenditure on commodities other than contraceptives. However expenditure on non-contraceptive commodities was USD7m out of USD70m in 2009 (10%) and USD1.9m out of USD61.7m in 2010 (3%) 281664/ Synthesis report Final draft V2/ 11th January 2012 43 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report Overall the team identified much less engagement with issues of maternal health drug security, and other aspects of SRH such as treatment of STIs; in practice, with the exception of Nicaragua the GPRHCS focus in the case study countries was very much on contraceptives. Some interesting global level led work has been done on maternal health commodities (see section 4.2) but generally contraceptives were much more of a priority for the Programme in the case study countries that we covered. The rationale for the GPRHCS focussing on contraceptives is that these are the items most commonly absent from country budgets and which are most reliant on donors. This would seem to be a sensible approach. This prompts the question therefore whether, given its relatively low level of engagement on maternal health commodities, and indeed maternal health issues (beyond family planning) in country, and the fact that maternal health remains a much more high profile area for donor support and national political commitment, whether the Programme should continue to include non-contraceptives in its scope. The definition of RHCS used by the Programme includes maternal health (see Box 1) but it does not have to. The Programme could focus on contraceptives only which have long been a neglected area. UNFPA HQ however is adamant that it should not do so, and that an integrated definition of commodities is essential to ensure their security; moreover a focus only on FP could be at expense of a wider approach to SRH. The review team believes however that within current resources, the Programme outcome (increased availability, access and utilization of RHCs for voluntary family planning, HIV/STI prevention and maternal health services in the GPRHCS focus countries) will only be achievable in some very limited areas in some target countries. 3.1.5.4 Conclusions and recommendations Limited evidence is available to assess the appropriateness of the method mix supplied to each country. However decisions on the commodities that the GPRHCS is to procure do seem to be arrived at with efforts to put government in the driving seat. At the same time the GPRHCS should be doing more to encourage governments and partners to engage in more long term strategic thinking about choice of commodities, in particular the balance between long term and short term methods, and the relative costs of methods. The Programme needs to consider how to use its limited resources in the most cost effective way to reach the most number of beneficiaries in the most appropriate way, and support governments in developing rational, socially just and sustainable decisions on method mix to reach the maximum number of users with suitable supplies in the future. 281664/ Synthesis report Final draft V2/ 11th January 2012 44 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report 3.2 How the GPRHCS has contributed to advancing the monitoring of national programmes Table 13 Summary of case study findings: monitoring of national programmes Stream 1 Sierra Leone Madagascar Mongolia Lao Nicaragua Ethiopia Burkina Faso CHANNEL adopted but not yet sufficiently operational to improve LMIS. HMIS to be revitalized. Results of the availability survey used by Gov. for planning. CHANNEL adopted but irregularly used. Improved presentation of data through implemen- tation of CHANNEL TA to national procurement and supply system (to make their own software compatible with CHANNEL Government monitoring capacity has deteriorated (political crisis) Improvement of LMIS through provision of computers, installation of CHANNEL, and training potential users. Reinforcing capacity of Medical Supplies Company Surveys on: (i) RHC availability at facility level and (ii) access to key RH services CHANNEL proposed but not adopted by Gov. Some training activities on MF. Development. and extension of LMIS. Adoption by Government of indicators developed by projects. Availability survey used to monitor quality of services. Support to the 2010 DHS. Support to Pharmaceutical Fund and Supply Agency for its automation of LMIS. TA to PFSA in the area of M&E system. Availability survey conducted in 2010 used for monitoring RHC as LMIS not yet operational GPRHCS MF and associate tools not directly applied to in- country M&E CHANNEL being implemented at decentralised level (region and district). However, both Department for Family Health and central medical stores use different softwares. Unlikely CMS adopts CHANNEL. GPRHCS MF does not match with the Gov. M&E system which in addition is poorly functional Stream 2 Benin Zambia Liberia Nigeria Uganda Lesotho Ghana Strengthening coordination mechanisms (which are still not functional). Provision of CHANNEL and training of users. This creates a duplication of LMIS software. Little evidence that GPRHCS contributed to improving the general M&E of country programmes LMIS monitoring visits are being supported through the GPRHCS. GPRHCS has been used to engage a consultant to undertake a baseline survey for the MOH of RH key indicators. TA to the central warehouse to monitor central stocks. Sensitization/ training workshop on CHANNEL. Revision and printing of contraceptives logistics management system tools Improved capacity at central level to use the info provided by the States. Participation in forecasting fora. Monthly review meetings and M&E visits at LG and State levels. Support to LMIS through training and the development of a draft logistics management strategy. Maintains (jointly with USAID) the contraceptive procurement table that sets out the commodity needs and gaps. Support to quarterly field monitoring and supportive field visits. CHANNEL adopted and training underway. Implementation and actual use of CHANNEL at decentralised level likely to be problematic. Capacity building of regulatory bodies aimed to monitor RHCS. Support to supervision visits. Surveys on availability of RHC at facility level. However, stocks are monitored using a tool that was produced under USAID support. 281664/ Synthesis report Final draft V2/ 11th January 2012 45 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report In all countries, strengthening in-country monitoring systems of national programmes has been a key area of the capacity building dimension of the GPRHCS. However, the volume of resources allocated to this area and the nature of the support provided varied from country to country. The table above shows the main activities carried out in this area, in each of the countries. The support provided by the GPRHCS has consisted of long and short-term TA, in-country and international training (including South-South transfers of experience and know-how), provision of computers, supervision, and funding of monitoring and evaluation (M&E) focal points within national entities. The contribution of GPRHCS to monitoring of national programmes depends greatly on the country context, which varies widely. Overall, the three following approaches have been supported: � Strengthening the LMIS � Conducting surveys � Linking monitoring of national programmes with existing HMIS 3.2.1 Strengthening LMIS In all countries, the GPRHCS has been providing support to the LMIS. In most countries efforts have been made to integrate the management of the RH commodities into the national LMIS for essential and generic drugs. However the portion of the logistic and management chain addressed varies among the countries. In all cases, strengthening the LMIS is a useful step towards improving the quality of the information collected and the smoothness of its communication to the entities in charge of programming the purchase and the distribution of the commodities. In many countries GPRHCS has provided resources for training and installation of CHANNEL software for stock control and supply chain management, or for other software systems in countries where CHANNEL is not appropriate. CHANNEL and the other supply chain information systems are focused on the supply side and cannot substitute an inclusive monitoring system. However they do have potential to generate useful data for monitoring supply-side elements of RHCS. To realise this potential additional work will be needed to strengthen MoH capacity for analysis and use of data for monitoring, decision-making and supply-chain management. Strengthening Country Office capacity in this area may be a necessary first step in some countries. In many countries the MoH is aware of the potential to expand systems designed for monitoring SRH supplies to include other health commodities. GPRHCS has been active in promoting this type of integration and raising awareness in the MoH of the potential benefits of RHCS monitoring as a pilot scheme which can be used more widely. 3.2.2 Conducting surveys In countries with major data collection and quality problems, GPRHCS has provided some support to DHS, and where DHS sexual and reproductive health data is insufficient UNFPA funds surveys to collect it (West Central Africa -WCA Regional Office). In addition, in all Stream 1 countries, specific surveys have been funded by GPRHCS to monitor the availability of contraceptives and other essential medicines in health units, this being one of the GPRHCS indicators which is generally not available from national health management information systems (HMISs). These surveys are repeated annually and are expensive. In countries where indicators on stock control are available, the data provided by these surveys do not differ much. In countries with weak government HMIS 281664/ Synthesis report Final draft V2/ 11th January 2012 46 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report systems, the GPRHCS surveys and others carried out by DELIVER are providing the only monitoring data available for RHCS. The surveys’ outcomes are therefore perceived by MoH as a means of monitoring commodity availability, which is one element of service quality, even though this was not their principal purpose. 3.2.3 Linking monitoring of national programmes with existing HMIS Whilst national HMIS can provide timely and reliable data in some places, in others (eg WCA countries) data collection is very infrequent and the information which is collected is unreliable. The GPRHCS’s own monitoring system has been designed to satisfy the programme’s own needs rather than to contribute to development of national programme monitoring. Efforts have been made to avoid development of parallel monitoring systems for RHC, and the GPRHCS’s own monitoring system has very limited impact on the HMIS as a whole. GPRHCS has not promoted development of inclusive RHCS monitoring systems which incorporate the MoH, NGOs and the private sector, and include baseline studies, demand data, and information on rational use of supplies, as well as information on supply and stock levels. The programme has however made a contribution to MoH monitoring through strengthening information systems in general, through material support to government monitoring activities, and through making its own monitoring information available to government. 3.2.4 Conclusions and recommendations A lot of effort has been put into Channel in most of the countries, but this was not always based on a full needs assessment and in some cases Channel is not the most appropriate solution for countries, either for stock control or for monitoring of other elements of the RHCS programmes. In addition, it proved to be difficult to make CHANNEL work in the context of some of the targeted countries. In order to realise the full potential of software and other information sources for RHCS monitoring at sector level, it will be essential to include data from NGOs and the private sector. In countries where there is participation by NGOs and the private sector in forecasting, and where they have access to supplies from the central stores, steps have been taken to develop more inclusive RHCS monitoring. GPRHCS should flag this as an important area of work and promote it. It will also be necessary to emphasise the benefits of a two-way information flow in the monitoring system to motivate people at all levels to provide timely and accurate information. Monitoring of specific elements which contribute to RHCS such as the effectiveness of procurement, promotion of a rational method mix, supplies and stock management have not been sufficiently included in GPRHCS work to date, though some of this is happening in Ethiopia, Sierra Leone and Madagascar. Technical support to Coordination mechanisms in which decisions are taken on forecasting and purchasing has been a key contribution of the GPRHCS to monitoring of national programmes. The contribution to demographic health survey (DHS) and the availability surveys have been useful and appreciated. However, they tend to be expensive and time consuming for the country office (CO) In most countries, poor HIMS represents a key obstacle to set up institutional and sustainable M&E systems of the national RHC programmes. The MF developed for the GPRHCS was not intended to monitor and evaluate country RH programmes, and is not an appropriate tool for this task. 281664/ Synthesis report Final draft V2/ 11th January 2012 47 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report 3.3 The efficiency of GPRHCS implementation at country level Table 14 Summary of case study findings: efficiency of GPRHCS implementation Stream 1 Sierra Leone Madagascar Mongolia Lao Nicaragua Ethiopia Burkina Faso -Focal person is the only staff paid by GP -CO is responsible for management of the GPRHCS (Reg and HQ provide technical guidance) -GPRHCS activities fully integrated into CO AWP -Focal point is the only staff paid by GP -Cumbersome management mechanisms induced by current political situation -Procurement made through Copenhagen is slow and products do not always have the specifications expected -Same as any UNFPA programme (nothing specific to GPRHCS) -No specific information available -GPRHCS activities integrated in the annual cycle for programming and management of UNFPA interventions at country level -GPRHCS would benefit from insertion of annual planning within a medium term framework -Reporting burden appears high to CO -Additional management work provided by GPRHCS has been absorbed by CO. -Implemen- tation mostly done by implementing partners. -A LT technical expert (embedded in the MoH) and a M&E focal point are paid by the GPRHCS -A key issue affecting the efficiency of GPRHCS is the limited national resources Stream 2 Benin Zambia Liberia Nigeria Uganda Lesotho Ghana -Efficiency of GPRHCS hampered by: absence of functional coordination mechanisms, lack of capacity building initiatives in RHCS at the CO level, lack of harmonisation and alignment of LMIS, and lack of broader M&E strengthening activities -No specific resources allocated to CO to implement and manage the GPRHCS -This has generated pressure on CO staff -Recruitment of a long-term TA in the MOH to coordinate RHCS has partially resolved this problem -Management of the GPRHCS was problematic before a RHCS coordinator was appointed -The positioning of this person in the MOH has been key to ensuring things are moved forward -Bureaucratic constraints (at central and State levels) negatively impacted on the efficiency of the GPRHCS (Gov being responsible for the implementatio n of activities through MoU). -A significant amount of the capacity budget is allocated to storage, clearance and verification of commodities -Limited capacity of LMS and of some IPs hamper efficiency -High dependence on donor funding and low public expenditure on RHCS were recognised as challenges -No additional resources allocated to the CO to manage the GPRHCS -CO has been able to absorb the additional workload of the GPRHCS -The key issue affecting the efficiency of the GPRHCS lies in the weak capacity of the MOHSW -Flexibility is seen as an asset -The vacant RHCS focal person position is a major challenge to the programme Following an external audit on the GHS (IP), UNFPA was not able to transfer funds to central GHS -Lack of a vehicle is seen by the CO as a challenge to the implementatio n of the programme 281664/ Synthesis report Final draft V2/ 11th January 2012 48 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report Data from the case studies is shown in the table. Country Offices have appointed GPRHCS Focal Points funded by GPRHCS to support programme implementation and there is a small percentage for overhead costs included in the GPRHCS budget, but other Country Office contributions which can be significant (transport, time of senior staff, etc) are covered from normal UNFPA programme resources. Country Offices in the case study countries had varying degrees of involvement in implementation, the majority passing this responsibility to the implementing partners. Country Offices indicated that there are often inefficiencies in implementation due to obstacles and lack of resources in the principal implementing partners, specifically the MoH. Ways to improve efficiency which have been suggested and/or used include funding a person responsible for RHCS in the MoH, rationalising reporting to UNFPA HQ, and development of a medium-term planning framework. These are discussed under the specific headings below. 