Tanzania: Contraceptive Security Assessment

Publication date: 2007

MARCH 2007 This publication was produced for review by the U.S. Agency for International Development. It was prepared by the USAID | DELIVER PROJECT and The ACQUIRE Project. TANZANIA: CONTRACEPTIVE SECURITY ASSESSMENT (FINAL DRAFT) Tanzania Contraceptive Security Assessment iv TANZANIA: CONTRACEPTIVE SECURITY ASSESSMENT (FINAL DRAFT) The authors' views expressed in this publication do not necessarily reflect the views of the U.S. Agency for International Development or the United States Government. Tanzania Contraceptive Security Assessment v USAID | DELIVER PROJECT, Task Order 1 The USAID | DELIVER PROJECT, Task Order 1, is funded by the U.S. Agency for International Development under contract no. GPO-I-00-06-00007-00, beginning September 29, 2006. Task Order 1 is implemented by John Snow, Inc., in collaboration with PATH, Crown Agents Consultancy, Inc., Abt Associates, Fuel Logistics Group (Pty) Ltd., UPS Supply Chain Solutions, Family Health International, The Manoff Group, and 3i Infotech. The project improves essential health commodity supply chains by strengthening logistics management information systems, streamlining distribution systems, identifying financial resources for procurement and supply chain operation, and enhancing forecasting and procurement planning. The project also encourages policymakers and donors to support logistics as a critical factor in the overall success of their health care mandates. The ACQUIRE Project The ACQUIRE Project – Access, Quality, and Use in Reproductive Health – is led by EngenderHealth in partnership with Adventist Development and Relief Agency, International (ADRA), CARE, IntraHealth International, Meridian Group International Inc, and the Society for Women and AIDS in Africa. SATELLIFE is a resource partner. The ACQUIRE Project’s mandate is to advance and support reproductive health (RH) and family planning (FP) services, focusing on facility-based care. The three intermediate results are increased access to quality RH/FP services, improved provider performance, and strengthened environment for RH/FP service delivery. Recommended Citation Patykewich, Leslie, Marie Tien, Erin Mielke and Tim Rosche. 2007. Tanzania: Contraceptive Security Assessment. Arlington, Va.: USAID | DELIVER PROJECT, Task Order 1 and New York, NY: The ACQUIRE Project. Abstract Over the last ten years, Tanzania’s reproductive health indicators have stagnated. The total fertility rate has leveled off at 5.7 and the increase in the contraceptive prevalence rate (CPR) has slowed down (13% in 1996 to 20% in 2004). Unmet need remains high and unchanged from 1999. Currently, more women in Tanzania have an unmet need for family planning (21.8%) than are using a modern method (20%). Maternal mortality has stagnated to 578 per 100,000 live births although 94% of pregnant women have at least one antenatal care visit. Recognizing the family planning challenges in Tanzania the country has developed a Reproductive and Child Health Strategy. The Strategy acknowledges that “the situation [FP] is contributed by inadequate range of FP methods, erratic supplies of contraceptives, provider’s biases to make informed choices and physical geographical distances to service delivery points.” Tanzania is actively working to ensure there is contraceptive security through the creation of Contraceptive Security Committees and increases by the Government of Tanzania to cover the contraceptive needs of the population. This assessment is to support these efforts by providing information on the issues and barriers and providing considerations to help improve contraceptive security in Tanzania. Considerations focus on priority issues, efficiency in use of available resources, and equitable access to reproductive health commodities - all of which can help ensure that all Tanzanians can choose, obtain, and use the contraceptives and other RH commodities they need, when and where they need them. USAID | DELIVER PROJECT The ACQUIRE Project John Snow, Inc. c/o EngenderHealth 1616 Fort Myer Drive, 11th Floor 440 Ninth Avenue Arlington, VA 22209 USA New York, NY 10001 USA Phone: 703-528-7474 Phone : 212-561-8000 Fax: 703-528-7480 Fax: 212-561-8067 E-mail: deliver_project@jsi.com E-mail: info@acquireproject.org Internet: deliver.jsi.com Internet: acquireproject.org Tanzania Contraceptive Security Assessment iii CONTENTS Acronyms…………………………………………………………………………………………………………. . v Acknowledgements .vii Executive Summary . ix Introduction .1 1. Context .3 2. Capital .9 3. Capacity .17 4. Commodities .29 5. Coordination.35 6. Commitment.39 7. Client .43 8. Considerations.49 References.55 Annexes Annex A: In-country Contacts .58 Annex B: Site Assessment Tool.61 Annex C: Focus Group Discussion Tool .68 Annex D: Contraceptive Security Workshop Agenda and Participant List .71 Tanzania Contraceptive Security Assessment iv Tanzania Contraceptive Security Assessment v ACRONYMS CHMT Council Health Management Team COPE Client-Oriented, Provider Efficient services CPR contraceptive prevalence rate CPT contraceptive procurement table CS contraceptive security DFID British Department for International Development DHS Demographic and Health Survey DRCHCO District Reproductive and Child Health Coordinator EHP Essential Health Package EPI Expanded Program on Immunization EU European Union FP Family Planning GFATM Global Fund for AIDS, Tuberculosis and Malaria GOT Government of Tanzania HIV/AIDS human immune deficiency virus/acquired immune deficiency syndrome IEC information, education and communication ILS integrated logistics system IMF International Monetary Fund IPPF International Planned Parenthood Federation IUD intrauterine device JSI John Snow, Inc. LAPMs long acting and permanent methods LGA Local Government Authority LIAT Logistics Indicator Assessment Tool LMIS logistics management information system LSAT Logistics System Assessment Tool M&E monitoring and evaluation MCH maternal and child health MDGs Millennium Development Goals MMR maternal mortality ratio MOF Ministry of Finance Tanzania Contraceptive Security Assessment vi MOHSW Ministry of Health and Social Welfare MOS months of stock MoU memorandum of understanding MSD Medical Stores Department MSI Marie Stopes International MST Marie Stopes Tanzania MTEF Medium Term Expenditure Framework NEDL National Essential Drugs List NFPP National Family Planning Programme NGO non governmental organization NHA National Health Accounts PPP purchasing power parity PMORALG Prime Minister's Office Regional Administration and Local Government PRSP Poverty Reduction Strategy Paper PSU Pharmaceuticals and Supplies Unit PSI Population Services International R&R Report and Request (form) RH reproductive health RCHS Reproductive and Child Health Section RHCS reproductive health commodity security SDP service delivery point SPARHCS Strategic Pathway to Reproductive Health Commodity Security SRH Sexual and Reproductive Health STI sexually transmitted infection SWAp sector wide approach (basket fund) TACAIDS Tanzania Commission for AIDS TB tuberculosis TFDA Tanzania Food and Drugs Authority TFR total fertility rate UNFPA United Nations Population Fund USAID United States Agency for International Development VAT value added tax WHO World Health Organization WTP willingness to pay Tanzania Contraceptive Security Assessment vii ACKNOWLEDGEMENTS Many people generously provided their time and knowledge to this assessment. The authors are grateful for the support of the RCH Section of the MOHSW, in particular Dr. Cosmas Swai. Our sincere thanks go to Charles Llewellyn and Michael V.C. Mushi of USAID/Tanzania and Kevin Pilz of USAID/CSL for their invaluable guidance and leadership. The authors would also like to thank the ACQUIRE Project for their contribution in and support of this assessment. In particular, we would like to acknowledge Grace Lusiola and Dr. Joseph Kanama of the ACQUIRE/Dar es Salaam, Tanzania office as well as Dr. Mathew H.N. Tambukwa and Josephine Tenga of the ACQUIRE/Iringa office. Our sincere thanks go to them and to all the others who participated in the assessment. Tanzania Contraceptive Security Assessment viii Tanzania Contraceptive Security Assessment ix EXECUTIVE SUMMARY This report presents the assessment findings on contraceptive security (CS) in Tanzania highlighting the progress and current challenges as well as providing considerations n an effort to help future planning in strengthening CS. The assessment was based on the Strategic Pathway to Reproductive Health Commodity Security (SPARHCS) framework to provide a better understanding of the CS situation. The assessment findings are grouped around the framework components of context, capital (financing), capacity, commodities, coordination, commitment, and the client. The assessment included secondary analysis of existing demographic and logistics data; a literature review of key policies, strategies and documents; key stakeholder interviews, a limited number of health facility site assessments and focus group discussions. Over the last ten years, Tanzania’s reproductive health indicators have stagnated after a period of steady improvements. The total fertility rate has leveled off at 5.7 and the increase in the contraceptive prevalence rate (CPR) has slowed down (13% in 1996 to 20% in 2004). Unmet need remains high and unchanged from 1999. Currently, more women in Tanzania have an unmet need for family planning (21.8%) than are using a modern method (20%). Maternal mortality has risen from 529 to 578 per 100,000 live births. The Reproductive and Child Health Section, within the Ministry of Health and Social Welfare, coordinates contraceptive security developing policies, facilitating planning with development partners and stakeholders, mobilizing financial resources, and providing support and monitoring at the regional and district levels. Commitment to family planning is demonstrated in the Reproductive and Child Health Strategies and several other policies and strategies developed to support the key goal of reducing maternal mortality. Dissemination of the strategies and monitoring of the targets could be improved to communicate the national goals programs and partners should be contributing to. The Government of Tanzania has shown their commitment through the funding for contraceptives. In 2006 the GOT funded 75% of the funds needed for public sector contraceptives. However, new funding mechanisms and budget processes continue to be challenges in securing consistent and reliable funding for contraceptives. Many donors have recently started to put their funds in to basket funding where all ministries must compete for resources. The allocation of resources is inconsistent and the amount of funds released to the MOHSW is unpredictable creating long procurement processes. Despite making tremendous progress in health infrastructure improvements Tanzania faces human resource challenges with insufficient numbers of health workers and weak capacity. The distribution and availability of skilled staff who can provide specific family planning methods influences where clients can access methods and places burdens on certain levels of health facilities. There are currently three logistics systems operating in Tanzania. The country has been phasing into an Integrated Logistics Systems (ILS) since 2005 as part of the response to health sector reform. The ILS will bring together most of the vertical programs and the Essential Drug Program into one system. There are low rates and delays in reporting of essential logistics data from the lower levels up to the central levels which have compromised the availability of data in the LMIS. Issues of following recording and calculating procedures persist among health facility staff. The Medical Stores Department is trying to meet the needs of all three logistics systems and is also adapting to the roll-out of the ILS as their roles and responsibilities are still being defined. Although contraceptives should be in full supply at MSD Tanzania Contraceptive Security Assessment x there are stockouts at facilities with the highest rates for oral contraceptives followed by injectables (the most preferred method). The site assessment showed high stockout rates for implants. Because the longer term goal is to transition the entire country to the ILS, the assessment highlights several challenges that may need to be considered as the roll out of the ILS continues including those related to capacity, procedural issues, and funding. The public sector is the main source of supply for all modern contraceptives (68%) with the exception of the male condom. Within the public sector, dispensaries are the primary source (31.5%) of all contraceptives and are the largest source for injectables (47%) and oral contraceptives (36%). Despite this, there remains a significant reliance on the higher level facilities for these resupply methods. This shows that there remains a relatively centralized provision of services for family planning. This dependence on the referral points (especially for resupply methods) puts a high burden on the client as well as on the facility and staff. Part of this issue could be addressed by increasing the role of the private sector. When looking at the total market the private sector could help further diversify and expand the coverage and availability of contraceptives. The primary goal of such a strategy would likely provide those with the ability and willingness to pay to have increased access to services and choices. It would also help rationalize the public sector’s limited resources allowing the public sector to focus more intensively on promoting longer term methods and reaching the poor and underserved. Coordination among key stakeholders and markets is a key component required for contraceptive security. According to the RCH Strategy, the MOHSW RCHS has the responsibility to “coordinate the activities of all partners and other stakeholders.” In recognition of the need to coordinate these varying entities at the central level, several working groups have been formed. It would also be important for the groups to revisit their mandate and perhaps rationalize the groups. Tanzania Contraceptive Security Assessment 1 INTRODUCTION Rationale Countries in the sub-Saharan Africa region are faced with the challenge of meeting increasing demand for contraceptives and reproductive health supplies. Having an adequate range of family planning methods is important in sustaining and building upon the strides already made in the region. Countries are also coping with changes in the funding environment as development partners and new mechanisms are introduced coupled with fluctuations in available resources. Other factors such as low human resource capacity, access, logistics, have lead many countries to take various approaches in addressing contraceptive security. Tanzania is actively working to ensure there is contraceptive security through the creation of a Contraceptive Security Committee and increases in funding by the Government of Tanzania to cover the contraceptive needs of the population. This assessment is to support these efforts by providing information on the issues and barriers and providing considerations to help improve contraceptive security in Tanzania. Is it hoped this information will serve as a starting point for strategic contraceptive planning. Methodology The methodology for this assessment is based on and adapted from the Strategic Pathway towards Reproductive Health Commodity Security (SPARHCS) diagnostic guide (Hare 2004) which is in turn based on the SPARHCS framework (Figure 1). Figure 1: Strategic Pathway to Reproductive Health Commodity Security Framework Tanzania Contraceptive Security Assessment 2 Figure 1 above depicts how six essential contraceptive security (CS) elements impact upon client demand and utilization of contraceptives. In every country, there is a context that affects the country’s prospects for achieving CS - national policies and regulations that bear on family planning/reproductive health and particularly on the availability of reproductive health (RH) supplies, and broader factors like social and economic conditions, political and religious concerns, and competing priorities. Within this context, commitment, evidenced in part by supportive policies, government leadership, and focused advocacy, is a fundamental underpinning for CS. It is the basis from which stakeholders invest the necessary capital (financing), coordinate for CS, and develop necessary capacities to ensure CS. The boxes in the figure elaborate on each of these three components. Coordination involves government, the private sector, and donors to ensure more effective allocation of resources. Households, third parties (e.g., employers and insurers), governments, and donors are all sources of capital. And, capacities must exist for a range of functions – policy; forecasting, procurement, and distribution; demand generation; service delivery; supervision, monitoring and evaluation, to name a few. Clients (youth, women and men) - at the center of the figure - are the ultimate beneficiaries of RHCS as product users, and as shown by the double headed arrows, the drivers of the system through their demand. Assessment Activities and Products The assessment visit took place in March 2007, and included the following specific activities: • Literature Review: A comprehensive literature review and inventory of key policies and strategies was conducted on the health sector situation, the national family planning program within the RCHS, and various other components of CS in Tanzania. All of the documents obtained and reviewed are listed in the Bibliography. In addition, secondary analysis relied on the following quantitative studies: Demographic and Health Surveys (1996-2004), the Tanzania Service Provision Assessment Survey 2006 Preliminary Report. The desk review also relied on a previously completed contraceptive forecasting and procurement exercise. • Key Stakeholder Interviews: The in-country visit included interviews with representatives from the Ministry of Health and Social Welfare (MOHSW), Ministry of Finance (MOF), USAID and UNFPA, non-governmental organizations (NGOs), social marketing organizations and others (see Annex 1 for list of interviewees). These interviews provided many of the essential observations that are reported throughout this assessment. • Site assessments: The in-country visit also included site assessments at public facilities (hospitals, health centres, dispensaries and medical stores), NGO sites and duka la dawas in Iringa, Morogoro, Arusha and Mafinga. In total, 12 sites were visited. As part of one of the site assessments, the team conducted a participatory exercise, Client-Oriented, Provider Efficient services (COPE) with the site which helped the team better understand and identify priority concerns among staff and clients [the exercise included client exit interviews]. • Client focus group discussions: The team also conducted two client focus group discussions. While findings are qualitative in nature, they serve as a way to ensure client perspective is considered and complement the other findings. Assessment Team The CS assessment team included consultants from the ACQUIRE Project, the USAID | DELIVER Project and a representative from USAID/Washington. Tremendous technical support was provided by the field offices of ACQUIRE and DELIVER. Tanzania Contraceptive Security Assessment 3 1. CONTEXT Tanzania’s political and economic transformation in the early 1990s has led to a growth in annual gross domestic product to 5.8 percent in 2004 and an annual economic growth rate which is among the best in sub-Saharan Africa. However, the national HIV/AIDS infection rate is 7 percent and the HIV/AIDS epidemic has seriously limited Tanzania’s potential, negatively affecting economic, education, and health indicators. Tanzania is ranked 162 of 175 countries in the 2004 United Nations Development Program Human Development Index and the World Bank estimates 2004 per capita income (PPP) at US$660. Life expectancy has plummeted from 65 years to 44 and continues to fall with AIDS as the leading cause of adult mortality affecting the labor market and straining the human resource capacity. Tanzania’s orphan population is currently estimated at over 1.1 million, over 50,000 children becoming orphans each year. Despite this, the recent Tanzania Demographic and Health Survey (DHS, 2004) revealed improvements in child survival with a 31 percent drop in infant mortality to 68 deaths per 1,000 live births—one of the lowest rates in East Africa. Deaths of children under-five have declined by 24 percent, from 147 deaths per 1,000 live births in 1999 to 112 in 2004. Table 1: Key Socio-Demographic Indicators Key Indicators 1999 2004 Total Population 34,762,710 37,626,920 Percent of Population Urban 22.3 23.82 Percent of Population Rural 77.7 76.18 Population Growth Rate 2.1 1.9 GNI per capita (PPP) $ 510 660 Adult literacy rate 75 69.4 Contraceptive prevalence rate (modern methods) 17 20 Contraceptive prevalence rate (all) 25.4 26.4 Total Fertility Rate (TFR) 5.6 5.7 HIV Prevalence 9 6.5 Infant Mortality 88 78.4 Maternal Mortality (per 100,000 live births) 529 578 Average age at marriage for women (20-49) 18.4 18.6 Average age at delivery of first child (20-49) 19.2 19.4 (25-49) Source: All data are from DHS and World Development Indicators except where noted The last ten years have seen reproductive health indicators leveling off. The total fertility rate has leveled off at 5.7, the increase in the contraceptive prevalence rate (CPR) has slowed down (between 1996 and 1999, CPR increased from 18.4 to 25.4. However, between 1999 and 2004, it only increased slightly from 25.4 to 26.4) and unmet need has remained unchanged between 1999 and 2004 at 21.8%. Maternal mortality has stagnated to 578 per 100,000 live births although 94% of pregnant women have at least one antenatal care visit. Recognizing the family planning challenges in Tanzania the country has a developed a Reproductive and Child Health Strategy. The Strategy acknowledges that “the situation [FP] is contributed by inadequate range of FP methods, erratic supplies of contraceptives, provider’s biases to make informed choices and physical geographical distances to service delivery points.” Additionally, Tanzania Contraceptive Security Assessment 4 human resources to provide FP services are constrained. To address these issues, FP guidelines and IEC materials are being developed and Community Based Reproductive and Child Health agents are being trained. 