Ten Good Practices in Essential Supplies for Family Planning and Maternal Health (2012)

Publication date: 2012

Ten Good Practices in Essential Supplies for Family Planning and Maternal Health Global ProGramme to enhance reProductive health commodity Security UNFPA: Delivering a world where every pregnancy is wanted, every birth is safe, and every young person’s potential is fulfilled. RHCS: Reproductive health commodity security is achieved when all individuals can obtain and use affordable, quality reproductive health supplies of their choice whenever they need them. Cover: Members of the Bandé Magaria School for Husbands. Credit: UNFPA Niger. 1ten Good Practices in essential Supplies for Family Planning and maternal health Contents PReFACe 2 ReACHING UNDeRSeRVeD COMMUNITIeS 5 1. Opening doors to family planning in remote, ethnic households of Lao PDR 5 2. Engaging men in reproductive health with The School for Husbands (Ecole des Maris) in Niger 7 3. Bancada Feminina: A space to address family planning and empowerment in Mozambique 11 4. Bajenu Gox ‘godmothers’ offer reproductive health information to younger women in Senegal 13 5. Multimedia campaign raises awareness and creates demand among vast audiences in Burkina Faso 15 STReNGTHeNING SUPPLY MANAGeMeNT 17 6. A strong system for RH supplies yields results in Madagascar 17 7. Two examples of institutionalizing RHCS in universities 21 A. In Mongolia’s pharmacy school, managing RH supplies is part of the curriculum 21 B. Institutionalizing RH supplies training in Ethiopia’s Addis Ababa University 22 8. Two ways to improve accountability and access in Sierra Leone 24 A. Monitors from civil society organization track family planning supplies 24 B. Community Wellness Advocacy Groups support distribution of RH supplies 26 MOBILIZING POLITICAL WILL AND FINANCIAL ReSOURCeS 27 9. Evidence-based advocacy wins support for family planning at the highest levels in Ecuador 27 10. Advocacy strategy for political and financial commitment to RHCS in Nicaragua 29 UNITeD NATIONS HIGH LeVeL MeeTING ON RHCS 31 - Report to the UNFPA Executive Board 31 - Call to Action 34 Global ProGramme to enhance reProductive health commodity Security2 The worldwide trend toward smaller families – average family size has declined by half since 1950 – is linked to advances in education and health care and increased opportunities for women. This great global success story can continue only if access to family planning continues to grow worldwide. UNFPA is intensifying strategic support to voluntary family planning through its Global Programme to Enhance Reproductive Health Commodity Security (GPRHCS). Countries participating in the programme are now reporting their own success stories backed by measureable results. The GPRHCS targets persistent challenges in reproductive health: unmet need for family planning, preventable maternal death and HIV/AIDS. It is thematic fund that catalyzes national action. • Some 222 million women in the developing world want family planning but cannot get it. This unmet need for contraception results in 82 per cent of all unintended pregnancies. • Becoming a mother can be dangerous and life- threatening. More than 287,000 women die every year from pregnancy-related causes, most of them preventable. Ninety-nine per cent of all maternal deaths occur in the developing world. The aim is reproductive health commodity security (RHCS), which is achieved when all individuals can obtain and use affordable, quality reproductive health supplies of their choice whenever they need them. RHCS has a pivotal and strategic role in accelerating progress towards the ICPD Programme of Action and the Millennium Development Goals, especially MDG5 to reduce maternal mortality. PReFACe In prenatal consultations in Guinea, pregnant women are offered a choice of family planning methods to consider postpartum. Credit: Mariama Sire Kaba/UNFPA Guinea. 3ten Good Practices in essential Supplies for Family Planning and maternal health How it works UNFPA launched the GPRHCS in 2007 to provide a structure for moving beyond ad hoc responses to stock-outs towards more predictable, planned and sustainable country-driven approaches for securing essential supplies and ensuring their use. It offers a framework for assisting countries in planning for their own needs. At the request of governments, UNFPA provides sustained multi-year support as well as more targeted and emergency support through the GPRHCS, working to: • Integrate RHCS in national policies, plans and programmes through advocacy with policy makers, parliamentarians and partners in government; • Strengthen delivery systems to ensure reliable supply, logistics information and management; • Procure contraceptives and other essential reproductive health supplies and promote their use through various mechanisms such as community- based distribution; and • Provide training to build skills at every step from forecasting needs to providing quality information and services in family planning, maternal health and the prevention of STIs, including HIV. Activities supported by the GPRHCS are carried out in collaboration with UNFPA’s invaluable partners, including the governments of participating countries, donors, other UN agencies, non-governmental organizations and civil society groups. Many activities are carried out with the close cooperation of UNFPA’s Country Offices, Maternal Health Thematic Fund and HIV/AIDS Branch. A track-record of results Since its launch in 2007, the GPRHCS has been highly effective in achieving its primary initial goal of mainstreaming RHCS both within UNFPA and, even more importantly, at the national level – particularly in those countries that have received its most committed and systematic support. The principal strength of the GPRHCS is that it empowers governments and national stakeholders to decide how to use these complementary funds according to national priorities and the particular areas where action is required in order for RHCS to be achieved, based on knowledge and evidence. For this reason, the profile of support provided by the GPRHCS varies considerably from country to country. The programme provides (and builds awareness of and support for) an overall, integrated vision of RHCS. It allows countries to allocate funds according to what is considered most important, complementing other work in related spheres of sexual and reproductive health, regardless of funding source (e.g. health SWAP, regular government resources, UNFPA country programme). For UNFPA, the GPRHCS is the main channel for providing technical and financial assistance for family planning. UNFPA also facilitates third-party procurement of essential reproductive health supplies. This publication shares numerous examples of activities in countries participating in the GPRHCS as of 2011. Examples are included from Burkina Faso, Ecuador, Ethiopia, Lao PDR, Madagascar, Mongolia, Mozambique, Nicaragua, Niger, Senegal and Sierra Leone. Many are Stream 1 countries in the GPRHCS, receiving sustained, multi-year support. A dynamic Call to Action issued at the first United Nations High Level Meeting on Reproductive Health Commodity Security concludes this publication, pointing to the way forward for this transformative work. In Lao PDR, a woman from the Lenten ethnic group obtains contraceptives at the village pharmacy. Credit: Vincent Gautier/UNFPA. 5ten Good Practices in essential Supplies for Family Planning and maternal health Access to reproductive health commodities is a priority not only for relatively easier-to-reach people in cities but also for those in more difficult-to-reach rural areas, for those who are less educated, young, disabled or displaced and for those who cannot afford to pay. In the 12 focus countries of the GPRHCS, up to 90 percent of the populations live in rural areas that are difficult to reach. ReACHING UNDeRSeRVeD COMMUNITIeS Trained agents visit every household once a month to provide counseling and services, including to adolescents and young people, married or unmarried. They speak the same ethnic language, belong to the same community, and share the same social norms. Community-based distribution agents In Lao People’s Democratic Republic (Lao PDR), specially trained ‘community-based distribution agents’ are the reason why more hard-to-reach women are using modern methods of contraception and why local family planning services are providing better care and serving more clients. This culturally-appropriate approach is urgently needed in light of high unmet need for family planning in poor, remote, mountainous areas. In Lao PDR, 80 per cent of the population lives in rural areas, mostly dispersed in small villages that are often difficult to access. Indigenous ethnic communities comprise 40 per cent of the population, with 49 ethnic groups from four ethno-linguistic families, each with its distinct culture, attitudes, and widely-differing livelihood systems. These communities have limited knowledge about family planning, and access to reproductive health services is almost non-existent. Despite steady economic growth, the population’s health status remains low and maternal mortality remain high. Many more couples want to use modern methods of contraception but lack access to reproductive health services and supplies. Growing with intensified support In June 2006, an initiative was launched to provide culturally-appropriate and client-friendly family planning services in remote communities, working through community-based distribution agents. The initiative was implemented by the Ministry of Health’s Mother and Child Health Center with support from UNFPA. In 2008, Lao PDR became a Stream 1 country in the GPRHCS, receiving multi-year support from UNFPA for the government’s efforts to ensure access to a reliable supply of contraceptives, medicine and equipment for family planning, HIV/STI prevention and maternal health services. Villages in three poor southern provinces of Attapeu, Saravan and Sekong – located in districts targeted by the government for intensified development efforts – were selected for priority interventions by district maternal and child health managers. The populations of these provinces have high percentages Opening doors to family planning in remote, ethnic households of Lao PDR1 Global ProGramme to enhance reProductive health commodity Security6 of ethnic groups in which many women do not speak the national language (Lao) and have little contact with other villages. Long distances and poor road conditions also make it difficult for villagers to access health facilities. How the approach works Using a bottom-up capacity development approach, selected villagers received training and minimal financial incentives to serve as community-based family planning service providers, delivering outreach family planning services (provisioning of condoms, oral contraceptives and injectables) free of charge. These community-based distribution (CBD) agents belong to the communities, speak the same language, and share social norms. Sexual and reproductive health (SRH) matters remain sensitive and may be considered shameful to discuss in public. The family planning providers are tasked with a set of duties: • Visit every household in their catchment village(s), discuss with and provide family planning information and services to the couple and to other family members at the client’s residence; • Provide family planning information and services to both adolescents and young people and married couples without discrimination; • Visit every household once a month to provide counselling and services to all people with reproductive health needs, including non-married people; • Submit a report that feeds into the contraceptive logistics management information system. A monitoring system is built into the initiative. CBD agents report to the district maternal and child health manager every month. They report on client numbers, obtain advice and secure a resupply of contraceptives. The agents’ reports are also communicated to the provincial and central levels. Different levels of managers provide periodic on-site supervision visits that also provide on-the-job training in the catchment villages, depending on local needs. This