3.3.1 Planning and financial administration Although GPRHCS has a 5-year implementation period, at country level it has been integrated with Country Office planning systems and works on the UNFPA annual planning and implementation cycle which runs from January to December. The annual work plan (AWP) is prepared in January, aligned with other UNFPA planning processes e.g. for the maternal health trust fund, so that joint planning is being developed, which has helped with the integration of RHCS into UNFPA core business. If the timing is right, then this planning is aligned with the respective national MoH planning cycle. Where this is not the case (as in five of the case study countries) the MoH contribution has to be developed specifically for GPRHCS, outside the normal Ministry planning processes. Planning takes into account the Country Offices’ expectations of funding, activities being based on a budget which is estimated on the basis of the previous year’s disbursement plus or minus a certain percentage. AWPs and budgets are submitted to HQ through the Regional Offices. Approval of the plans is generally completed by March or April, with the first budget disbursements normally following soon after, although there have been additional delays in some years and countries. Once Country Offices receive funds they channel them to implementing partners, who are normally required to request funds and report on implementation on a quarterly basis. According to UNFPA Headquarters, funds which have not been spent by the end of November cannot be guaranteed for carry over to the following year although countries can request them again if delays in implementation are justified. HQ reports that it is possible for a country office to make a written request to CSB before the end of the year that it wishes to carry over activities into the following year but apparently no such requests have ever been received from the COs. These annual planning and financial administration arrangements are not conducive to efficiency in implementation at country level. For one thing, it was not apparent to the review team that HQ and the Country Offices all had a common understanding of the arrangements and, their constraints (and the reasons for them) and their potential flexibility. In terms of the arrangements themselves, whilst annual planning has the advantage of flexibility, many GPRHCS activities span more than one year and implementing partners need a medium term financial commitment from UNFPA to organise their work, particularly where this involves contracting staff or developing LMIS and other systems. Lack of a medium term planning framework makes it harder to incorporate longer-term goals into the planning process, and ensure that activities are aimed towards GPRHCS objectives. Due to delays in approval of plans and disbursements (see section 4.5), there is a significant period of time when Country Offices and implementing partners have no funding, and IPs and Country Offices report that if activities are to continue they have to be funded by the partners’ own resources. This may limit the range of potential implementing partners to those who have access to alternative funds to use as bridging finance. The lack of facilities for guaranteed carry-over of unspent funds also means that a year’s activities may have to be squeezed into a 281664/ Synthesis report Final draft V2/ 11th January 2012 49 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report significantly shorter period of time, sometimes no more than 6 months if there are delays in disbursement from HQ. Other UNFPA projects working in RHCS have simpler and more workable financial and administrative systems for planning and funds disbursement (e.g. UNFPA-Netherlands bilateral project in Nicaragua). It is unfortunate that the GPRHCS operates the current system which is cumbersome and has a negative impact on efficiency of implementation at country level. Although lack of carry-over of unspent funds is now part of the generally adopted accounting practice (IPSAS) of UNFPA (and soon all UN agencies) it creates a degree of inefficiency in projects that are multi-year. In countries where the MoH planning cycle has a different periodicity (e.g. Ethiopia, whose cycle runs from July to June), difficulties in coordinating planning and financial disbursements with public sector implementing partners are more acute. This means that UNFPA has to engage in separate negotiation with the Federal MoH on the detailed content of its annual country programme as a whole (of which GPRHCS is treated as a part). Moreover uncertainty about financing available for the GPRHCS has meant that UNFPA has only been able to make firm commitments for one year at a time. As a result there is only a six month window in which commitments and financial planning align. In Ethiopia the government gets round this in terms of its budget by making assumptions on future levels of funding but programmatically this is more complicated, and implementation has been exacerbated by delays in fund release and planning approvals as discussed above. 3.3.2 Operational efficiency GPRHCS is integrated into Country Office AWPs. Operational efficiency of GPRHCS in the Country Offices depends to a large extent on the technical and project management capacity of the GPRHCS Focal Point. Some countries have been able to contract staff with both project management and RHCS experience, which has enhanced the efficiency of implementation. There has been limited training and capacity building for other Country Office staff (see section 4.2.3). Most GPRHCS activities are implemented through partners which means that the efficiency of the programme also depends to a large extent on that of the partners. UNFPA has oversight responsibilities and monitors IP activities and progress through quarterly reports and some field visits. As disbursements to partners are quarterly and linked to satisfactory reporting, UNFPA can put pressure on partners to improve their implementation, but at the end of the day efficiency depends on the partners themselves rather than the Country Offices. Both public and non-public sector partners have mixed records. The efficiency of UNFPA procurement for GPRHCS is also outside the control of the Country Offices. In some instances there have been significant delays in filling orders, and procurement under one year’s budget is often reported under the following year, making it difficult to track spending and budget execution. The reporting burden for GPRHCS Stream 1 countries is high, with a good deal of the Focal Points’ time taken up in report preparation. Streamlining of internal reporting requirements would leave more time for Focal Points to support partners and to carry out UNFPA’s own GPRHCS activities such as advocacy. 3.3.3 Institutional issues Implementation of GPRHCS has coincided with regionalisation and decentralisation of UNFPA itself, aimed at aligning all programmes more closely with regional needs. The role of Regional Offices is to be enhanced with more decision-making taking place at regional level. Full implementation of this process is 281664/ Synthesis report Final draft V2/ 11th January 2012 50 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report still on-going and line management structures including the potential management role of the Regional Offices in GPRHCS are not clear. For GPRHCS, Country Offices work both through Regional Offices and directly with HQ, sending reports to both levels, although key decisions including financial allocations are still taken at HQ. The lack of clear definition of the role of the Regional Offices increases the reporting workload and the time taken in intra-institutional coordination for Country Office staff and reduces the efficient use of scarce technical resources at regional level. The GPRHCS budget has small overhead allocations and implementation relies on management and material support from the Country Office. The programme usually pays the salary of the Focal Point, but his/her transport and other expenses may have to be covered by core funds or other programmes. If the Country Offices have sufficient resources to cover the needs of GPRHCS this is not an issue, but in some countries GPRHCS represents a major proportion of the overall Country Programme budget, and in countries where resources are stretched this is producing an additional load which the Country Office can find it difficult to cover. 3.3.4 Efficiency in completing activities on time and as planned As discussed above, UNFPA is not an implementing agency, and many of the activities of the GPRHCS are carried out by implementing partners (the MoH, as well as NGOs in most countries and the private sector in a very few). Completion of the activities according to plan is not therefore completely within the Country Office’s control. Inefficiencies in implementation within UNFPA are also passed on to partners (e.g. late funds disbursement mentioned above). Apart from external factors which are beyond the control of UNFPA or the implementing partners (political instability, natural disasters, etc), Country Offices consider that an important obstacle to completion of AWPs on time has been late disbursement of funds from HQ discussed above. Activities frequently have to be carried out in shorter periods than planned, to avoid having to return unspent funds to HQ. HQ attributes some of the causes of delays to the need for countries to modify their AWPs in the course of the planning process, a failure by some of the countries to provide satisfactory financial reports on time, and the tight turn around time after the annual planning meeting when all countries are expected to submit plans within two weeks. It is not always possible to identify delays in receipt of procured commodities from the reports submitted by Country Offices. For example, commodity procurement which has been carried out with supplies delivered to the country will be reported as implemented, although in some cases the supplies may be held up in customs (e.g. Sierra Leone). 3.3.5 Conclusions and recommendations: Efficiency of implementation has been affected by: � Late disbursement of funds from HQ � Lack of a medium-term planning framework � Inefficiency in implementation by partners, especially MoHs � Heavy reporting burden � Delays in reporting by the Country Offices � External factors including political instability and natural disasters 281664/ Synthesis report Final draft V2/ 11th January 2012 51 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report Efficiency could be improved by: � Development of medium-term planning frameworks in all countries (which would also help to cover countries where IP planning cycles do not coincide with UNFPA cycles) � Beginning the planning process before the start of the year. A planning process which begins in January for that same year is always going to be running late. � Ensuring funds are disbursed on time, and permitting carry-over of unspent funds to the following year � Streamlining reporting procedures to reduce reporting burden on Focal Points � Clarifying financing and administration processes, for example in the form of a short manual that could be issued to all GPRHCS staff so that they have a common understanding of the processes they are meant to be following. � Ensuring Country Offices have sufficient resources to support programme implementation, especially in countries where GPRHCS is large and the rest of the Country Programme is relatively small � Where implementation is inefficient due to lack of resources in MoH, funding a technical staff member within the Ministry � Ensuring that monitoring of IP is used as an opportunity to improve partners’ efficiency wherever possible. 281664/ Synthesis report Final draft V2/ 11th January 2012 52 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report 4.1 Introduction The GPRHCS is led by Commodity Security Branch in New York. The GPRHCS is very closely entwined with the functions of that Branch such that the GPRHCS is essentially the CSB programme. The role of the global team is to provide strategic direction and coordination for the Programme as a whole, mainstream RHCS into UNFPA and in other UN bodies as appropriate, develop strategic partnerships with global development partners, build an enabling environment for RHCS e.g. by encouraging lower prices on commodities, fund raise from donors at international level, and run global level procurement exercises to service the country programmes. It has also developed tools such as CHANNEL to help with Programme implementation. Staff at HQ level who work on the Programme include the Branch Chief (Jagdish Upadhyay), three global RHCS technical advisors (the coordinator Kechi Ogbuagu, the strategy adviser Ben Light based in Brussels, and the maternal health adviser Kabir Ahmed) other staff supporting finance, resource mobilisation and commodity procurement in New York, and two staff in the Procurement division in Copenhagen who support the programme on procurement issues. These posts are all funded by UNFPA core funds. The role of the regions is to support capacity development at country level, carry out regional level advocacy activities, enable the countries to access technical assistance, and to act as the interface between global and country level on programme planning and reporting. At the 5 regional and sub-regional offices in Thailand, Kazakhstan, South Africa, Panama, and Senegal there are 7 RHCS Programme Advisers providing support to the implementation of the Programme. Around the time that the GPRHCS started, UNFPA made the decision to decentralise its regional functions from New York and relocate them nearer to their countries. The regional advisers are part of those teams, reporting to the Heads of Regions, but funded by the GPRHCS and working closely with the CSB team in New York as well as the RHCS focal points in countries. The regional advisers are responsible for supporting the programme in all the countries in their region or sub-region which participate in GPRHCS which limits their capacity to provide enough support, particularly in Africa. This is exacerbated when they are required to cover other regional office tasks outside their GPRHCS remit. Various strategies have been tried to supplement their capacity (see Box ) 4 Global and regional level findings 281664/ Synthesis report Final draft V2/ 11th January 2012 53 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report 4.2 How regional and global activities of the GPRHCS have enhanced country level work 4.2.1 Scope of study The review looked at four areas where the regional and global team support the work of the country offices: � Internal capacity building of UNFPA staff � Capacity building of government staff and systems � Technical assistance to country programmes � Advocacy activities The review focussed on these areas because the case study approach gave the opportunity to assess the effectiveness of these inputs. The regional and global teams’ role in programme management is discussed in section 4.5 4.2.2 Overview of support to countries The following table shows the type of support which case study countries received from regional and global level. In general the level of support is limited. Box 6 Developing supplementary capacities New methods of working have been introduced to try and overcome problems of the shortage of UNFPA staff at regional level. This has included training national consultants who can be contracted as needed by UNFPA Country Offices (which was also hoped to be a way of overcoming the problem of rotation of trained staff in MoHs, the national consultants being able to train newcomers), and developing the capacity of national institutions to carry out technical assistance and capacity building work at national and regional levels. Training of national consultants has not turned out to be a long- term solution, as trained personnel were quickly contracted for full-time work in other organizations. Partner institutions are expected to provide a more sustainable response, but they are expensive (and may become more so once they are indispensable), and their work provides no visibility for UNFPA or GPRHCS whose contribution may therefore not be recognised. Examples include the MIH (Mauritius Institute of Health), PRISMA and CIES in Latin America, who work with LACRO and WCARO and BKKBN which focuses on the Asia Pacific region and has also trained programme managers from other regions. The evaluation team reviewed documentation written by these organizations but did not interview them directly. 281664/ Synthesis report Final draft V2/ 11th January 2012 54 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report Table 15 Summary of case study findings: global and regional support to countries Stream 1 Sierra Leone Madagascar Mongolia Lao Nicaragua Ethiopia Burkina Faso -Training in CHANNEL -Some technical assistance in MOU development -Advocacy -Technical assistance -Experience interchange -Facilitation of S-S cooperation -Training -Capacity building -Advocacy -Regional training events -Procurement training -Development of consultant register -Distance technical assistance -Training -Support with integrated LMIS and CHANNEL -Regional advocacy activities -Capacity building -Experience interchange -Introduction of multi-year planning system -Technical assistance through institutions -Advocacy -Limited support for capacity building -Recruitment of consultant for MoH work -Development of consultant register -Technical assistance -Organisation of regional meetings for experience interchange -Support in recruitment of technical specialists Stream 2 Benin Zambia Liberia Nigeria Uganda Lesotho Ghana -Limited technical assistance and training -Experience exchange in international meetings -Technical assistance -Training -Joint review in annual meetings -Support with procurement -Advocacy -Very limited training and technical assistance -Very little support of any kind -Training in CHANNEL (though it is not used in Uganda) -Some advocacy support -Capacity building for UNFPA and partners -Technical assistance -Advocacy -Limited training and technical assistance 4.2.3 Capacity building 4.2.3.1 Background Capacity building in the GPRHCS has been carried out without an overall strategy. The original programme document however, proposed that there should be an RHCS Integrated Capacity Development Strategy [RHCS ICDS]: “To facilitate the work of country office staff and—more specifically—their national counterparts and as a complement to the development of the orientation tools and guidelines, an integrated capacity development strategy, developed at the global level, is to be available for adaptation in countries receiving GPRHCS funding under streams 1 and 2”12. This ICDS has not been developed. The monitoring and evaluation framework of the programme proposes some early signs of what capacity should look like when it is built– by including RHCS in key sector strategies, by creating and supporting a national coordination mechanism, and by encouraging national capacity in forecasting for example. However the actual process and approach to capacity development are not expressed anywhere, leaving the country offices, with some support from regions, to work out what needs to be done and how to do it. This is expecting a lot from the RHCS focal points. Several of them were national RH experts who are now _________________________ 12 GPRHCS programme document 2008, p28 281664/ Synthesis report Final draft V2/ 11th January 2012 55 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report expected to support capacity in areas which have long been problematic and are technically complex such as distribution systems and LMIS. Moreover they are expected to operate at an international level with other development partners in this field. 