1.1 Key Family Planning Partners The following describes the key partners involved in trying to improve the family planning and reproductive health situation in Tanzania. MOHSW Reproductive and Child Health Section (RCHS) within the Directorate of Preventive Services (DPS) – The main stakeholder for contraceptive security in Tanzania is the Reproductive and Child Health Section of the MOHSW. According to the Reproductive Child Health Strategy, the RCHS has the following responsibilities: • facilitate joint planning with development partners for effective coordination and implementation of strategy • collaborate with RCH stakeholders and partners to plan for the implementation of the strategy • advocate for the implementation of the strategy • develop/review policies, guidelines and standards • Review the list of standard essential equipment and supplies for provision of quality reproductive health care • Coordinate the activities of all partners and other stakeholders • Mobilize and facilitate allocation of resources • Provide technical support to regions and districts • Facilitate capacity building at national, regional and district levels • Promote RCH research development • Collect data, analyze and utilize for planning purposes and provide feedback to regions and districts1 In addition, the DPS is responsible for facilitating the strategy and process in collaboration with the Directorate of Hospital Services (DHS), which oversees all hospital-based care for the MOHSW. Medical Stores Department (MSD) MSD is a semi-autonomous institution under the Ministry of Health and Social Welfare (MOHSW) established by an act of Parliament in 1993 to replace the Central Medical Stores with a parastatal entity whose responsibilities are to procure, store, and distribute drugs and related medical supplies and equipment. MSD’s major responsibilities are to: • Receive and process all orders for medicines and related medical supplies and equipment • maintain and expand ongoing storage and distribution activities for all commodities and equipment • deliver supplies and equipment for dispensaries or health centers to the District Medical Officers 1 RCH Strategy Tanzania Contraceptive Security Assessment 5 • collect, aggregate, and send logistics management information systems (LMIS) reports • use data from logistics MIS reports for resupply to districts and health facilities • provide financial status reports to districts, health facilities, and program managers • obtain commodity and equipment requirements from PSU for timely procurement planning. With the expansion of the Integrated Logistics System (ILS) their role will also expand to packing custom orders for facilities in the central location in Dar es Salaam and eventually to Mwanza, Iringa, and Moshi Zonal stores. Pharmaceuticals and Supplies Unit (PSU) The responsibilities of the PSU are largely oversight and coordination. It has the leadership mandate for all commodity-related interventions and coordination among key stakeholders, including MSD, Program Managers, donors, MOHSW Directorates, and Ministry of Finance (MOF). PSU undertakes the following: • review tenders for the procurement of medical equipment for the LAPMs • receive and review annual forecasts, consumption, and stock balances of program-related commodities from Program Managers and provide feedback • inform appropriate entities (MSD, Directorate of Policy and Planning, Ministry of Finance [MOF], donors, and others) of any changes in product selection and use that would affect forecasting, budgeting, financing, and procurement of commodities • advocate, promote, and ensure inclusion of all health commodities in the annual Medium Term Expenditure Framework (MTEF) budgeting process and document. The PSU, as manager for essential drugs and sexually transmitted infection (STI) drugs through Indent, Kit, and Capitalization Systems, and now conversion to the integrated logistics system (ILS), also has commodity-specific responsibilities including: • receive, review, and analyze aggregated reports pertaining to essential drug distribution to primary health care facilities and district and regional hospitals; provide timely commodity supply and management decisions to MSD • use logistics MIS reports to prepare and update forecasts on commodity requirements for their program.2 Ministry of Regional Administration and Local Government With health sector reform and decentralization, the Prime Minister's Office Regional Administration and Local Government (PMORALG), has an increasing role in health and therefore family planning. “Local government authorities in Tanzania prepare their budget plans in a medium-term budget framework, consistent with the national strategy for economic growth and poverty reduction (MKUKUTA).”3 “Local governments are responsible for promoting public health and the establishment and maintenance of hospitals, health centers, … and dispensaries.”4 2 Tanzania DELIVER Final country report 3 http://www.logintanzania.net/plans.htm 4 http://isp-aysps.gsu.edu/projects/tanzania/finalreport1.pdf Tanzania Contraceptive Security Assessment 6 TFDA The Tanzania Food and Drugs Authority (TFDA), a semi-autonomous body under the MOHSW is a regulatory body responsible for controlling the quality, safety and effectiveness of family planning contraceptive supplies. TFDA is responsible for drug and medical device registration, licensing, inspection and surveillance, import and export control and laboratory analysis testing for quality, safety and effectiveness. In addition, the TFDA regulates promotion of drugs within the country. UNFPA UNFPA continues to be the lead UN agency for promoting Reproductive Health Commodity Security (RHCS). At the country level, UNFPA focuses on training and demand driven technical assistance, improving the environment for financial support and reduce policy and procedural barriers to ensuring RHCS, promoting the development of more efficient and sustainable long term financing strategies to meet national reproductive health commodity needs and working in partnership with government and other stakeholders. USAID Within USAID/Tanzania’s Health Program, a core focus is “increasing use of family planning services.” USAID supports projects and initiatives that work on improving service provision capacity, supply chain management as well as social marketing of contraceptives.5 At the global level, USAID’s Office of Population and Reproductive Health provides “strategic direction, technical leadership and support to field programs…” Specifically, its Contraceptive Security Team works to “advance and support planning and implementation for contraceptive security” at the country, regional and global levels. 6 Social Marketing Organizations • PSI: PSI’s Tanzania Program supports contraceptive social marketing for male and female condoms and, beginning in August/September 2007, pills as a way to increase access to and reduce unmet demand for family planning methods. PSI aims to serve as a “bridge between free or highly subsidized public sector programs and commercial approaches.” As part of its strategy, PSI supports IEC campaigns using “mass media, training, posters, mobile video units (MVUs) and road shows to reach both high transmission areas and rural areas.”7 They social market condoms (Salama brand) and distribute oral contraceptives. • Tanzania Marketing and Communications: AIDS, Reproductive Health & Child Survival (The T-MARC Project). T-MARC uses social marketing to expand and improve access to branded FP products (male and female condoms and pills) targeting key populations. T-MARC also increases general awareness through a series of communication interventions. They social market condom (Dume brand) and distribute oral contraceptives. Non-Governmental Organizations • Marie Stopes Tanzania (MST): Marie Stopes Tanzania is an NGO that provides general health care specializing in FP in both short and long term methods. Their centers are mainly urban and peri- urban settings. MST offer general health services, with a focus on family planning, including youth- friendly services and peer education. MST also coordinates with the MOHSW to offer and generate demand for outreach services in 140 public sector facilities in rural areas. MST sees a high demand for implants and for female sterilizations through outreach services. MST obtains supplies from the District Reproductive and Child Health Coordinator (DRCHCo), including implants, Depo-Provera, 5 http://tanzania.usaid.gov/so.php 6 Ready Lesson Overview. http://pdf.usaid.gov/pdf_docs/PNACW660.pdf 7 http://www.psi.org/where_we_work/tanzania.html Tanzania Contraceptive Security Assessment 7 pills, and IUDs. For purchasing implants Marie Stopes Tanzania joins with Marie Stopes Kenya and Uganda to purchase from suppliers, and MST also purchases medical equipment for LAPMs directly from suppliers. MST has funding from a range of donors, including Canadian CIDA, the European Commission, DFID, and the Global Fund for AIDS, Tuberculosis and Malaria (GFATM) • UMATI: UMATI, is an International Planned Parenthood Federation (IPPF) affiliate headquartered in Dar es Salaam. They have been providing sexual and reproductive health (SRH) education, information and services since 1959. UMATI has played a leadership role in providing RH services to youth between the ages of 10-24. UMATI has 13 urban and semi-urban clinics nationwide and community based distribution centers. They are an independent, non-profit reproductive health and rights organization. To adapt to the changing SRH environment their current strategy is shaped around the five “A’s”: Abortion, Advocacy, Adolescents/Young People, HIV/AIDS and Access. They have financial support largely from IPPF as well as from TACAIDS and support in-kind. In addition, a very small amount of funding comes from income generation from the cost recovery program. They provide several brands of oral contraceptives (Microgynon, Marvelon, Microlut, Postinor, Lofemenal, Microval), injectables (Depo Provera and Megestone), implants (Norplant), IUDs (Copper T), male and female condoms, and some spermicides, as well as minilaparotomies and No-Scalpel Vasectomy. Their contraceptives are procured through the IPPF system as well as through the MSD. All of the equipment for LAPMs is procured through IPPF. 1.2 POLICIES AND REGULATIONS The following are key policies and regulations that affect family planning and contraceptive security in Tanzania. Tanzania Development Vision 2025 The Tanzania Development Vision 2025 serves to set the country’s long term development goals and serves as the foundation for government strategies. In support of its overarching aim of achieving high- quality livelihood for the people, the vision lays out several goals specific to reproductive health and family planning. Specifically, the vision supports - quality primary health care for all - quality reproductive health services - reduction in infant and maternal mortality8 Millennium Development Goals (MDG) MDG Indicators for 2004-05 related to family planning such as 1) improving maternal health: MMR and 2) combating HIV/AIDS, malaria and other diseases (which has as one of its indicators, increase in use of condoms among married women and CPR). Poverty Reduction Strategic Paper In the PRSP, health was prioritized third among areas deserving attention, specifically identifying issues of poor level of health education, weak service provision (especially in rural areas). Specifically, the government has committed to lowering maternal mortality with initiatives focusing on reproductive health and family planning. 8 Tanzania: Population, Reproductive Health and Development Tanzania Contraceptive Security Assessment 8 National Health Policy While not specifically mentioning family planning or reproductive health, the National Health Policy is important in that it highlights the policy of improving equity and focusing services on the underserved and those at risk. Guidelines for Preparing Medium Term Plan and Budget Framework for 2005/6- 2008/9 According to the Guidelines for preparing the annual MTEF, priority areas include: - “rationalization of the allocation of drugs, medical supplies and equipment at all levels - availing health/medical personnel in health facilities particularly in the remote areas - Promoting and protecting, reproductive health rights including access to family planning, contraceptives, adolescent reproductive health services, to allow choices and control of fertility outcomes by women and youth - Improve human resource capacity at all levels in terms of quantity, quality and skills mix”9 Tanzania Joint Annual Health Sector Review In 2005, key stakeholders convened to review the country’s progress in achieving its goals and monitoring its performance. As part of the meeting, a new set of milestones were agreed upon and committed to. The milestones to support Maternal and Child Health (milestone 4) includes finalizing a roadmap for reducing maternal mortality with defined indicators to be annually measured and monitored with priorities fully integrated into MOH MTEF and council comprehensive health plans for FY2006/710. National Population Policy The newly updated Population Policy defines reproductive health as “the right to have a satisfying and safe sex life, the capacity to reproduce safely and the freedom to decide when and how often to do so.” One of the key policy directions in support of RH is “strengthening a quality reproductive health service delivery system, including systems to ensure reproductive health commodity security.”11 National Reproductive and Child Health Strategy The vision of the National RCH Strategy is to have a “healthy and well-informed Tanzanian population with access to quality reproductive and child health services that are accessible, affordable and sustainable and which are provided through an efficient and effective support system.”12 The aim of family planning services is “to help couples and individuals choose the number, spacing and timing of the birth of their children; to prevent unwanted pregnancies and associated morbidity and mortality; to make FP available, accessible and affordable to all who are sexually active.”13 Within the family planning section, there are specific objectives, targets and indicators for the program to use, to measure progress, and help dictate strategies. 9 Guidelines for the Preparation of the Medium Term Plan and Budget Framework 10 Tanzania Joint Annual Health Sector Review 11 National Population Policy 12 RCH Strategy 13 RCH Strategy Tanzania Contraceptive Security Assessment 9 2. CAPITAL Sustainable and consistent funding for contraceptive services and supplies are critical as Tanzania works towards increasing CPR and meeting existing demand. Therefore, this section will focus on capital from the perspective of the source of funding (public, donor, household). It also looks at background information, trends and patterns that provide insight on the government’s ability to meet future funding needs. The last National Health Accounts (NHA) estimate was for the fiscal year 1999/2000 and did not provide contraceptive expenditures information down to the functional level (type of care). However, it does show that the public sector contributes 44% of the total health expenditure. Within the public sector, this can be further broken down by MOHSW (18.7%), the district/local government (19.6%), other ministries (1.1%) and the regional governments (4.1%). The NHA shows households contributing up to almost half (47%) of total health expenditures and the NGO’s making up 6.8%. Figure 2: Total Health Expenditure (1999/2000) Households 47.2% Districts 19.6% Ministry of Health 18.7% NGO's 6.8% Other Ministries 1.1% Private Insurance 2.5% Regions 4.1% Source: WHO While this information is for health generally, it does provide some understanding of the important stakeholders for family planning funding. It also reminds us of the complexity in truly understanding and the difficulty in attaining detailed information on funding specific to family planning, contraceptives or reproductive health. It is for this reason that many discussions about family planning funding are specific to family planning commodity costs – as this is one component where there typically is specific information. The funding of family planning in Tanzania has undergone a rather extensive evolution. Beginning in the 1950’s, family planning was first introduced and funded by IPPF through the establishment of its in- country affiliate, UMATI. Not until the 1980’s did the MOHSW establish its National Family Planning program with support from UNFPA. A decade later, a number of additional donors began supporting Tanzania Contraceptive Security Assessment 10 family planning in Tanzania with both expanded support for existing programs (NFPP and UMATI) as well as the establishment of new stakeholders (PSI and Marie Stopes). The twenty first century marked the addition of yet more funding stakeholders (GFATM, etc) and partners (T-MARC). It also marks the era in which Tanzania began its health sector reform process. Table 2: The Evolution of Family Planning funding in Tanzania 1959 - 70s: • UMATI funded by IPPF 1980s: • UMATI funded by IPPF • MCH/FP (MoH) funded by UNFPA 1990s: • NFPP (MoH) funded by UNFPA, USAID, KfW, DFID • UMATI funded by IPPF, USAID, UNFPA • PSI funded by USAID, Netherlands • Marie Stopes Tanzania funded by Marie Stopes International, USAID 2002-to date: • NFPP (MoH) funded by Government, Basket funds, USAID, WB, Global Fund (condoms) • UMATI funded by IPPF, TAC AIDS, local income generation • Marie Stopes Tanzania funded by Marie Stopes International, Canadian CIDA, European Commission, DFID, GFATM • Social Marketing organizations: ¾ PSI funded by Netherlands, GFATM, KfW ¾ T-MARC funded by USAID 2.1 PUBLIC SECTOR The GOT has progressively demonstrated their commitment towards contraceptive security through increased contributions to funding contraceptives over the last ten years. In 2006 Tanzania was one of the few countries in the region where the government provided a majority of the funds (75 percent or $7.79m) for procuring public sector contraceptives (in the case of the GOT, this was a combination of internally generated revenue and basket funding). This was an increase from 47 percent ($4.19m) in 2005. Figure 3 shows that the funding trend for contraceptives has steadily increased in terms of the value of commodities over the past five calendar years. Figure 3: Funding trend for public sector contraceptives (US$, millions) $1 $2 $3 $4 $5 $6 $7 $8 $9 $10 $11 2002 2003 2004 2005 2006 $2.04 $5.20 $4.73 $8.97 $10.15 GOT/BASKET USAID UNFPA Tanzania Contraceptive Security Assessment 11 Further commitment is seen by the increased use of internally generated funding as opposed to donor sourced basket funds. For