community-based distribution model of family planning outreach service has demonstrated positive results and is now adapted for scaling up by the Ministry of Health and development partners as a model for community-based distribution within Integrated Maternal, Newborn and Child Health (MNCH) package. In this approach, the role of the CBD agents would be expanded by adding MNCH services to the agents’ current package of services. In the UNFPA supported programme to Lao PDR 2012- 2015, this CBD initiative will be further scaled up to other geographic areas that are hard to reach. Progress and key results When client-friendly and free-of-charge family planning services are provided to communities that cannot afford to access such services, remote and ethnic populations become more receptive to using them. When community agents are involved in implementing and monitoring of services, in-built accountability systems are developed. Overall, the family planning uptake in CBD catchment areas has gone up from 12 per cent in 2007 to 45.42 per cent in 2011. Contraceptive prevalence rate has increased sharply in many of these remote areas. It reached 60 per cent in March 2012 from a baseline of 13.2 per cent in 2006 in the Ah Gnor catchment area, Taoi District, Saravan Province. Developing the capacity of community service providers to deliver culturally appropriate services has demonstrated positive results. In some districts, the level or extent of family planning services provided by special family planning providers now exceeds that of district A community-based distribution agent shares family planning information. Credit: UNFPA Lao PDR. 7ten Good Practices in essential Supplies for Family Planning and maternal health 2 Men can be powerful allies to improve women’s access to reproductive health services. The Government of Niger in collaboration with UNFPA has developed the School for Husbands initiative (École des Maris) to involve men in the promotion of reproductive health and promote behavioral change towards gender equality. A commitment to better health Men’s dominance and attitudes are major obstacles to women taking advantage of reproductive health care in Niger, according to a 2007 survey conducted with support from UNFPA. The School for Husbands, launched that same year, aims to change this, transforming men into allies for women’s reproductive health and family planning. In Niger, 74 per cent of women are illiterate and about 60 per cent of girls are married before the age of 15. Violence against women is widespread. The use of family planning is low, with a contraceptive prevalence rate of only 5 per cent, and the rate of maternal death is high. Niger joined UNFPA’s Global Programme to Enhance Reproductive Health Commodity Security in 2008. The government quickly demonstrated an increased level of political and financial commitment and country ownership, using the national budget line to procure reproductive health commodities, and in the first year more than $1 million was raised from in- country partners for reproductive health commodities procured by UNFPA. The Adventures of Foula In October 2008, a strategic partnership was formed with Animas-Sutura, an NGO, to carry out an information, education and communication (IEC) campaign with peer training centred around a series of radio sketches called ‘The Adventures of Foula’. The campaign is directed towards marginalized and underserved populations including the military and rural communities. With UNFPA funding, the radio show coverage rose to hundreds of villages and neighbourhoods, with thousands of broadcasts on community radio, and with discussion sessions reaching tens of thousands of women and men. Initially under the leadership of the former First Lady, it has continued and expanded in subsequent years. This campaign set the stage for an initiative focused on men. The School for Husbands The School for Husbands initiative is based on a project started in the Zinder region in 2007. It is hospitals. In Kaluem District, Sekong Province, 557 family planning clients received contraceptives from CBD agents in February 2012. In contrast, only 324 clients had used services at district hospitals and health centers the previous year in February 2011. Communities are increasingly receptive to using family planning services, due in part to the process of developing capacity locally and using a participatory approach that respects local culture and values. This helps to ensure the sustainability of efforts, as does the built-in monitoring system that supports accountability for progress. engaging men in reproductive health with The School for Husbands (École des Maris) in Niger Family planning is discussed with family members in their home. Credit: UNFPA Lao PDR. Global ProGramme to enhance reProductive health commodity Security8 a place of discussion, decision making and action. There is a spirit of volunteerism and community involvement, with the emergence of husbands as responsible actors in their own development. All members are equal; the school is structured but not hierarchical, which reinforces a united group spirit. The principles of active listening and mutual respect are essential. In order to ensure this equality within the group, during each meeting a different member is identified to gather information (such as the RH indicators from the local health centre) and facilitate the discussion, which reinforces the principle that all members are leaders. The aim is to prepare the men to serve as role models for their communities and thereby to bring about change. The concept of the initiative was defined with the Ministry of Health in 2008. A participatory stakeholder workshop gathered all involved parties, including regional administrative and health authorities, health agents, national NGOs and married men from local communities. This participatory approach ensured alignment with the local cultural and religious values, and continues to be used during implementation. Initially, 11 ‘pilot schools’ were set up in two districts in the Zinder region. In 2010, the strategy was expanded to all six districts of this region, and as of 2011, a total of 131 schools are operational in Zinder. In another region, Maradi, 46 schools were established in 2011. How the schools work The target group is married men, 25 years or older who, as unpaid volunteers, participate in sensitization on the importance of reproductive health services. Most schools have 8 to 12 members, with no more than five schools per health centre. Selection criteria, determined by husbands, are adaptable but often A midwife offers counselling on family planning to a couple at the national reproductive health centre in Niamey, Niger. Credit: Tagaza Djibo/UNFPA. 9ten Good Practices in essential Supplies for Family Planning and maternal health are as follows: to be married, to allow your wife (or wives) to use reproductive health services, to be at minimum 25 years old, to volunteer (unpaid), to accept participation by your wife (or wives) in local associations, to be available for your school, to possess moral values, to advocate harmony in your family, to support your family. A school meets two times per month to discuss and analyze specific challenges related to RH in the community, and to propose solutions. For example, a school may notice a decrease in prenatal consultations and decide to conduct sensitization by identifying the pregnant women in the village, and then visiting their husbands to discuss any obstacles to obtaining services. To provide support, two local non-governmental organizations supervise each school. One NGO is specialized in capacity building and community work and is in charge of the ‘coach’ – a leader responsible for 10 to 12 schools. The coach monitors the capacities of each school, assists in implementing activities, and assists in bi-monthly meetings. The coach helps the group to resolve problems and find appropriate solutions. The coach also assists the group in developing an action plan and monitoring its progress. To facilitate this work, UNFPA Niger and its partners have developed a monitoring journal (cahier de suivi). The second NGO brings technical reinforcement by providing counseling and information on RH services such as prenatal care or contraceptive methods, to ensure the husbands’ access to knowledge. In addition to the coach, a ‘moderator’ assists the school. This person may be a local health agent, midwife or religious leader. There is close collaboration with the local health agents and structures such as the administrative and traditional authorities, which ensures the strategy’s sustainability. Members of the regional health structures, local health agents and coaches receive a four-day training in the strategy of the School for Husbands. The husbands also receive a training which is based on four modules: leadership; group dynamics; coaching techniques; and communication techniques, advocacy and negotiation. A key challenge in this strategy is how to ensure a continuous motivation of the husbands. Responses include the exchange of good practices and efforts to motivate the members to continuously improve their results. Not all schools can be expected to work well and UNFPA Niger has closed down around 10 schools that did not show enough motivation. Another challenge is to ensure transfer to the next generation. A mechanism is being developed to integrate young men in a sort of preparation phase to their adult life, where the members work with these groups to sensitize them on reproductive health issues. elements of success The coherence of the School for Husbands with socio- cultural and religious values ensures appropriation of the strategy. Also, the fact that members contribute actively and have a role to play in the development of their community keeps them motivated for the voluntary work. Monitoring visits shows an outside interest in the husbands’ results and provide opportunities for the men to demonstrate their work. An integrated approach ensures good synergy amongst actors and structures involved, e.g. NGOs, health centers, religious and traditional leaders. The School for Husbands is based on a participatory approach so it can be easily adapted to the values Guest speakers like this midwife answer reproductive health questions raised by men in a School for Husbands. Credit: UNFPA Niger. Global ProGramme to enhance reProductive health commodity Security10 and needs of a community and replicated in many other settings. The strategy has had a positive impact on reproductive health, but can easily be adapted or expanded to other thematic areas depending on the priorities of each context. UNFPA Niger is planning to integrate thematic areas such as forced marriage and prevention of malnutrition, reinforcing and continuing the development of the husbands’ capacities and knowledge. The School for Husbands has been implemented by the Gender and Human rights component in Niger, but with the amelioration of RH as a main objective, which has ensured a less ‘medical’ approach with a stronger focus on behavioral change and enhanced linkages in programming. Results are documented Results obtained in three years are impressive. “Since the establishment of the Schools for Husbands, visits to the integrated health centre and the utilization of contraceptive methods have increased,” Yahya Louché, the head of the Bandé district observed. He noted that other community mobilization activities, including the use of community radio, as well as improved supplies of reproductive health commodities, are also having an impact. A woman from the village added her point of view: “Formerly, we were afraid of the maternity in the same way that one is afraid of death. But now we go there with enthusiasm.” In this village, use of family planning services has tripled. The number of childbirths attended by skilled health personnel has doubled. The rate of antenatal visits rose from 28.62 per cent in 2006 to 87.30 per cent in 2010, according to the figures from the Bandé Integrated Health Centre. Significant results have been documented: (1) behavioral change among men, from conservative attitudes to involvement and commitment of men in favor of reproductive health with better dialogue, listening and understanding of health issues observed since the husbands have joined the School for Husbands; (2) improvements in reproductive health indicators, e.g. the RH indicator on post-natal consultations in the Bandé community in Zinder increased from 13 per cent in the first trimester of 2009 to 40 per cent in 2011; (3) results beyond initial objectives including construction of public lavatories for health centres, construction of houses for midwifes to allow better RH services, and participation of members in sensitization during vaccination campaigns and other health activities. The involvement of men in the promotion of RH is a decisive positive factor of behavioral change, based on access to accurate information on RH, contraceptives, prenatal care, etc. The personal involvement of each husband allows a better understanding and helps put an end to certain taboos and misconceptions. The greatest success of the School for Husbands initiative may be its inspiration to other countries. After seeing a UNFPA presentation on the project at the Conference on Population, Development and Family Planning in Francophone West Africa, several countries, including Burkina Faso and Guinea, expressed their desire to replicate the programme as a way to build demand for family planning services. The effort was also praised by other countries participating in the first United Nations High Level Meeting on Reproductive Health Commodity Security.Members of the Bandé Magaria School for Husbands. Credit: UNFPA Niger. 