4.2.3.2 Global contribution The global level has not directly addressing capacity building of partners (i.e. government and other stakeholders such as NGOs). The global team’s position is that the countries are responsible for this, with the support of the regions. The global level has however held several internal planning meetings and provided opportunities for RHCS focal points to work in New York for short periods, which the beneficiaries described as very helpful in terms of increasing their exposure to, and understanding of a range of issues. 4.2.3.3 Regional contribution The Regional Office role is to support Country Offices and regional capacity building initiatives rather than direct capacity building in-country (i.e. of partners), which is normally done by the Country Offices themselves. At the start of the GPRHCS the Regional Offices placed more emphasis on internal UNFPA capacity building, country visits by Regional Office staff being one of the key methods used. Country visits are now less frequent due to budget constraints. Now that the GPRHCS is established there is little exclusive internal UNFPA capacity building, although there are still needs for support in various areas which are identified elsewhere in this report (e.g. in further development of the potential of CHANNEL, in TMA, etc.). Regional Offices help Country Offices identify needs for internal capacity building, and help supply the personnel resources to do it when possible. Internal capacity building is often now integrated with global and regional initiatives for capacity building of government staff and systems: when training courses and conferences are mounted at global or regional level they are offered to UNFPA as well as MoH and other relevant stakeholders. Regional Offices have also supported country programmes through joint workshops and through facilitating exchange and cross-fertilisation of ideas. When several countries are facing the same problems (such as withdrawal of donor aid for contraceptives) there have been exchanges on experiences in market segmentation, approaches to including sexual and reproductive health in social security systems etc. Regional Offices have also organised some successful South-South training (and technical assistance), including participation by UNFPA staff, government and other implementing partners where appropriate (e.g. cooperation between Madagascar and Burkina Faso on development and installation of an interface program linking CHANNEL with the central depot software systems). All the country offices interviewed had had some form of capacity building support through the appropriate regional office, but none had had very much, and several RHCS focal points had only received training some while ago in the early days of the Programme. Much of the capacity building support was geared towards very specific issues such as use of CHANNEL rather than wider RHCS issues as a whole. 4.2.4 Technical assistance Whilst staff from HQ periodically visit Country Programmes and offer valuable technical assistance whilst they are there, technical assistance requests from Country Offices are directed to the Regional Advisers. Countries send a request annually to their Regional Office who programme their own and other institutions’ technical assistance for the Country Offices. Technical assistance is also carried out during country visits 281664/ Synthesis report Final draft V2/ 11th January 2012 56 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report by Regional Office RHCS advisers. As mentioned, travel has been reduced and advisers have also been loaded with other commitments, so there is less individual attention to countries. This is reflected in the WCA survey results13. The technical assistance support is used to varying degrees by the different countries. The sourcing of TA is appreciated, but overall has not been used much. Some countries reported that their requests for assistance had not been met because of pressures of work on the regional advisers and so they had looked to the local market to supply consultants. Several of the countries asked for more direct support from the Regional Advisers believing that their experience with the Programme across various countries gave them a good insight into RHCS. 4.2.5 Advocacy Support by HQ and Regional Offices in high-level advocacy has been important for GPRHCS, both in- country and at regional level working with the Economic Communities and other regional fora. In-country, presence of staff from the regional and HQ offices gives more weight to advocacy initiatives and enables access at a higher level of government. Country Offices appreciate this support. Advocacy work by the Regional Offices varies according to regional needs. For example in LAC where RHCS has been more widely accepted by national MoHs as a key programming element, policies have been developed and RHCS has been mainstreamed in most countries’ national plans. Regional Office support for advocacy is now more niche support at regional level, such as advocacy for introduction of emergency contraceptives, sexual and reproductive health rights, etc. In WCA support for advocacy includes development of an advocacy toolkit for training parliamentarians, journalists, donors (still work-in- progress) and a focus on capacity building for advocacy work in-country. Regional level advocacy with Economic Communities and with regional parliamentarians is expensive, and regional offices do not have sufficient resources to cover it. Although it may be an effective way of reaching top decision-makers, it is not currently a focus area of work. LACRO carries out regional advocacy through the LA RHCS forum, which is a ‘talk-shop’ for all organizations working in the field. It was started as a GPRHCS initiative by the Regional Office and is now integrated with the RHSC. It may have an impact on Country Office work in the future. 4.2.6 Conclusion and recommendations The impression gained by the review team was that the approach to internal capacity building of UNFPA staff is piecemeal. This is partly because of resource constraints, but largely because there is no systematic approach to assessing the roles of the RHCS focal persons, identifying their training needs, and coordinating how these could be met. As a result the approach to capacity building of partners is also rather piecemeal even though many of the issues that have to be addressed are similar and there is considerable potential for being more systematic. The lack of specific capacity building for RHCS focal points may be one cause of this. TA is more systematically organised although resource constraints at regional level make it difficult to meet all requests. _________________________ 13The survey was carried out by the West and Central Africa Office to explore the difficulties which countries had in implementing the programme. Results were discussed in the 2010 Dakar SRO individual report. 281664/ Synthesis report Final draft V2/ 11th January 2012 57 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report Advocacy work by the regions and HQ may be valuable, but again resource constraints limit activities. 4.2.6.1 Recommendations on capacity building � The proposed Integrated Capacity Development Strategy should be developed, addressing both the needs of partners in countries and those of UNFPA staff including the RHCS focal points, the regional advisers, and other UNFPA staff who address RHCS either as all or part of their jobs. This should include a systematic assessment of the skills of those staff, especially the RHCS focal points and the regional advisers, against a mapping of the sort of skills needed to successfully support the GPRHCS programme at country level. � Resources should be allocated to develop this strategy and then to address the training needs through a variety of methods – distance learning, exchanges, study etc. This may have significant resource implications but it would undoubtedly be worthwhile investment that UNFPA HQ, and its donors should support through Programme funding. � Attention should be given to maintaining levels of capacity in UNFPA staff so that new staff are trained swiftly. � Other UNFPA Country Office staff should be included in the capacity assessment to ensure a wider base of capacity in Country Offices. 4.2.6.2 Recommendations on technical assistance � Regional Offices have an important role in identifying specific areas where Country Offices need additional technical input, such as expert support in assessment of the potential use of CHANNEL as an integrated stock control system, methods of integrating it with existing software used in central procurement systems and stores, etc. � Technical assistance for implementing partners should continue to be planned jointly with the Country Offices, Regional Offices contributing ideas and supporting Country Offices in identifying local and regional resources for technical assistance. � Regional and global level personnel have an overview of the programme and should use this to facilitate more South-South technical assistance and interchange between participating countries. � Additional technical assistance input may be needed from Regional Offices to implement medium-term planning systems for GPRHCS, both within Country Offices and with implementing partners 4.2.6.3 Recommendations on advocacy � Regional and global levels have an important role to play in high level advocacy at country level, and should support Country Offices in a) identifying where regional and global input is required and can be effective, and b) participating in in-country advocacy. In countries where RHCS is already mainstreamed, niche advocacy on specific areas may be the most important contribution. � As regional advocacy events are expensive to mount, Regional Offices should explore the possibility of piggy-backing on regional events mounted by UNFPA and other organizations to promote RHCS issues. � Where Country Offices need additional in-country support, materials such as the ARO advocacy toolkit should be made available, together with country-specific advice on the best way to use it. 281664/ Synthesis report Final draft V2/ 11th January 2012 58 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report 4.3 Awareness raising 4.3.1 Introduction ‘Ensuring sustainability of RHCS interventions within countries requires continuous advocacy to secure a supportive policy environment.’ UNFPA, 2007 Raising awareness and advocacy can be defined in different ways. In the case of the GPRHCS, there is both raising awareness of the issue of RHCS itself and raising awareness of the GPRHCS as a way of addressing the issue. Furthermore, some of the awareness-raising has been done to (the less informed) and other awareness-raising activities have been conducted with others e.g. working alongside partners in the framework of the Reproductive Health Supplies Coalition (RHSC). The original Programme document14 proposed that advocacy primers be developed, and that there would be a GPRHCS Advocacy and Dissemination Initiative (contracted out to NGOs, CSOs, Regional Inter- Parliamentarians Fora) to work globally and regionally to advocate for RHCS and disseminate information resources developed by the Global Programme. None of these has happened, although the WCA Regional Office has developed an advocacy toolkit, and some advocacy briefs have been developed by APRO. Identifying awareness-raising activities carried out specifically by the GPRHCS at the global level is difficult, as there are blurred lines between the Programme and Commodity Security Branch at UNFPA HQ. Staff at CSB are funded by UNFPA core funds but do not clearly distinguish between the activities they carry out as CSB and the global level activities supported by the Programme. Consequently, the section below contains rather a mixed bag of activities, to which it is reported the GPRHCS (or at least UNFPA) has contributed. 4.3.2 Activities to date The following is a summary of some of the global-level awareness-raising activities reported between 2007 and 2011. A full list is at Annex 7. 4.3.2.1 Activities within UNFPA: Awareness raising activities have been conducted for a variety of audiences including: members of UNFPA staff who do not work on the GPRHCS but have an interest in it or relevance to it; various external representatives who attend ad hoc or regular UNFPA meetings; and members of UNFPA staff who have responsibilities for the GPRHCS. 4.3.2.2 Among current and potential donors Awareness raising activities for this group included an annual donor meeting (since 2009) which includes both current and potential donors, publication of the GPRHCS Annual reports and other documents such as ‘Success Stories in Reproductive Health Security’, various ad hoc meetings both formal and informal and assorted presentations e.g. to the RH Supplies Coalition. _________________________ 14 The team has been referring to the 2008 version. 281664/ Synthesis report Final draft V2/ 11th January 2012 59 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report 4.3.2.3 With and to other partners UNFPA has worked alongside other partners to try to establish prominence of RHCS issues. Partners include the Reproductive Health Supplies Coalition where UNFPA supports the Secretariat, leads one of the Coalition’s three working groups (on Market Development Approaches) and participates actively and regularly in other activities of the Coalition. Others include the PMNCH (see Box ), and H4+115, and in particular WHO with whom a collaborative initiative on critical life savings medicines has been formed. 4.3.2.4 In potential programme countries and at regional level It was reported to the review team that the GPRHCS works with the West African Health Organisation (WAHO), the East African Community (EAC), the Inter-Governmental Authority on Development (IGAD) and the Southern African Development Community (SADC) and through them, with parliamentarians in the concerned countries. The CEOs of EAC and IGAD have also reportedly been supported to attend a UNFPA Executive Board meeting in New York. 4.3.2.5 In current programme countries The UNFPA-WHO Collaborative Initiative on Critical Life-Saving Maternal/RH Medicines mentioned above supported studies to review access to these medicines in Lao PDR, Nepal, Burkina Faso, Philippines, DPR Korea, Ethiopia, Vanuatu, Mongolia and the Solomon Islands; _________________________ 15 H4 is compromised of UNICEF, WHO, UNFPA and the World Bank plus UNAIDS. Box 7 Examples of results from partnerships With PMNCH: UNFPA is co-chair of one of the six priority areas within the PMNCH 2009-2011 workplan (Priority Area 3: Essential Commodities).It was reported to the review team that the prominence of commodities in the PMNCH workplan (and it being chosen as one of six priority areas from an initial list of 37) was a direct result of UNFPA’s advocacy. Similarly it was reported to the review team UNFPA is the likely reason behind family planning being so high up in the recent commitments made under the Global Strategy for Women and Children. With the Reproductive Health Supplies Coalition: UNFPA has been actively involved in a number of initiatives with the RHSC including the development of AccessRH which it is now implementing, with the support of various donors . When fully operational this will allow countries to order a number of different commodities from a variety of manufacturers at up-front prices negotiated by UNFPA. UNFPA will carry out demand planning to maintain appropriate stock levels thereby reducing procurement times for clients who will be able to have their products shipped as soon as their funding becomes available, rather than having to go through a lengthy full scale international procurement exercise. This is expected to reduce stock outs and lower prices for participating countries. AccessRH also incorporates the RHinterchange website which contains up to date information on contraceptive orders and shipments for more than 100 countries. 281664/ Synthesis report Final draft V2/ 11th January 2012 60 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report 4.3.3 Conclusions and recommendations 4.3.3.1 Conclusions The GPRHCS has a broad definition and interpretation of awareness-raising activities. Activities range from simple engagement and meetings with other partners and participating in partner organisation’s events and activities, to a very specific meeting held in September 2007 for RHCS champions from around the world. Activities for GPRHCS staff would seem to be more concerned with technical capacity building than broader awareness raising, although these are claimed as such. While it is true that there is general value in being at the table to ensure the place of RHCS, a lot of the activities appear to be more ad hoc rather than systematic and strategic. In the absence of an advocacy strategy at the global level, raising awareness appears to have been mostly opportunistic. There does not appear to be a clear understanding within the programme of the objective of their global level awareness- raising activities. Differentiating between the types of awareness-raising depending on the audience, including awareness raising TO (the ‘unconverted’) and awareness raising WITH (i.e. working alongside partners within the RHSC) needs to be strategically thought through and clarified by the GPRHCS/CSB. Other than the planning meetings and the annual donor meetings, the GPRHCS appears to have a policy of ‘piggy-backing’ awareness-raising activities in an ad hoc manner onto already planned events by themselves or partners rather than holding their own events. This is not necessarily a bad approach, if it is done strategically i.e. key events and organisations are identified in advance, resources are prioritised and allocated appropriately and the message that the GPRHCS is conveying is not lost in the rest of the meeting or event. Generally attribution of change to the GPRHCS is difficult, although there are some exceptions summarised in Box . This is not necessarily a problem for RHCS, but it does mean that that the visibility of the GPRHCS itself can be affected amongst key stakeholders, potential donors and the public. Interviews with stakeholders suggest that the GPRHCS is not particularly well known and has low visibility beyond those immediately connected with it. Even amongst those who are aware of the Programme, there is reportedly not always a clear understanding of the achievements of the Programme, its added-value, design and scope. UNFPA is in the unusual position of leading on a multi-donor global programme, but from within the UN. It has been a learning process for the organisation, and extra effort is needed to establish the visibility of the GPRHCS and clearly communicate its achievements as distinct from those of the host organisation. The clarity, regularity and user-friendliness of communications from the GPRHCS have reportedly not always been ideal. In comparison to other initiatives such as the Partnership for Maternal Neonatal and Child Health (PMNCH), and the Global Fund for example, there appears to be much less marketing and communication. Moreover most of the communications that do exist are targeted at those who have some knowledge of RHCS, rather than those who have little understanding but are potentially influential. Awareness-raising internally within UNFPA seems to have been more successful although this is an impression gained from a limited number of interviews. It was outside the scope of this review to look at mainstreaming on RHCS in UNFPA above country level. Successes in advocacy at the country level are noted elsewhere in the report, but the link between global- level activities to raise awareness about RHCS and the Programme, regional-level activities and country- 281664/ Synthesis report Final draft V2/ 11th January 2012 61 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report level activities is less clear. Once again, a strategy and a strategic approach, coupled with ensuring staff at each level has the information, capacity and skills to raise awareness as needed, would improve effectiveness. The absence of an attractive, comprehensive, user-friendly, up-to-date website, addressing all the information gaps noted in this section and with all relevant publications (possibly with a public and a private face), seems to be a major gap in the area of raising awareness about RHCS and the Programme. Finally, PMNCH and the Global Strategy for Women and Children are moving towards a more integrated approach to commodities in general rather than RH commodities. The GPRHCS needs to take this into consideration and ensure that they are on the same page with these other more visible initiatives, whilst maintaining its own focus, so that the messages are clear when they are conveyed to stakeholders at all levels – but particularly in country. 