example, in fiscal year 2002/03 to 2005/06, all public sector funding for family planning commodities was provided either through direct donor support (USAID, UNFPA) or through the donor basket. Public sector family planning commodity funding in FY2005/06 was solely provided through internally generated funding with no donor basket funding used. However, since 2004/2005 there has been a steady decrease in funds allocated from basket funding as shown in Table 3. The table illustrates the funds allocated for contraceptive procurement since the initiation of basket funding. Table 3: Funds Mobilized for Public Sector Contraceptive Procurements Fiscal Year Amount in U.S. $ Type of Contraceptive Procured 2002/2003 1,519,500 Injectables 2003/2004 3,518,420 Orals and injectables 2004/2005 7,717,090 Orals, injectables, and implants 2005/2006 5,818,770 Orals, injectables, and implants 2006/2007 4,590,120 Orals, injectables, and implants 2007/2008 4,600,000 (anticipated) Orals, injectables, and implants The Ministry of Health and Social Welfare has been very successful in advocating for and getting a line item in the MTEF for contraceptives. This helps ensure that commitments will be allocated specifically for contraceptives and that the line item will be revisited yearly during the Medium Term Expenditures Framework (MTEF) annual process. Budgeting process Public sector funding for family planning is obtained through the MTEF. The budgeting process begins in February with requests occurring in June to correspond with the fiscal year (July 1 – June 30). Ministries receiving funding that support public sector family planning include: the MOHSW (Preventive Services specifically for FP commodities, as well as for some recurrent costs) and PMORALG and Local Government Authority (LGA) for recurrent health costs at the Regions and LGA levels. As mentioned above, it is quite challenging and near impossible without a detailed Reproductive Health Account exercise to truly understand the public sector funding for reproductive health within these ministries. Therefore, much of the discussion of public sector funding is limited to family planning commodities. Despite the successes identified in terms of securing funding for family planning, there are also several challenges. Some of these relate to the budgeting process and are not specific to family planning. For example, release of funds through the MTEF process begins in August and can stretch out to May of the following year. Additionally, disbursements are made in quarterly allocations rather than one release at the beginning of the fiscal year. In addition to the timing of disbursements, there is also an issue regarding the amount of funds released. The amount requested and the subsequent allocations released do not necessarily correspond. For example, there is an outstanding amount of 2.4 billion Tanzania Shillings (TSh) from fiscal year 2006/2007 with contraceptive security stakeholders not sure whether this will be allocated and when. Because funding is not fungible, if it is not spent within the fiscal year (for example, due to delays in disbursement, etc), it is sent back to the Treasury. All of this makes planning for and procurement of contraceptives a lengthy and unpredictable process. These procedures also create inefficiencies especially the inability to procure larger quantities and take advantage of economies of scale. Table 4 below shows that Tanzania’s share of spending on health as a proportion of total government expenditure is 12.7 percent. Tanzania Contraceptive Security Assessment 12 Table 4: Government and Health Expenditure Indicators (2003) Indicators Value Total expenditure on health as percentage of gross domestic product 4.3 General government expenditure on health as percentage of total expenditure on health 55.4 Private expenditure on health as percentage of total expenditure on health 44.6 General government expenditure on health as percentage of total government expenditure 12.7 Out-of-pocket expenditure as percentage of private expenditure on health 81.10 Private prepaid plans as percentage of private expenditure on health 5.4 Source: WHO When compared to other countries in sub-Saharan Africa this percentage is among one of the highest in the region. Figure 4: Regional Comparison of Total Health Expenditure and CPR 12.7 7.2 10.7 9.6 11.8 10.9 7.2 5 10.2 0 2 4 6 8 10 12 14 Ta nz an ia Ke ny a Ug an da Eth iop ia Za mb ia Mo za mb iqu e Rw an da Gh an a So uth Af ric a 0 10 20 30 40 50 60 THE CPR 2.2 DEVELOPMENT PARTNERS Historically, funding for contraceptives has come from a variety of sources which included DfID, KfW, UNFPA, and USAID. Beginning in fiscal year 2002/2003 the development partners began to shift from in-kind contraceptive donations to making direct contributions to basket funding or pooled funding. DfID, UNFPA, and KfW contribute to basket funding. These contributions are made to the MOF where the MOHSW along with all other ministries must lobby and compete to obtain funds as they are not specifically earmarked for contraceptives. This is one of the largest challenges and threats for the RCHS in sustaining funds for contraceptives. USAID is the only development partner remaining to provide direct, in-kind contraceptive commodities. USAID provides contraceptives to the RCHS. As the only donor not participating in the basket, USAID’s role has been to help support the government during its transition to basket funds. Specifically, USAID has provided the GOT with emergency procurements of contraceptives when funding through the GOT/basket were not readily available or there were procurement challenges in using these funds. In the Tanzania Contraceptive Security Assessment 13 following graph, the spike in USAID funding in 2005 is an example of this. With the expectation that these challenges will decrease as the GOT becomes more familiar with the process, it is expected that this role for USAID will perhaps shift in focus to additional support of social marketing. Figure 5: Sources of funding for public sector contraceptives, 1996-2006 (US$, millions) UNFPA was the main provider of condoms, complemented by USAID, until they began supporting basket funding starting in 2002. Since then the World Bank’s Tanzania, Multi-sectoral AIDS Program (T-MAP), Global Funds Round 4 funds have been used to procure condoms for the public sector including approximately $20M from USAID during the basket funding transition period. These funds are outside of basket funding. These funds also highlight the challenge in managing numerous funding sources. For example, there is currently $2.7M in funds where MSD has procured $1M worth of condoms through a pre-qualified list of suppliers. The remaining $1.7M will be procured through an international competitive bid. Currently, the Global Fund s providing pre-qualification assistance to the MSD for condoms scheduled for 2009-2011. The Global Fund round 2 has $60M to cover projected condom needs through 2009. The NACP has received 1billion in TSh for condoms from the MTEF and they also have funds through the Global Funds for condoms. However, because budget line items are not fungible there is not an option to use the money received from the MTEF to purchase other contraceptives or HIV/AIDS commodities such as HIV/AIDS test kits. This illustrates the impact of poorly coordinated funding and the pressures to spend down funding (in perhaps inefficient ways). The GFATM is another example of these pressures. Tanzania has been under scrutiny by the GFATM due to in part to the absorptive capacity issues and the resulting slowness in spending funds. Their recent experiences may jeopardize future GFATM funding through additional rounds. This in turn will impact programs such as PSI that are depending on this funding for condom support. 2.3 HOUSEHOLD FUNDING There is very little detailed information on private household funding on family planning, contraceptives or reproductive health. The 2003 NHA exercise provides some information on household contributions to health in general. Almost half (47%) of total health expenditures are spent on health. Out-of-pocket health expenditures as a proportion of private expenditures were 81%. The majority of household Contraceptive Funding by Source 0 1 2 3 4 5 6 7 8 9 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Years Pr od uc t C os t i n $ (M ill io ns ) UNFPA USAID DFID KfW GOT/BASKET Tanzania Contraceptive Security Assessment 14 spending took place in the public sector (71.9%) with the remainder at non-profit (15.1%) and private facilities (13.0%). It is important to remember that households are less inclined to spend their money on preventive services (including family planning). 2.4 FORECASTED REQUIREMENTS The MOHSW conducts an annual forecasting exercise (with a mid-year review). This activity serves as the basis of procurement planning as well as evidenced based justification for annual funding request for family planning supplies. The following table summarizes the contraceptive requirements (not including male and female sterilizations) for the public sector for 2006-2009. This information is based on the most recent forecasting exercise. Table 5: Ministry of Health Forecasted Commodity Requirements Total Contraceptive Requirements 2006 2007 2008 2009 Oral contraceptives 7,124,223 7,832,000 8,300,000 8,800,000 IUD 15,000 20,000 24,000 28,800 Injectables 2,854,049 3,150,000 3,465,000 3,775,000 Condoms 21,276,051 27,500,000 31,625,000 36,370,000 Implants 37,750 45,300 52,000 57,300 Source: 2007 CPT exercise The table below translates the contraceptive requirements into financial requirements for each method (with the exception of condoms). These prices apply the unit costs used by the procuring organization (i.e., USAID, GOT/basket). Funding is available to meet the 2006/2007 requirements through the MTEF. The USAID requirements for Lo-Femenal and Copper-T include both planned and new projections. A regularly scheduled mid-year review of the CPT’s will update these figures and take into account any updated information on the release of basket funds. Table 6: Ministry of Health Contraceptive Financial Requirement – 2006-2009 (US$) 2006/2007 2007/2008 2008/200914 Condom Global Funds Global Funds T-MAP Injectable $ 2,931,368 $ 3,092,480 $ 3,694,944 Microgynon $ 317,137 $ 673,625 $ 458,753 Microval $ 137,323 $ 173,613 $ 173,903 Lo-Femenal -- $ 2,009,843 $ 1,600,000 Implants15 $ 1,133,091 $ 955,323 $ 961,052 IUDs -- $ 97,044 $ 82,500 Subtotal $ 4,518,918 $ 7,001,927 $ 5,288,653 Additional amount if Implanon purchased @ US$30/unit - $ 835,907 $ 959,516 Total $ 4,518,918 $7,837,835 $ 7,930,669 Source: 2007 CPT Exercise 14 Does not include USAID funding 15 The estimated cost of implants were based on MSD’s ability to obtain Implanon at $16/unit. The higher unit cost for Implanon is also included as a comparison to demonstrate the additional amount needed is a framework contract cannot be established. Tanzania Contraceptive Security Assessment 15 2.5 LONGER TERM FUNDING While the RHCS has had great success in securing funding thus far, they will continue to face challenges in satisfying the funding requirements for family planning supplies. This is in part because of the continued need to compete for limited resources and also because there is a growing population of family planning users (due to population growth). Figure 6 demonstrates the potential funding gap based on the estimated funding requirements and funding available through 2013. The funding requirements are based on the projections taken from the contraceptive procurement tables (CPT) and projected forward using the same trends in methods seen historically. The funding for 2008-2009 are an average of funding from the past three years plus 5% inflation added onto each year. This scenario does not take into account any increase in uptake due to improved capacity or demand creation. The strides the RHCS has made to secure funding from within its own revenue and the MTEF will need to be sustained while diversifying funding sources by further engaging the private sector, household funding, and possibly looking at other global mechanisms to fund contraceptives. Figure 6: Potential Funding Gap – Estimated requirements v. Estimated Funding $- $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000 $6,000,000 $7,000,000 $8,000,000 $9,000,000 $10,000,000 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 Funding requirements based on estimated commodity needs Expected funding available (based on avg of past 3 years + 5% inflation) Tanzania Contraceptive Security Assessment 16 Tanzania Contraceptive Security Assessment 17 3. CAPACITY 3.1 HUMAN INFRASTRUCTURE Over the years, Tanzania has made tremendous progress in improving access to health infrastructure throughout the country with current data estimating that about 80% of the population has access to health services and over 90% of the population lives within 10 km of a health facility16. However, similar to many countries in the region Tanzania is faced with human resource challenges in serving the population. Therefore, there are insufficient numbers of health workers to staff these facilities. It is estimated in the Tanzanian MOHSW’s 2001-2002 Human Resources for Health Census that the country has approximately 25,000 skilled health staff17. This compares poorly to neighboring Kenya which has almost three times the health staff (74,000) even though their population is slightly smaller18. For family planning, these human resource challenges are a strong contributing factor to the country’s inability to satisfy the unmet demand. While there are other barriers to satisfying this unmet need, the “key bottleneck preventing effective health care delivery… is the supply of human resources for health.19” While human resources is a cross cutting issue and one that affects all health programs and disease burdens, this assessment examined the impact on family planning, specifically focusing on two key issues: 1) the staffing levels and patterns and 2) the capacity of health staff. 3.1.1 SERVICE PROVIDER STAFFING LEVELS AND PATTERNS The distribution of staff ranging from hospitals down to the dispensary level shows a wide disparity in staffing patterns both in quantity and the range of skill levels in the public sector. According to the recent Health Facility Assessment, on average there are only four service providers at the dispensary level. For rural family planning clients, the dispensary level is closest service delivery point and a key access point for satisfying unmet demand. While many family planning clients receive their pills (35.9), injectables (47.3) and condoms (12.2) at the dispensary level, a significant number are accessing family planning services from higher levels. For example, 21% of pill users are relying on public health centers and 12% are relying on district hospitals. This dependence on the higher levels may be due to the fact that “while the physical infrastructure exists (at dispensary level), few of these facilities are staffed with the skilled health workers necessary to deliver the critical interventions…. As a result, medical facilities that are adequately staffed (i.e., those at the higher levels) attract patients from a far wider geography than anticipated, often skipping steps in the referral process.20” This was confirmed in the assessment site visits. At two referral hospitals, (one District and one Regional), of the portion of clients who came to the facility for oral contraceptives, 93 percent were for revisits. For injections, of the clients who came for injections 90 percent were re-visit or re-supply clients. This reliance on higher levels referral point for resupply imposes increased barriers (transport, costs, time) on the client as well as an additional burden on the higher level facilities (increased number of clients, insufficient time to dedicate to appropriately referred clients, i.e., those for IUD insertions and other LAPMs). 16 Health Sector Strategic Plan (2003-2008) 17 Investing in Tanzanian Human Resource for Health 18 Ibid. 19 Ibid. 20 Ibid. Tanzania Contraceptive Security Assessment 18 Table 7: Staffing patterns for service provision assessment facilities Type of facility Consultant /specialists Physicians /clinical officers AMOs/ clinical assistants Nurses/ midwives Other specialty Other clinical Other support staff Number of facilities (weighted) Referral hospital 14 27 2 305 12 258 293 1 Regional hospital 2 13 11 96 3 104 20 2 District hospital 0 11 5 41 2 46 13 9 Other hospital 0 4 2 15 3 24 12 12 Specialized hospital 0 6 0 35 0 106 24 1 Health centre 0 2 0 3 0 5 2 55 Dispensary 0 1 0 1 0 2 0 528 Stand-alone (VCT/PMTCT/ART) 0 0 0 0 0 19 2 3 Total 16 64 20 496 20 564 366 611 Source: Tanzania 2006 SPA preliminary report As indicated, a national survey reports that unmet demand for FP is 17% in urban and 24% in rural areas. However, according to the same survey, BCG vaccination coverage (which requires at the very least, the same skill level and capacity as required for family planning provision) is 96% in urban areas and 90% in rural areas. This disparity highlights that the high unmet demand for family planning may not only be due to insufficient staffing levels, but also perhaps to a lack of rationalized staffing patterns and insufficient technical capacity/skill among the service providers. 3.1.2 SERVICE PROVIDER TECHNICAL CAPACITY In addition to staffing patterns, the technical capacity of service providers may be a contributing factor to unmet demand (especially for preferred method). For example, while it has often been assumed that the low uptake in IUDs was due to client preference, it is now thought to be due to provider bias caused in part by a lack of training in IUD insertion (and removal). As seen in the above section, another contributing factor is that those who are trained in and equipped for IUD provision, many of these service providers are overwhelmed with clients (i.e., for resupply methods) who should ideally be treated by lower cadre of staff and those at dispensary levels. Shifts in brand or the introduction of new methods, in combination with the need for general contraceptive technology updates, were also identified gaps in service capacity. For example, the government’s decision to shift from Norplant to Implanon requires training service providers in this new brand before they can provide this method to clients. Such an example highlights the impact of policy changes on service provision. Another challenge to improving capacity is the inconsistency between local government reforms and health sector reforms. While “the local Government Guidelines for Comprehensive District Plans do not permit support for training of more than one week in duration…. The shortest MOH training module for family planning is two weeks long.21” Lastly, supervision and routine on the job training are important strategies for capacity building and quality assurance. It serves to provide health providers with feedback on their performance and allows supervisors to monitor problems and resolve issues in a timely manner. As mentioned, inadequate staffing levels obviously also inhibit adequate supervision. Regular supervision of health facilities is conducted by the council health management teams (CHMT) using a matrix system. Interviews with health facility staff 21 Pile and Simbakalia, 2006 Tanzania Contraceptive Security Assessment 19 during the site assessments revealed that supervision takes place but is often infrequent. Several replied they had not received any supervision within the last three to six months. The table below shows that 10% of facility staff had not received any supervision for contraceptives in the last six months. However, this is compounded by the fact that family planning is not well represented as a skill or priority among those who are doing the supervising. As noted earlier, part of the reason could be that the reproductive and child health coordinators are not part of the CHMT therefore overlooking family planning and reproductive health. Other reasons could be unclear supervision guidelines or not spending enough time at the health facilities to provide substantial input to the facility staff. Table 8: Percentage of facilities that received a supervisory visit from a higher level by product Product Facility authority Within the last month Within the last 2–3 months Within the last 4–6 months Over 6 months ago Never HIV and syphilis test kits Government 35% 16% 11% 16% 22% NGO 29% 14% 14% 10% 33% Contraceptives Government 59% 17% 7% 7% 9% NGO 55% 17% 3% 7% 17% STI drugs Government 41% 16% 13% 12% 18% NGO 37% 18% 6% 8% 30% SP Government 47% 16% 4% 8% 25% NGO 38% 21% 5% 0 30% ORS Government 