11ten Good Practices in essential Supplies for Family Planning and maternal health 3 Bancada Feminina: A space to address family planning and empowerment in Mozambique empowering women and girls is the aim of the ‘Bancada Feminina’ (Women’s Caucus or Female Stand) in Mozambique. For two hours each week, women and girls between the ages of 12 and 35 meet at several locations in Maputo to discuss personal and pressing issues related to sexual and reproductive health. Meetings for girls and women This initiative was launched in 2008 and has now emerged to become a popular event among the target audience. Between 20-70 participants take part in this meeting forum each time it takes place, at locations including Associação Moçambicana para Desenvolvimento da Família (AMODEFA), community centres, schools, and the office of the Gabinete de Atendimento a Mulher e a Criança Vitima de Violencia, which receives victims of violence. Participants come from a broad range of socio- economic and educational backgrounds. Some live in the city and some in communities on the outskirts of the Maputo. At every meeting forum the group decides the issues to be discussed, which often include issues related to partners, use of contraceptives, abortion, gender equality, small- scale business opportunities, decisions related to reproductive health, and violence against women. Young female coordinators from AMODEFA facilitate the meeting forums. They have been trained in human rights, sexual reproductive health and other social areas related to women. Sometimes special guests are invited to take part in the discussion, serving as role models. One of the main challenges is related to the continuity of the intervention as the women and girls, sometimes due to other obligations, miss various meetings; the consistency of the impact decreases as a result. Another challenge is the reluctance of some participants to share their problems or issues in the group discussion, which may be attributed to shyness A young woman learns about reproductive health at a youth-friendly health centre run by AMODEFA in Mozambique. Credit: Amancio Miguel/UNFPA. Global ProGramme to enhance reProductive health commodity Security12 and passivity. Some participants face challenges in moving forward to apply the new knowledge, ideas and strength in their daily life. The age difference between girls of 12 years and women of 35 years has been an obstacle for some younger girls, who do not feel comfortable and confident enough to share their problems with the group. Making a positive impact Young women themselves report improvements in their level of decision making with respect to their sexual reproductive health, rights and self-esteem. Another positive result is the involvement of the men in the forums. Media coverage, notably by national television, has mobilized more women to attend. Traditionally, it is taboo to discuss sexual and reproductive health with adolescents in Mozambique. Lack of employment and educational opportunities, and the social and cultural environment, contribute in many cases to an early sexual activity among young people – often unprotected – which put them at risk of several illnesses related to sexual and reproductive health. Many girls and young women become pregnant, drop out of school and suffer severe social stigma for dishonoring their families. Among girls, 17.7 per cent are married before the age of 15 and 51.5 per cent are married before the age of 18 (MICS, 2008). Girls and young women are four times more likely to be infected by HIV than boys and young men. The maternal mortality ratio is 500 maternal deaths per 100,000 live births, with deaths among young women 15-24 years old accounting for 36.8 per cent of maternal deaths (Census, 2007). While the government has made positive strides in addressing the sexual and reproductive health rights and needs of young people, progress have been more visible at the policy level than in service delivery and increased demand. It is especially important to create a comfortable space for dialogue and exchange of views and experiences with young people, especially young women. Due to the interest generated by this successful UNFPA initiative to help inform girls and women in Mozambique of their sexual and reproductive health and rights, local organizations are set to replicate the ‘Bancada Feminina’ approach. The concept is gaining exposure through advocacy and is being replicated by several local NGOs and integrated into the efforts of AMODEFA partners. Showing high-level support, Mozambique’s First Lady celebrates the launch of a family planning campaign. Credit: Amancio Miguel/UNFPA. 13ten Good Practices in essential Supplies for Family Planning and maternal health 4 The community approach to promoting maternal health has been strongly developed in Senegal, particularly through the Bajenu Gox, women community leaders with special training who promote good maternal and newborn health practices in each village. Striving to achieve the MDGs Of the 12.3 million inhabitants of Senegal, 58 per cent live in rural areas, which explains in part why only 52 per cent of births take place in a health-care facility. The shortage of qualified healthcare staff such as midwives, obstetricians, anesthetists and pediatricians, particularly in rural areas, is a persistent problem. The high total fertility rate of 4.9 is another factor that contributes to the high maternal mortality ratio of 410 deaths per 100,000 live births. Senegal is making progress towards MDGs 4 and 5, but still too slowly. Contraception use is low with only 10 per cent of married women using modern methods in 2005, reflecting low demand, inadequate supply and shortfalls in stock. The unevenness of access to emergency obstetric and neonatal care and of the availability of midwives remains a challenge, with high levels of inequality that disadvantage rural inhabitants, young people and the poor. There are some 200 severe obstetric complications every day. Family planning is key national action The first strategic guideline in the National Healthcare Development Plan 2009-2018 is to “accelerate combating maternal, newborn and infant-juvenile mortality and morbidity”. According to the State of the World’s Midwifery 2011, the package of specific actions is comprehensive: re-launching family planning; adequate antenatal care coverage of high quality in all districts; systematic tracking of HIV in pregnant women; extension of assistance to childbirth with increased use of partograms, Caesarean Section and availability of blood; essential care for newborns; adequate post-natal care coverage; appropriate care Bajenu Gox ‘godmothers’ offer reproductive health information to younger women in Senegal Women recognized as leaders in their communities attend training on reproductive health issues and become ‘Bajenu Gox’ to support younger women. Credit: UNFPA Senegal. Global ProGramme to enhance reProductive health commodity Security14 for low birth weights; and ARV prophylaxis among sero-positive women. The strong political will to promote maternal health has been transformed into concrete activities such as the cost-free policy, which has made access available to the most disadvantaged. Delegation of tasks to State midwives has made possible increased access to emergency obstetric and neonatal care and family planning, and decentralization of health-care skills to regions and local communities. The university and two faculties of medicine offer opportunities to train more personnel, develop skills and strengthen the supervision of training. Launching the Bajenu Gox strategy In 2009, the President of the Republic called for the establishment of an innovative strategy called Community Initiative Bajenu Gox. It is based on traditional values around the involvement of the paternal aunt in monitoring a pregnant woman and the mother-child pair, a tradition of solidarity where the older women assist the younger women with health care. This aunt is represented in the strategy by women community leaders who serve as godmothers of women in their neighborhood or village during pregnancy, childbirth and postpartum. UNFPA provided technical and financial support to formulate the Bajenu Gox strategy and to train the first 56 women in the district of Kolda – all recognized as leaders in their communities. With continued UNFPA support through the Global Programme to Enhance Reproductive Health Commodity Security, more than 1,200 women in three regions have received training to become Bajenu Gox. UNFPA support has encompassed a range of activities: • supporting the programme’s formulation and test, including the definition of criteria for selecting and training women leaders for the first Bajenu Gox training; • mobilizing community stakeholders including NGOs and women’s associations; • documenting of the process of implementation in three regions of Kolda, St. Louis and Matam; • increasing the supply of RH information services (in particular family planning) through advocacy, securing contraceptive supplies, producing equipment, and training of health personnel with a focus on long-acting methods of modern contraception; • improving acceptance of the programme, in particular among men, by focusing on the choice of women leaders in each community at the start of implementation; • building capacity of the Bajenu Gox (1,236 trained in the three regions at the time of the study) on reproductive health including family planning, to enhance the dissemination of messages and minimize misconceptions; • mobilizing additional technical and financial partners; and • mobilizing political commitment at all levels to a community initiative based on social values. Thus far, some of the challenges include compliance with selection criteria to identify women community leaders, responding to the increasing demand for reproductive health services, and coordination among partners.   Seeking results in reproductive health The strategy aims to accelerate the achievement of MDGs 4 and 5. It seeks to promote an increase in the use of reproductive health information and services, including family planning. It also aims to increase the involvement of local and private sector partners, and contribute to strengthening the health system by providing qualified personnel through a suitable technical platform. The acceptance and success of this innovative approach can be attributed in part to the selection process. Women recognized as leaders in their communities are selected by their peers. These leaders then receive training in topics rarely discussed in the open yet at the heart of women’s health. 