4.3.3.2 Recommendations � Develop a coherent goal, a strategy and an associated activity plan to support GPRHCS advocacy. The strategy needs to address how to reach new supporters, the balance between being opportunistic and strategic about raising awareness, and how to develop the current range of publications. � Establish capacity in communications, raising awareness and advocacy at global level in the GPRHCS. � Review the annual report format to look for improvements in readability, user-friendliness and accessibility and review alternative outputs of the programme e.g. the success stories publication, again depending on audiences and objectives. � Establish an attractive, well-design, comprehensive and user-friendly website for the GPRHCS, launch it (perhaps at the next donors meeting) and keep this up-to-date with all documents, events and achievements of the GPRHCS. Also, ensure Dashboard is kept up-to-date. 4.4 Resource Mobilisation 4.4.1 What resources has the GPRHCS mobilised? 4.4.1.1 Scale of funds The GPRHCS has mobilised considerable and increasing funds to finance its work. Between 2007 and 2010 some $253m was raised from donors for the Programme, with a further $151m contributed in the first seven months of 2011 or pledged for the remainder of 2011-12. The average annual rate of increase of contributions during 2007-2010 has been 58%. These contributions compare favourably to the RHCS Thematic Trust Fund, which ran from 2004 to 2006, addressing broadly similar issues16. _________________________ 16 The Thematic Trust Fund aimed to divide its spending 90% on commodity procurement and 10% on capacity building. GPRHCS was launched with the intention of devoting 60% of its expenditure to capacity building and 40% to commodities. 281664/ Synthesis report Final draft V2/ 11th January 2012 62 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report Graph 1: Resource mobilisation from donors by the GPRHCS and RHCS Thematic Trust Fund, 2004-12 ($m) Sources: 2004-10 UNFPA Annual Accounts data; 2011-12 GPRHCS Resource Mobilisation office data This funding may be compared to UNFPA’s estimate of need for RHCS of $150m17 annually during 2007- 12. So the GPRHCS has moved steadily from covering 18% of this estimate in 2007 to 64% in 2010, and a probably similar share of coverage in 2011. 4.4.1.2 Predictability and diversification of funds Within the field of RH commodities, a premium is attached to predictability of funding, which provides the ‘security’ of avoided stockouts and allows scaling up of programming to meet unmet needs. Since 2008, the UK, the Netherlands, Luxemburg, Denmark and the EC have all funded the GPRHCS using multi-year pledges, covering periods of between two and five years, which does offer greater funding predictability. Between them, these five donors have accounted for almost 89% of GPRHCS contributions and pledges to date. This is a more successful result than that achieved by the UNFPA core funds, for which the number of donors contributing in a multi-year pledge format has fallen steadily from 77 in 2006 to 46 in 201018. Another important objective is diversification of funding sources, to reduce the risk of changes in individual donor priorities or strategies. The recent addition of new donors – e.g. the EC, Denmark – is positive in this respect, although the UK and the Netherlands remain significantly the largest donors. It is difficult to separate the effects of three factors in explaining donor expansion: (a) a track record and the increasing visibility of results that may be attributable to the GPRHCS; (b) changing priorities within the donors in question and the lack of alternatives to the GPRHCS; and (c) the exemplary force of the continued _________________________ 17 This estimate, which includes capacity building needs, has not been revised since the GPRHCS was launched. It is unclear if it takes full account of changes in method mix, which may raise the cost of meeting unmet need. 18 Source UNFPA ‘Report on Contributions by Member States and Others and Revenue Projections’ for the years 2005 to 2011. 281664/ Synthesis report Final draft V2/ 11th January 2012 63 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report commitment of longstanding GPRHCS donors, such as the UK and the Netherlands, which are often characterised as demanding and trend-setters. 4.4.1.3 Government co-financing and the private sector One factor that does not appear to be tracked is cofinancing of GPRHCS outputs by recipient governments. This is unfortunate as a key objective of the GPRHCS is to mobilise national resources in this way. UNFPA does collate information on government cofinancing of its programmes more generally (possibly because it is difficult to disentangle GPRHCS outputs from general country programme outputs), which does not demonstrate any upward trend: Graph 2: Country co-financing of UNFPA programmes, 2005-10 ($m) Sources: UNFPA Annual Accounts data Similarly, apparently due to the challenges of collecting such data, UNFPA does not track expenditure on RHCs in the private sector. 4.4.1.4 Inter-institutional initiatives Beyond its country-based outputs, the GPRHCS also mobilises resources via inter-institutional initiatives. This includes contribution19 to the work of the RH Supplies Coalition, coordinated through a secretariat managed by PATH. Amongst other RHC-related objectives, the Coalition advocates for additional funding for commodities20. Though a thorough assessment is beyond the scope of this review, given its wide- ranging expertise and potential economies of scale, support for the Coalition probably represents an effective use of UNFPA RM funds. For instance, the RHSC uses data from its RH Interchange procurement database to track (within 14 focus countries) budget lines for RHCs and also actual _________________________ 19 UNFPA contributes to RHSC’s Global Advocacy Mapping Exercise; AccessRH ($6m in 2010; $4m in 2010 – all from UNFPA General Resources); RHSC meetings; and also a multi-year commitment of $500,000 to RHSC Secretariat support. The UN Foundation supports the Pledge Guarantee [awaiting amount from Beatriz]. 20 Goal 1 of the Coalition’s 2007-2015 Strategic Plan is “Increase the availability, predictability and sustainability of financing for RH Supplies”. 281664/ Synthesis report Final draft V2/ 11th January 2012 64 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report government expenditure21. The Coalition has also steadily increased donor contributions to its work since 2007 (see Error! Reference source not found.16 below), also raising the number of Coalition members from 15 then to over 130 currently. This includes donors not currently contributing to the GPRHCS, such as the Gates Foundation, USAID and KfW. Table 16 Donor support and Secretariat expenses ($m) Donor support Secretariat cost Balance 2007 1.3 1.5 -0.2 2008 5.3 1.3 4.0 2009 7.9 1.1 6.8 2010 10.6 1.9 8.7 Source: RHSC Additionally, the RHSC’s Pledge Guarantee is an innovative instrument established to convert as yet unrealised aid guarantees into short run, low cost commercial credit for the purchase of SRHCs – so increasing the leverage available from existing resource mobilisation. Beyond the resources mobilised for SRHCS through this, the Guarantee has now been extended to other health sector procurement. After a protracted period of investment, a revolving stock fund supported by the GPRHCS known as Access RH, also supported by the GPRHCS, became operative in December 201022. As of July 2011, only a third of the GPRHCS’s initial funding of $6m had been allocated to orders, though an additional $8m is agreed or planned. From an initial view, it appears that Access RH is technically proven, but not yet fully successfully marketed to countries as a purchase mechanism, with UNFPA apparently pushing for greater efforts in this regard. Issues such as the stocking of branded rather than generic products also appear not yet to have been fully resolved. 4.4.1.5 Further aspects Beyond financial resources, the GPRHCS has also mobilised human resources from donors, in the form of occasional consultancy inputs, such as from DELIVER (USAID-financed – not yet implemented) on the cost-benefit analysis of commodity investments. UNFPA policy is not always one of maximising the resources mobilised for the GPRHCS. An example is USAID’s recent offer to fund the GPRHCS, with which the agency was apparently impressed, but which was declined by UNFPA, with a request from the UN agency instead for ‘broader’ (core) funding23. The funding that USAID was reported to have shifted to research and TA in place of the GPRHCS could perhaps potentially be viewed as resources mobilised in part by the GPRHCS. 4.4.2 What has been the cost of this? Expenditure related to resource mobilisation is not tracked by the GPRHCS. Much is contained within the costs of the UNFPA’s Executive Board & Resource Mobilisation Division (IERD) budget. This budget _________________________ 21 In the RHSC’s 2009 Monitoring and Evaluation Report, it found that ‘rarely was the actual [budgeted] amount spent’, with out-turns generally being lower. 22 An initial order was placed for 23.8m male condoms. As of July 2011, 92.6m male condoms had been ordered. In theory, AccessRH could also be used by pooled funding within countries. 23 Source: Interview by Yasmin Hadi with Beverley Johnston, USAID 281664/ Synthesis report Final draft V2/ 11th January 2012 65 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report covers spending on the Board, media outputs and work with external organisations such NGOs and national parliaments, in addition to the UNFPA’s resource mobilisation department. The department in turn covers core funding as well as other programmes beyond the GPRHCS. Table.17 gives the full IERD budget, though unfortunately no break-down of spending within this was available: Table 17 IERD budget at UNFPA headquarters level, 2007-10 Year $ 2007 $5.4 million 2008 $5.3 million 2009 $5.6 million 2010 $5.7 million Source: UNFPA accounts Country co-financing arrangements (i.e. using government funds within GPRHCS programmes) are generally made through UNFPA country offices and so the costs of promoting these is outside of the IERD budget. The central resource mobilisation office in New York has liaison offices in Washington, Tokyo, Copenhagen, Brussels and Geneva. The GPRHCS does not fund any staff at headquarters (or liaison office) level – only at regional and country offices. Key GPRHCS RM duties include organisation of the annual donors’ meeting and dealing with donor staff and their consultants. There are indications that the current RM budget is used with economy. For example, the costs of the single annual donor meeting - for which the GPRHCS covers UNFPA staff travel only – see Table.18, below. Apart from the annual donors’ meeting, donors are apparently only invited to already scheduled meetings rather than to any specifically commissioned ones. Table 18 Travel cost for Donors’ meeting, 2008-10 Year $ 2008 7,182 2009 40,404 2010 18,618 Total 66,203 Source: UNFPA accounts. Note: donors’ costs are additional to this, as are UNFPA staff salaries. Approximately six staff within the UNFPA RM office work with GPRHCS donors, each acting as focal point for a certain donors. Focal points who began with an exclusive focus on GPRHCS fund raising now also have responsibility for raising UNFPA core funds, which may take half of their time24. Some hiring decisions – for instance staff with fund-raising experience from the private sector – have demonstrated innovation and commitment on the part of UNFPA. However, such staff are given little in the way of field experience and familiarisation with UNFPA before they start their work, which may initially restrict their productivity. _________________________ 24 This split between GPRHCS and other RM responsibilities seems on the face of it in contradiction to the description in the UNFPA ‘Report on Contributions by Member States and Others and Revenue Projections’ for 2011 that thematic programmes operate “separate resource mobilisation streams”. An explanation from UNFPA is that the split helps to ‘mainstream’ GPRHCS within the organization. It is also true that raising core funds has become an increasingly urgent priority for UNFPA. 281664/ Synthesis report Final draft V2/ 11th January 2012 66 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report It is likely that greater investment in resource mobilisation by the GPRHCS would yield additional funds far in excess of the cost of such investment, as many potential advocacy tasks cannot be carried out given current staffing levels. While Denmark has recently agreed to contribute to the programme, there has not been time available for concerted approaches to major potential donors such as Sweden, Norway or Germany – with the former two currently concentrating on maternal issues and the latter on the private sector25. There is also only very limited time to attend to external organisations that are very labour intensive to service in terms of advocacy and information – such as the European Parliament and certain NGOs. What communications is provided reduces time available for other RM tasks. Subjective impression suggests that several potential donors do not enjoy a high level of expertise in relation to SRH (partly due to rapid rotation) and UNFPA must spend significant time in educating such donors about the importance of RHCS. This issue can affect current and past GPRHCS donors as well as potential future ones. Additional RM human resources would also facilitate demonstrating country ownership and a results focus to donors, insofar as it is the case, a labour-intensive and increasingly important requirement. 4.4.3 How does the GPRHCS compare to similar organisations in resource mobilisation? 4.4.3.1 Introduction Subjective information (interviews) suggests that UNFPA’s GPRHCS performs similarly to other UN agencies in terms of resource mobilisation26. The WHO does enjoy better funded Resource Mobilisation – i.e. it has a dedicated RM staffer for each technical issue. Sensibly, the WHO, UNFPA and other major organisations working in SRH (such as UN Women, MSI and IPPF) share information regarding actual and potential donors. The RH Supplies Coalition is sometimes used as a venue for such interchanges, though it could probably be used more still for effective fund mobilisation. 4.4.3.2 Donor/UNFPA cycles As with other UN agencies and NGOs, the GPRHCS’s donor funding is affected by the demands of donor cycles. This can mean that funds are both released later than anticipated, or very late in UNFPA’s financial year and that they must be spent by certain deadlines. Delays may occur, for instance, while donors await progress reports from GPRHCS relating to past funds. The bulk of donor contributions arrive in the last quarter of UNFPA’s financial year (ending December), with much in the last few weeks. This means that UNFPA’s certified annual accounts will tend to show large unspent balances, which must constantly be explained to donors. UNFPA’s IPSAS accounting system only counts funds as spent when goods have been delivered (rather than when orders have been placed), which may be several months after an order. Delays in donor funds transfers, and their arrival towards the end of the year, is part of the explanation for the variation between GPRHCS funding and expenditure: _________________________ 25 Introducing donors with RHCS experience in the private sector might help UNFPA broaden its focus in this area, in addition to the benefit of the funds that they bring. 26 Although as one interviewee put it when comparing the GPRHCS to UNICEF, “children is an easier sell than contraceptives”. 