48% 17% 4% 0 25% NGO 37% 21% 7% 5% 31% Vitamin A Government 48% 23% 6% 4% 20% NGO 43% 25% 8% 8% 16% Vaccines Government 66% 18% 6% 3% 8% NGO 69% 11% 9% 4% 0 Source: 2003 Tanzania Stock Status Report 3.2 SUPPLY CHAIN MANAGEMENT As part of their health sector reform strategy, the MOHSW began to integrate numerous vertical programs in 2002. The MOHSW developed a plan to develop a corresponding logistics system. The expectation is that the Integrated Logistics System will bring together most of the vertical programs (with the exceptions of the Expanded Program on Immunizations (EPI) and National Tuberculosis and Leprosy Program) and the Essential Drug Program into one system. However, this system has not been fully or completely rolled out and as a result, there are currently three logistics systems functioning in Tanzania: the kit, indent, and integrated logistics system (ILS). The contraceptives in the kit and indent systems are supplied through a separate vertical system using the contraceptive Report & Request (R&R) form. Tanzania Contraceptive Security Assessment 20 • Kit: includes a pre-packaged set of essential drugs and products that is packaged and distributed at the central level by a push system to health facilities and dispensaries. Because facilities could not specify exactly what they need, supplies would either be unused or there would not be enough to meet demand resulting in stockouts. • Indent: a pull system that allows health facilities to send orders using the R&R form to the District Reproductive and Child Health Coordinator (DRCHCO) who then compiles the orders on a quarterly basis and forwards them to MSD/Central. • ILS: each facility determines its own supply needs and manages its funds in an account allocated by the MOHSW. The ILS R&R also includes essential drugs and a selection of STI drugs and laboratory supplies. Of the 21 regions 5 are on the kit system (Kigoma, Lindi, Singida, Tabora, Tanga), 9 are on the indent (Arusha, Kagera, Kilimanjaro, Manyara, Mara, Morogoro, Mtwara, Mwanza, Shinyanga), and 7 (Dar es Salaam, Dodoma, Iringa, Mbeya, Pwani, Rukwa, Ruvuma) have been trained on the ILS system. Figure 7: Status of ILS Implementation by Region This section of the assessment will examine the aspects of the supply chain, following each of the components of the logistics cycle: forecasting, financing (see capital section), procurement, product selection/registration, inventory management and LMIS. ILS Indent 12% Dar es Salaam Pemba Zanzibar Arusha Kilimanjaro Tanga Pwani Moro-goro Lindi Mtwara Ruvuma Iringa Singida Tabora Mbeya Rukwa Kigoma Kagera Mwanza Mara Manyara Shinyanga Dodoma Kit Tanzania Contraceptive Security Assessment 21 Due to the state of flux, it is difficult to determine whether gaps are in transition or longer term in nature. However, the assessment attempts to examine the intended design of the ILS as well as some of the gaps, opportunities and challenges identified during this transition time. Forecasting Forecasting is completed on an annual basis, with a mid-year review, through the Contraceptive Procurement Table (CPT) exercise with the Contraceptive Security Committee at the beginning of the year prior to the MTEF process. This is a consultative process that includes all stakeholders and provides a coordinated effort for the GOT and development partners to determine funding and ordering requirements over the next three years for the public sector and social marketing programs. The CPT requirements are conducted for all modern contraceptive supply methods. Issues data from the MSD is used as a proxy for consumption because of the low reporting rates of the R&R form. For T-MARC sales data to distributors is used as a proxy for consumption. Other partners who provide family planning commodities are also included in the forecasting exercise. Marie Stopes and UMATI receive a majority of their supplies from the MOHSW therefore their needs are captured through stock, receipt and issues data. PSI’s sales and stock data including their projections of condoms and oral contraceptives over the next year were taken into account. The ACQUIRE project has also conducted a long term forecasting exercise using Reality Check tool. This information was also factored into the annual CPT exercise. Procurement The MSD follows established procurement mechanisms for all essential health commodities in the country as prescribed by the laws and guidelines in the 2004 Public Procurement Act. Although a semi- autonomous organization MSD is reliant on funds being released by the RCHS before it can initiate any procurement, including tendering or contracting. The release of funds by the MOF is on a quarterly basis rather than on an annual basis and funds are not always released on time or in the amount expected. This has led to a lengthy procurement process of over 18 months inclusive of quantification to budget allocation, availability of funds, tendering, contracting, and finally to the actual receipt of products in- country. The release of funds in quarterly tranches also prevents the RCHS and MSD from ordering large quantities in advance which prevents procurement efficiencies and taking advantage of economies of scale. Product Selection and Registration As part of the transition from vertical logistics systems to an ILS, it was important to prioritize among the health commodities to determine those that are absolutely essential for routine ordering and reporting within the new logistics system. The priority list was based on a classification scheme which categorized the products into priority and additional commodities to facilitate ILS management. The classification of products includes 99 products for health centers and dispensaries and 166 for the hospital level. Family planning products are considered priority. All contraceptives including generics are to be included on the National Essential Drugs List (NEDL) and registered with the Tanzania Food and Drug Authority (TFDA). However, through the recent CPT exercise, it was recently discovered that Lo-Femenal is not officially registered in Tanzania. Inventory Management The establishment of a priority list of drugs and supplies under the ILS is intended to help the MSD in inventory management. In addition, the MSD is to set a minimum/maximum level at the zonal levels to help strengthen inventory management. However, in part because the min/max has yet to be fully developed, stock management is a challenge for MSD at the zonal stores and at the central level. There Tanzania Contraceptive Security Assessment 22 continues to be contraceptive stockouts of priority supplies. Table 9 shows the stock status of MSD central of all of the priority items. Table 9: Stock Status at MSD Supply Status Percentage (%) Products (n) Percentage of product stocked out 11 18 Percentage of products with less than 9 months of stock 40 67 Percentage of products with 9-24 months of stock 28 47 Percentage of products with greater than 24 months of stock 20 33 Missing product (client card) 1 1 Total 100 166 Source: Tanzania Stock Status report 2003 Health facilities following the indent and kit systems should maintain a stock of three months of FP products on hand. There were overstocks by over 20 months of Microval and IUD’s at all government and NGO health facilities because of low consumption of these products. Condoms at government and NGO health facilities showed a 12 month overstock. This may be attributed to poor record keeping of condoms. For example, one health facility visited during the site assessment only recorded condoms for FP purposes but did not record the ones dispensed for the prevention of HIV/AIDS in their daily register. LMIS At the central level, under the ILS system, the supply chain is managed by the MOHSW through the PSU. They provide general oversight, coordination with other ministries and government agencies, technical assistance, participate in annual forecasting, work with the MSD on procurement and distribution of supplies and equipment, and collection and analysis of data from the facilities. The MSD procures, stores, packs and distributes supplies and equipment directly to health centers, dispensaries, and District Medical Officers (DMOs). They are also responsible for providing feedback reports to the PSU, monitor and maintain financial statements, and distribute management tools. There are still shortages in human resources to meet the demands of a national integrated logistics system. Figure 8 describes the intended flow of information and product under the ILS as well as the roles and responsibilities at each level. Tanzania Contraceptive Security Assessment 23 Figure 8: Movement of Supplies and Information in the ILS Under the ILS, the dispensaries and health centers request supplies to the district pharmacist on a quarterly basis (sites within each district are assigned to one of three delivery groups that allows for staggered ordering to avoid one large order and minimizes transportation problems). In design, MSD packs the order specific for each facility and delivers them to the districts (who are responsible for transportation and distribution to the sites within their district). NGOs and FBOs are eligible to use the ILS (where applicable) and the indent system as well. Each order is based on a seven week cycle (rounded to two months) and a maximum of seven months of stock on hand has been established. The ILS was designed to help improve supervision through the built-in routine reporting system which occurs when the R&R form is sent up via the districts to the DMO for approval. via MSD vehicle MSD Central and Zonal Stores Dispensaries and Health Centers District via district vehicle via MSD or hospital vehicle Dispensaries & Health Centers: Serve clients Prepare orders Collect local funds Hospitals : Prepare hospital orders and funding MSD Central/Zonal: Procure Store Distribute Role MOH Programme Managers MOH Central: Forecast needs Allocate central funds Supervise CLIENTS Hospitals (government/FBO/NGO) Flow of supplies Flow of orders NGO Dispensaries and Health Centers via district or NGO vehicle Districts: Review & approve dispensary and health center orders Allocate local funds Deliver to facilities Store supplies in transit Tanzania Contraceptive Security Assessment 24 In general, the key logistics data is not making its way up to the central level nor is supervision or feedback flowing down. This impacts the accuracy of the forecasts, the responsiveness of the ILS to site requirements, the quality of the data, and the confidence in and potential sustainability of the overall system. There are several factors that could explain the low reporting. In 2004, there was a national shortage of contraceptives. During this time, requests from districts and facilities were not filled. As a result, health managers began to lack confidence in the system. This may have been compounded by lack of follow-up supervision by the MCH coordinators. Furthermore, the lack of supervision resulted in poor data quality, creating cyclical challenges in the ILS reporting. For example, during the recent CPT exercise several data entry errors were discovered. This further compromises the quality of consumption data and limits their ability to make adjustments in stock from area to area. A recent indicator of the reporting rate comes from the February 2007 CPT exercise. Only 10 percent of the contraceptive reports had been received for the second half of 2006 and only 46 percent in the first half. The table below highlights the low reporting rate over the past two years. The first column shows what percent of facilities had submitted an R&R by February 2007. Although the table shows that reports are eventually turned in, it also illustrates that R&R forms are taking up to a year and a half to arrive. Table 10: Reporting Rate from Facilities to RCHS % reporting to RCHS by February 2007 Feb 06 Aug 06 Feb 07 Jan-Jun 05 68% 79% 85% Jul-Dec 05 14% 44% 67% Jan -Jun 06 --- 20% 46% In addition to low reporting rates, there are other barriers to data for decision making within the logistics system. It is expected for regions implementing the ILS that consumption data will be available at the MSD in the ILS database. However, issues with the IT contractor over the last year have delayed the launch of the ILS database. Ultimately, the expectation is that this database will be linked to MSD’s automated MIS (ORION). Currently, the MSD system is only configured to capture stock levels and distribution from MSD central and zonal stores (District issues to SDPs, including UMATI and Marie Stopes, are based on R&Rs). It has been recommended by the National Advisory Contraceptive Security Committee to establish weekly meetings between MSD, DELIVER, Supply Chain Management Systems (SCMS) and the contractor for progress reports to expedite the linking of the ILS database to MSD’s live ORION database to provide consumption data. ILS Considerations This assessment did not specifically focus on the ILS. However, in consideration of the fact that the longer term goal is to transition the entire country to the ILS, we have identified several challenges that may need to be considered as the roll out of the ILS continues. • Capacity − In general, it appears that capacity issues will continue to challenge the effective implementation of the ILS. While such a system provides the decision making to the lowest level so that they are able to control their product availability, this requires additional skills and time on these staff. Through site assessments, it was found that service providers were using different calculations and average months of consumption to determine quantity needed. It was also found that the correct R&R forms were not always being used to order supplies in the ILS regions. One-third of health workers in the ILS had Tanzania Contraceptive Security Assessment 25 some challenges using the R&R forms and this was found in several of the facilities visited. They either had not been properly trained on the use of the forms or were not using them. While this may be addressed during supervision or through more frequent refresher trainings, in some cases, staff may not have the capacity for these skills at all. For example, according to an assessment finding, “no amount of additional training will help those staff that failed and alternative ordering method may be needed.22” − During the assessment, it appeared that several health staff trained in ILS had not fully transitioned over to the system (due to lack of confidence or understanding). As a result there were numerous examples of improvisation. For example, under the ILS system, district stores should not maintain any buffer stock. However, the site assessment and anecdotal evidence suggest that this still occurs. Additionally, it was found at a district hospital they keep only one month of stock on hand because they are nearby the municipal stores and can replenish easily. • Procedures − In addition to capacity constraints, there also appear to be some procedural and bureaucratic issues affecting the effective implementation of the ILS. Funding is seen to be the most obvious barrier. Of those regions trained in the ILS, several have not received their funding allocations from the MOF and therefore, have not been able to utilize the system. − The current ILS does not have a mechanism to fill backorders nor does it have procedures for late or emergency orders. For example, if a facility orders a method and it is not filled by MSD there is not a tracking system to fill the requested method in the next order. It is therefore up to the districts to continually order the method until the order is fulfilled. − From the district to facility level, there were reports that there were delays in receipt of supplies. It is unclear what the barriers and obstacles are or whether this is a combination of weak supervision, late orders, or transportation issues. − There also seems to be some confusion between the role of the MSD and that of the MOHSW especially in terms of notifying sites and stakeholders of changes in policy. For example, when the government made the switch from Norplant to Implanon, MSD was asked to disseminate a letter to sites when they deliver supplies to the districts. However, in one of the regions visited the District and Regional Reproductive and Child Health Coordinators had not heard this information (a letter was also sent to the DMOs who were responsible for ensuring this information is forwarded on to the facility levels). In such a case, it is unclear whether the MSD was assisting the MOHSW in their notification of this policy change or if the expectation was that the MSD was leading the notification. • Funding − The MOHSW has thus far been successful in leveraging support to roll out the ILS. Of the seven regions who have been trained four sites were supported by USAID and the MOHSW garnered additional support from DANIDA for the other three sites. A group of give regions will be trained next with DANIDA supporting one region and the expectation that USAID will support the others in 2008. 22 2005 Tanzania LIAT Tanzania Contraceptive Security Assessment 26 3.3 CAPACITY – MONITORING AND EVALUATION As indicated earlier, Tanzania has committed to a number of relevant goals, targets and indicators related to family planning and contraceptive security. However, the following table illustrates inconsistency and gaps in some of these M&E components. For example, the maternal mortality ratio indicated in the MDG differs from that included in the PRSP as does the CPR goal according to the MDG and the RCH Strategy. In addition, it is unclear the source of much of this data (example: CPR baseline in the RCH Strategy= 22%) making it difficult to use as the basis for monitoring and evaluating progress. Furthermore, as indicated earlier, it does not appear that key stakeholders are aware of these national commitments to goals and targets again making it difficult for respective initiatives to effectively contribute to national plans. In terms of measurement, Tanzania has a number of national surveys that help measure progress and impact. For example, the Demographic and Health surveys, the Health Facility Assessments, and the national Census are all extremely valuable sources of family planning data. However, the country does not have the ability to effectively collect routine information to track ongoing progress. Even those indicators the country commits to tracking prove problematic. For example, both the PRSP and the RCH Strategy include the indicator (# of new clients). However, no progress has been reported against these due in part to the challenges in the capacity of the health management information system. Or if data is collected, it is often analyzed too late to serve M&E functions and provide useful analysis. The LMIS section of this assessment highlighted the challenges surrounding the monitoring and tracking of routine logistics information and the impact of this on forecasting, funding and product availability. It appears that throughout the health system, there is not a capacity for or commitment to using data for decision making. During the COPE exercise at one site, service providers noted that “data was not used for the facility to plan and evaluate the services” This seems to create a vicious cycle as there is little motivation to complete and submit records where there is a belief that the information is not used or valued at numerous levels of the system. Table 11: Inventory of goals, indicators and targets for family planning Policy/strategy Objective/Goal Indicator Target Tanzania Development Vision 2025 Reduction in infant and maternal mortality None None Improve maternal health Maternal mortality ratio 578 per 100,000 (target or baseline?) Combat HIV/AIDS, malaria and other diseases % of current contraceptive users who use condoms (any contraceptive method, currently married women 15- 49) 7.8(target or baseline?) Millennium Development Goals (2004-05) Combat HIV/AIDS, malaria and other diseases Contraceptive prevalence rate (any modern method, currently married women age 15-49) 20(target or baseline?) Poverty Reduction Strategic Paper lowering maternal mortality MMR from 529 per 1000,000 (1996) to 450 per 100,000 by 2003 Tanzania Joint Annual Health Sector Review Reducing maternal mortality with defined indicators -- -- Tanzania Contraceptive Security Assessment 27 National Population Policy Improving maternal and child health and family planning -- -- raise CPR -- from 22% to 30% increase the number of health facilities integrating syndromic management of STI in FP services -- by 10% Reduce level of adolescent pregnancies -- from 54 – 10% Increase provision of youth-friendly