15ten Good Practices in essential Supplies for Family Planning and maternal health 5 With advocacy to raise awareness and create demand, Burkina Faso is setting the stage for progress in reproductive health, including family planning. Community theatre, TV and radio all play a part. Intensified support for RH supplies Burkina Faso was among the first ‘proof of concept’ countries in the UNFPA Global Programme to Enhance Reproductive Health Commodity Security (GPRHCS). Launched in 2007, this intensified support to family planning and maternal health programming swiftly showed results. The Government of Burkina Faso and UNFPA are committed to a programme to ensure access to a reliable supply of contraceptives, medicine and equipment for family planning, HIV/STI prevention and maternal health services. Such action is critical in a country with a high rate of maternal death, high fertility rate and rapid population growth. Of the 15.8 million people in Burkina Faso, 46 per cent are under the age of 14, with adolescents facing a high risk of childbearing. The fertility rate is 6.0 children per woman, and the annual population growth rate of 3.1 per cent overwhelms economic growth. Launching a public outreach campaign An extensive public outreach campaign using film, radio and theatre has reached an estimated audience of 60 per cent of the population with family planning messages. Launched in 2008, the multi-media campaign promotes reproductive health information and services in all regions, especially rural areas, with films aired at community meetings, national radio broadcasts, and television coverage and community theatre. Promotional materials were widely distributed, including posters, leaflets, image boxes and calendars. Burkina Faso’s multi-media campaign has continued to reach hundreds of thousands of women, men and young people. In the four years of GRPHCS support from 2008 through 2011, there have been many creative uses of theatre and mass media. Burkina Variétés programming for radio and TV broadcast was produced in local languages, directly reaching people in villages with family planning messages presented as entertainment, with films aired at 2,300 community meetings in 2008 alone. The Forum Theater performed hundreds of theatre presentations in rural villages, helping to reach approximately 125,000 people, including those who may not have access to mass media. TV and radio spots were broadcast nationally on TNB network, on private TV channels, and on the national and rural radio stations. The Press Caravan covered four regions of the country, reaching administrative, traditional and religious authorities and the general population with messages on reproductive health through reporters from TV, radio and newspapers who participated in the caravan. This programme also provided community leaders with an opportunity to directly address the public and highlight the good news that, overall, indicators of family planning were improving. Multimedia campaign raises awareness and creates demand among vast audiences in Burkina Faso Performances like this provide family planning information. Credit: UNFPA Burkina Faso. Global ProGramme to enhance reProductive health commodity Security16 Media and meetings make an impact In addition to creative media outreach, advocacy meetings on family planning were facilitated by the Association of Religious and Traditional Leaders of Burkina Faso. In a similar vein, the Burkina Faso Muslim Population and Development Organization network implemented advocacy activities to gain the attention of preachers, imams and Muslim women. This broad media and meeting programme made information on family planning available to a wide variety of diverse social groups, reinforcing their awareness of sexual and reproductive health and reproductive rights. The focus on delivery of family planning services – both supply and demand – contributed to significant improvements in family planning indicators, with a consistent positive trend. The number of new contraceptive methods users increased to 121,766 in the second quarter of 2011 – this is a 26.5 per cent increase in the value of this indicator from second quarter of 2010. Injections and pills remain the most popular contraceptive methods. The momentum initiated by the multimedia campaign has continued to grow, building political commitment and sustainable financing for reproductive health supplies. In 2011, Burkina Faso mobilized 500 million francs CFA (about $1 million US dollars) to purchase contraceptives, up from 300 million francs CFA (about $600,000 US dollars) in 2010. Political engagement in the area of family planning continued to be substantial, and family planning remained a priority in the national population policy. A national consensus workshop featuring a new RHCS strategic plan was chaired by the Minister of Health in March 2011, bringing together central and regional directorates, technical and financial partners, civil society organization partners and the media. Developing capacity for RHCS The media campaign plays a catalytic role in the country’s progress, which is moving forward on several fronts: Important capacity development activities include training of staff at more than 200 service delivery points in forecasting and procurement, and training of district health practitioners in every region on the use of computerized logistics management information system to avoid supply stock-outs. CHANNEL software entered the final stages of rollout across all of Burkina Faso’s health regions and districts and regional and national hospitals in 2010. The country has a national strategic plan for RHCS included in its national strategic plan for sexual and reproductive health. Burkina Faso also has included RHCS in its Poverty Reduction Strategy Paper (PRSP) and integrated RHCS within its overall health sector programme. In Burkina Faso, the challenge is to sustain and accelerate progress made. Country-driven efforts in demand creation and advocacy are working. Now health systems must be strengthened to meet the growing demand for all reproductive health information and services. High levels of unmet need must be effectively reduced. Community theatre in Burkina Faso. Credit: UNFPA Burkina Faso. 17ten Good Practices in essential Supplies for Family Planning and maternal health STReNGTHeNING SUPPLY MANAGeMeNT Reproductive health is a priority in Madagascar, where the government is using CHANNeL software for control, transparency and follow-up in the management of health supplies. Use of modern contraception tripled Madagascar is a striking success story of how to improve family planning and reproductive health despite facing severe difficulties including a high rate of poverty, largely rural population, transportation problems due to poor infrastructure, and a recent political crisis. The use of modern contraception tripled over a ten-year period from 9.7 per cent in 1997 to 29.2 per cent in 2008-09, surpassing the government’s goal and closing in on the target of 36 per cent by 2012. This increase of 11 percentage points stands in contrast to the country’s relatively stagnant rates during the years leading up to targeted UNFPA support through the Global Programme to Enhance Reproductive Health Commodity Security. Another positive trend is the reduction in unmet need for family planning, which has decreased from 24 per cent in 2004 to 19 per cent in 2009 and 2010, with about 40 per cent of demand yet to be satisfied, according to national Ministry of Health data. Madagascar has received sustained, multi-year funding as a priority Stream 1 country in the GPRHCS since 2007. The programme provides support to procure reproductive health commodities and to develop capacity to strengthen the health system. Because Madagascar is also a first-wave country of the Maternal Health Thematic Fund, the support provided is closely integrated. A strong system for RH supplies yields results in Madagascar6 Improving the way a country’s health system manages RH supplies is often a complex and gradual process with an emphasis on developing national capacity, mechanisms and procedures. Stakeholders in a county first agree on which logistics management information system (LMIS) to adopt, promote and roll out. Then begins work in forecasting, procurement, storage and distribution, identification of sources, training to develop service provider’s skills – followed by monitoring and evaluation to measure results. Minister of Health Johanita Ndahimananjara described progress in reproductive health commodity security at a GPRHCS meeting in April 2012. Credit: UNFPA. Global ProGramme to enhance reProductive health commodity Security18 Reproductive health supplies are stacked high in a warehouse of Guatemala’s national supply management system. Credit: Sabrina Morales/UNFPA Guatemala 19ten Good Practices in essential Supplies for Family Planning and maternal health Access, choice and reliability The GPRHCS monitoring framework has captured some impressive results: • Access to appropriate methods is improving: The percentage of service delivery points (SDPs) offering at least three modern contraceptive methods improved in Madagascar from 30.8 per cent 2009 to 47.8 per cent in 2010 to 97.2 per cent in 2011; • More shelves are reliably stocked: Clinics and other service delivery points reported ‘no stock-out’ of contraceptives at 63.3 per cent in 2008, 74.4 per cent in 2009, 79.6 per cent in 2010 and 90.8 per cent of SDPs in 2011; • Choice of method is better assured: The percentage of SDPs offering at least three modern methods of contraception increased from 30.8 per cent in 2009 to 47.8 per cent in 2010 to 77.5 per cent in 2011. More specifically, the availability of three modern methods has improved between 2010 to 2011 from 50 per cent to 97.3 per cent at primary- level SDPs, from 50.6 per cent to 94.9 per cent in secondary-level SDPs, and from 61.8 per cent to 85.7 per cent at tertiary level SDPs; and • Key medicines are available: All the tertiary-level SDPs (100 per cent) in Madagascar have the five life-saving medicines for maternal and reproductive health available. Behind this progress is a computerized logistics management information system (LMIS). Computerized system for health supplies First, Madagascar conducted an analysis of its LMIS, seeking integration. Analysis showed there was a centralized procurement system, political will for the integration of commodities, a manual for quantification of commodities needs, a committee for logistics that met regularly, and a logistical system decentralized to regions and health districts. There was also technical and financial support from UNFPA. However, several parallel systems of information and logistics existed for vertical health systems, the social and political crisis ended some financial support, and the ability to stock warehouse pharmacies at the central and district level was limited. Another challenge was the use by the pharmacies of illegal and parallel sources for supplies. Madagascar moved decisively to introduce computerized health supplies management, developing a programme of action for the integration of health commodities for the period 2008-2012. Steps were also taken to reinforce capacity for procurement of material and human resources. Decentralization of the national budget for the purchasing of medicines in regions and districts was another action. Given limited access to the Internet and frequent power outages, it was decided that data from the service delivery points would be obtained quarterly from district purchase orders and sent to the central level on CD ROM to be stored and analyzed. Soon, CHANNEL software was adopted for management of commodities in all 22 regions and 100 districts nationwide. The government adopted CHANNEL as part of its Integrated Action Plan for Health (PAIS), an important step for strengthening the country’s health logistics system. In 2009, CHANNEL was installed in pilot districts by the Ministry of Health with support from UNFPA, including distribution of 109 computers to the districts for using CHANNEL. Training in commodity logistics built capacity at several levels, with 33 RHCS focal points to serve as trainers at central and regional levels, and 299 RHCS focal points at district level. Districts quickly saw results, with