281664/ Synthesis report Final draft V2/ 11th January 2012 67 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report Table 19 Variation between GPRHCS funding and expenditure, 2007-2010 ($m) funding expenditure difference 2007 26.7 10.9 15.8 2008 58.4 17.6 40.8 2009 72.5 87.4 - 14.9 2010 95.3 93.9 1.4 Source: GPRHCS contribution accounts; GPRHCS expenditure accounts. Note: these data excludes GPRHCS expenditure (including on behalf of donors not classified as GPRHCS donors) on fragile states. Inclusion of such funds would change GPRHCS expenditure to 2007: $32.5m; 2008: $30.3m; 2009: $92.0m; and 2010: $93.9m. 4.4.4 What has been the context of resource flows to RHCS? 4.4.4.1 Contributions to UNFPA generally The GPRHCS’s successful resource mobilisation has taken place within a context of steadily increasing donor funding for UNFPA ‘regular resources’ (core funds), rising from $351m in 2005 to $491m in 2010. But as Error! Reference source not found. shows, the GPRHCS has expanded much faster than have regular resources. The GPRHCS has risen from 6% of the value of core funds in 2007 to 19% in 2010. Table 20 Growth in Resource Mobilisation, various elements of UNFPA 2006 2007 2008 2009 2010 average RHCS Thematic trust fund -34.2% -44.9% - - - -39.5% GPRHCS - - 118.7% 24.1% 31.4% 58.1% UNFPA regular resources 7.1% 16.3% -1.9% 9.5% 4.6% 5.9% maternal thematic - 269.0% 34.6% -0.7% 101.0% obstetric fistula thematic 8.3% 67.3% -27.6% 12.7% -54.9% 1.0% Source: various UNFPA documents 4.4.4.2 Global aid for RHCS There have been a number of signs of increased donor focus on SRH over recent years. The US, Germany, France and the UK have all announced increased funds for SRH, and the number of major donors in the field has gone from three in the early 1990s to about ten today. In the private sector, Merck (manufacturers of Implanon) announced in June 2011 the planned reduction of prices and new financing and procurement options. Thus, the GPRHCS may to an extent have been merely a beneficiary of this trend, making resource mobilisation easier. Also, from the point of view of many donors, there are few other options to UNFPA for engagement with government-run health systems in this field – though USAID’s DELIVER programme shows that a long term commitment by a donor can be converted to the creation of an alternative implementing agency infrastructure. Between them, UNFPA and USAID accounted for more than two thirds of donor funding of contraceptives in 2010. In contrast, there are many more options for engagement with the private sector, through organisations such as MSI, IPPF, DKT, PSI, etc. Some 13% of donor contraception funding was through social 281664/ Synthesis report Final draft V2/ 11th January 2012 68 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report marketing initiatives in 2010. Apart from some very small projects, there remains little interaction between UNFPA and the private sector. But closer examination of donor funding shows that the RM environment is in fact still a challenging one for sexual and reproductive health commodities (SRHCs). Total donor support fell by 1.5 per cent from $238.8 million in 2009 to $235.6 million in 2010. And this total has grown minimally from 2005, not even keeping pace with inflation. Within the total, the most substantial funding growth has been through PSI and the German agencies BMZ/KfW (which also favours a social marketing approach), while more than half of funding is still on a bilateral basis. The GPRHCS has done well to take an average of 23% of annual total donor funding for SRHCs during 2008-201027, a significant share. Table 21 Global donors to reproductive health commodities ($m) 2005 2006 2007 2008 2009 2010 Total donated funds 207.5 208.6 223.1 213.7 238.8 235.2 Annual change - 0.5% 7.0% -4.2% 11.7% -1.5% GPRHCS commodity spend - - - 25.8 73.5 62.9 GPRHCS as proportion of total - - - 12% 31% 27% Source: ‘Donor support for contraceptives and condoms for HIV/STI prevention – 2010’; UNFPA global donor support database Graph 3 Trends in major donor support for commodities, 2005–2010 Source: ‘Donor support for contraceptives and condoms for HIV/STI prevention – 2010’; UNFPA global donor support database _________________________ 27 An additional 7% of the total was accounted for by other elements of UNFPA in 2010. 281664/ Synthesis report Final draft V2/ 11th January 2012 69 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report 4.4.4.3 Changing nature of SRHC aid Recent years have seen movement from simple SRHC procurement to greater concentration on country capacity building and manufacturer quality considerations – led not least by GPRHCS itself, as well as USAID. This has presented difficulties for resource mobilisation, as UNFPA (and others) have struggled to demonstrate measurable effects of such supply side work to potential donors. Also, the GPRHCS requests funds for countries based on the historical FP method mix. Yet such method mixes are dynamic, with a current tendency from short term methods to longer term ones which require greater initial investment. 4.4.5 Conclusions and recommendations � GPRHCS resource mobilisation has generally been successful, whether measured against estimated need, UNFPA RM more generally or the SRHC funding environment; � Greater investment in RM capabilities would be likely to yield a significant positive return in increased GPRHCS contributions; � UNFPA itself has a preference for core funding, an issue discussed widely within the UN28, which may handicap future GPRHCS RM; � Although some friction may be inevitable between conflicting donor and UNFPA financial cycles, donors (especially those supportive of the Paris Agreement) should be able to synchronise their contributions better (i.e. make them earlier in the year); � More must be done to track government spending on RH commodities – a critical factor in the GPRHCS strategy, by UNFPA but ideally acting in concert with other major players (e.g. via the RHSC); � A similar ambitious approach is needed by UNFPA to gather data on private sector RHC markets, without which global unmet need cannot be addressed; � The collection of such data on private sector resource mobilization might be only a first step in a strategy of closer collaboration with the private sector, which seeks to achieve better leverage from private resources and activity; � As much as is possible (this is more challenging), expenditure on capacity building (not only by UNFPA) should also be tracked, with attempts to register effects and so better direct future investment. 4.5 The effectiveness of the bottom up approach to management and internal coordination of the GPRHCS. 4.5.1 Overview Commodity Security Branch is very committed to the concept of a bottom up approach to management and internal coordination of the GPRHCS because of the need of the Programme to meet country priorities. In practice what this means is that countries do have a lot of scope to establish priorities, but this is within a fairly rigid process of planning and administration. Also whilst each country has developed its own outputs _________________________ 28 See http://www.un.org/en/ecosoc/julyhls/pdf11/oa-2011-concept_note-critical_mass.pdf 281664/ Synthesis report Final draft V2/ 11th January 2012 70 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report and outcomes and prepares its AWP in conjunction with national implementing partners (primarily the MoHs), approval of the plans and key decisions on overall programme outcomes and outputs, countries to include in the programme, resource allocation, monitoring and reporting are taken at HQ. Devolution of the definition of programme outputs to country level has been an effective way to ensure integration with MoH programmes, and bottom-up planning ensures that the programme has flexibility to align with country needs. This is a clear strength of the Programme. But as discussed earlier it has also led to inclusion of a wide range of SRH activities without sufficient prioritisation or consideration of how they may be the catalytic inputs that the Programme aims for. HQ and the regions do engage in a process of challenging the content of plans, and activities are sometimes turned down for funding. The countries reported that they found this very useful and that it led to an improvement in the plans. However more needs to be done, before plans are formulated, to assist countries with prioritisation. This is discussed in section 3.1.4.1. Line management arrangements and decision-making on key issues are centralised. The line management role of the regional offices (if any) needs to be specified more clearly in relation to GPRHCS. Currently Country Offices report to both Regional Offices and HQ, some reports and documents being channelled through the Regional Offices for their feedback before being finalised and submitted to HQ. However Country Offices continue to communicate directly with HQ when they feel it is necessary. Funding is channelled directly from HQ to Country Offices. Lack of clear definition of line management functions at regional level may be due to the coincidence of the GPRHCS with UNFPA’s regionalisation and devolution of responsibilities to regional level, which is still underway. Once regionalisation is fully implemented these problems may disappear. Decisions on financial allocations to countries and inclusion of new countries in the programme are taken at HQ. Neither Country Offices nor Regional Offices are fully aware of the process, criteria and priorities of financial resource allocations from year to year. The process of allocation of funds and the approval of workplans and disbursements by HQ have been subject to delays which affect programme implementation, as discussed in earlier. There is also some overlap in responsibilities or functions of different HQ offices (such as CSB and Procurement) which can affect programme implementation. For example lack of agreement between HQ departments on requirements for procurement documentation has affected Regional Office initiatives to increase MoH procurement through UNFPA in a number of Latin America and the Caribbean (LAC) countries. 4.5.2 Conclusions Programme management is a mixture of bottom-up activity planning and in-country resource allocation carried out at country level, and top down overall decision-making on resource allocation between countries and on programme management systems (MF, reporting, funds flow) taken at HQ level. The emphasis on bottom up determinatation of activities has given GPRHCS essential flexibility to align with country needs, but at the same time presents challenges to retaining the strategic focus of the programme on achievement of sustainable RHCS. Each level of UNFPA is doing its best, within limited staffing and financial resources, but there needs to be more engagement between the levels, with more support from the top to the bottom. 281664/ Synthesis report Final draft V2/ 11th January 2012 71 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report 4.5.3 Recommendations The Programme should maintain its emphasis on country level priority setting. However HQ and the regions need to consider how to give countries better support in establishing those priorities, and negotiating them with government. A number of strategies should be considered: • Increasing the number of, role and resources available to the regional advisors, to enable them to play a greater part in planning, and pre-planning activities; • Committing more resources to capacity building of in country GPRHCS staff to enable them to have a wider and deeper understanding of RHCS; • Using the country level strategic planning process to set priorities and agree them with government. GPRHCS country level resource allocation should be more closely aligned to these plans. A process of mid term review should be encouraged for the plans to keep them relevant. • Developing more systematic approaches to in country programme monitoring, rather than just relying on the overall MF, the expenditure focussed annual reports. The purpose would be to give countries a tool that they would find useful for managing their performance, and determining priorities. 281664/ Synthesis report Final draft V2/ 11th January 2012 72 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report 4.6 The extent to which the monitoring framework and system meets the needs of the GPRHCS Table 22 Summary of case study findings: experiences with the Monitoring Framework Stream 1 Sierra Leone Madagascar Mongolia Lao Nicaragua Ethiopia Burkina Faso -Both AWPs and annual reports are structured to fit with the MF (that pre- existed) -So MF captures all activities that have been implemented -MF indicators are not completely aligned with activities and interventions in the country -Outcome and outputs were previously designed to fit with the National Strategic Plan for RHCS -MF’s output indicators are not well geared to capture some of Mongolia’s activities under the GPRHCS -MF does not cover all activities implemented under GPRHCS -HIMS needed to document some of the indicators which is a problem considering HIMS’ performance in Laos -MF is time- consuming for CO (requires field surveys and/or info not provided by existing MIS systems) -Some of the MF indicators are too broad so tend to ‘deviate’ activities from RHCS support -Not all indicators relevant to the Nicaraguan context -Important activities are not reflected in the MF indicators -MF meets the need of the GPRHCS but difficult to integrate with existing UNFPA and Gov. systems -MF requires additional indicators (to those included within the Ethiopian M&E system) necessitating at additional survey -Late adoption of MF makes difficult comparison year on year -CO found MF not sufficiently focused RHCS -No information available Stream 2 Benin Zambia Liberia Nigeria Uganda Lesotho Ghana -No information available -MF seen as an useful tool by CO -However, documenting all indicators is very demanding and time consuming -MF captures central and national level activities, but does not capture information below this level or at the facility level -MF captures all activities which are implemented in Nigeria -MF captures all activities carried out under the GPRHCS -CO was not able to determine base lines for all areas -No information available (as there is currently no M&E officer in the CO) -MF captures all activities that have been implemented -AWP reworked with regional support so indicators fit with MF The core element of the GPRHCS M&E system is the monitoring framework (MF), which contains the goal, outcomes and outputs of the programme and their respective indicators. It also includes some programme management indicators. See MF in Annex 2. The MF was developed in 2009 with TA support from various donors in order to address the weaknesses in the original Programme logframe and establish indicators for the Programme as a whole. It was adopted and shared with the GPRHCS countries in 2010. Since then, reports on the MF are prepared annually by all countries involved in the GPRHCS and submitted together with complementary narrative and financial reports. There are additional reporting elements for Stream 1 countries (annual questionnaires, etc). The 281664/ Synthesis report Final draft V2/ 11th January 2012 73 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report MF and reports are supplemented by occasional physical monitoring by Regional Office and HQ staff during country visits. All this information is gathered in the GPRHCS annual reports. A summary of case study country performance against the MF is at Annex 3, based on the 2010 annual reports made to UNFPA. Generally the Regional Office advisers like the M&E system and feel it meets their needs, although some of its indicators are not readily available from national HIS. Country Office opinions on the MF are mixed; whilst the importance of a standard instrument is recognised, a “one size fits all” system has limitations in capturing key information from diverse countries and programmes, and the reporting system is cumbersome. The introduction of the MF has been a major step forward for the GPRHCS, so that annual Programme reports to donors are becoming much more consistent and robust. However the evaluation team identified issues in the design and operation of the M&E system, which if addressed could further its evolution. 4.6.1 Design issues The MF includes a range of indicators addressing different aspects of RHCS, but coverage is uneven. There is a preponderance of indicators which focus on policy, coordination, procurement and distribution. Three of the six outcome indicators address availability of commodities at facility level and two monitor uptake (CPR and unmet need). These are all important to include, but others need to be developed at output level to fill the gap between availability and uptake. The GPRHCS definition of commodity security includes demand side issues, access and service delivery, so some indicators need to address these. Many of the indicators have been achieved by several of the case study countries (see Annex 3). This is laudable, but more need to be developed to raise the bar and address approaches to RHCS that need to occur after initial coordination mechanisms have been set, MoUs signed etc. There is a preponderance of indicators focussing on early stages of the Programme. Although there is an indicator which looks at the number of countries maintaining allocation within SRH/RHCs budget line for contraceptives, there is no quantification of the funding made available. Ultimately if RHCS is to be sustained countries are going to have to spend more of the resources under their control on commodities. The M&E system should track progress towards the strategic and operational goals of the programme. It should provide a snapshot of country progress towards RHCS and possible graduation from the Programme and provide a means of identifying whether specific advances have been made or obstacles met during implementation. As GPRHCS is country-led and indicators at goal and outcome level include national SRH data, input to the M&E system should be compatible with national information systems wherever possible, although additional information will clearly be needed for UNFPA’s own M&E purposes. Although the GPRHCS’s overall goal, outcomes and outputs were developed during the programme design stage, when implementation started participating countries were expected to develop their own country- specific outputs. These often differ from the global outputs in content and priority. The MF does not necessarily cover all activities carried out at country level (e.g. Laos, Nicaragua, Liberia) and the indicators included in the MF are not always aligned with the interventions supported by national programmes (e.g. Madagascar). 281664/ Synthesis report Final draft V2/ 11th January 2012 74 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report As a one-size-fits-all method of collating comparative data from all participating countries, the MF and reporting formats do not take into account important elements which are country-specific and affect implementation. Examples are countries with federal structures, with social and political instability, and with specific priorities in SRH. As country reporting tries to take this into account, the reports are not always consistent with each other. Neither does the MF specifically identify activities at regional level. It also does not distinguish between partial and full achievement of indicators. There is a certain degree of repetition in the information required in different elements of the M&E system. These repetitions are reflected in the various reports which are prepared by Country Offices for the Regional Offices and HQ. Joint reporting with the MHTF has not added value (on paper reporting or in terms of timing), and has made it more difficult to identify the level of resources which has been used specifically in GPRHCS. The M&E system does not foster reporting of information on innovation and successes. That would certainly be something worth developing and a good way to improve adherence of both the COs and heir partners in country to the M&E system. 