information and services -- by 30% of all facilities Increase the number and proportion of partners communicating about RCH issues -- from 45 to 60% by 2010 (male involvement) -- CYP (dispensed) -- -- New FP clients (breakdown by method and gender) -- -- Total FP clients (CPR) -- -- # of service providers trained in integrated RH and are practicing -- -- Method mix among current users of contraception -- National Reproductive and Child Health Strategy -- % of SDPs experiencing stock outs in pills, injectables, or condoms in the last quarter -- Tanzania Contraceptive Security Assessment 28 Tanzania Contraceptive Security Assessment 29 4. COMMODITIES Currently, there are seven methods of modern contraceptives available in Tanzania: oral contraceptive pills, injectables, condoms, spermicides, implants, IUDs, and sterilization. Temporary and short term methods include the male condom, combination and progestin only oral contraceptives, and injectables. Long term methods available are IUDs, implants, female and male sterilization. Injectables are the most popular method with Depo-Provera the most popular method now being replaced by the generic brand Petogen. Table 12: Methods available by sector with brands Method Public sector UMATI, MST Social Marketing Commercial Combination pills 9 (LoFemenal, Microgynon) 9 (Lo-Femenal, Microgynon, Mamelon) 9 (Duofem: T- MARC) PSI to begin Aug/Sept 2007 9 Emergency contraception X 9 (Postinor) X 9 Progestin only pills Microval Microlut, Microval X 9 Injectable 9 (Depo-Provera, Petogen23, Megestron) 9 (Petogen, Megestron) X 9 Male condoms 9 (generic) 9 (MST: Raha and Lifeguard) 9 (Salama/PSI) Dume/T- MARC) 9 Female condoms X 9 9 (Care/PSI) (Lady Pepeta: T-MARC) 9 Spermicides X 9 (Neosampoon) X X Implants 9 (Implanon) 9 (Implanon) X X IUD 9 (Copper-T) 9 (Copper-T) X 9 (private hospitals) Female Sterilization 9 9 X 9 (private hospitals) Male Sterilization X X X 9 (private hospitals) 23 The MOH procures generic Depo-Provera, currently a brand called Petogen from a German manufacturer Tanzania Contraceptive Security Assessment 30 4.1 METHODS Oral Contraceptives The CPR for pills is 6% with 80% of pill users relying on the public sector for supplies. Recently, the MOHSW together with the major social marketing organizations have identified the untapped market of “duka la dawas” as an alternative source for pill users. While this requires a policy change, such a decision has the potential of increasing coverage and client options and access. If as would be expected, more women shift from the public sector facilities to the duka la dawas as their source of pills, this would have the secondary benefit of reducing the burden from the public health infrastructure for this resupply method. Another policy which impacts access and knowledge is the legal restriction of advertisement of oral contraceptives. Emergency Contraceptive Pills (ECP) are not available in the form of a dedicated product in the public sector. This may be an important option for the MOHSW to introduce. Having a dedicated product would serve to raise the visibility of the existence of (and access to) emergency contraception. Implants Implants have been available in Tanzania’s public health system since 1991, and in the private health facilities since 1994. Currently, CPR for implants is just .5% with more than three quarters of these users accessing the method from the public sector. USAID has been the main procurer of implants for the public sector. USAID has announced that it has shifted from procuring Norplant to Jadelle and the MOHSW has decided to purchase Implanon rather than Jadelle. Any change in methods has implications for policies, service delivery capacity, and client awareness. There is an added implication associated with the introduction of Implanon and that is one of cost. Implanon costs approximately $30/unit. The government can receive a significant discount (to approx. $16/unit) if it enters into a contract framework with the manufacturer. Even with this reduced price, procurement of implants make up 25% of the yearly contraceptive costs for the public sector, yet only 9% of the publicly issued methods. In addition, with the decision to go with Implanon as opposed to Jadelle leaves the responsibility for funding this method exclusively with GOT/basket funds resulting in additional financial considerations for this method if CPR continues to increase. The assessment team and stakeholders noted clients being turned away for implant insertions, due to lack of supply. Injectable Contraceptives Injectables are the most popular modern method with a CPR of 8.3% with more than 80% of these users relying on the public sector. The MOH has recently shifted to a generic manufacturer of injectables. While previously, Depo-Provera was provided as a kit, the new manufacturer provides the product and syringe individually. While MSD assured consultants that the onus would be on MSD to ensure that when lower levels ordered supplies they would get both product and syringe, it is worth closely monitoring this to ensure a seamless transition. Intra-Uterine Devices (IUDs) The IUD market in Tanzania is not well established. Overall CPR for IUDs has declined from .6% in 1999 to .2% in 2004. This was often thought to be due to client preferences but several stakeholders have begun to point to supply side issues. During the assessment, cases were noted of clients seeking IUDs who had been turned away over the prior period of several months due to lack of supplies. Most notably, there is a lack of updated information on medical eligibility criteria and training on IUD insertion for providers and the lack of IUDs, and IUD insertion and removal equipment at facilities. Perhaps this may be one of the reasons for the decreasing reliance on the public sector for IUDs. In 1996, of IUD users, Tanzania Contraceptive Security Assessment 31 more than 90% relied on the public sector for the method, with the remainder sourced through private and NGO providers. In 2004, only 48% of IUD users are accessing this method through the public sector. Condoms The condom CPR is 2% with most (almost 80%) of those using condoms relying on non-public sector as their source. Condoms are widely available in stores and pharmacies and through social marketing distribution. However, there is some concern that there is not sufficient coverage in rural/remote areas. The National AIDS Control Program (NACP) will be working with the RCHS to develop a condom distribution strategy. 4.2 SOURCE OF SUPPLY The public sector is the main source of supply for all modern contraceptives (68%) with the exception of the male condom. Within the public sector, dispensaries are the primary source (31.5%) of all contraceptives and are the largest source for injectables (47%) and oral contraceptives (36%) as shown in Figure 9 below. Despite this, there remains a significant reliance on the higher level facilities for these resupply methods. For example, of pill users relying on the public sector, 21.1% rely on the health centre and 14.8% rely on district hospitals or higher. This shows that there remains a relatively centralized provision of services for family planning. As mentioned in the health infrastructure section, this dependence on the referral points (especially for resupply methods) puts a high burden on the client (waiting time, transport) as well as on the facility and staff. That said, the district hospital serves as the primary facility for both female sterilizations (28%) and implants (29%). Figure 9: Source of method within the public sector 0% 20% 40% 60% 80% 100% Pill Injections Condom Female sterilization Implants Referral/spec hospital Regional hospital District hospital Health centre Dispensary Village health post CBD worker Source: DHS 2004 In examining the total market, the public sector is the main source of supply (68%) for all modern contraceptives with the exception of the male condom, for which clients go to the private pharmacies (35.9 percent) and shops/kiosks (36.8 percent) illustrated in Figure 10. Religious and voluntary facilities provide the most female sterilizations outside of the public sector. The private sector (23%) plays a relatively small but important role in the provision of contraceptives. Religious and voluntary facilities are a source that serves 7% of the population. Tanzania Contraceptive Security Assessment 32 Figure 10: Source of method by type 0% 20% 40% 60% 80% 100% Pill Injections Condom Female sterilization Implants Government/parastatal Private medical Other private Religious/voluntary Source: DHS 2004 In further examining the total market, it appears that the private sector is not being optimally tapped. Engaging the private sector could further diversify and expand the coverage and availability of contraceptives. The primary goal of such a strategy would likely provide those with the ability and willingness to pay to have increased access to services and choices. It would also help rationalize the public sector’s limited resources allowing the public sector to focus more intensively on reaching the poor and underserved. Many of the opportunities to better tap into the comparative advantage of the private sector are method- specific. For example, there is likely not a significant market for female sterilization in the private sector both because of the costs and skill required for such a method as well as the limited number of acceptors of this method (CPR for female sterilization = 2.6%). However, there may be significant private sector market potential for pills with examples of success generated in numerous countries. Pills are the second most popular modern method (CPR=6%). Furthermore, the skill required for resupply is relatively small. While type 1 pharmacies are permitted to provide pills and injectables, current guidelines prevent “duka la dawas” (type 2 pharmacies) from doing so. Recently, the MOHSW has supported reducing this barrier for pills. The MOHSW and key counterparts within the social marketing industry will further advocate for such a policy change. The following scenario shows the current source mix as well as the mix with an increase in private sector provision. Allowing these pharmacies to provide these methods would increase the number of options and accessibility for clients and allow public sector service providers more time to provide family planning counseling, offer LAPMs, and reduce the number of revisits for re-supply methods. Tanzania Contraceptive Security Assessment 33 Figure 11: Change in Source Mix (Pill) Change in source mix (Pill) 0% 20% 40% 60% 80% 100% Other medical 14.70% 43.10% Private medical 2.30% 2.30% Religious/voluntary 4.60% 4.60% Public sector 78.40% 50.00% DHS 2004 Private sector goal 4.3 SUPPLY SITUATION Since contraceptives are on the Essential Drug List, they should be in full supply at the central level. However, the most recent information on the stock status in the country comes from a situation analysis in 2005 which revealed that over half of the facilities sampled had been stocked-out of at least one FP product for over 30 days within the last year (implants were not assessed). Oral contraceptives had the highest stock out rates for Microgynon (94%) and Lo-Femenal (70%). This was followed by Depo- Provera (60%), condoms (35%) and IUDs (12%). These stockouts were most likely to occur in public sector facilities than in the private sector. The 2005 assessment did not look at the availability of equipment and supplies necessary to perform IUD insertions and removals, implant insertions and removals, or male and female sterilizations. An earlier assessment of the stock situation showed government facilities at all levels also experienced stockouts of Depo-Provera, Microgynon, and condoms within the last six months. Furthermore, the zonal warehouse level experienced high rates of stockouts within the last six months of Depo-Provera (100%), Microgynon (75%), and condoms (50%). At the health facility level there were between 6% and 26% of stock outs in Depo-Provera. NGO facilities at the dispensary level also experienced stockouts within the last six months. Half of the NGO health centers had stocked out of Microgynon and condoms. The average duration of stockouts was two months at government health centers and dispensaries compared with only a little over one month at NGO health facilities. These findings show consistently high stock out rates of Depo-Provera, the most popular method. Some of the reasons can be attributed to incorrect ordering by all levels starting at the district level, not ordering on time, inadequate stock levels at the central level, and uneven commodity distribution within the zones24. 24 2005 Situation Analysis of the Family Planning Program Supply Chain Tanzania Contraceptive Security Assessment 34 Figure 12: Percentage of government and NGO facilities that experienced a stockout of contraceptives within the previous six months Government NGO 0 20 40 60 80 100 Mi cro gy no n® Lo -F em en al® Mi cro va l® Co nd om s De po -P rov . IU D Products Pe rc en t Zonal warehouse Hospital Health center Dispensary 0 20 40 60 80 100 Mi cro gy no n® Lo -F em en al® Mi cro va l® Co nd om s De po -P rov era ® IU D Products Pe rc en t Health center Dispensary Source: 2003 Tanzania Stock Status report While only qualitative in nature, the following table shows the stock out pattern found during the field visit during this assessment. Table 13: Site Assessment Stock status – day of visit Method Brand # of facilities that dispense/provide (n=11) Stockout today? NO Stockout today? YES % of facilities with stockout day of visit Combination Pill LoFemenal 11 9 2 18% Microgynon 11 9 2 18% Progestin only Pill Microval 10 6 4 40% Injectable Depo- Provera 11 10 1 9% Implants Norplant 5 3 2 40% Implanon 6 4 2 33% IUD Copper T 11 9 2 18% Male condom 11 11 0 0% Tanzania Contraceptive Security Assessment 35 5. COORDINATION Coordination among key stakeholders and markets is a key component required for contraceptive security. The following are findings both on the types of coordination mechanisms that currently exist and the effectiveness and capacity of these mechanisms for information sharing among providers, programs, resources, and activities. In addition, the section considers areas where coordination could be strengthened. The assessment considered government, the private sector, and donors at the central, regional, and district level. According to the RCH Strategy, the MOHSW RCHS has the responsibility to “coordinate the activities of all partners and other stakeholders.” As described in the context section, there are numerous stakeholders involved in family planning service provision, financing, supply chain, regulatory functions, demand creation and others. 5.1 CENTRAL LEVEL In recognition of the need to coordinate these varying entities at the central level, several groups have been formed. It was reported that the RHCS has three multi-sectoral working groups (1) Advocacy, 2) Information, Education, Communication (IEC), and 3) Service Delivery. The intended scope of these groups function well beyond family planning and include broader maternal health issues, HIV/AIDS, and child health (EPI, IMCI) issues which may compromise the ability to adequately focus on family planning. Furthermore, several stakeholders that would presumably be involved in such groups were either not aware of their existence or if they continued to function. Several stakeholders agreed to follow up to determine the status of the working groups and to work to revitalize them. It would also be important for the groups to revisit their mandate and perhaps rationalize the groups. For example, there may be some overlap between the IEC and advocacy groups. No matter whether the existing groups are revitalized or new groups are established, there are opportunities and needs that are currently not being adequately coordinated. For example, in terms of IEC, PSI and T- MARC are both implementing IEC campaigns as will be the USAID-funded ACQUIRE Project in May, in close collaboration with the MOHSW. However, not all of these stakeholders had a clear understanding of whether there is an overall RCH IEC strategy and how they were contributing to it – raising concerns that there may be inconsistent messaging or gaps in the overall strategy. Similarly, stakeholders noted examples of training that demonstrated a lack of coordination between an overall training strategy and demand generation activities and contraceptive supplies for the family planning services in the country. A Contraceptive Security Committee was established mid-2004 to monitor contraceptive stock status at the central and zonal levels, monitor actual contraceptive distribution rates versus projections, monitor the status of ongoing procurements and upcoming shipments of contraceptive supplies and equipment. The committee’s deliberations have remained focused on the shorter-term, logistical challenges in keeping the contraceptive pipeline flowing as far as the zonal levels. As the Chair of this group, the RCHS has been effective in coordinating the various stakeholders to discuss and improve logistics issues. However, this group alone does not have authority for making budgeting or policy decisions related to contraceptive security. In addition, there are issues that affect product availability and contraceptive security that are beyond the scope of this working group, suggesting the need for a higher-level group of decision-makers to develop a longer-term, programmatic vision to orient interventions and policies over the next five to ten years. Such a group would provide significant support to the MOHSW and is consistent with Tanzania Contraceptive Security Assessment 36 UNFPA’s recommendations for promoting contraceptive security and supports many of the plans of action the MOHSW has signed onto. As UNFPA has a clear mandate and global strategy for contraceptive security, they may be the most appropriate and adequately elevated group to support the MOHSW with such a group. Similarly, attention at the District level to contraceptive security needs to be given to ensure that supplies and equipment at zonal levels reach district and facility levels where they are needed. A CS Committee may provide opportunities for the formation of ad hoc or subgroups if needed. For example, regarding the total market, there is some concern that NGO and social marketing strategies may be overlapping and that the MOHSW may not be optimally tapping these other sectors to reach the national family planning goals. For example, PSI and T-Marc could potentially be targeting the same client group/segment. Similarly, in urban areas, UMATI and Marie Stopes may also be targeting the same segment of clients. With such a high unmet demand in the country, there should be a mechanism to better coordinate roles and rationalize segments of the population. Furthermore, these groups do not currently have a platform to raise issues that may be affecting their ability to increase access. For example, during the CS assessment, there was much discussion regarding the policy constraints limiting the ability for “duka la dawas” to offer pills. However, there was not a formalized mechanism for the affected stakeholders to collectively initiate dialogue. The CS Committee may serve as such a mechanism providing stakeholders with an opportunity to share issues and to strategically coordinate support to change policy. In addition to a total market group, there may be need to form a subgroup to improve coordination between the MSD and the MOHSW. As indicated earlier, there appears to be a disconnect between supply and demand issues. This is especially true with the introduction of new methods, a new demand creation activity or the training of additional providers which result in an unpredicted spike in uptake that the MSD is not prepared for. For example, the transition to Implanon, which will be the only implant offered in the country, will require training of health facility staff, ensuring the implants and the accompanying equipment is available and in stock in the health facilities. With the transition from donor funding allocated specifically for FP supplies to basket funding in which the MOHSW needs to advocate for health program funding, there has been a recommendation that the MOHSW and MOF establish a joint committee. Although it is unclear if this committee has been operationalized, it would be important for the RCHS to closely collaborate with the MOHSW representative on this committee to convey challenges the FP Program has encountered related to funding procedures and to advocate for FP funding. In addition to MOHSW-initiated coordinating bodies, the donors have also developed a group to improve coordination of efforts and harmonize strategies. The Development Partners Group (DPG) on health includes representatives from all of the international donors that support health-related activities in Tanzania. It appears that family planning in general, and contraceptive supplies specifically, are a topic of discussion in these groups with one DPG member saying that “within the DPG, for the past 2 years we have spent more time discussing contraceptive logistics than any other single subject in the health sector25. 