fewer stock-outs, especially for contraceptives. Madagascar finalized its national RHCS strategy in 2009, included RHCS in the Madagascar Action Plan and other plans and, for the first time, included RH commodities on the national drug list. In 2010, another 56 RHCS focal points participated in LMIS training. Training also enhanced the skills of more than 100 health service providers who received instruction in new contraceptive technologies, notably Global ProGramme to enhance reProductive health commodity Security20 long-lasting implants; 86 health centres have since added this service to expand choice of method. The country also took steps to improve the procurement and distribution of condoms. In May 2010, it was confirmed that the National AIDS Programme, a department within the new ministerial structure, would become responsible for managing condoms and UNFPA would provide assistance to improve comprehensive condom programming. After major investment in its logistic management information system over the previous two years, by the end of 2010 Madagascar had a functional LMIS capable of providing inventory and monthly consumption data. By 2012, 70 per cent of reproductive health commodities in Madagascar were integrated into the SALAMA system, and CHANNEL had become the exclusive software program for reproductive health commodities management. Addressing a meeting of GPRHCS Stream 1 countries, the Minister of Health reported striking results: • integration of health commodities for over 60 per cent of vertical programmes; • strengthening of capacity for the central procurement of materials, transport, computers and human resources; • an increase in available medicine and therefore a decrease in stock-outs; and • improvement in the quality of medicines distributed, due to better stock management in the central warehouse. Commitment to a secure supply of contraceptives The county overcame resistance to change in its supply management system by involving all parties and sharing information about the benefits of an integrated approach. A wide range of stakeholders and partners in Madagascar identified the improved logistics system as a key factor of its success. They have found that user-friendly software such as CHANNEL can help to improve the management of commodities, and their use in national programmes is feasible, acceptable and effective. Sensitizing district managers helps to ensure the use of the data. In a demonstration of commitment, the government’s allocation to the national budget line for contraceptives increased by 32 per cent from 2008 to 2009. However, as a result of the lingering social and political crisis, the reproductive health commodity needs of the country could not be mobilized by the government in 2011. Presently, UNFPA is the only partner supporting the Ministry of Health in purchasing RH commodities, which is not enough to cover all needs. Without this support, however, the contraceptive prevalence rate would most certainly A van delivering essential supplies encounters challenging transportation conditions. Credit: UNFPA Madagascar. These motorbikes are used to deliver reproductive health supplies. Credit: UNFPA Madagascar 21ten Good Practices in essential Supplies for Family Planning and maternal health have fallen in recent years, negatively affecting the health of women and children. Government commitment and supportive policies play critical roles in meeting national health goals, with family planning and reproductive health clearly included in poverty reduction plans. Experts in Madagascar say this is the foundation for successfully meeting the goal of increased use of modern methods of contraception for an increased CPR. Many players were involved and supported the government’s efforts, from international and local NGOs to donors, including UNFPA and USAID. These groups worked together, taking advantage of each organization’s comparative advantage, to achieve national goals. The strategic selection and support of partners is another important factor for success, in particular in supporting action for hard- to-reach and underserved populations, so those most in need can access reproductive health supplies and contraceptives. The political crisis that has rocked the country since 2009 has considerably weakened Madagascar’s economic performance and health system. Health centres have closed, transport of reproductive health commodities to districts and health facilities has been affected by restricted budgets, and organizational and staff changes are reducing overall effectiveness. NGOs are helping to maintain positive momentum and address the demand created by the last several years of successful programming by contributing positively to family planning through outreach strategies and community-based distribution. The challenge now is how to sustain success in the face of economic downturn. The population of Madagascar, estimated at 18 million, is likely to double within 25 years. With 85 per cent of the population living below the poverty line in this island country off the southeastern coast of Africa, voluntary family planning is an important strategy for poverty reduction and for achieving the Millennium Development Goals. 7 Two examples of institutionalizing RHCS in universities A. In Mongolia’s pharmacy school, managing RH supplies is part of the curriculum Hundreds of pharmacists graduate each year in Mongolia with special training in family planning services and supplies. In addition to quality of care, they learn how to manage a computerized supply chain for a steady flow of essential supplies from warehouses to the couples who need them. Training leads to RHCS curriculum Training in reproductive health commodity security is now part of the School of Pharmacy’s curriculum at the Health Sciences University of Mongolia (HSUM). Previously, a lack of knowledge and skills among pharmacists and supply chain managers contributed to shortfalls in essential supplies. To address the lack of specialized training in health supply management, the government and UNFPA started by training 12 health professionals in 2008 and quickly expanded to 150 in 2009, 222 in 2010 and 367 in 2011. The country is equipping pharmacists with training, knowledge and tools in response to rising demand for family planning, and to ensure a safe and secure system for reproductive health supplies. Training continues to play a central role in the effort to achieve RHCS. UNFPA support for the process The Government of Mongolia, in collaboration with the UNFPA Asia Pacific Regional Office (APRO), created a plan to incorporate RHCS trainings into the ongoing curriculum of the School of Pharmacy Global ProGramme to enhance reProductive health commodity Security22 of the Health Sciences University of Mongolia. A Memorandum of Understanding was signed by the Ministry of Health of Mongolia, UNFPA and HSUM whereby the UNFPA Regional Office agreed to provide technical support for the development of curriculum and to build the capacity of the School of Pharmacy’s faculty. To further South-South cooperation and knowledge exchange, UNFPA supported the participation of teachers of the School of Pharmacy in an international training programme on RHCS conducted by BKKBN (Indonesia), in regional- and local-level workshops, and for a study tour to learn from the experience of Ethiopia’s Addis Ababa University. This approach to enhancing long-term sustainability and national ownership has been the cornerstone of support provided by UNFPA through its Global Programme to Enhance Reproductive Health Commodity Security. In 2011, APRO provided technical assistance to develop in-service RHCS curriculum and reviewed the proposed training materials developed jointly by the School of Pharmacy and the UNFPA Country Office. Training-of-trainers helped to strengthen both the transfer of knowledge and the systems themselves. Three types of training modules were developed for different audiences: (1) service providers at the grass root levels, (2) provincial reproductive health programme managers and warehouse specialists, and (3) policy makers. APRO provided support for developing and improving the facilitation skills of the faculty, and ensured that the trainings were practical and skills-based. Feedback and advice from APRO field testing showed that shifting the pedagogical methods of university professors from a top-down formal approach to a more interactive approach between students yielded more effective learning. After the modules were developed and reviewed, training programmes for in-service staff were initiated in 2011. The first trainings for pre-service students rolled out during the academic session in 2012. As a lasting result of these efforts, all new pharmacists and supply chain professionals in the country who graduate after 2015 will have received training and skills in various aspects of reproductive health commodity security during their university years. Results, even in remote areas Even in remote rural areas, access to contraceptives and the availability of a choice of methods has improved since the focus on training began several years ago. The percentage of service delivery points offering at least three modern methods of contraceptives increased from 93.5 per cent in 2010 to 98.2 per cent in 2011. Those offering five life-saving maternal and reproductive health medicines increased from 76.8 per cent in 2010 to 86.8 per cent in 2011. The percentage of service delivery points offering at least three modern methods of contraceptives increased from 93.5 per cent in 2010 to 98.2 per cent in 2011, and those offering five life-saving maternal and reproductive health medicines increased from 76.8 per cent in 2010 to 86.8 per cent in 2011. B. Institutionalizing RH supplies training in ethiopia’s Addis Ababa University A curriculum on reproductive health commodity security evolved over time, from orientation and training, to an ongoing collaboration with the Public Health School and School of Pharmacy. Courses lead to collaboration A presentation by UNFPA to faculty members at Ethiopia’s Addis Ababa University sparked an ongoing collaboration between the UNFPA Country UNFPA supported a workshop to finalize the pharmacist training curriculum on RHCS and family planning. Credit: UNFPA Mongolia. 23ten Good Practices in essential Supplies for Family Planning and maternal health Office and the School of Public Health. At this event, several years ago, participants discussed reproductive health commodity security and its challenges in developing countries. Leaders in the School of Public Health became interested in contributing to capacity building through training on RHCS that would start in Ethiopia initially and then expand throughout the region. The School of Public Health and UNFPA soon organized several orientation courses on RHCS for students undertaking diploma courses in public health. Based on their success, faculty decided to develop a curriculum on RHCS that the School would use as a component of its longer diploma courses as well as short courses. Faculty from the School of Public Health and School of Pharmacy drafted the curriculum. The RHCS curriculum The RHCS curriculum starts with a comprehensive background discussion about RHCS issues, discusses the impact of national policy on commodity security, introduces technical aspects of RHCS, and explains the tools used in assessing RH commodity security. Other important topics include logistics management information systems and advocacy for RHCS. Building on this effort, the School of Pharmacy is preparing to develop its capacity to provide training on RHCS. The Training of Trainers Course held in December 2011 was the latest event in this success story about building institutional capacity and developing knowledge and skills among students who will play key roles in reproductive health services, including the management of supplies. This particular training near Addis Ababa gathered 24 participants including the Dean of the Faculty and faculty members of Addis Ababa University School of Public Health, as well as participants from the university’s School of Pharmacy. Also attending were representatives from the Ministry of Health, DKT (a social marketing