4.6.2 Operational issues Variations in the interpretation of the MF reflect weaknesses in the strategy and focus of GPRHCS, and lack of clarity in communicating programme aims and priorities to Country Offices. Country GPRHCS programmes should be focusing on the output level of the MF, with implementation of activities aimed specifically at improving RHCS. These in turn will eventually contribute to overall GPRHCS outcomes and goals of improving access to SRH and improving SRH status. In practice country programmes have not focused exclusively on RHCS-related activities. Countries have taken the global GPRHCS goal and outcome indicators as justification for including work aimed at increasing access to SRH services and improving their quality in general, rather than focussing on RHCS outputs and on the RHCS issues reflected in the output indicators. A key operational problem for M&E is the lack of availability of reliable information, in particular in countries where HIMS is weak, and the need to conduct expensive field surveys to fill the gaps. As data is not available on the 3 outcome indicators related to stocks in health facilities, field surveys have been carried out to get the information in all Stream 1 countries and are planned to be repeated annually. This may not be a sensible or cost-effective exercise, although some of the data is used – or could be used - by MoHs. The M&E system also requires annual reporting on general SRH indicators, but information on these is not available on an annual basis in most countries, although some middle-income countries with better HMIS may be able to provide the data. Although there have been improvements in implementation of the M&E system with growing numbers of countries now getting their reports in on time, in practice the MF and related narrative and financial reports are used for reporting to Regional Office and HQ, but not for much else at country level. In some regions more training is still needed to ensure the system is used correctly, and that reports are prepared on time. In all countries, the potential of the system to highlight successes and failures and to guide the work in- country is not fully utilised, partly because the system does not correspond to specific country needs. In some COs, there is a lack of specific M&E capacity, both for GPRHCS and for other on-going programmes, and at country level there is no organizational culture of utilisation of M&E information to analyse and improve performance. As a consequence, the perception of the M&E tends to be a bit ‘passive’ and most countries still report on activities rather than results. Once activities have been 281664/ Synthesis report Final draft V2/ 11th January 2012 75 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report completed and indicators satisfied, MF reports and country questionnaires (Stream 1) in subsequent years are reduced to repetition of box-ticking. At the same time, there is a need for better standardisation and consistency in annual narrative and financial reports, which vary widely in content and quality between countries, and over time within countries, making it difficult to follow progress and track activities from year to year. This is not incompatible with the UNFPA bottom up approach to programme priority setting, and would in fact enable country variations to be clearer and better understood, rather than for them to be simply omitted from some reports as they do not fit the MF. In 2010 WCA Regional Office carried out a survey on difficulties in implementation of the GPRHCS which filled gaps in the information provided on a regular basis by the M&E system. The M&E system should produce this type of information itself and present it in a way it can be used to inform HQ. 4.6.3 Conclusions and recommendations: The MF was developed late in the course of the implementation of the GPRHCS. However, it is now used by all the COs. AWPs and annual reports tend to be structured accordingly. The MF is seen as demanding and time-consuming by some country offices. The definition of the targets set up in the MF for a large number if the outputs’ indicators should be revisited as all country programmes seem to be performing, even over performing, and yet RHCS cannot be said to have been achieved in all those countries The absence of baseline is a limitation to use the MF to measure progress. The MF does not necessarily cover all activities carried out at country level and the indicators included in the MF are not always aligned with the interventions supported by national programmes. The MF is sometimes difficult to integrate into existing UNFPA and Government M&E systems. In some countries, poor performance of HMIS is a limit to document some of the indicators of the MF. There is room for improvement in the M&E system to ensure that it is flexible and user-friendly, and provides consistent two-way information for management and Country Offices on the advance of the programme. 281664/ Synthesis report Final draft V2/ 11th January 2012 76 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report [1] About UNFPA UNFPA, the United Nations Population Fund, is the world's largest multi-lateral source of funding for population and reproductive health programmes. Since it began operations in 1969, the Fund has provided nearly $US 6 billion in assistance to developing countries. UNFPA works with governments and non-governmental organizations in over 140 countries, at their request, and with the support of the international community. We support programmes that help women, men and young people: [a] Plan their families and avoid unwanted pregnancies [b] Undergo pregnancy and childbirth safely [c] Avoid sexually transmitted infections [STIs] - including HIV/AIDS [d] Combat violence against women. Together, these elements promote reproductive health- a state of complete physical, mental and social well being in all matters related to the reproductive system. Reproductive health is recognized as a human right, part of the right to health. UNFPA also helps governments in the world's poorest countries, and in other countries in need, to formulate population policies and strategies in support of sustainable development. All UNFPA-funded programmes promote women's equality. UNFPA works to raise awareness of these needs among people everywhere. We advocate for close attention to population problems and help to mobilize resources to solve them. UNFPA assistance works. Since 1969, access to voluntary family planning programmes in developing countries has increased and fertility has fallen by half, from six children per woman to three. Nearly 60 per cent of married women in developing countries have chosen to practice contraception, compared with 10- 15 per cent when we started our work. [2] Background UNFPA’s work in the sphere of Reproductive Health Commodity Security is designed to move beyond ad hoc responses to stockouts of the past towards more predictable, planned and sustainable country-driven approaches for securing and using essential RH supplies. It is designed to galvanise, institutionalise and facilitate coordination of national efforts to enhance RHCS. Contraceptive use has increased in many developing countries in the past decade, but significant challenges still exist. The leading indicators suggest there is much progress to still be made: • 76 million [4 out of 10] pregnancies in developing countries are unintended. • Approximately 35 million pregnancies are terminated through induced abortion. • One third of maternal deaths occur among women with unintended pregnancies. The majority of unintended pregnancies are caused by non-use of modern family planning practices: • As many as 200 million sexually active and fertile women in developing countries report interest in spacing or limiting births [i.e., are at risk of unintended pregnancies], but do not practice modern family planning practices. • Reasons range from limited availability of contraceptive methods to issues in accessing services to lack of information about contraception and pregnancy risk. Projections based on public-sector contraceptive supply donation and funding trends point to shortfalls in the supply of contraceptives and condoms for family planning and HIV prevention over the next two decades. These predicted shortfalls [for supplies only, exclusive of the systems needed to deliver them] are Annex 1: Terms of Reference 281664/ Synthesis report Final draft V2/ 11th January 2012 77 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report the result of increasing demand and large numbers of people entering the reproductive age group. Ensuring a continuous supply to meet the demand for contraceptives, condoms, and other reproductive health [RH] medicines and commodities necessary to address critical public health needs is a complex responsibility shared among country governments, international donors, NGOs and the private sector. It is an issue not only of resources but also of their efficient and effective use. In response to these acute challenges, the development community has developed the policy area of RHCS. RHCS is the ability of all individuals to obtain and use affordable, quality reproductive health commodities of their choice whenever they need them. RHCS is essential to meeting the target of universal access to reproductive health by 2015, as called for by the International Conference on Population and Development [ICPD] and reiterated at the 2005 World Summit. It is also critical in the fight against HIV/AIDS. Global Programme to enhance Reproductive Health Commodity Security: Since 2007, the Global Programme to enhance Reproductive Health Commodity Security [GPRHCS]—financed by UNFPA’s Thematic Fund for Reproductive Health Commodity Security [RHCS—has helped UNFPA work with national governments to carry out the diverse and multi-faceted work needed to achieve RHCS. Previous efforts responding to ad-hoc requests from countries for technical assistance and supplies failed to generate country-driven, sustainable approaches to commodity security. UNFPA developed the Global Programme specifically to help countries plan for their own needs in the sphere of RHCS. The Global Programme is designed to act as a catalyst to national action and the prioritisation and subsequent mainstreaming of RHCS into national health policies, programmes, budgets and plans. As a result, countries are beginning to move towards more predictable, planned and sustainable country-driven approaches to securing essential supplies and ensuring their use. To ensure this extra funding has a clear measurable impact, the Global Programme provides multi-year funding to a relatively small number of ‘Stream 1’ countries. These predictable and flexible funds are then used to help countries develop more sustainable approaches to RHCS: ensuring the reliable supply of RH commodities and the concerted enhancement of national capacities and systems. Of the eleven current Stream 1 countries, receiving this country-defined package of medium-term support, Ethiopia, Burkina Faso, Mozambique, Nicaragua and Mongolia have been receiving support since 2007; Madagascar, Laos, Niger and Haiti since 2008; with Mali and Sierra Leone joining in 2009. In 2009, the Global Programme was also active in a further 62 countries funded under streams 2 and 3. Stream 2 provides less extensive highly targeted support to strengthen elements of RHCS in either one or more countries [providing the possibility of regional initiatives] – with some 30 countries benefiting in 2009. In the remaining countries, Stream 3 funding provides help to countries avoid stockouts of contraceptives and reproductive health drugs and equipment that would otherwise occur. This type of emergency funding fills a gap caused by weak infrastructure, poor planning and low in-country capacity. Stream 3 also allows the Global Programme to work closely with UNHCR and other partners to deliver RH commodities in times of humanitarian emergencies – be they man-made or due to natural disasters. As per the original document, the Global Programme is designed to produce the following results: At national level: • Reproductive health commodity needs met consistently and reliably for all who need them; • Strong inter-linkages between RHCS and national RH and HIV/AIDS programmes and policies; • Enhanced capacity of national stakeholders and improved systems [particularly for RH commodity supply, quality of care, demand and access]; • Mainstreaming of RHCS through gradual increases in government-controlled funding to finance capacity and system enhancement and planned commodity provision; • Increased national ownership and management of all aspects of RHCS. At international level: • Regular and dependable funding flows necessary to implement multi-year plans of action; • More strategic international support for RHCS; 281664/ Synthesis report Final draft V2/ 11th January 2012 78 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report • Better collaboration among UN Agencies and better integration of RHCS in the context of joint country level work; • Stronger strategic partnerships among global development partners through work with the global Reproductive Health Supplies Coalition and development of stronger links with international funds such as the Global Fund for AIDS, TB and Malaria. The overwhelming focus of the Global Programme is at country level. It should be clear however that, as per the programme document, the Global Programme takes its guiding principles from the Paris Declaration on Aid Effectiveness. In that sense, it was always conceived to be a catalyst—taking full account of in-country realities and possibilities—to facilitate the mainstreaming of Reproductive Health Commodity Security into national health policy, programmes, plans and budgets. For that reason, focus, scope, objectives and progress vary from country to country. [3] Purpose The purpose of the consultancy is to carry out the Mid-Term Evaluation of the Global Programme to enhance Reproductive Health Commodity Security [GPRHCS]. The evaluation will contribute to the evidence base to answer critical questions about effectiveness (including cost-effectiveness where possible) of approaches used to date to improve reproductive health commodity security [RHCS]. It will also aim to understand whether and how the GPRHCS, with tailor-made multiple strategies undertaken simultaneously at national, regional and global levels has assisted in advancing the programme. The two main objectives are to: [1] Assess the relevance, effectiveness and efficiency of the current strategies and approaches designed to improve RHCS – as financed by the GPRHCS [2] Assess the coordination, management and support from UNFPA global and regional levels to national level efforts. The evaluation findings and recommendations will be used to: • Help adjust RHCS strategies and approaches and improve the quality of national efforts to improve RHCS and mainstream it into relevant health policies, programmes, plans and budgets • Enhance RHCS support—technical, programmatic, financial and in the field of advocacy—from global, regional and country levels • Document lessons learnt to contribute to the knowledge base on the mainstreaming of RHCS into relevant health policies, programmes, plans and budgets at national level [and how this national level process can be supported and promoted at regional and global level] • Document lessons learnt to contribute to the management and coordination of the GPRHCS and other UNFPA-wide thematic approaches and initiatives. Principal evaluation users will be: • UNFPA Country Offices and national stakeholders involved in RHCS and related fields • UNFPA senior management and staff, particularly from Country Offices and those involved in the management of thematic funds • UNFPA donors • Partner organisations working in RHCS and related fields [particularly members of the Reproductive Health Supplies Coalition – www.rhsupplies.org] [4] Key Evaluation Questions National level work The evaluators will identify evaluation questions building upon the purpose and scope of the evaluation guided by some of the factors described below. Therefore, the present questions in TORs are only indicative. The evaluators will come up with the final questions in their inception report. The evaluation will make use of the standard OECD/DAC evaluation criteria namely relevance, effectiveness, efficiency, impact and sustainability. At national level— particularly in Stream 1 countries—in the sphere of RHCS, it will look at progress as per the four output areas in the GPRHCS M&E Framework which has been being used since 2008. The four output areas are: 281664/ Synthesis report Final draft V2/ 11th January 2012 79 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report [1] Country RHCS strategic plans developed, coordinated and implemented by government with their partners [2] Political and financial commitment for RHCS enhanced [3] Capacity and systems strengthened for RHCS [4] RHCS mainstreamed into UNFPA core business (UN reform environment) The evaluation will be guided and informed by the OECD/DAC evaluation criteria: [1] Relevance – To assess and gauge: [1] The extent to which the Global Programme encourages appropriate policy and programme interventions; and [2] The extent to which the use of funds in selected Stream 1 countries is making appropriate use of the opportunity the programme provides to develop and implement a multi-year integrated nationally-defined and nationally-driven strategy to improve RHCS. Re. [2]: What approaches have been used? What constraints exist? What constraints have been overcome? What were the contributing factors? [2] Effectiveness – To assess and gauge: [1] The extent to which the Global Programme provides appropriate parameters to allow countries to take systematic action to improve RHCS at national level; and [2] The extent to which the GPRHCS is working as a catalyst to: a. Ensure the consistent availability of RH commodities for those who need them. This should also include a focus on the extent to which the Global Programme is facilitating national efforts to build long-term sustainability of in-country commodity security by allocating and using own resources to purchase RH supplies. b. Ensure the systematic development of national capacity to negate the need for external assistance in this sphere This will include analysis of extent to which