25 Tanzania DELIVER Final Report Tanzania Contraceptive Security Assessment 37 5.2 ZONAL, REGIONAL AND DISTRICT LEVEL COORDINATION Several reports have documented the need to improve family planning coordination (and commitment) at the regional and district levels especially as the country continues to decentralize management and supervision of health services. This concern was reiterated by key informants. According to the RCH Strategy, there are clear roles for the zonal RCH Coordinator, Regional Health Management Team (RHMT) and the Council Health Management Team (CHMT). However, the “District Council Health Management Teams … do not by statute include the reproductive and child health coordinators26,” thus limiting their ability to effectively coordinate family planning programs, strategies and funding. The ACQUIRE Project, in close coordination with the District Executive Directors and CHMTs, has highlighted the need to more effectively engage these coordinators at the zonal, regional and district levels. Similarly, there appears to be a disconnect between MOH budgeting for family planning and that covered by the local government budgets, leading to potential for gaps and overlaps, “The local government reforms and the health-sector reforms are not well synchronized. For example, the Local Government Guidelines for Comprehensive District Plans do not permit support for training of more than one week in duration. Yet the shortest MOH training module for family planning is two weeks long27.” 26 Pile and Simbakalia, 2006. 27 Pile and Simbakalia, 2006. Tanzania Contraceptive Security Assessment 38 Tanzania Contraceptive Security Assessment 39 6. COMMITMENT This section examines the enabling environment for reproductive health and family planning, including government leadership, advocacy, and direct and indirect support to ensure product availability and choice for all women and men who want to use modern contraceptive methods. 6.1 POLICES AND STRATEGIES As indicated in the context section, there is significant commitment to family planning in policies and strategies, in part due to its instrumental role in achieving a key goal for the country – reducing maternal mortality. The following table provides a snapshot of key strategies and whether maternal mortality, reproductive health/family planning, contraceptive security is specifically included and whether there are supporting targets. In addition to the inclusion of product availability and contraceptive security in the National Population Policy, PRSP and National RCH Strategy, the commitment towards CS has also been demonstrated through the Government of Tanzania’s inclusion of contraceptives in the national Essential Drug List and their involvement in and endorsement of several CS initiatives: • In November 2005, Tanzanian family planning stakeholders participated in a Regional East Africa RHCS Workshop in which the country developed a plan of action • In September 2006, the Ministry of Health attended the Africa Union Ministers of Health meeting in Maputo • In June 2006, the Ministry of Health participated in a UNFPA sponsored CS Advocacy Workshop • The MOHSW also leads an ongoing multi-partner Contraceptive Security Committee (CS) whose main role is to, in a collaborative manner, discuss and suggest approaches on meeting the challenges and issues that face commodity security in Tanzania Table 14: Commitment to Family Planning in National Policies and Strategies MMR RH/FP CS Targets Tanzania Development Vision 2025 √ √ National Health Policy MDG √ √ √ National Population Policy (2006) √ √ Poverty Reduction Strategic Paper √ √ √ √ Tanzania Joint Annual Health Sector Review (2005) √ National RCH Strategy (2006-2010) √ √ √ √ National HIV/AIDS Policy (2001) √ PMTCT X VCT/ PLHA Tanzania Contraceptive Security Assessment 40 While family planning does appear to be included in many of the relevant strategies, it appears that stronger attention could be dedicated in both the PRSPs (which only have one indicator: “# of new family planning acceptors”)28 as well as the HIV/AIDS Policy which has limited reference to reproductive health/family planning. Furthermore, it appears that commitment falls short when it comes to translating this language into action. There is a lack of consistency among the targets, and lack of commitment to measuring progress. For example, while both the MDG and the PRSP include a target for reducing maternal mortality, their target numbers appear to be different. In terms of measurement of progress, while this may be in part due to capacity issues (see capacity section), the lack of ability to show progress to these indicators infers that the commitment may need more follow through by the RHCS and MOHSW. As indicated, much credit should be given to those who advocated for and recognized the importance of the inclusion of family planning in national policies and strategies and who participated in the contraceptive security initiatives. However, these documents do not appear to be widely disseminated and therefore do not adequately serve to communicate the goal to which programs and partners should be contributing. During key informant interviews at both the central and lower levels, there was consistent lack of awareness or understanding of the national policies and strategies. Contextual factors may also be affecting stakeholders’ ability to advocate for and highlight family planning. As part of the country’s health sector reform initiative, family planning programs were integrated into the RCHS. While this supports the comprehensive nature of services, family planning is just one component of RCH, and may not be given the attention it previously had. Similarly, as mentioned earlier, at the lower levels, the RCH coordinators at the regional and district level tend to be co-opted rather than full members of the respective management health teams thus limiting the visibility and attention to family planning. 6.2 ADVOCACY AND LEADERSHIP The RCHS deserves much recognition for its efforts to secure funding for family planning. The leaders have been successful in establishing a line item in the budget for family planning commodities. As evident in the following figure, the government has also been very effective in lobbying for funding allocation for commodities. In 2005 GoT/basket funding made up nearly half of total funding. Figure 13: Funding trend for public sector contraceptives (US$, millions) $1 $2 $3 $4 $5 $6 $7 $8 $9 $10 $11 2002 2003 2004 2005 2006 $2.04 $5.20 $4.73 $8.97 $10.15 GOT/BASKET KfW DFID USAID UNFPA 28 Pile and Simbakalia, 2006 Tanzania Contraceptive Security Assessment 41 With the government’s move to a basket fund, more and more programs (both within health and across sectors) are required to vie for limited resources. This requires new skills and partnerships within the ministries. And while historically, the RCHS has been successful in ensuring funding, they may be required to expand their lobbying efforts and elevate family planning to a higher level to mobilize sufficient resources and support. To date, it does not appear that there has been much advocacy by civil society within Tanzania. Marie Stopes Tanzania, UMATI, and women’s groups are logical champions for grass roots and national advocacy for family planning and could prove to be strong allies for the RCHS. Other important, and yet to be tapped advocates include the Tanzania Parliamentary Association on Population and Development (TPAPD), the Parliamentarians’ Group on HIV and AIDS and the African Women Ministers and Parliamentarians (Tanzania Chapter). While maternal mortality, HIV/AIDS, and other social issues do receive media attention, family planning and contraceptive product and service availability appear to be only modestly referenced. In terms of the MDGs, the link between family planning (CPR) and MMR could be used more effectively. The following graph clearly shows the correlation between the two and this could prove a powerful advocacy tool for additional financial and resource support for family planning. Figure 14: Maternal Mortality and Contraceptive Prevalence Maternal Mortality and Contraceptive Prevalence 0 500 1,000 1,500 2,000 2,500 Sie rra Le on e An go la Nig er Rw an da CA R Gu ine a B uis sa u Ch ad Bu run di Eth iop ia Ma da ga sc ar Ta nz an ia Ga bo n So uth Af ric a Ca pe V erd e Bo tsw an a M at er na l M or ta lit y R at io (p er 10 0, 00 0 liv e bi rt hs ) 0 10 20 30 40 50 60 M odern C PR % MMR CPR A recent analysis shows the linkage between population growth and other sectors and MDGs (education, poverty reduction). Therefore, these findings can be used to advocate for support for family planning from a wider audience. Donors can also continue to be strong allies for contraceptive security. In particular, UNFPA and USAID both have global strategies supporting commodity security. With this support come technical assistance, advocacy, support and funding. It is important for the RCHS to better understand the support available from these groups. Specifically, UNFPA has been and continues to be the lead UN agency for promoting RHCS and therefore has been intensifying its engagement on RHCS at the global, regional and country levels. It is strongly recommended that the RCHS approach UNFPA to determine how best to harness this support. Tanzania Contraceptive Security Assessment 42 Tanzania Contraceptive Security Assessment 43 7. CLIENT Contraceptive security exists when every person is able to choose, obtain, and use quality contraceptives and other essential reproductive health products and services whenever s/he needs them. This definition reminds stakeholders that clients (women and men) are the ultimate beneficiaries of RHCS as product users, and are therefore the intended drivers of the system through their demand. To better understand the client perspective, the assessment examined trends related to family planning knowledge and use. In addition, consultants sought to understand client perceptions through a series of focus group discussions with 20 participants and client interviews (in the COPE exercise). Because the client information is limited in scope and anecdotal in nature, it serves only to add qualitative support to quantitative findings. 7.1 MET NEED FOR CONTRACEPTION There has been a steady increase in contraceptive use among married WRA in Tanzania with modern method CPR increasing from 13% in 1996 to 20% in 2004. Between 1996 and 1999, Injectables surpassed pills as the most prevalent method used among married women and they continue to increase significantly (from 5% in 1996 to 8% in 2004), followed by pills. Short term, resupply method use is significantly higher than that of long acting methods (IUD, implant, female sterilization). Although qualitative in nature, responses from the two focus group discussions mirror the national trends with most choosing and accepting an injectable, followed by pills and then implants and IUDs. Reasons provided for method selection are: 1) injectables: long interval between dosages, advice from friend; 2) pill: provider recommended and ease (“swallow (pill) and forget”); 3) implant: long interval and manageable and 4) IUCD: no side effects. Despite increases, disparities in use remain. While rural use among Married Women of Reproductive Age (MWRA) has almost doubled from 1996 (8.3%) to 2004 (15.5%), use among this segment remains significantly less than that among urban MWRA. Not surprisingly, disparities also exist in both education and wealth variables with the MWRA from the wealthiest quintile of the population using modern family planning at more than three times the rate of the poorest quintile. Among the Mainland districts, the highest contraceptive use among married women is in Kilimanjaro (38.3%), Dar es Salaam (34.8%) and Ruvuma (34.8%) and the lowest CPR is in Tabora (7.8), Shingyanga (7.5) and Mwanza (9.2%). Table 15: Contraceptive Prevalence by Background (MWRA) 1996 1999 2004 BY RESIDENCE Modern method (any method) Modern method (any method) Modern method (any method) Urban 23.7 28.9 34.3 Rural 8.3 10.5 15.5 BY EDUCATION No education 6.8 6.8 8.3 Primary incomplete 12.5 11.7 16.5 Primary complete 21.5 20.5 25.7 Secondary+ 31.5 33.5 38.2 BY WEALTH QUINTILE 1 Lowest N/A N/A 10.7 Tanzania Contraceptive Security Assessment 44 2 Second N/A N/A 12.8 3 Middle N/A N/A 15.6 4 Fourth N/A N/A 24.1 5 Highest N/A N/A 36 BY GEOGRAPHIC AREA Dodoma 11.4 N/A 22.2 Arusha 11.3 N/A 34.7 Kilimanjaro 23.7 N/A 38.3 Tanga 12.6 N/A 29 Morogoro 13.3 N/A 29.9 Coast 23.5 N/A N/A Pwani N/A N/A 19.3 Dar es Salaam 23 N/A 34.8 Lindi 15.7 N/A 30.1 Mtwara 11.3 N/A 25.9 Ruvuma 15.2 N/A 34.8 Iringa 7.7 N/A 26.4 Mbeya 11.5 N/A 23.5 Singida 12.9 N/A 16.9 Tabora 11.1 N/A 7.8 Rukwa 7.6 N/A 13.1 Kigoma 10.4 N/A 12.2 Shingyanga 4 N/A 7.5 Kagera 5.3 N/A 15 Mwanza 8.4 N/A 9.2 Mara 5.4 N/A 10.8 Manyara N/A N/A 17.3 Town West N/A N/A 11.2 Source: DHS 1996, 1999, 2004 Increases in use can likely be attributed to increased knowledge of methods, with knowledge of short term methods (pills, injectables, and condoms) at more than 90% by 2004. Knowledge of implants has increased astonishingly fast (increasing from just 24% in 1996 to 54% in 2004) while increases in knowledge of IUDs has been somewhat slower (from 49% in 1996 to 57% in 2004). Table 16: Knowledge of contraceptive methods (all respondents) (Tanzania DHS, 2004) Method 1996 1999 2004 Pill 78.4 86.3 92.5 IUD 48.8 53.8 57.2 Injections 70.8 80.9 90.1 Condom 72.2 83.2 90.4 Female sterilization 60.7 62.5 69.3 Male sterilization 24.8 27.3 28.2 Implants 23.5 40.3 54.1 Female condom - 41.4 55.9 Source: DHS 1996, 1999, 2004 Tanzania Contraceptive Security Assessment 45 7.2 REASONS FOR DISCONTINUATION In examining the distribution of discontinuation of contraceptive methods in the five years preceding the 2004 DHS, trends exist according to main reason for discontinuation. For example, side effects appear to be one of the main reasons for discontinuation for Implants (47%), IUDs (42%), injectables (39%), and pills (31%). These are important challenges that warrant both intensive IEC and service provision improvements. The findings for IUDs is inconsistent with responses from the focus group discussion in which respondents indicated IUDs were preferred and selected because there were no side effects. Table 17: Reasons for Discontinuation (Tanzania DHS, 2004)29 Became pregnant To become pregnant Husband disapproved Side effects Health concerns Access/ availability More effective method Inconvenient to use Infrequent sex Pill 8.2 37 2.7 31 1.2 4.5 4.3 3.4 2.6 IUD 0 35.4 5.4 42.4 2.8 0 4.7 0 0 injectables 2.1 34.1 2.6 38.6 2.2 7.8 2.2 0.7 4.7 Condom 5.8 33.1 12 3.2 0.3 2.4 14.2 4.3 10.9 Implants 0 19.4 0 47.4 0 7.3 12.9 0 8.7 LAM 20 39.9 1.8 0 0 0 15.8 6.7 5.8 Source: DHS 2004 7.3 UNMET NEED FOR CONTRACEPTION Despite the increase in knowledge of family planning methods and the increases in modern method use of contraception, unmet need remains high and unchanged from 1999. Currently, more women in Tanzania have an unmet need for family planning (21.8%) than are using a modern method (20%). These women have limited options for reaching their reproductive goals. They may abstain from sex, or they may also have an unplanned or mistimed pregnancy and birth or chose to undergo an abortion (although illegal in most cases and expensive). Similar to trends in contraceptive use, disparities exist in unmet need. Again, there is less unmet need among women who reside in urban areas than rural (17% vs. 24%), among those who are wealthier (wealthiest: 15% vs. poorest: 24%), and among the more educated (Secondary+ education: 10% vs. 22% of those with no education). Table 18: Unmet Need for Contraception by Background (all women) UNMET NEED 1996 1999 2004 for spacing 12.1 11.5 11.6 for limiting 6.5 5.8 5 Total 18.6 17.2 16.6 BY RESIDENCE Total Unmet Need Total Unmet Need Total Unmet Need Urban 15.1 13.7 16.6 Rural 19.2 18.6 23.5 29 Percent distribution of discontinuations of contraceptive methods in the five years preceding the survey by main reason for discontinuation, according to specific method. Tanzania Contraceptive Security Assessment 46 BY WEALTH QUINTILE 1 Lowest N/A N/A 23.9 2 Second N/A N/A 22 3 Middle N/A N/A 25.8 4 Fourth N/A N/A 22.5 5 Highest N/A N/A 15.4 BY EDUCATION No education 19.1 18.4 22 Primary incomplete 19 12.8 22.9 Primary complete 18.6 19.3 22.6 Secondary+ 14.1 10.6 10.4 BY AGE 15-19 10.5 10.7 18.6 20-24 21 19.3 23.2 25-29 21.7 21.4 22.2 30-34 20.4 20.4 23.1 35-39 23.6 19.2 23.4 40-44 22.8 12.1 24.4 45-49 11.8 18.1 13 MARITAL STATUS Currently Married women 23.9 21.8 21.8 Unmarried women 7.9 8.4 5.9 Source: DHS 1996, 1999, 2004 Geographic differentials also exit with the highest unmet demand in Kigoma (30%), Mara (28%) and Dodoma (28%) while the lowest unmet demand exists in Mbeya (11%), Dar es Salaam (13%), and Ruvuma (14%). Table 19: Unmet need by Geographic Region BY GEOGRAPHIC AREA (Region) 1996 1999 2004 Dodoma 21.3 N/A 27.6 Arusha 16.2 N/A 14.5 Kilimanjaro 13.7 N/A 18.1 Tanga 19.1 N/A 20.1 Morogoro 17.2 N/A 15.6 Coast 16.6 N/A N/A Pwani N/A N/A 24.6 Dar es Salaam 14.9 N/A 12.5 Lindi 19.2 N/A 21.3 Mtwara 17.7 N/A 23.6 Ruvuma 20.4 N/A 14.3 Iringa 14.7 N/A 17.5 Tanzania Contraceptive Security Assessment 47 Mbeya 15.3 N/A 10.8 Singida 21.6 N/A 25 Tabora 16.7 N/A 23.4 Rukwa 18.7 N/A 16.8 Kigoma 15 N/A 30.4 Shingyanga 18.7 N/A 31 Kagera 23.9 N/A 22.1 Mwanza 21.6 N/A 26.7 Mara 27.1 N/A 28.2 Manyara N/A N/A 24.8 Town West N/A N/A 26.4 Source: DHS 1996, 1999, 2004 According to findings from focus group discussions in two sites in Iringa, clients perceived the largest contributor to unmet need was a fear of side effects. 