organization), JSI/ Ethiopia and the UNFPA Country Office. expanding access and method choice Additional stories are available on the UNFPA website about the Government of Ethiopia’s comprehensive plan to make implants – an effective, long-acting and reversible contraceptive – widely available throughout the country to women who want to delay pregnancy. Read more at these links: http://www.unfpa.org/public/home/news/pid/8418 http://www.unfpa.org/public/home/news/pid/4675 Participants in a training-of-trainers workshop to develop capacity in the national logistics management information system visit a warehouse. Credit: UNFPA Ethiopia. Global ProGramme to enhance reProductive health commodity Security24 8 Two ways to improve accountability and access in Sierra Leone Sierra Leone has introduced new approaches to manage drugs and medical supplies, including contraceptives. The country has adopted a computerized system and deployed monitors and community wellness advocates to see that essential supplies reach people who need them. A. Monitors from civil society organization track family planning supplies Members of a civil society organization (CSO) are monitoring health commodities in Sierra Leone, reducing theft and enhancing accountability. An independent monitoring system More than 50 per cent of drugs and medical supplies meant for public health facilities went unaccounted for in Sierra Leone, both before and after the end of the 1991-2002 civil war. The Health For All Coalition, a CSO in Sierra Leone, is making a difference for their country, with support from UNFPA. They are an integral part of an independent monitoring and evaluation system. A close monitoring strategy – from the quay and airport to the central medical store, district medical stores and peripheral health units – is showing results: Theft of drugs has been reduced, availability of drugs at the facility level has increased, and access to health services and drugs has improved. The government introduced the civil society component to enhance its newly computerized system to track and manage essential supplies, and to support its Free Health Care Initiative for pregnant women and children under five. It also made a first-ever budget allocation to reproductive health commodities, including for family planning, in 2011. At the same time, Community Action Groups are working to increase demand and ensure that the strengthened supply chain reaches a growing community of receptive women and families. Addressing specific challenges Until 2011, Sierra Leone had no budget for reproductive health commodities, despite the high maternal mortality ratio of 857 maternal deaths per 100,000 live births. The drugs supply chain management system faced many challenges: • poor accounting and transparency systems; • poor record keeping, management and reporting for drugs; • general lack of stewardship of the drugs and supplies; • ineffective drugs distribution system; • stock-out of essential Family Planning and RH life- saving drugs and supplies; • theft of drugs meant for public health facilities being recycled to private pharmacies, sold in the street or smuggled to neighbouring countries. The government and development partners saw the need to strengthen the drug supply chain The drug supply in Port Loko District is monitored by staff of a civil society organization. Credit: UNFPA Sierra Leone. 25ten Good Practices in essential Supplies for Family Planning and maternal health management system through oversight and performance monitoring. This would address problems in the health system and help to achieve the successful implementation of the Free Health Care initiative. The CSO approach is working A key role was awarded to a civil society organization (CSO) active in ‘voice’, accountability and advocacy in the health sector. The Health For All Coalition- Sierra Leone (HFAC-SL) was contracted to undertake monitoring of health commodities and supplies, advocate for a sustainable drugs supply management system, and advocate for the inclusion of funds for RH commodities in the national health budget. UNFPA supports the Health For All Coalition in working towards the establishment of a robust, independent monitoring and evaluation system that will monitor health commodities at all levels and ensure that sustainable mechanisms are in place for the procurement and supply of reproductive health commodities. The approach is working. It is effective in improving accountability and transparency in the management and use of health commodities in Sierra Leone. The Health For All Coalition has encouraged health personnel to change their attitudes and be more responsible in the management and use of public goods. This partnership between the Coalition and UNFPA is yielding demonstrable results: • Leakages of drugs and supplies have been reduced. For example, HFAC drug monitors discovered a total of 450 cartons of excess drugs worth $85,000 and returned them to the central medical store. Also, 24 CCTV cameras have been installed in the Central Medical store; • Accountability in the management and use of drugs has increased, with the percentage of drugs accounted for increasing from 50 per cent prior to 2010 to 93 per cent in 2011; • Incidences of interception of stolen drugs have decreased by 25 per cent from 2010 to 2011; • More women and children under five are accessing free health care: In 2011, deliveries in health facilities increased by 45 per cent; uptake of family planning methods increased by 140 per cent; and children under five accessing health care increased by 214 per cent; • Sierra Leone made a budget allocation for RH commodities for the first time in 2011, of approximately $165,000 for the year. Another sign of progress is the recognition of the Coalition as performing a legitimate and formal monitoring function. This was highlighted by the signing of Memorandum of Understanding (MOU) with development partners such as DFID, UNICEF and the Anti-Corruption Commission (ACC). Improving implementation Challenges to implementation have been effectively addressed. When health care providers rejected HFAC drug monitors as policing rather than complementing their work, HFAC met with key officials in the Ministry of Health and set up a sensitization tour in all 14 districts across the country. At district level HFAC met with all in-charges and store managers to raise awareness on roles and responsibilities. When HFAC reported evidence of misuse and no action followed, HFAC engaged directly with the Minister of Health and other high-level officials and partners including the Anti-Corruption Commission. HFAC now reports directly into the Health Sector Coordinating Committee, and presents reports to the President of Sierra Leone in the presence of senior government officials and the United Nations, donor community, NGOs and civil society. When funding and logistics hindered HFAC monitors at district level, a full review was conducted and discussed with donors. UNFPA equipped HFAC with two monitoring vehicles, 14 motorbikes, four digital cameras, one photocopier and a printer. When HFAC found it difficult to obtain information and documents, a drug distribution matrix was created with the Ministry of Health, UNFPA, DFID and UNICEF featuring every stakeholder in the drug distribution Global ProGramme to enhance reProductive health commodity Security26 process. Strategic response to obstacles is a key to success. UNFPA and civil society networks are also working together to advocate for the inclusion of family planning as a flagship project under the government’s 2013–2017 Poverty Reduction Strategy Paper (PRSP), known as the Agenda for Prosperity. To promote this aim, the Health For All Coalition organized a high- level stakeholder advocacy meeting in June 2012, as the first in a series of meetings. The Ministry of Health and various stakeholders, including Parliamentarians and the inter-religious council, reaffirmed their commitments to advocate for family planning’s inclusion in the Agenda for Prosperity. B. Community Wellness Advocacy Groups support distribution of RH supplies Community Wellness Advocacy Groups (CAGs) are another one of the strategies employed to help overcome the challenges to effective RH commodity distribution in Sierra Leone. Agents of social change Community Wellness Advocacy Groups are central to a community empowerment programme that is led by the Ministry of Social Welfare, Gender and Children’s Affairs (MSWGCA) in cooperation with the Ministry of Health and Sanitation. CAGs now operate in 120 chiefdoms in 9 of the 13 districts in Sierra Leone. Members of CAGs are referred to as Community Wellness Advocates. They are often powerful and respected women such as traditional birth attendants and female FGM/C initiators (Soweis). These women become agents of social change to empower communities, given additional training in a range of sexual and reproductive health and gender issues. This role provides a critical referral link between the communities and different service providers. The advocates may, for example, refer community members to appropriate facilities offering family planning services and essential supplies, fistula screening and treatment, resources related to sexual violence, free legal services, or skilled care during childbirth. Community Wellness Advocates use song, dance and drama in marketplaces, road shows and other venues. They also participate in local meetings and move door-to-door offering accurate information and dispelling the widespread myths and misconceptions about reproductive health, including family planning. Collaborative, rights-based approach The approach is integrated and human-rights based, which enhances the collaboration of partners in sharing technical expertise and comparative advantages. Statistics Sierra Leone, the main body responsible for statistical activities in Sierra Leone, supports all implementing partners in the generation of data through the DHS and census. Technical and logistical support is provided by government offices, NGOs, and CBOs with UNFPA and others – including further training in reproductive health, literacy classes, monitoring and support in report writing. Traditional authorities such as tribal heads and chiefs and religious leaders support the CAGs by setting up community bylaws and rules related to sexual and reproductive health, especially maternal health. In Sierra Leone, members of a Community Wellness Advocacy Group rehearse a theatre sketch. Credit: UNFPA Sierra Leone. 