RHCS-related national capacity has improved in: policy; advocacy; procurement; logistics; supply chain management; demand creation to family planning and peri-natal care services c. Mainstream RHCS into appropriate parts of national health policies, programmes, plans and budgets. [3] Efficiency – To assess and gauge: [1] The extent to which the Global Programme provides appropriate guidance to facilitate appropriate coordination of RHCS work at national level [2] The extent to which coordination mechanisms are in place [set up, reinvigorated or supported by the GPRHCS] to build understanding of RHCS and related challenges, exploit synergies among in-country stakeholders and promote efficient use of RHCS-related technical, financial and human resources at country level. This will include analysis of extent to which RHCS work is helping bring about the integration of national efforts, on the one hand, to tackle HIV/AIDS and, on the other hand to improve Reproductive Health, Maternal Health and Family Planning 281664/ Synthesis report Final draft V2/ 11th January 2012 80 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report [4] Impact and Sustainability – To assess and gauge: [1] Results accomplished to date? How progress and results are being monitored? The extent to which attribution can be assigned to the GPRHCS and measured. [2] Level of national commitment to RHCS and the likelihood of improvements being sustained. This will include analysis of: [•] the extent to which RHCS has been mainstreamed into the appropriate national health policies [including PRSPs, SWAps, HSRs, UNDAF, etc.] programmes, plans and budgets; [•] what needs to continue and what more needs to be done to ensure that improvements in RHCS are maintained and sustained in-country. [5] Overall recommendations What are the priority programming areas for the next few years? What are the ‘conditions for success’ to ensure RHCS is effectively mainstreamed into appropriate parts of national health policies, programmes, plans and budgets move national programmes forward? What has to be done to ensure that RHCS-related national capacity is systematically improved and maintained in the spheres of policy, advocacy, procurement, logistics, supply chain management, demand creation to family planning and peri-natal care services. [5] Key Evaluation Questions – Global and Regional level work At the global and regional level, the evaluation will focus on the five main areas of support: [A] Capacity Development, [B] Measurement, Monitoring and Evaluation [C] Awareness Raising and Resource Mobilization [D] Partnership Building [E] Internal coordination and management It will aim to assess how these have contributed to progress at national level, in addition to internal management and coordination. Questions could include some of the following: [1] Capacity Development: What support has been provided and what guidance has been developed by UNFPA staff and partners? What is the perception of the usefulness of the support/guidance that has been developed by UNFPA staff and partners? For UNFPA, what are the plans to support capacity development at country level from regional and global levels? [2] Measurement, Monitoring and Evaluation: How has the GPRHCS contributed to advancing the monitoring of programmes? How is the support provided to countries related to monitoring and evaluation? [3] Awareness Raising and Resource Mobilization: What has been the role of the GPRHCS and related advocacy activities of partners, particularly in the Reproductive Health Supplies Coalition [RHSC] in raising awareness of RHCS and related issues among policy makers, international organizations, the general public and donors? What has been the contribution of RHCS [and the GPRHCS] as an entry point to raising awareness of: reproductive health [including family planning and FP services]; maternal health [particularly with regard to maternal mortality]; HIV/AIDS prevention [particularly with regard to condom provision – see UNFPA’s Comprehensive Condom Programming strategy]. How has the GPRHCS contributed to increasing resources for RHCS and other RH supply related work? Within UNFPA? Among other partners? [4] Partnership Building: How effective is the coordination among partners at the global and regional level? What role has been played by: UNFPA? How can UNFPA enhance coordination in the sphere of RHCS? [5 Internal coordination and management: 281664/ Synthesis report Final draft V2/ 11th January 2012 81 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report How effective has the management and internal coordination of the GPRHCS been? What lessons can be drawn for management of both the GPRHCS and other thematic funds and approaches [both from inside and outside UNFPA]? [6] Evaluation Approach Sampling approach: The mid-term evaluation will focus on a sample of countries with a variety of experiences and at different stages of implementation. The period covered will be from 2007 to 2009, and selected counties will have been involved in the GPRHCS for no less than one year. A subset of the selected countries will be visited and serve as in-depth case studies. Given the need to focus on lessons learnt to date, in-depth case studies will focus on countries which have been receiving GPRHCS support starting no later than 2009. By concentrating on the more mature programmes, the evaluation will be better placed to make informed and credible judgments about the effectiveness of the approaches and lessons learnt. The following are the selection criteria for in-depth case studies: • On-going RHCS support with at least 18-24 months in the implementation phase • National partners and country office interest and availability for evaluation • Multi-year funding provided for integrated approach to improve RHCS • National coordination mechanism exists to facilitate and seek to ensure stakeholder participation In order to get a broad picture of the types of support the Global Programme has been able to make available, the mid-term evaluation will focus on: • Field visit to four Stream 1 countries deemed to best meet the selection criteria – that is [•] Ethiopia, Madagascar, Sierra Leone; and Nicaragua. • Desk review of 10-15 countries (Streams one, two and three countries). In addition, the global and regional coordination, management and support mechanisms will be assessed to ensure optimal support to countries. The evaluation will look at efforts within regions and at the global level as well as the interdivisional efforts. LIST OF GPRHCS COUNTRIES Stream I Countries Stream 2 Countries 1 Burkina Faso 1 Benin 2 Ethiopia 2 Bolivia 3 Haiti 3 Botswana 4 Laos 4 Burundi 5 Madagascar 5 Central Africa Republic (CAR) 6 Mali 6 Chad 7 Mongolia 7 Congo (Brazzaville ) 8 Mozambique 8 Congo DRC ( Kinshasa ) 9 Nicaragua 9 Cote d'Ivoire 10 Niger 10 Djibouti 11 Sierra Leone 11 Ecuador 12 Eritrea 13 Gabon 14 Gambia 15 Ghana 16 Guinea 17 Guinea Bissau 18 Lesotho 19 Liberia 20 Malawi 21 Mauritania 22 Namibia 23 Nigeria 281664/ Synthesis report Final draft V2/ 11th January 2012 82 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report 24 Papua New Guinea 25 Sao Tome 26 Senegal 27 Sudan 28 Swaziland 29 Timor Leste 30 Uganda 31 Yemen 32 Zambia 33 Zimbabwe Stream 3 countries will be all other developing countries which are not listed above. [7] Methodology Once selected, the evaluation team will work with UNFPA to develop a methodological Inception Report which will provide details on the approach to be followed. The Inception Report will be presented to the Technical Division/UNFPA for approval prior to the commencement of the research. The Inception Report should among other things provide details on the following: • The indicator framework used to evaluate GPRHCS progress [from GPRHCS M&E Framework] • Details of methods for collecting data from the selected sample of countries [a] Details of how each in-depth country case study will be organised and conducted [b] Details of how work in selected countries not subject of a country visit will be organised and conducted • Details of how the regional and global elements will be assessed • Details of data collection instruments • Types of data analysis to be conducted • Proposed schedule of country visits • A schedule of detailed outputs and dates in line with the work programme of deliverables scheduled below. Key principles for the design of the evaluation approaches are as follows: • Participatory process to involve and strengthen capacity of stakeholders in design, data collection, analysis and planning for implementation of recommendations using national coordination mechanisms • Approach as a learning process for a relatively new area of intervention; an opportunity to take stock and see how the different approaches are working and assess results to date. The country visits will provide the evaluation team with an opportunity to discuss with UNFPA staff, Government counterparts and other development partners. The visits will also help facilitate stakeholder involvement in the evaluation process. Country visits will be undertaken to each of the four Stream 1 countries for duration of one week in each. Desk work will complete the analysis of progress in other Stream 1, Stream 2 and Stream 3 countries. In each country, UNFPA will identify and recruit a national consultant to assist in facilitating the process and ensure national participation. To understand national progress in other GPRHCS funded countries and to complement the in-depth country visits in the selected countries, the evaluation team will: [•] use a variety of methods including e- mail surveys, telephone interviews with UNFPA staff and partners; and [•]carry out a review and synthesis of secondary sources of data and analysis such as: previous evaluations, all programme documentation, other RHCS reports, mission reports and national, regional and global reporting to assess global and regional components of the GPRHCS and other RHCS-related work. [8] Management & Support Arrangements In order to ensure utility and transparency, TD will establish a Reference Group [RG] to serve in an advisory role to the evaluation team. The evaluation will be managed by the Commodity Security Branch of 281664/ Synthesis report Final draft V2/ 11th January 2012 83 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report UNFPA’s Technical Division (TD) in collaboration the RG which will include a representative from the Division for Oversight Services (DOS), Programme Division (PD) and Geographic Division (GD). The evaluation will follow the UNEG ethical guidelines for evaluation, which require adherence to key principles such as utility and transparency in approach. This requires that the evaluation approach and methodology is guided by intended users’ needs and that stakeholders are consulted on the approach. The role of the RG will be to provide input to the methodological approach which will guide the evaluation as well as to assist with the validation of findings and recommendations. TD will arrange for RG meetings at strategic times during the course of the evaluation. The RG will consist mostly of UNFPA staff with expertise in evaluation and in the technical area of RHCS. TD will also provide support to the team throughout the period of the evaluation, assisting with the preparation of data and the provision of background information materials as required. TD, in collaboration with the relevant Regional Offices, will assist the evaluation team in arranging country visits. UNFPA Country Offices will provide the necessary logistical and administrative support to the evaluation team whilst they are in the field, including involvement and participation of national stakeholders and recruitment of a national consultant to join the evaluation team. [9] Tentative Timetable Tentative Schedule and Outputs & Deadlines Item Target Timing Meetings Constitution of Reference group, Finalisation of TOR and selection of Evaluation Team August 2010 CSB/TD with Evaluation Team HQ Briefing of Evaluation Team 1st March 2011 CSB/TD with Evaluation Team Preparation and Submission of Inception Report with detailed methodological approach End of March 2011 Reference group (RG) Meeting to consider inception report and detailed methodology Conduct research including country visits Mid April 2011 to End of June 2011 Draft summary paper of key findings of the evaluation to feed into SP End of June 2011 HQ debriefing on key evaluation findings, recommendations Mid July 2011 CSB/TD with Evaluation Team First draft of evaluation report due – Reports for each country, global/regional level and synthesis report Mid July 2011 RG Meeting to review first draft report UNFPA and national stakeholders review draft report and provide feedback and comments End of July 2011 Second Draft of Evaluation Report Mid August 2011 RG Meeting to consider Second 281664/ Synthesis report Final draft V2/ 11th January 2012 84 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report Item Target Timing Meetings draft report Final Report End of August 2011 Dissemination of Report September 2011 [10] Evaluation Team Composition All evaluation team members will have a relevant background in evaluation, health policy and programme issues in developing countries. All team members must also have the ability to travel to the in-depth case study countries. It is preferred that the same team visits all the countries to ensure consistency. The evaluation team will be supported by a national consultant recruited by UNFPA in each of the case study countries. The Team Leader should possess a background in public health, preferably in reproductive health with some experience in RHCS and have field experience and prior experience leading large-scale thematic evaluations. Prior experience in evaluating RH or RHCS programmes is highly desirable. The team should include a health professional with in-depth expertise and knowledge in RHCS. Areas of technical competence: • Language proficiency: English and French [with at least one team member fluent in Spanish] • In-country or regional work experience • Evaluation methods and data-collection skills • Analytical skills and frameworks, such as gender analysis • Process management skills, such as facilitation skills • Gender mix in team composition. Goal: Universal access to Reproductive Health by 2015 and universal access to comprehensive HIV prevention by 2010 for improved quality of life Outcome: Increased availability, access and utilization of RHCs for voluntary family planning, HIV/STI prevention and maternal health services in the GPRHCS focus countries Output 1: Country RHCS strategic plans developed, co-ordinated and implemented by government with their partners Output 2: Political and financial commitment for RHCS enhanced Output 3: Capacity and systems strengthened for RHCS Output 4: RHCS mainstreamed into UNFPA core business (UN reform environment) Programme Management Indicators: Indicators: Indicators: Indicators: Indicators: Indicators: Indicators: 1. Adolescent birth rate 2. Maternal Mortality Ratio 3. Youth HIV prevalence rate 1. Average Unmet need for FP (45 countries) 2. Average Contraceptive prevalence rate of modern methods (45 countries) 3. No. of stream 1 countries with Service Delivery Points (SDPs) offering at least three modern methods of contraceptives 4. No. of stream 1 countries where 5 life-saving maternal /RH medicines from UNFPA list is available in all facilities providing 1. Number of countries where RHCS strategy is integrated with national RH/SRH, HIV/AIDS, Gender, & Reproductive Rights strategies (45 countries) 2. Number of countries with strategy implemented (National strategy/action plan for RHCS implemented) (45 countries) 3. Number of countries with functional co- ordination mechanism on RHCS or RHCS is included in broader 1. Funding mobilised for GPRHCS on a reliable basis (e.g. multi-year pledges) 2. UNFPA signed MOUs with Stream 1 country governments 3. RHCS mainstreamed in regional policies and strategies through UNFPA work with global, bilateral and regional organizations/partners (Regional Economic Communities) 4. Number of countries included RHCS priorities (45 countries) in: a) PRS b) Health sector policy and plan 1. Number of countries using AccessRH for procurement of RHCs resulting 20% reduction in lead time (45 countries) 2. Number of pre- qualified suppliers of IUDs and condoms for use by UNFPA and partners 3. Number of Stream 1 Countries making ‘no ad hoc requests’ to UNFPA for commodities (non- humanitarian) 4. Number of Stream 1 Countries forecasting for RHCs using national technical expertise 1. Expenditure of UNFPA /CSB core resources for RHCS increased) 2. GPRHCS planning takes into account lessons learned in RHCS mainstreaming (45 countries) 3. Number of countries with RHCS priorities included in (45 countries): a) CCA b) UNDAF c) CPD d) CPAP 4) Number of UNFPA Country Offices with increasing funds allocated to RHCS (45 countries) 1. No. of countries achieving at least 60% of work plan outputs (45 countries) 2. No. of country offices with completed and budgeted Annual Work plan by end of December each year (45 countries) 3. No. of country offices submitting mid-year progress report to respective regional offices by 15 June each year (45 countries) 4. No. of country offices submitting completed annual narrative program report to respective Regional Offices by 15 December (45 countries) Annex 2: Programme Monitoring Framework Goal: Universal access to Reproductive Health by 2015 and universal access to comprehensive HIV prevention by 2010 for improved quality of life Outcome: Increased availability, access and utilization of RHCs for voluntary family planning, HIV/STI prevention and maternal health services in the GPRHCS focus countries Output 1: Country RHCS strategic plans developed, co-ordinated and implemented by government with their partners Output 2: Political and financial commitment for RHCS enhanced Output 3: Capacity and systems strengthened for RHCS Output 4: RHCS mainstreamed into UNFPA core business (UN reform environment) Programme Management delivery services 5. No. of Stream 1 Countries with Service Delivery Points with ‘no stock outs’ of contraceptives within last 6 months 6. Funding available globally for contraceptives / condoms coordination mechanism (45 countries) 4. Number of countries with essential RH commodities in EML (Contraceptives and life saving maternal/RH medicines in EML) (45 countries) 5. Number of countries maintaining allocation within SRH/RHCs budget line for contraceptives (45 countries) 5. No of Stream 1 Countries managing procurement process with national technical expertise 6. No of Stream 1 Countries with functioning Logistics Management Information System (LMIS) 7. No of Stream 1 Countries