7.4 REASONS FOR NOT USING A CONTRACEPTIVE METHOD While not factored into the unmet need, the reasons why currently married women who are not using a contraceptive method and who do not intend to use in the future can also be telling. According to the Tanzania DHS (2004), cost (0%), lack of access (.3%), knowledge of source (1.1%) and knowledge of method (1.8%) do not appear to be significant reasons for not intending to use a contraceptive method in the future. However, the main reasons for not intending to use are fear of side effects (25%), opposition by respondent (15%), and spousal opposition (7%). Fear of side effects has increased from 5% in 1996 to 26% in 2004. As knowledge of family planning methods increased, it appears that so have myths and misconceptions regarding methods. This finding is consistent with the finding that one of the highest reasons for discontinuation is side effects. Both suggest that while IEC may have been effective in increasing knowledge, the quality of the information and the counseling that is associated with services may need to be improved Findings from focus group discussions in two sites in Iringa indicate similar trends. Out of 17 respondents at two sites, 12 reported fear of side effects (side effects that were mentioned included abdominal pain, dizziness, headache, delay conception, false pregnancy, prolonged menstrual bleeding, palpitations, weight loss, weight gain and abdominal swelling) and religious reasons as the main reasons for not using a family planning method. This was followed by 9 reporting perceived spousal refusal. Only lack of access (reported by 5 respondents) was inconsistent with the national findings. Again, this information is qualitative in nature and can not be used to make any national assumptions. Table 20: Percent distribution of currently married women who are not using a contraceptive method and who do not intend to use in the future by main reason for not intending to use. Infrequent sex Subfecund, infecund Wants more children Respond ent opposed Spouse opposed Religious prohibition Health concerns Fear of side effects 1996 1.7 1.2 27.1 20.5 6.9 1.7 1.3 4.7 2004 3.1 8.7 15.6 15.5 7.4 2.2 2.3 26.1 Source: DHS 1996, 2004 Tanzania Contraceptive Security Assessment 48 7.5 TOTAL DEMAND and UNMET NEED Total demand for family planning is the sum of the current proportion of MWRA using contraceptives (both traditional and modern methods) and the proportion of MWRA who are not using a contraceptive, but expressed a need either to space or limit births. Both CPR and unmet need for family planning have plateaued in Tanzania, but there remains a high level of unmet need. If unmet need were met, the total CPR for Tanzania would be 48.2%. Discussions with stakeholders revealed differing opinions about the level of attention that should be given to generating demand for family planning, and the role of demand generation activities (including community mobilization, communications and marketing activities) in relation to service delivery and training. Some indicated that efforts should be focused on meeting the current needs of those with unmet need, as opposed to increasing demand. The justification provided is that if the current system can not meet existing demand, it is unwise to create even more demand that will likely not be able to be met with current capacity and resources. Therefore, some stakeholders suggested a focus on supply side factors (quality of care, coverage of services and product availability, improved skills and infrastructure for LAPM) and improving the quality of information (through improved IEC and counseling) and satisfying latent demand rather than focusing on building new demand. In order to build the capacity to meet the current demand requires integrated strategies for service delivery, training of providers, community mobilization and marketing and communications. Others emphasized that even if there is a latent demand for the service, awareness needs to be raised that services exist and that the clients are welcome. Also, because the permanent methods are not reversible, potential clients require a longer time to consider these options and decide whether to use these methods or not. Longer term IEC strategies and information should be in place long before the client may choose to use such a method. Figure 15: Total Demand for Family Planning Source: DHS 1996, 1999, 2004 13 17 20 5.4 8.4 6.4 23.9 21.8 21.8 0 10 20 30 40 50 60 1996 1999 2004 Unmet need (MWRA) CPR traditional CPR modern Tanzania Contraceptive Security Assessment 49 8. CONSIDERATIONS CAPITAL • The RCHS should continue their successful efforts in advocating for public sector funding of contraceptive methods and services. However, fluctuations due to a number of reasons including development partner constraints, competing priorities within the ministries, and how the current political environment prioritizes health do not guarantee stable funding for contraceptives, family planning, or reproductive health. There are several strategies stakeholders can adopt that may help stakeholders better position the country in terms of long term funding requirements: • Routine monitoring of family planning funding is important for advocacy, planning and management. Indicators that may provide stakeholders with a better understanding of the funding situation include: ƒ Funding gap (funding need vs. available funds) ƒ Trends in funding according to source for contraceptive supplies and equipment for the public sector ƒ Commitment/disbursement ration ƒ Amount of returned/unspent funds allocated to FP contraceptive supplies and equipment • Available data related to family planning funding tends to be specific to family planning commodity costs. Funding for other components of family planning, while equally important, are much more complex to understand and collect. That said, ongoing efforts should continue to advocate for the collection of this information especially if the country is conducting national health account exercise or other activities that could potentially collect this valuable information. • Diversify and rationalize funding sources: As mentioned, the government shows great commitment to family planning in its allocation of internally generated and basket funding to the procurement of contraceptives. However, to meet increasing demand, the government may be able to leverage new/untapped sources and more rationally manage the funding sources currently available. For example, the GFTAM may be a potential source of funding for family planning supplies. Similarly, allocating World Bank funding for condoms frees up existing government resources for other methods. • Advocacy: Continued and expanded advocacy is required to ensure long term support for family planning. Stakeholders have proven effective in lobbying for support through traditional channels. However, there are yet to be tapped stakeholders who will need to play a stronger role in supporting family planning funding. For example, with decentralization, the local government authorities play an increasing role in funding health programs. As the LGAs conduct their budget review and allocation process, it is important that family planning needs are considered. To reach decision-makers beyond the national level, the Reality √ Family Planning Forecasting Tool extends existing national level family planning projection tool methodology, to project contraceptive prevalence, user, commodity and service needs at the regional, district and site levels. • New trends: The MOH has been very effective in responding to the transition to basket funding. It is equally important for them to look for and understand any new funding trends (i.e., direct budget support) that the government may be moving towards and considering the implications for family planning. Tanzania Contraceptive Security Assessment 50 CAPACITY Human Infrastructure • Revisit supervision matrix – Supervision of health facility workers can be useful in receiving valuable information on the quality of the service provided to clients, provide insight on how the health system is functioning, including the logistics system, and a way to emphasize new policies and procedures. The supervision matrix should be revisited to re-assess the frequency and length of visits to health facilities. Additionally, the reproductive and child health coordinators should be added as official members of the CHMT so that family planning is not overlooked during supervision visits both in terms of supporting health facility staff in the provision of contraceptive methods and services to clients but also ensuring that the procedures for ordering supplies are correctly followed and that there are sufficient supplies and equipment. • Devolution of responsibilities to lower cadre and to lower level SDPs - Family planning programs can learn from the success of the immunization program and use their model as justification for devolution of service provision responsibilities. For example, skills required to administer the BCG vaccine are similar to (or more complicated than administering injectable contraceptives). One possible strategy, as indicated in the following graphic, to address the capacity and ability of health workers to meet the needs of the clients is to rationalize and devolve responsibility to the lower level SDPs and increase the use of duka la dawas. Allowing health center and dispensary health facility staff to administer injectables will free up more time for hospitals to counsel clients on family planning, and to provide LAPM services. And authorizing duka la dawas to sell oral contraceptives increases the number of access points for clients to choose from and reduces the burden of re-visit and re-supply visits on public sector facilities. Figure 16: Devolution and rationalization of health services by levels Resupply pills Duka la Dawa Reg’l Hospitals increase LAPM, shift injectables to lower/pills to private District Hospitals increase LAPM, shift injectables to lower/pills to private Health Centre @ 50,000 people increase injectable/shift pill to private Dispensary: cater to 6,000 - 10,000 people increase injectable/shift pill to private VHW: Provision of preventive services offered in homes Tanzania Contraceptive Security Assessment 51 • Routine monitoring: While the government has committed to family planning and product availability, there appears to be a disconnect between the identification of indicators and objectives and the routine monitoring of them. Establishing consistent indicators, targets and baselines, clarifying sources and including routine tracking and progress in appropriate meetings may help ensure progress towards national goals. Supply Chain Management • Improve reporting of information up to the central level – In coordination, the PSU, RCHS, and MSD should ensure that all required data and forms, such as the R&R forms, reflect the full range of contraceptive supplies and equipment [this is a problem that not all equipment is in the MSD catalog], are being correctly filled out and sent upwards according to guidelines. The need for accurate and timely consumption, stock data, and ordering information is vital to not only ensuring the LMIS is up- to-date but provides the data needed for accurate reporting, monitoring, analysis, and procurement of contraceptives and related equipment to avoid stock-outs and to ensure the correct distribution of supplies and equipment to health facilities. The MSD and RCHS should determine the mechanisms and flow of receiving the R&R forms from the zones and regions up to the central level. • Use of available logistics data and funding information – Combining supply chain information and funding allocation information can serve both as an advocacy tool to raise awareness of contraceptive security and also reinforce the need for routine monitoring. The recommendation is to present and share stock and procurement information that is already available from the MSD along with funding allocation and disbursement schedule information from the RCHS at the regular CS Committee Meetings. Because disbursements and the amount are not released on a predictable basis it is important to closely track and monitor disbursements and anticipated funding. A recommendation is to develop a disbursement schedule spreadsheet that contains disbursement, allocation, and expenditure information for contraceptive procurement which will be monitored quarterly by the CS Committee. This will be compared with MSD’s procurement plan to identify any possible stockouts if planned procurement is not fully funded. As a regularly scheduled agenda topic, any issues identified will then be channeled upwards by the CS Committee members and brought to the attention of their respective higher levels at the RCHS, MSD, and PSU to raise the profile of these particular issues and facilitate and advocate for the more timely release of funds. • Roles and responsibilities between MSD and RCHS - Because MSD is responsible for distribution of commodities it has direct contact with many of the zones, districts, and health facilities. They would seem to be a natural point of contact and vehicle for the dissemination of policy information. However, this responsibility should be clearly stated and agreed upon by the RCHS, who sets policy, and MSD to avoid miscommunication and to ensure national policies are widely and commonly known at all health care levels. Similarly, the roles of DMOs and CHMTs in communicating policy changes should be clarified in relation to the RCHS and MSD responsibilities. • Refresher training - Until the ILS is fully operational in all of the regions there should be a revitalization of the indent system as a refresher on the use of the R& form in conjunction with an emphasis on improved supervision. A refresher on the ILS is also recommended since the last training took place in March 2005. • Integrated Logistics System – Adjustments and improvements will be made as the ILS continues to be rolled out. The recommendation for the Tanzania USAID | DELIVER PROJECT and MSD to meet Tanzania Contraceptive Security Assessment 52 on a weekly basis to expedite the linkage of the ILS and MSD databases was made above. Fully funding the other regions that have been trained in ILS is also imperative to transition the entire country to one logistics system more quickly to reduce and eliminate the multiple procedures, forms, ordering schedules, packaging requirements, and capacity currently demanded by the MSD to keep track of. Enabling the ILS to meet emergency needs and backorders will further enhance the system and build the users’ trust in the system to fully meet their demands. • Product and equipment selection/registration: − As indicated, Lo-Femenal is not officially registered in Tanzania. Steps should be taken to register Lo-Femenal. In addition, stakeholders should renew Duofem’s registration if necessary and ensure that all the generic stock that MSD procures is also registered before arrival. − There are around 1000 products included in MSD’s Essential Drugs and Medical supplies list. While there is a tendency to add to this list, it is important to keep it manageable. It is also important to ensure that all LAPM medical equipment is included and available in MSD. • Funding – Additional funding from USAID and development partners will be needed to continue the training and rollout of ILS in the remaining 14 regions. COMMITMENT • Improve data for advocacy – To continue the RCHS advocacy efforts, the use of and dissemination of available tools and information such as the RAPID presentation can be effective in generating better understanding of the impact of family planning investments. • Expand efforts - In addition to improved data for advocacy efforts, there is also a potential to leverage a larger network of stakeholders. For example, advocacy efforts could target Parliamentarian Committees (i.e., the Tanzania Parliamentary Association on Population and Development, Parliamentarians’ Group on HIV and AIDS, African Women Ministers and Parliamentarians (Tanzania Chapter). Additionally, more efforts could be made to other ministries (such as labor, education, agriculture, etc) in demonstrating the long term effect and impact family planning has on the environment, agriculture, education and the economy. COMMODITIES • Pills - Currently, stakeholders are working to expand access to pills by reducing barriers to pill provision by the duka la dawas. It is critical that this is not seen as a campaign by those with self interest and that the MOHSW takes on a leadership role in this campaign. If successful, it would be important for this group to consider the implications of this policy change. For example, social marketing organizations must ensure they have the capacity and resources to meet any uptake in demand for pills through the duka la dawas. Similarly, service providers in the public sector should be informed that they can inform clients that duka la dawas can be an alternate source of pill resupply for clients. • Revitalize IUD - Overall CPR for IUDs has declined from .6% in 1999 to .2% in 2004 as has reliance on the public sector for IUDs. In 1996, of IUD users, more than 90% relied on the public sector with the remainder sourced through private and NGO providers. In 2004, only 48% of IUD users are accessing this method through the public sector. This shift may be due to supply side issues in the public sector such as the lack of current training in IUDs for providers and the lack of IUD equipment at facilities. Further understanding of the barriers to IUD uptake should be explored with a corresponding investment in public sector initiatives. Tanzania Contraceptive Security Assessment 53 • Emergency Contraception - While the public sector has been effective in keeping a rational number of methods available, the MOHSW may want to consider the introduction of a dedicated product for emergency contraception. Having a dedicated product would serve to raise the visibility of the existence of (and access to) emergency contraception. Obviously, this would have both financial implications as well as those related to service delivery and policy. COORDINATION • Policy changes - As new polices, brands of methods or types of services are introduced, proper dissemination of information is critical to ensure the following: 1) proper planning to prevent shortages of supplies and equipment, 2) awareness by health facility workers so they can counsel clients and provide services safely, and 3) availability of appropriate supplies and services for clients. For example, during a site assessment, health facility staff noted they were not aware of the transition from Norplant to Implanon although it is already occurring nationwide. To ensure providers are fully prepared to serve clients, close coordination is needed between the RCHS and its relevant counterparts (e.g., MSD, DMOs, CHMTs, RCH Coordinators). • ILS rollout - As the country transitions to the ILS system close collaboration is necessary between PSU, MSD, RCHS, MOF, and the USAID | DELIVER PROJECT to ensure a smooth transition. The USAID | DELIVER PROJECT will be implementing the roll-out of the ILS and can assist in the coordination with the RCHS to establish a coordinated timeline with all of the partners involved to harmonize training and subsequent transfer of information to facility staff at the lower levels, ensure the drugs on the priority list will be in full supply at MSD central and at the facility level, and that minimum and maximum levels of stock are in place. The treasury will need to release the drug allocations in concurrence with new ILS regions to allow an immediate conversion to ILS and minimize any delays. • National IEC Strategy - The RCHS has been coordinating the CS efforts and will continue to do so as they seek ways to increase CPR in Tanzania. Creating demand will require the involvement of many partners and a targeted and unified approach to prevent overlap in coverage of population segments and messages. This could be articulated by creating a national family planning IEC strategy. The social marketing and service delivery groups, MST, PSI, T-MARC, and ACQUIRE, have expressed the need for such a national strategy. A guiding strategy would provide the foundation for improved coordination and synergy between each organization’s respective efforts to promote products, services and behavior changes. The RCHS can play a coordinating role to harmonize these efforts using the Behavior Change and Communication working group as a vehicle to develop a national family planning IEC strategy. • Integrated strategies for IEC, Training, Service Delivery and Logistics – Building on a national IEC strategy for family planning, it is important for RCHS’ various partners to build complementary and mutually reinforcing strategies for training of service providers and for provision of family planning methods and services. For example, where provider training in FP counseling and clinical procedures is planned, an IEC campaign or community mobilization can help to channel sufficient client load for effective practicum sessions. Ongoing client load ensures newly trained providers maintain their proficiency in clinical techniques. Efforts to expand access to services require prior planning to guarantee the necessary products and related equipment are all available as needed to meet the demand. Tanzania Contraceptive Security Assessment 54 Tanzania Contraceptive Security Assessment 55 REFERENCES The ACQUIRE Project Tanzania. National Scale-Up of the Revitalization of Long-Acting and Permanent Methods of Contraception in Tanzania. Draft. December 2006. Amenyah, Johnnie, Barry Chovitz, Erin Hasselberg, Ali Karim, Daniel Mmari, Ssanyu Nyinondi, and Timothy Rosche. 2005. Tanzania: Integrated Logistics System Pilot-Test Evaluation: Using the Logistics Indicator Assessment Tool. 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Reproductive and Child Health Strategy, 2005-2010. Dar es Salaam, Ministry of Health. Ministry of Finance and Ministry of Planning, Economy and Empowerment. March 2006. Guidelines for the Preparation of the Medium Term Plan and Budget Framework for 2006/7 – 2008/9 (Part 1). Dar es Salaam, Ministry of Finance and Ministry of Planning, Economy and Empowerment. Tanzania Contraceptive Security Assessment 56 Ministry of Health and Social Welfare. October 2003. Tanzania Stock Status Survey: Commodity Availability for Selected Health Products: Baseline Survey for Integrated Logistics System, 2003. Dar es Salaam.: United Republic of Tanzania, Ministry of Health and Social Welfare. Ministry of Health, Reproductive Health Services. 2005. Situation Analysis of the Family Planning Program Supply Chain. Dar es Salaam, Ministry of Health. National Bureau of Statistics (NBS) [Tanzania] and ORC Macro. 2005. Tanzania Demographic and Health Survey 2004-05. Dar es Salaam, Tanzania: National Bureau of Statistics and ORC Macro. National Bureau of Statistics [Tanzania] and Macro International Inc. 2000. Tanzania Reproductive and Child Health Survey 1999. Calverton, Maryland: National Bureau of Statistics and Macro International Inc. Noviatus, N., Mshana, M., Mero, F., and Kanama, J. Rapid Assessment on FP Commodities Stockout in Iringa and Kilimanjaro Regions Trip Report. 