27ten Good Practices in essential Supplies for Family Planning and maternal health High-level support for the national family planning strategy in ecuador includes a personal commitment by the President of the Republic, along with government support of $8 million for the strategy plus $7 million to procure modern contraceptives through UNFPA. Developing a national strategy Evidence-based advocacy has mobilized high-level support for the Inter-sectoral Family Planning National Strategy (ENIPLA) in Ecuador, including a personal commitment by the President of the Republic and government support of $8 million, plus $7 million to procure modern contraceptives through UNFPA in 2011. The country also centralized the procurement of reproductive health commodities for a more efficient system. These results were achieved in the process of building understanding and technical capacity among government health staff at the national and regional level, supported by catalytic funding from UNFPA of $700,000 total over several years. The country has the second-highest rates of fertility in adolescents in the Andean sub-region and population dynamics differ dramatically among population groups. Early on, findings of a survey showed the urgent need to address adolescent pregnancy and to provide modern family planning services to indigenous people and other underserved populations. Rights-based approach The process was grounded in the national Constitution, which recognizes the right of each person to decide how many children to have and when to have them. It was ‘synergy’ – the combination of many efforts – that won such high-level support, and a combination of advocacy, political dialogue, institutional capacity-building through training, and efforts to facilitate access to quality reproductive health commodities. It is a success story in mobilizing political and financial commitment. Ecuador’s comprehensive, human rights perspective has allowed UNFPA to support government and civil society initiatives in advocacy, spokesperson preparation, improvement of reproductive health services and strengthening of informed demand. To systematize this experience, a consultancy firm was evidence-based advocacy wins support for family planning at the highest levels in ecuador9 MOBILIZING POLITICAL WILL AND FINANCIAL ReSOURCeS Reproductive health commodity security is a powerful platform for reducing unmet need and achieving reproductive rights, but it is largely dependent on donors at the present time. Many countries have taken action to mobilize political will and financial resources for RHCS. Vigorous and committed support at the highest national levels is an important factor in achieving sustainable results. Global ProGramme to enhance reProductive health commodity Security28 hired which, in addition to offering expertise in these issues, has a history of participation in the struggle for sexual and reproductive rights. The most evident result of UNFPA’s work has been the consolidation of the Inter-sectoral Family Planning National Strategy. The strategy promotes sexual and reproductive rights, including the right of all people to access and use methods of family planning. It is informed by gender, culture and human rights. This strategy has become a flagship project for the State and receives an annual investment of approximately $8 million for its implementation, which guaranties its sustainability. In addition, the government mobilized $7 million in resources for the procurement of modern contraceptives through UNFPA. About the process For many years, UNFPA has taken a comprehensive approach that includes advocacy, institutional strengthening through training, the establishment of strategic alliances, and the support of social participation. Elements of success include a role for UNFPA in constructing legal frameworks that guarantee rights to sexual and reproductive health, the capacity and commitment of trained personnel, free access to the methods of family planning, sexuality education and strong alliances with women’s and youth movements. The historic process of advancements in the legal and regulatory framework of sexual and reproductive rights in Ecuador can be seen in a series of legal advancements from the 1995 Law Against Violence Against Women through the 2011 Statute on Intercultural Education. At the same time important National Development Plans, RH Norms and Regulations, including family planning, have been developed. The National Constitution, in effect since 2008, recognizes among its articles the right of each person to decide how many children to have and when. The Inter-sectoral Family Planning National Strategy and the Adolescent Pregnancy Prevention Plan were developed in 2009 and 2010, respectively. UNFPA has supported the process since its inception, through gathering evidence regarding trends in fertility and maternal mortality, trends in adolescent pregnancies, and cost studies of the provision of Free Maternity and Children Services. This evidence was used for the development of ENIPLA and for the advocacy work with the Presidency. Currently, UNFPA is supporting the process of implementing the national strategy through cooperation with the social sector ministries. A strong sense of national ownership and motivation for implementation and continuation of the ENIPLA was developed through the process of training and the exchange of information and experience. National- level entities engaged in sexual and reproductive health have been strengthened with the participation of civil society, NGOs and youth groups. In the future, it will be important to sustain progress through an ongoing process of training, experience exchange, information and two-way communication. The Inter-sectoral Family Planning National Strategy promotes the exercise of and guarantees sexual and reproductive rights, including the right of all people to access and use methods of family planning. The strategic objectives are to promote comprehensive sexuality education; strengthen sexual and Young women in Ecuador. Credit: UNFPA Ecuador. 29ten Good Practices in essential Supplies for Family Planning and maternal health reproductive health services, including family planning; and transform socio-cultural patterns regarding sexuality and family planning through communication strategies. The strategy’s comprehensive view links access to family planning to all action focus points, going beyond health issues. Support from UNFPA Within the framework of the Global Programme to Enhance Reproductive Health Commodity Security, UNFPA supports ENIPLA through strategic lines: • Advocacy and political dialogue with national and local authorities is supported through the preparation of spokespeople in civil society and government institutions, evidence gathering, preparation of argumentation guides, and development of communication strategies; • Strengthening of national capacities is supported through updating and training of health personnel in family planning regulations and follow-up standards, design of the RH Excellence Centre for training and re-certification, and improving the family planning logistical and managerial system; • Strengthening of strategic alliances is supported at the national level with social sector ministries, academia, scientific federations, NGOs, women’s and youth organizations and at the regional level through partnerships with the International Gyno- Obstetric Federation FIGO/FESGO and PRISMA (a regional NGO), among others; • Technical assistance, coordination and monitoring is supported through technical assistance to the Ministry of Health to coordinate and implement the RHCS annual work plan, which includes the consolidated procurement of modern contraceptives and other RH commodities with government funds. One of the most important foreseeable challenges is the need to sustain the strategy as a State policy, moving beyond current political contexts, and taking into account that the access to contraceptive methods is not always an easy subject for governments. The current legal frameworks that uphold the sexual and reproductive rights of the population will continue to play a central role in achieving future progress. Advocacy strategy for political and financial commitment to RHCS in Nicaragua10 Institutionalizing RH indicators in three spheres of commitment – a RHCS committee, sector-wide cooperation agreement, and the Common Basket Fund – fosters a positive environment for increased RH commodities access in Nicaragua. Fostering a positive environment A steadily increasing trend of access to modern contraceptive methods, with a corresponding decreasing trend of unmet need in family planning, has resulted in important positive changes in key RH indicators in Nicaragua over the last decade. Nicaragua’s population growth rate declined from 3.5 per cent in the period 1971-1995 to 1.7 per cent in the period 1995-2005. Maternal death and adolescent fertility have also declined. The acceleration of the demographic transition in Nicaragua is marked by changes in the growth and age structure of the population, and by a reduction in the dependency ratio, reflecting a rapid decline in fertility from 4.9 children per woman in 1995 to 2.9 in 2005. Reproductive health care coverage has been enhanced in this time period. In particular, family planning has improved with community distribution of reproductive health commodities, and maternal health has improved with increased skilled birth attendance. Use of modern family planning is increasing, while unmet need for family planning is decreasing. Before 2006, Global ProGramme to enhance reProductive health commodity Security30 all modern contraceptives were donated but there is now national funding. Making these achievements sustainable requires adequate and well-targeted investment flow as well as public policies formulated to foster conditions for local development and enhance human capital. Advocacy strategy UNFPA and other partners with support from the GPRHCS have developed an advocacy strategy aimed at enhancing government commitment towards RHCS. The strategy consisted in generating awareness of the importance of RHCS and its implication for MDG 5 in three spheres. First, an RHCS Committee was developed in 2005 and integrated by the Ministry of Health (MOH), UNFPA, DELIVER-USAID, the Institute of Social Security, and NGOs working in contraceptives distribution. The Committee provides technical assistance to the MOH for the forecasting, procurement and distribution of contraceptives. Second, the Nicaraguan Government and social development partners, joined by UNFPA in 2007, signed an agreed-upon Code of Conduct ensuring future cooperation in sector-wide development of a five year health plan. With the support of the GPRHCS, the UNFPA Country Office was able to advocate for the inclusion of RHCS indicators in the current 2011-2015 Multiannual Health Plan. In the Plan, 3 of 11 outcome indicators and 15 of 62 output indicators relate to reproductive health. Adolescents and youth have been recognized in the plan as priority group, in particular for the prevention of adolescent pregnancy. Third, a Joint Financing Arrangement (JFA) Memorandum of Understanding was signed between the government and development partners, defining a set of health priorities as well as tools, calendars and mechanisms for technical and financial planning, monitoring and evaluation. The FONSALUD Committee represents only a small number of development partners (Luxembourg, Finland, The Netherlands, Austria, Spain and UNFPA) but is significant in terms of the volume of resources dedicated to the health sector, and therefore to the importance government gives to this committee. With support of the GPRHCS, UNFPA, as the unique agency channeling funds through this Common Basket Fund, participates as an active member of this health sector committee for decision-making, planning and monitoring. Commitment to RHCS As a result of the government’s sustained commitments to increasing access to modern contraception, the allocation of funds for the procurement of contraceptives rose from 10.5 per cent in 2007 to 36.9 per cent in 2008. This commitment dropped to 11.9 per cent in 2009 as the financial commitment from the government was affected due to an economic crisis and a phase out of cooperation by some donors. Despite the fiscal restraints of economic downturn, the institutionalization of reproductive health indicators in these three spheres of commitment – RHCS committee, sector-wide cooperation agreement, and the Common Basket Fund – continues to foster a positive environment for increased access to reproductive health commodities in Nicaragua. Training in computerized supply logistics management has improved skills for this group and many others. Credit: UNFPA Nicaragua. 