with co- ordinated approach towards integrated health supplies management system 8.No of stream 1 countries adopting/adapting a Health Supply Chain Management information tool (e.g. CHANNEL, PIPELINE) into national system 5) Number of countries with all the relevant joint UN programmes for SRH and MNH that include RHCS (45 countries) 6) No. of national/regional institutions providing quality technical assistance on RHCS in the areas of Training and Workshops, Advocacy, Monitoring & Progress Reviews, and Programme Development with countries (1 in each of 5 regions) 5. No. of country offices submitting completed financial report to respective Regional Offices by 15 December (45 countries) 6. No. of Regional Offices submitting reviewed AWPs to Technical Division/HQ by mid January (5 Regional Offices) 7. No. of Regional Offices submitting mid-year report by mid July and annual report of mid January to Technical Division/HQ (5 Regional Offices) 8. Country work plans reviewed and allocation made By HQ by 1st week of March 9. Semi annual and annual progress review/planning meeting organized for all GPRHCS Stream 1 counties by CSB/TD 10. Consolidated annual Goal: Universal access to Reproductive Health by 2015 and universal access to comprehensive HIV prevention by 2010 for improved quality of life Outcome: Increased availability, access and utilization of RHCs for voluntary family planning, HIV/STI prevention and maternal health services in the GPRHCS focus countries Output 1: Country RHCS strategic plans developed, co-ordinated and implemented by government with their partners Output 2: Political and financial commitment for RHCS enhanced Output 3: Capacity and systems strengthened for RHCS Output 4: RHCS mainstreamed into UNFPA core business (UN reform environment) Programme Management GPRHCS report (programmatic and financial) prepared by end of March of following year by HQ 281664/ Synthesis report Final draft V2/ 11th January 2012 88 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report Annex 3: Summary of Progress against the MF for Case Study Countries Stream One Ethiopia Burkina Faso Lao Madagascar Mongolia Nicaragua Sierra Leone Goal: Universal access to Reproductive Health by 2015 and universal access to comprehensive HIV prevention by 2010 for improved quality of life Adolescent birth rate 17% (2005) 104/1000 66 per 1,000 women aged 15- 19 133/1000 (2010) 29.5 per 1000 (2010 est.) 113/1000 (2010) 146/1000 (2008) Maternal Mortality Ratio 673 / 100,000 (2005) 484/100,000 405/100,000 live births 510/100,000 (2010) 45 / 100,000 (2010) 60.5/100,000 (2009) 857/100,000 (2008) Youth HIV prevalence rate 2.1% (2005) 1.3% No recent data available 0.1% (2010) 0.0% (2009) 0.2% (2010) 1.05% (2008) Outcome: Increased availability, access and utilization of RHCs for voluntary family planning, HIV/STI prevention and maternal health services in the GPRHCS focus countries Average Unmet need for FP 34% (2005) 28.8% 27% 47% (2009) 14.4.% (2008) 10.7% (2006/07) 28% (2008) Average Contraceptive prevalence rate of modern methods 32% (2005) 17.4% 35% 29% (2009) 52% (2009) 69.8% (2006/07)) 7% Percentage of Service Delivery Points (SDPs) offering at least three modern methods of contraceptives 1°: 98% 2°: 100% 3°: 100% 69.9% 83% 30.8% 1°: 92.9% 2°: 100% 3°: 100% 1°: 99.5% 2°: 100% 3°: - 1°: 728 out 1202 2°: 9 out of 42 3°: 1 out of 5 Percentage % of delivery facilities that have at least FIVE maternal/RH drugs (including Ergometrine, Magnesium Sulfate and Oxytocine) 1°: 64% 2°: 70.4% 3°: 100% 51.4% 56% 80.3% 1°: 77.4% 2°: 67.8% 3°: 83.3% 1°: 100% 2°: 100% 3°: - 1°: 768 out 1147 2°: 27 out of 40 3°: 3 out of 5 % of Service Delivery Points with ‘no stock outs’ of contraceptives within last 6 months. 1°: 2% only 2°: none 3°: none. 81.3% 31% All SDPs: 74.7% 1°: 7.1% 2°: 0 3°: 0 1°: 70.2% 2°: 38.1% 3°: - 1°: 661 out 1202 2°: 23 out of 42 3°: 3 out of 5 281664/ Synthesis report Final draft V2/ 11th January 2012 89 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report Stream One Ethiopia Burkina Faso Lao Madagascar Mongolia Nicaragua Sierra Leone Output 1: Country RHCS strategic plans developed, co-ordinated and implemented by government with their partners 9 RHCS strategy is integrated with national RH/SRH, HIV/AIDS, Gender, & Reproductive Rights strategies Yes:RH & HIV/AIDS. No: Gender mainstreaming Yes Yes:RH & HIV/AIDS. No: Gender mainstreaming Yes Yes Yes; RH No: HIV/AIDS & gender mainstreaming Yes 10 National strategy/action plan for RHCS is implemented. Yes Yes Yes Yes Yes Yes Yes 11 Functional co-ordination mechanism on RHCS or RHCS is included in broader coordination mechanism Yes Yes Yes Yes Yes Yes Yes 12 Essential RH commodities are included in EML (Contraceptives and life saving maternal/RH medicines in EML) Yes Yes Yes Yes Yes Yes Yes Output 2: Political and financial commitment for RHCS enhanced 13 Funding mobilised for GPRHCS on a reliable basis Budget line exists Budget line exists but decreasing expenditure since 2009 No budget line item No (not possible as long as the political crisis has not been solved) Budget line exists Allocations for 2010 increased 40% over last year. Budget line exists MoH expect to fund all RHCs combined with use of loan funds if necessary No budget line MOU signed with country government Yes Yes Yes Yes Yes Yes Yes Output 3: Capacity and systems strengthened for RHCS Use of AccessRH for procurement of RHCs resulting in 20% reduction in lead time. No No No No No No No Number of ad hoc requests to UNFPA for commodities (non- humanitarian) in 2010 0 1. None None None None None Forecasting for RHCs using national technical expertise Yes Yes No Yes Yes Yes Yes Management of procurement process by national technical expertise Yes Yes Yes Yes (except for donor commodities ) Yes Yes (except for UNFPA commodities) Yes 281664/ Synthesis report Final draft V2/ 11th January 2012 90 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report Stream One Ethiopia Burkina Faso Lao Madagascar Mongolia Nicaragua Sierra Leone Functioning Logistics Management Information System Yes In part. Yes In progress Yes Yes Yes Co-ordinated approach towards integrated health supplies management system Yes Yes No Yes Yes Ye Yes Adoption or adaptation of a Health Supply Chain Management information tool into national system Yes Yes. Yes Yes Yes Yes Yes Output 4: RHCS mainstreamed into UNFPA core business (UN reform environment) GPRHCS planning takes into account lessons learned in RHCS mainstreaming Yes Yes. Yes Yes Yes Yes Yes RHCS priorities included in CCA, UNDAF, CPD and CPAP Yes except CCA Yes Yes except CCA Yes: UNDAF, CPD & CPAP. No: CCA. Yes Yes: (some in progress) Yes Country Office allocations increased to RHCS in 2010 Yes Yes Yes No Yes Yes Yes All the relevant joint UN programmes for SRH and MNH include RHCS Yes Yes No Yes No no relevant joint programme Yes 281664/ Synthesis report Final draft V2/ 11th January 2012 91 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report Stream 2 Benin Ghana Lesotho Liberia Nigeria Uganda Zambia Goal: Universal access to Reproductive Health by 2015 and universal access to comprehensive HIV prevention by 2010 for improved quality of life 1 Adolescent birth rate 21% (DHS 2006) Rural: 82 /1000 Urban: 49/1000 (GDHS, 2008) 96/1,000 girls aged 15-24 (DHS 2009) 32% (LDHS); 37% (MIS) No recent data 25% 28% aged 15-19 (DHS 2007) 2 Maternal Mortality Ratio 397/100 0000 NV (DHS 2006) 350 / 100,000 to 451 / 100,000 various sources 1,155/100,000 live births (DHS 2009) 994/100,000 live births (LDHS 2007) 545 / 100,000 (NDHS 2008) 435_/100,000 live births 591/100,000 (DHS 2007) 3 Youth HIV prevalence rate 15-19 age old (0,2%), 20-24 age old (1,2%) – (DHS 2006) 2.1% (2009) 9.3% (DHS 2009) 1.7% (LDHS 2007) No recent data available 3.9% females 1.3% males 4.7% 15-19 (DHS 2007) Outcome: Increased availability, access and utilization of RHCs for voluntary family planning, HIV/STI prevention and maternal health services in the GPRHCS focus countries 4 Average Unmet need for FP 30% (2006) 35% (2008) 23% (2009) 36% (2007) 20% (2008) 41% 28% (2009) 5 Average Contraceptive prevalence rate of modern methods 6% (2006) 17% (2008) 45.6% 2009 11% (2007) 10% (2008) 18% 33% (2009) Output 1: Country RHCS strategic plans developed, co-ordinated and implemented by government with their partners RHCS strategy is integrated with national RH/SRH, HIV/AIDS, Gender, & Reproductive Rights strategies Yes Yes Yes: RH Strategy (but a draft) & HIV/AIDS No: current Gender Policy, (under revision) Yes: Yes: RH & gender mainstreaming strategies. Yes Yes National strategy/action plan for RHCS is implemented. Yes Yes plan exists but not implemented Yes Yes Yes Yes Functional co-ordination mechanism on RHCS or RHCS is included in broader coordination mechanism Yes Yes combined with Comprehensive Condom Programming Committee. Yes Yes Yes Yes Unplanned requests for RHCs No information No 1 No Yes No 281664/ Synthesis report Final draft V2/ 11th January 2012 92 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report Essential RH commodities are included in EML (Contraceptives and life saving maternal/RH medicines in EML) Yes Yes Includes modern contraceptives but not lifesaving MH drugs Yes except implants and Cefixime Yes Yes Yes Output 2: Political and financial commitment for RHCS enhanced Funding mobilised for GPRHCS on a reliable basis Yes Yes Budget line exists but expenditure static No Yes Budget line exists but expenditure static Budget line exists but expenditure static 09-10 RHCS priorities in PRS, Health sector policy and plan Yes Yes Yes except PRS Some Yes except PRS Yes Yes except PRS Output 3: Capacity and systems strengthened for RHCS Use of AccessRH for procurement of RHCs resulting in 20% reduction in lead time. Yes - Yes No No No Yes Output 4: RHCS mainstreamed into UNFPA core business (UN reform environment) GPRHCS planning takes into account lessons learned in RHCS mainstreaming Yes Yes No . No Yes No Yes RHCS priorities included in CCA, UNDAF, CPD and CPAP Yes Yes Yes Yes Yes except CCA Yes Yes Country Office allocations increased to RHCS in 2010 Yes Yes Remained the same Yes Yes Yes Increased All the relevant joint UN programmes for SRH and MNH include RHCS Yes Yes Yes No Yes Yes Yes 281664/ Synthesis report Final draft V2/ 11th January 2012 93 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report Annex 4: Input Diagram 281664/ Synthesis report Final draft V2/ 11th January 2012 94 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report Joseph Abraham, Systems development specialist, Commodity security branch, Technical division, UNFPA, New York Dr. Gifty Addico, RHCS Advisor, UNFPA, Johannesburg Dr Kabir Ahmed, Technical Adviser, UNFPA, New York Filomena Aitken, DFID, London Dana Aronovich, Performance Manager, John Snow Inc. USAID DELIVER Project, Boston Yves Bergevin, Coordinator, Maternal health thematic fund, SRHB Technical division, UNFPA, New York Jessica Bernstein, Consultant, Population Action International, Washington Julia Bunting, Team Leader, AIDS and Reproductive Health Team, Human Development Department, DFID, London Marieke Boot, Policy Officer – International Aid and Cooperation, Sector Education, European Commission, Brussels Louis Charpentier, Chief, Evaluation Branch, Division for Oversight Services, UNFPA, New York Dr Andres de Francisco, Deputy to the Director, Partnership for Maternal Newborn and Child Health (PMNCH), Geneva Hugo González Programme Adviser in LACRO Beatriz De La Mora, Resource Mobilisation Specialist, UNFPA, New York Paul Dowling, Director, Commodity Security, John Snow Inc. USAID DELIVER Project, Boston Wener Haug, Director, Technical division, UNFPA, New York Lisa Hedman, Department of Essential Medicines and Pharmaceutical Policies, World Health Organization (WHO), Geneva Annex 5: List of People Interviewed 281664/ Synthesis report Final draft V2/ 11th January 2012 95 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report Beverly Johnston, Senior Policy Advisor, USAID Office of Population and Reproductive Health, Washington Heimo Kaakkonen, Chief, Resource mobilisation branch, Information and external relations division, UNFPA, New York Desmond Koroma, Consultant – Monitoring and Evaluation, Commodity Security Branch, UNFPA, New York Daniele Landry-Mugengana, adviser in Senegal SRO Dr Laura Laski, Chief, Sexual and reproductive health branch, Technical division, UNFPA, New York Elly Leemhuis-de Regt, Senior Adviser, Ministry of Foreign Affairs, The Hague, Netherlands Benedict Light, Senior Technical Adviser on Reproductive Health Commodity Security, UNFPA, Brussels Dr Jemilah Mahmood, Chief, Humanitarian response branch, UNFPA HQ, New York Purnima Mane, Deputy executive director (Programme) and Assistant Secretary General, UNFPA HQ, New York Sandra McDonagh, Health Adviser, Sexual & Reproductive Health AIDS & Reproductive Health Team, DFID, London Thidar Myint, Technical Specialist, Commodity Security Branch, UNFPA, New York Penda Ndiaye, adviser in Senegal SRO Dr Kechi Ogbuagu, Coordinator Global Programme to Enhance Reproductive Health Commodity Security, Commodity Security Branch, UNFPA, New York Ian Pett, Chief Health Systems and Strategic Planning Health Section, Programme Division, UNICEF, New York Ms. Mika Saijo, Administrative Assistant, Commodity Security Branch, UNFPA, New York David Sarley, John Snow Inc. 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The activities have included: • Occasional lunchtime sessions within UNFPA headquarters in New York; • UNFPA Executive Board informal side-sessions; • Ad hoc ‘mentions’: at the UNFPA Executive Board (there was conflicting feedback on this point); • Inclusion of a relevant paragraph in speeches of UNFPA’s Executive Director (and at least one reference in an interview) - the same rule is apparently applied to speeches by other UNFPA staff. • Overhaul of the RHCS section of UNFPA website and maintenance of Dashboard (up to 2008) • Meetings of/for the GPRHCS: i. One RHCS Champions Meeting (New York, September 2007) for government representatives from about a dozen countries which produced a communiqué; ii. 2009 GPRHCS Planning Meeting; iii. Joint Planning Meeting of the Thematic Trust Funds for 20 countries and all Regional Offices (New York, January 2010); iv. RHCS Technical Consultation/Capacity Building Meeting, (Nairobi, March 2010); v. Progress Review Meeting for Stream 1 countries (Addis Ababa, June 2010) which was closed by the Ethiopian Minister of Health; and vi. Regional Joint Strategic Review Meetings of the Thematic Trust Funds (Dakar, and Johannesburg, January 2011 and Bangkok, February 2011) (b) Among current and potential donors • Annual donor meetings: There have been three annual donor meetings thus far in Burkina Faso (May 2009), Helsinki (April 2010) and Barcelona (April 2011). The invitee list has apparently broadened to now include both current and potential donors; • Annual reports: GPRHCS reports for 2008, 2009 and 2010; Annex 7: Global Level Awareness Raising Activities 281664/ Synthesis report Final draft V2/ 11th January 2012 110 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report • Ad hoc bilateral meetings: both formal and informal; • Other ad hoc meetings: e.g. at DFID London (November 2010); • Ad hoc presentations: to RH Supplies Coalition meetings and relevant conferences (e.g. Kampala, November 2009); • Other publications: In 2010 for the first time, two short documents were published, the 28-page ‘Success Stories in Reproductive Health Security’ and the 20-page ‘Reproductive Health Commodity Security Update’. (c) With and to other partners • Reproductive Health Supplies Coalition: UNFPA (rather than the GPRHCS per se) is part of the RHSC’s Executive Committee, supports the Secretariat, leads the Market Development Approaches Working Group and participates in other activities of the Coalition e.g. in the recent Coalition meeting ‘Access for All’ in Addis Ababa in June 2011 (The GPRHCS annual reports also note Coalition activities UNFPA has contributed to); • PMNCH: UNFPA is co-chair of one of the six priority areas within the PMNCH 2009-2011 workplan (Priority Area 3: Essential Commodities). In fact, it was reported to the review team that the prominence of commodities in the PMNCH workplan (and it being chosen as one of six priority areas from an initial list of 37) was a direct result of UNFPA’s advocacy. ‘PA3’ has various activities contained within its workplan29 and the GPRHCS has reportedly hosted two meetings of this work stream; • H4+130: UNFPA reportedly shares information with this group. UNFPA has also reportedly contributed to the WHO publications ‘Priority Medicines for Mothers and Children 2011’ and the ‘Packages of Interventions for Family Planning, Safe Abortion Care, Maternal, Newborn and Child Health’ (2010); • Global Strategy for Women and Children31: Again it was reported to the review team that UNFPA is the likely reason behind family planning being so high up in the recent commitments made; and • UNFPA-WHO Collaborative Initiative on Critical Life-Saving Maternal/RH Medicines: A presentation was made in Geneva in April 2010 at a PMNCH meeting on the findings of eight country studies which reviewed the status of access to key maternal life-saving medicines. The presentation was reportedly attended by regional GPRHCS advisers, WHO and UNICEF. A short paper on the findings of the study was also presented at a conference in Kampala. _________________________ 29 http://portal.pmnch.org/essential-commodities 30 H4 is compromised of UNICEF, WHO, UNFPA and the World Bank plus UNAIDS. 31http://www.everywomaneverychild.org/images/content/files/global_strategy/full/20100914_gswch_en.pdf 281664/ Synthesis report Final draft V2/ 11th January 2012 111 UNFPA Global Programme to Enhance Reproductive Health Commodity Security: Synthesis Report (d) In potential programme countries and at regional level • Working with regional economic institutions: It was reported to the review team that the GPRHCS works with the West African Health Organisation (WAHO), the East African Community (EAC), the Inter-Governmental Authority on Development (IGAD) and the Southern African Development Community (SADC) and through them, with parliamentarians in the concerned countries. The CEOs of EAC and IGAD have also reportedly been supported to attend a UNFPA Executive Board meeting in New York. • Ad hoc Workshops: e.g. a workshop in Bangkok in 2010 on family planning. (e) In current programme countries • UNFPA-WHO Collaborative Initiative on Critical Life-Saving Maternal/RH Medicines: Studies were done between 2008-2010 of to review access to these medicines in Lao PDR, Nepal, Burkina Faso, Philippines, DPR Korea, Ethiopia, Vanuatu, Mongolia and the Solomon Islands;

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