30th October – 8th November 2006. MOH, NACP, MSD, EngenderHealth. Pile, J., and Simbakalia, C. 2006. Tanzania Case Study: A Successful Program Loses Momentum, A Repositioning Family Planning Case Study. The ACQUIRE Project/EngenderHealth. New York, NY. President’s Office, The Planning Commission.1992. The United Republic of Tanzania, National Population Policy. Dar es Salaam, The Government of Tanzania. Population Planning Section, Ministry of Planning, Economy and Empowerment. December 2006.Tanzania: Population, Reproductive Health and Development. ). Dar es Salaam, Population Planning Section, Ministry of Planning, Economy and Empowerment PSI Tanzania. Available at: http://www.psi.org/where_we_work/tanzania.html Review of the Local Government Environment in Tanzania. Available at: http://isp- aysps.gsu.edu/projects/tanzania/finalreport1.pdf The United Republic of Tanzania, Local Government Information. 2007. Available at: http://www.logintanzania.net/plans.htm USAID Mission to Tanzania, Health Program. Available at: http://tanzania.usaid.gov/so.php Tanzania Contraceptive Security Assessment 57 ANNEXES Tanzania Contraceptive Security Assessment 58 ANNEX A: IN-COUNTRY CONTACTS Dar es Salaam MOHSW/RCHS Dr. Cosmas Swai, Family Planning Manager Neema Voniatus, Supplies Officer USAID Charles Llewellyn, Population Health Officer Michael V.C. Mushi, Project Management Specialist (Health) EngenderHealth/ACQUIRE Project Grace Lusiola, Country Director Jane Wickstrom, FP/RH Services Team Leader (NY) HPI Halima Sharif Marie Stopes Tanzania Pharis Moenga, Head of Marketing & External Relations JohnBosco Basomingua, Advocacy & External Relations Manager MSD Beatus Msoma Goodlameck R. Mero, Sale Officer PRINMAT Keziah M. Kapesa, Executive Secretary PSI Nils Gade, Executive Director Dr. Alex Ngaiza, HIV/AIDS Programme Manager T-MARC Hally Mahler, Communication Advisor Halima Mwinyi UMATI Walter Mbunda, Executive Director John Haule, Procurement and Supply Officer Edna Kuliwaki, Finance and Administrative Officer UNFPA Chilinga Asmani, National Programme Officer Iringa Region Engender Health/ACQUIRE Project Tanzania Contraceptive Security Assessment 59 Mathew H.N. Tambukwa, Field Manager, Iringa Josephine Tenga, Project Assistant, Iringa Regional Medical Officer (RMO) Adeodaltus Mhagama, RMO (RHS) Dr. Vahya Msigwa, RMO, Acting Medical Officer In-charge Bernard M.N. Nzungu, Regional Administrative Secretary, Regional Administration and Local Government, Anna, District RCH Officer Iringa Regional Hospital Ms. Shemhilu, RCH In-Charge Eline Mtega, Nurse, RCH Clinic Ngoma Health Center Serena Tambukwa, Nurse, RCH In-Charge Ngumbilo Dispensary Zaituni Mshangila, Clinic Officer In-Charge Pellagie Mwalonga, Nurse Midwife, RCH Clinic MSD/Iringa Benjamin Hubila, Manager Mafinga District Hospital Dr. Emily Mbata, District Medical Officer Deonisia Ngata, Assistant RCHCo Imelda Ngailo, DRCHCo, RCH clinic Niumigwa Ambakisye, Mortuary Attendant M.I. Mwakiwonde, Preventive health Diana Lugenge, Reception Jane Maliaki, Labour Ward Bernarda Tweve, Male Ward Malaika Mougo, Grade 1 Leon Fayas Kilufi, Guard Egno Soko, Pharmacy Paskalina Mpee – Laboratory Nicolina Msilu, OPD Moses Tawete, Ward 5, surgical Morogoro Region Dr. M. Massi, RMO Margaret Wapalila, Regional Nursing Officer, RCH Coordinator Imaculata Mhagama, Municipal District RHC Coordinator Bertha Mwihumbo, Vomero District, District RCH Coordinator Dr. Sardi, Acting DMO Gertrude, Municipal DMO Morogoro Regional Hospital Lisfa Lung’wesha, PHNB Service Provider Tanzania Contraceptive Security Assessment 60 Uhuru Health Center Sharifa Kharmis, Nurse Midwife Seventh Day Adventist Dispensary Leah Mgalle, Nurse Midwife Deborah Lyoba, RCH In-Charge Mafiga Health Center Veronia Nchinga, Nurse Midwife UMATI Manager Arusha Region Arumeru District Store Janet Pallangyo District RCH Coordinator Arusha District Store Regina Darabe, Assistant District RCH Coordinator Moshi District Store Agenta Shayo, District RHC Coordinator Mt. Meru District Store Dr. Chande, Medical Officer in Charge Nicoaranga Lutheran Hospital Ruth Kiyungai, RCH Coordinator Tanzania Contraceptive Security Assessment 61 ANNEX B: SITE ASSESSMENT TOOL Tanzania SPARHCS Assessment Site Assessment Tool (for Public and NGO/FBO sites) Site Name: __________________ Location (district, town/village): ___________________ Type of Site: hosp. clinic health center other: ________ Managed by: MOH NGO Date of Visit: ______________ Respondent Name: ______________________________ Position: _______________ Contact Info (cell): ____________________________________ SERVICE/ACCESS • Is there demand for Family Planning? Is it increasing/decreasing? • What methods are supposed to be offered (as opposed to what is available) at the site? • What is the family planning method preference? Has this changed? • What are the main reasons for unmet need (fear of side effects, perceived spousal objection, religious, access, etc)? • How often are clients turned away/referred because services and/or products (that should be available a/c to norms and standards) are not available at the site? • Is there a full supply or rationing of FP? • Have stock outs occurred in the past year? Please describe: For Public sites • Does the site charge for FP products and services (cost recovery system)? Please describe: ____________________________________________________________________________ ____________________________________________________________________________ Tanzania Contraceptive Security Assessment 62 • Is there a waiver for the poor? Do these mechanisms work? • Is there access to affordable, quality FP services for clients who are able and willing to pay for them (beyond public sector sites)? For NGO’s/FBO’s • Is there a cost recovery program? What is the fee structure? • Is there a waiver for the poor? • What are prices/fees for family planning services/methods? Service or product (include brand name) Cost/unit • What is the intended market? • Is there a demand for family planning services, products (ATP, WTP)? Is it increasing/decreasing? CAPACITY/INFRASTRUCTURE • Please describe your training (in counseling, logistics, technical skills – i.e., IUD/implant insertion/removal)? • Has there been any follow-up training provided to maintain skills and knowledge? • What is the number and position of current staff trained in ILS (Integrated Logistics System) and/or Logistics management? • Have you received supervision in the past 6 months? By who and what activities were performed? • Is there a dispensing protocol? Please describe: Tanzania Contraceptive Security Assessment 63 • Is there dispense to user data/daily register? Yes No (Complete chart) • Is there a prescribing protocol? Please describe: • What instruments/Equipment (i.e. blood pressure cuffs)/supplies for LAPMs (complete table at end) REPORTING AND INFORMATION • Please describe reporting of information (i.e. routine reports, flow, frequency) • Does your facility communicate with District/Region personnel at least quarterly? • Does the facility report logistics data? Yes No • To whom and how often (check and obtain copy of form): POLICIES • Are there any policies restricting FP services or limiting access to clients? • Do you provide any outreach services (i.e. community based distributors Probe about how they report back to the center)? • Are there any limitations in provision of family planning by specific cadres of staff? INVENTORY CONTROL • How are adjustments to inventory made for shortages and overages as a result of stock reconciliation? • Is the current stock level adequate to meet demand for essential drugs at this facility? • Are there guidelines for maximum and minimum stock levels at this facility? • Are there certain commodities that you always stock out of before re-supply? (if yes, list top three products) • Is there any system for re-distributing stock? Tanzania Contraceptive Security Assessment 64 STORAGE • Where are contraceptives stored? • Comment (space adequate, conditions): • What do you do with damaged/expired products? ORDERING • Who orders contraceptives? ____________ How often are orders placed? (ask to see the form) • How do they decide how much to order? • Who supplies? (list all suppliers) • What is length of time between placement of orders and receipt of orders? • What do you do for emergencies (stockouts)? How many times in the past 3 months? Why did you need it? How long does it take to receive them? TRANSPORT • Do they deliver or does the facility collect the supplies? _________________________How often does this occur? • Does the facility have adequate transport? • Are there any funds to take alternative transport if needed (i.e. dala dala’s)? Tanzania Contraceptive Security Assessment 65 Stock Status (add method and brands as needed) Method Brand Unit SOH (physical count- balance) SOH (card) Updated Physical count and SOH match Expiration (if yes, # of units) AMC (see last 3 months SOH cards) Stockout today? (Y/N) # of and duration of stockouts (past 6 months) 1 2 3 4 5 6 7 8 9 Combination Pill LoFemenal cycle Microgynon cycle Progestin only Pill Microval cycle Injectable Depo- Provera vial Implants Norplant Implanon IUD Copper T Male condom Female Tanzania Contraceptive Security Assessment 66 condom Client Numbers (check facility records if available) Method # of clients Dec 06 Jan 07 Feb 07 Pills Injections IUD Implant Condoms Female sterilization Male sterilization Other LAPM Equipment Checklist Do you have the following LAPM equipment and instruments IUD insertion/removal EQUIPMENT Light source sufficient to visualize cervix (gooseneck lamp/angle poise or flashlight will suffice) Standard operating Instruments Curved 8.5” Forceps Tenaculum or Vulselum 10” Forceps Alligator Jaw 8” Forceps Sponge 9.5” Straight Forceps Curved Scissors 8.5” 12.5” Uterine Sound Vaginal Speculum Graves (Medium) Vaginal Speculum Graves (Large) Instruments for Norplant, Jadelle and Implanon insertion/removal Standard operating instruments Syringes, 10 ml (for local anesthesia) Needles, Hypodermic, 22 Gauge x 1- 1/2” (for local anesthesia) Handle, Surgical Knife, Size #3 (for Jadelle and Norplant) 24 Blade, Surgical, Size #11 (for Jadelle and Norplant) Curved Forceps, 5-1/2” (for removal of all brands) Forceps, Mosquito, Straight, 5” (for removal of all brands) Forceps, Mosquito, Delicate, Curved, 5” (for removal of all brands) 5 Trocars (for Norplant and Jadelle) Instruments for minilaparatomy for female sterilization (only items in addition to basic laparoscopic surgical instruments) Standard operating instruments Baby Babcock intestinal forceps, 7.5” Surgical handle #3 graduated in cm Surgical Blade #11 Specialized instruments Ramathobodi uterine elevator, 28 cm in length Ramathobodi tubal hook Instruments for no-scalpel vasectomy for male sterilization Standard operating instruments Ringed Clamp Dissecting Forceps 68 ANNEX C: FOCUS GROUP DISCUSSION TOOL DRAFT Tanzania SPARHCS Assessment CLIENT Focus Group Discussion Tool Date: Location: Requirements: - translator - prearranged group of clients A. Service access and utilization: 1. Where did you purchase/access your last contraceptive? (if intercept is NOT at a site) If it is, ask ‘is public sector the main source of supply?’ WHY? Facility Reason(s) Dispensary Pharmacy Kiosk Friend Duka la dawa Other 2. Is there nearby access to affordable, quality private or voluntary FP services/supplies? 3. How much time does it take to reach this location? 69 4. Would you prefer to purchase/access your contraceptive at another location? a. If no, why? b. If yes, why and where? Facility Reason Dispensary Pharmacy (name) Kiosk Public health facility Friend Duka la dawa Other 5. Have you ever sought a FP method and were turned away or referred to other facilities because basic services or products (as expected according to norms and standards) are not available at their preferred source? 6. In the last 3 visits, have you been able to purchase/access the contraceptive(s) you wanted? If not, what was the reason? a. Cost (too expensive) b. Out of stock? How often has this occurred? c. The right staff was not available (to provide injection, insert IUD, dispense pills, provide counseling) 7. What are the main reasons for unmet need (e.g., fear of side effects, perceived spousal objections, religious reasons, lack of access, etc.)? 8. During your last visit, were you satisfied with the providers’ service to you? If not completely satisfied what as the reason(s)? 70 B. Contraceptive Preference: 9. What is your method of preference? 10. Why do you prefer to use this method? 11. What was the type of method you last purchased/received? 12. If different, why did you not use the method you prefer? 13. How did you learn about the contraceptive you purchased/received? 14. Have you ever discontinued a family planning method? What are the reasons for discontinuing use of contraceptives (e.g., lack of satisfaction, side effects, spousal objections, lack of physical access to a facility or other resupply source, lack of product, financial constraints, did not get preferred method)? C. Willingness to Pay/Ability to Pay: 15. How much are you paying for services and supplies, and what are you charged for? 16. Would you be willing to pay (more) for your contraceptives if: a. The facility location was closer? b. The wait was shorter? c. The staff was more responsive? d. Would you be able to pay a higher price? 17. For the last contraceptive you purchased did you feel it was too expensive or just right? 18. Can you estimate how much of your household income is spent on contraceptives each month? 71 ANNEX D: CONTRACEPTIVE SECURITY WORKSHOP AGENDA AND PARTICIPANT LIST AGENDA CONTRACEPTIVE SECURITY COMMITTEE MEETING 29-30 MARCH 2007 Millennium Hotel, Bagamoyo, Tanzania Contraceptive security: Contraceptive security exists when every person is able to choose, obtain, and use quality contraceptives whenever s/he needs them. Purpose of contraceptive security workshop: This workshop will convene key contraceptive security stakeholders to focus on programmatic and strategic areas, looking at medium to long term aspects of contraceptive security. At the meeting, participants will use findings from a recent contraceptive security assessment as well as existing documentation and policies to identify strengths and opportunities as the basis for generating recommendations to improve the contraceptive security situation in country. Expected outcome: - Understand the concept of contraceptive security, as well as the current situation in Tanzania - Clarify roles in promoting and achieving contraceptive security in Tanzania - Strengthen coordination of respective strategies to foster contraceptive security - Develop key recommendations that address barriers and optimize opportunities to ensure contraceptive security - Commit to ongoing monitoring of progress through bi-monthly Contraceptive Security Committee meetings Thursday, 29 March, 2007 Time Topic Presenter/Facilitator 9:00 – 9:30 am Opening Remarks Dr. Zakaria Berege, Acting Chief Medical Officer, MOHSW Charles Llewellyn, Population and Health Officer, USAID/Tanzania 9:30 – 10:00 am Review Meeting Objectives Review Schedule Introductions Kevin Pilz, AAAS Policy and Science Fellow, USAID 10:00 – 10:15 am Tea Break 10:15 – 11:00 am Context • FP Policy • RAPID • DHS • SPARHCS Framework Leslie Patykewich, DELIVER Project 11:00am – 12:30 SPARHCS Methodology and Findings Leslie Patykewich, DELIVER Project 72 pm • Commitment/Policy • Capital/funding • Capacity - supply chain and service delivery • Coordination • Client utilization and demand Erin Mielke, ENGENDERHealth Project Marie Tien, DELIVER Project 12:30 – 1:30 pm Lunch 1:30 – 2:00 pm Discussion, Questions & Answers 2:00 – 2:30 pm Support of contraceptive security: Ongoing interventions and strategies Dr. Cosmas Swai, Program Officer, Reproductive and Child Health Section, MOHSW Dr. Chilanga Asmani, National Programme Officer, UNFPA Dr. Theopista John, National IMCI Programme Officer, WHO 2:30– 3:10 pm Considerations - financing - client access - coverage - method mix - source - increase capacity - last mile 3:10 – 3:45 pm Discussion, Questions & Answers 3:45 – 5:00 pm (working tea break) Group work*: • Prioritize issues • Illustrative group work areas: - Comparative advantage of a total market approach - Mobilizing resources - Capacity - Satisfying unmet need Friday, 30 March, 2007 Time Topic Presenter/Facilitator 9:00 – 9:30 am Reconvene and review 9:30-10:30 Presentation of Group work 10:30-10:45 Tea 10:45-12:00 Discussion, Q & A 12:00-1:00 Lunch 1:00 – 3:00 Collectively agree on recommendations and identify any overarching needs Identify next steps: - Contraceptive Security Committee 73 - Commitment 3:00 Closing remarks Michael Mushi, Project Management Specialist (Health), USAID Participant List NO. NAME ORGANIZATION EMAIL ADDRESS Phone number 1. Leslie Patykewish JSI/W leslie_patykewich@jsi.com 2. Marie Tien JSI/W mtien@jsi.com 3. Erin Mielke EngenderHealth/N YC Emielke@engenderhealth.org 4. Kevin Pilz AID/W kpilz@usaid.gov 5. Charles Llewellyn USAID/TZ cllewellyn@usaid.gov +255 754-333 315 6. Raz Stevenson USAID/TZ rstevenson@usaid.gov +255 754-788 102 7. Sithara Batcha USAID/TZ Sbatcha@usaid.gov +255 754-782 220 8. Mike Mushi USAID/TZ mmushi@usaid.gov +255 754-565 546 9. Tim Rosche JSI/DELIVER/TZ trosche@jsi.co.tz +255 713-387 438 10. Johnnie Amenyah JSI/SCMS/TZ jamenyah@jsi.co.tz +255 787-192 527 11. Dr. Chilanga Asmani UNFPA asmani@unfpa.org +255 754-781 124 12. Majige Selemani MPEE majige@yahoo.com +255 754-525 846 13. Dr. Cosmas W. Swai RCHS / MoHSW cwswai@excite.com +255 754-371 473 14. Hoka P. Mbundi Marie Stopes TZ hpanya@mst.or.tz +255 754-511 663 15. Walter M. Mbunda UMATI wmbunda@umati.or.tz +255 754-784 618 16. Mary Mshana NACP / MoHSW mwankuu1@yahoo.com +255 787-236 868 17. Chapmans Marro TBS cmarro2002@yahoo.co.uk +255 754-691 246 18. Mary Ringo MSD mringo@msd.or.tz +255 754-375 333 19. Dr. Alex A. Ngaiza PSI angaiza@psi.or.tz +255 754-269 923 20. Prisca Rwezahura T-MARC prwezahura@tmarc.or.tz +255 784-264753 21. Dr. Nsiima Mshumba Marie Stopes TZ drmushumba@mst.or.tz +255 784 260 543 22. Johnbosco Basomingera Marie Stopes TZ jbosco@mst.or.tz +255 787 744 433 23. Goodlameck Mero MSD gmero@msd.or.tz +255 754-264 125 24. J. M. Kanjenje MoF kachenjej@yahoo.co.uk +255 754-460 459 25. Anita Masenge PSU / MoHSW anitasillo@yahoo.co.uk +255 784-868 644 26. Neema Voniatis RCHS / MoHSW nvoniatis4@hotmail.com +255 754-309 332 27. Dr. Kanama J. R. EngenderHealth/TZ jkanama@engenderhealth.org +255 784-350 222 28. Dr. Faustine Njau Department of Policy and Planning / MoHSW faustinenjau@hotmail.com +255 784-787 118 For more information, please visit www.deliver.jsi.com. USAID | DELIVER PROJECT John Snow, Inc. 1616 Fort Myer Drive, 11th Floor Arlington, VA 22209 USA Phone: 703-528-7474 Fax: 703-528-7480 Email: deliver_project@jsi.com Internet: deliver.jsi.com Rationale Methodology Assessment Activities and Products Assessment Team 1.1 Key Family Planning Partners The following describes the key partners involved in trying to improve the family planning and reproductive health situation in Tanzania. MOHSW Medical Stores Department (MSD) Pharmaceuticals and Supplies Unit (PSU) Ministry of Regional Administration and Local Government TFDA UNFPA USAID Social Marketing Organizations Non-Governmental Organizations 1.2 POLICIES AND REGULATIONS Tanzania Development Vision 2025 Millennium Development Goals (MDG) Poverty Reduction Strategic Paper National Health Policy Guidelines for Preparing Medium Term Plan and Budget Framework for 2005/6-2008/9 Tanzania Joint Annual Health Sector Review National Population Policy National Reproductive and Child Health Strategy 2.1 PUBLIC SECTOR 2.2 DEVELOPMENT PARTNERS 2.3 HOUSEHOLD FUNDING 2.4 FORECASTED REQUIREMENTS Source: 2007 CPT Exercise 2.5 LONGER TERM FUNDING 3.1 HUMAN INFRASTRUCTURE 3.1.1 SERVICE PROVIDER STAFFING LEVELS AND PATTERNS 3.1.2 SERVICE PROVIDER TECHNICAL CAPACITY 3.2 SUPPLY CHAIN MANAGEMENT Forecasting Procurement LMIS 4.1 METHODS Oral Contraceptives Implants Injectable Contraceptives Intra-Uterine Devices (IUDs) Condoms ANNEX A: IN-COUNTRY CONTACTS ANNEX B: SITE ASSESSMENT TOOL SERVICE/ACCESS CAPACITY/INFRASTRUCTURE REPORTING AND INFORMATION POLICIES INVENTORY CONTROL STORAGE ORDERING TRANSPORT Instruments for minilaparatomy for female sterilization (only items in addition to basic laparoscopic surgical instruments) Standard operating instruments Instruments for no-scalpel vasectomy for male sterilization ANNEX C: FOCUS GROUP DISCUSSION TOOL ANNEX D: CONTRACEPTIVE SECURITY WORKSHOP AGENDA AND PARTICIPANT LIST

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