31ten Good Practices in essential Supplies for Family Planning and maternal health The report to the UNFPA Executive Board was drafted and reviewed in consultation with the workshop participants at the end of Day One and early on Day Two. A representative of the group was selected to deliver the report. During the formal lunch with the UNFPA Executive Board, the following statement was delivered by Her Excellency Zainab Hawa Bangura, Minister of Health and Sanitation, Sierra Leone: Your Excellencies, First Ladies, Colleague Ministers and Honourable Members of Parliament Distinguished Ladies and Gentlemen, Good Afternoon I have been requested to brief all of you, especially the Executive Board of UNFPA, on our deliberations on the two-day High Level Meeting on Enhancing Reproductive Health Commodity Security on 7th and 8th September 2011 organized by the United Nations Population Fund here in New York. Twelve focus countries in the UNFPA Global Programme met to discuss how to enhance commodity security in their respective countries to meet the International Conference on Population and Development (ICPD) and MDG goals. Discussion focused on the pivotal and strategic roles of reproductive health commodity security in achieving global and national development goals. As countries, we shared our experiences and reported on what we have achieved, especially in the four years since the Global Programme was launched. Countries reported unprecedented progress in the use of modern methods of contraception, with CPR (contraceptive prevalence rate) often increasing by as much as 4 or 5 percentage points per year on the average. This has helped to reduce rates of maternal death and prevent HIV infections. We are achieving notable successes by directing sustained, multi-year funding towards underserved populations and by building the capacity of our health systems. Many of us described how our integrated supply management systems are reducing costs, making effective use of resources, and reducing wastage. United Nations High Level Meeting on Reproductive Health Commodity Security Report to the UNFPA executive Board First ladies, ministers of health and parliamentarians numbered among the 80 people present at the first High Level Meeting on Reproductive Health Commodity Security, September 2011 in New York. The event provided an opportunity to share experiences among 12 priority countries in the UNFPA Global Programme to Enhance Reproductive Health Commodity Security. The event included four panel discussions, plenary sessions, presentation to the UNFPA Executive Board and a Call to Action that voluntary family planning, secured by a steady supply of contraceptives, is a national priority for saving women’s lives. The event concluded with a Report to the UNFPA Executive Board and agreement on a Call to Action. Global ProGramme to enhance reProductive health commodity Security32 The Global Programme to Enhance RHCS was highlighted by almost all of us as an important means for implementing the UN Secretary-General’s Strategy for Maternal and Child Health as well as the HANDtoHAND campaign. Through this programme, our countries received support for procuring contraceptives for family planning and essential life-saving drugs and equipment for maternal health care as well as for strengthening our health systems. The High Level Meeting started with opening remarks by the UNFPA Executive Director and the First Ladies of Sierra Leone and Nigeria. After an overview of UNFPA and the Global Programme to Enhance Reproductive Health Commodity Security, we listened to speakers in four panels, each followed by questions and answers. The four panel topics were: • Mobilizing Political and Stakeholder Commitment for RH and RHCS • Mobilizing and Committing Financial Resources • Strengthening Integrated Commodity Supply Management Systems for the Health Sector • Ensuring Access to Family Planning Services for Underserved Communities PANEL 1 emphasized the importance of placing RHCS on the national development agenda, and of Sierra Leone’s Minister of Health and Sanitation, Zainab Hawa Bangura, addressed the Executive Board at UN Headquarters in New York. Credit: Desmond Koroma/UNFPA. 33ten Good Practices in essential Supplies for Family Planning and maternal health political commitment by the national leadership, with presidents and first ladies making reproductive health and rights their personal priorities. PANEL 2 addressed the need to leverage resources at all levels, enhance partnerships and coordination, show results to guide programmes and justify additional funding both within countries and by donors, and to allocate and effectively disburse funds. A main point that was emphasized is the need to scale up successful country-driven initiatives. PANEL 3 addressed the need to strengthen weak health systems as well as integrate parallel supply systems so as to enhance efficiency. Also emphasized was the key role of logistics management information systems, including training in computer software for e-LMIS. PANEL 4 focused on hard-to-reach groups. We talked about underserved groups in our countries, such as those who are young or who live far from health facilities. Mongolia noted harsh winters and Lao PDR described mountainous terrain. Throughout the day, we shared experiences and examples of initiatives in the 12 participating countries. Such experiences and examples were in the areas of advocacy, human resources development, logistics management, improving procurement and storage of supplies, and training on such subjects as the CHANNEL computer software, emergency obstetric care, and new contraceptive technologies. Some interesting success stories shared by participants are: 1. In Niger, the School for Husbands, for the education of men on family planning and maternal health, has mobilized men and led to increases in ante-natal care attendance and uptake in family planning services; 2. Madagascar highlighted their successes in community-based distribution; 3. Lao PDR described innovative approaches to serve remote populations in remote mountainous areas; 4. Ethiopia reported on task shifting and the expansion of a task force for contraceptive supply; 5. Mali presented its work to reach underserved population and also support to blood transfusion; 6. Haiti noted that the Global Programme’s targeted focus is helping a country with many needs make reproductive health a priority, along with a unique integrated supply chain management system; 7. Mozambique emphasized integrated and coordinated support for maternal health and family planning; 8. Nicaragua emphasized the work on cervical cancer and integration of its supply management system; 9. Mongolia highlighted the use of effective public- private partnerships in passing an amended procurement law; 10. Nigeria highlighted the importance of involving traditional and religious leaders and other community gatekeepers in a geographically and ethnically diverse country to deliver RH commodities; 11. Burkina Faso has contracted out its community- based distribution activities to local NGOs and associations with significant impact on CPR; 12. For Sierra Leone, I spoke about the introduction of robust software, the CHANNEL, and stronger supply system which is reducing maternal death and bringing tremendous results. All of these examples and experiences were shared by us in our discussions. The discussions led to the creation of a Call to Action agreed by all 12 countries. On behalf of all of us, I would like to thank the Executive Board members for meeting and engaging with us during this high level meeting which is the first of its kind for the Global Programme. I would also, on behalf of all of us participating at this meeting, like to encourage our governments, international donors and UNFPA to continue support for reproductive health commodity security. The Global Programme to Enhance Reproductive Health Commodity Security is working and many of our countries are committed to achieving progress towards the MDGs. I wish to thank all of you, especially members of the Board, for your kind attention. Global ProGramme to enhance reProductive health commodity Security34 Enhancing Reproductive Health Commodity Security New York, 7-8 September 2011 We, the participants of the High-Level Meeting on Enhancing Reproductive Health Commodity Security held in New York on 7-8 September 2011, WeLCOMe PROGReSS made in recent decades in ensuring that more individuals worldwide are now able to exercise their right to reproductive health, including the right to plan and space their families, and the results achieved in increasing the use of modern methods of contraception and reducing maternal death and HIV infections; ReAFFIRM our commitment to achieving the Millennium Development Goals and to the principles of the United Nations Secretary-General’s Global Strategy for Women’s and Children’s Health, and commend the high-level political commitment by our Heads of State and Governments to sexual, reproductive, maternal, newborn and child health and to scaling up efforts to meet demand for reproductive health commodities; CONCeRNeD that despite progress disparities persist in access to sexual and reproductive health information, services and essential supplies, and that the poor and other vulnerable groups, including young people, continue to be underserved and suffer high unmet need; AWARe that spending for sexual and reproductive health programmes, including for maternal and family planning services, is not sufficient to meet current and future needs, we acknowledge that there is global consensus that family planning is a cost-effective investment in human development, especially important given the global economic crisis; AFFIRM that comprehensive sexual and reproductive health services including for voluntary family planning, ensured by a secure supply of reproductive health commodities, is a national priority for saving women’s lives, improving maternal health and preventing HIV; ReCOGNIZe that reproductive health commodity security, with its strong family planning focus, Call to Action Mrs. Helen Onma Mark, spouse of the Senate President of Nigeria; Mrs. Sia Nyama Koroma, First Lady of Sierra Leone; Dr. Babatunde Osotimehin, Executive Director, UNFPA; Ms. Julia Bunting, DFID. Credit: Omar Gharzeddine/UNFPA. 35ten Good Practices in essential Supplies for Family Planning and maternal health This Call to Action was issued at a meeting organized by the United Nations Population Fund and attended by senior representatives of 12 Stream One countries of the UNFPA-initiated Global Programme to Enhance Reproductive Health Commodity Security. The countries represented were: Burkina Faso, Ethiopia, Haiti, Lao People’s Democratic Republic, Mali, Madagascar, Mongolia, Mozambique, Nicaragua, Niger, Nigeria and Sierra Leone. provides a powerful platform for governments to align efforts according to national priorities and to accelerate the reduction of unmet need for family planning and so allow women, men and young people throughout the world to exercise their right to reproductive health; We, FIRST LADIeS, PARLIAMeNTARIANS, MINISTeRS, HeReBY INDIVIDUALLY AND COLLeCTIVeLY CALL ON countries and national stakeholders, including civil society and the private sector – according to their respective roles and responsibilities – to partner and collaborate to: 1. Reinforce existing political and financial commitments for reproductive health commodity security: a) Provide political leadership to bring about sustainability in reproductive health commodity security by: developing and expanding social protection mechanisms; strengthening partnership and coordination; leveraging, allocating and using resources equitably at all levels; demonstrating results to mobilize support; and scaling up successful country-driven initiatives; b) Take concerted action to demonstrate that the primary responsibility for the achievement of reproductive health commodity security lies with national government and ensure increased resource allocation for reproductive health in line with global and regional commitments. 2. Invest in stronger supply chain management systems for reproductive health commodities: a) Establish integrated supply management systems for health to improve efficiency including functional logistics management information systems using modern information and communication technology in order to ensure consistent, reliable supply of quality-assured reproductive health commodities; b) Establish a sustainable national mechanism for human resource development to strengthen capacity to deliver reproductive health commodity security. 3. ensure expanded and equitable access to services: a) Ensure that under-served and hard-to-reach groups (with a focus on protecting adolescent girls) can exercise their right to informed choice and can access and use sexual and reproductive health information and care, including voluntary family planning; b) Increase partnership, collaboration and coordination among all stakeholders and at all levels and strengthen the capacity of civil society and parliamentarians to represent the grassroots and to hold governments accountable for their commitments to reproductive health commodity security. United Nations Population Fund Commodity Security Branch 605 Third Avenue New York, NY 10158 www.unfpa.org © 2012

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