The Global Programme to Enhance Reproductive Health Commodity Security - Annual Report 2010

Publication date: 2010

Foreword ii Executive Summary iii Introduction v SECTION ONE: Goal and outcome 1.1 GOAL: Universal access to Reproductive Health by 2015 and universal access to comprehensive HIV prevention by 2010 for improved quality of life 1 1.2 Outcome: Increased availability, access and utilization of reproductive health commodities for voluntary family planning, HIV/STI prevention and maternal health services in the Global Programme on RHCS focus countries 5 SECTION TWO: Output-level results 2.1 Output 1: Country RHCS strategic plans developed, coordinated and implemented by government with their partners 19 2.2 Output 2: Political and financial commitment for RHCS enhanced 23 2.3 Output 3: Capacity and systems strengthened for RHCS 28 2.4 Output 4: RHCS mainstreamed into UNFPA core business (UN reform environment) 31 2.5 Cluster achievements 35 2.6 Programme management 36 SECTION THREE: Selected areas of achievement 3.1 Prequalification and Quality Assurance policy/WHO 39 3.2 Partnership for Maternal, Newborn and Child Health (PMNCH) 40 3.3 National capacity on procurement 40 3.4 Reproductive Health Supplies Coalition 40 3.5 Coordinated Assistance for RH Supplies (CARh) 41 3.6 Emergency/humanitarian response 41 3.7 UNFPA and WHO collaboration 42 3.8 Collaboration with MSI and IPPF 42 SECTION FOUR: Key issues in RHCS 4.1 Support to family planning 45 4.2 Support to condom programming 51 4.3 Building capacity for logistics management 55 4.4 Capacity development of institutions for technical assistance 60 4.5 Advocacy and resource mobilization 62 SECTION FIVE: Commodities 5.1 Allocation of funds for commodity purchases 65 5.2 Contraceptives and condoms 66 5.3 Benefits of commodities supplied 67 Table of ConTenTs SECTION SIX: Finance 6.1 GPRHCS contributions and expenditures 69 6.2 Expenditure on capacity development 70 6.3 Trends in commodity provision and capacity development 70 6.4 Linking resources to results 74 SECTION SEVEN: Challenges and lessons learned 75 CONCLUSION: Moving forward 79 Annex 1: Contraceptives provided to Stream 2 and 3 countries 80 Annex 2: Male and female condoms provided to Stream 2 and 3 countries 82 Annex 3: Estimates for adolescent birth rate, maternal mortality ratio, contraceptive prevalence rate and unmet need for family planning 83 Annex 4: Global Performance Monitoring Framework 85 TABLES Table 1: Adolescent birth rate and percentage of women aged 15 to 19 years who had children or were currently pregnant at the time of various surveys for GPRHCS Stream 1 countries Table 2: Percentage of females aged 15 to 19 years who had children or were currently pregnant at the time of the survey by household wealth quintile for selected GPRHCS Stream 1 countries Table 3: Maternal mortality ratio for GPRHCS Stream 1 countries Table 4: Unmet need for family planning for GPRHCS Stream 1 countries, percentage Table 5: Contraceptive prevalence rate (modern methods): Stream 1 countries, percentage Table 6: Percentage of service delivery points (SDPs) offering at least three modern methods of contraception in GPRHCS Stream 1 countries Table 7: Percentage of sampled SDPs by type of facility, offering at least three modern methods of contraception in GPRHCS Stream 1 countries in 2010 Table 8: Percentage of SDPs with five life-saving maternal/RH medicines (including three UNFPA priority medicines) available in GPRHCS Stream 1 countries Table 9: Percentage of SDPs reporting ‘no stock-out’ of contraceptives within the last six months in GPRHCS Stream 1 countries Table 10: Trends in commodity support among major donors, 2005-2009 Table 11: Trend in donor expenditure by commodities, 2005-2009 Table 12: RHCS strategy integrated into sectoral strategies in Stream 1 countries Table 13: RHCS strategy integrated into sectoral strategies in Stream 2 countries Table 14: RHCS strategies/action plans and coordinating committees in Stream 1 countries Table 15: RHCS strategies/action plans and coordinating committees in Stream 2 countries Table 16: Amount mobilized from donor countries in US$ Table 17: RHCS issues included in PRSPs, health policies and SWAPs in Stream 1 countries Table 18: RHCS issues included in PRSPs health policies and SWAPs in Stream 2 countries Table 19: Stream 1 countries using national technical experts for forecasting and procurement of RH commodities Table 20: Stream 1 countries with RHCS priorities included in: a) CCA, b) UNDAF, c) CPD, d) CPAP and e) AWP Table 21: Stream 2 countries with RHCS priorities included in: a) CCA, b) UNDAF, c) CPD, d) CPAP and e) AWP Table 22: Programme management indicators, 2010 Table 23: Male and female condoms provided to Stream 1 countries in 2010 Table 24: Contraceptives provided to Stream 1 countries in 2010 Table 25: Couple years of protection (CYP) provided to Stream 1 countries in 2010 Table 26: Total funds available in 2010 Table 27: Commodity and capacity development expenditures 2009-2010 (US$) Table 28: Breakdown of capacity development expenditures 2009-2010 (US$) Table 29: Contraceptives provided to Stream 2 and Stream 3 countries in 2010 Table 30: Contraceptives provided to Stream 3 countries in 2010 Table 31: Male and female condoms provided to Stream 2 countries in 2010 Table 32: Male and female condoms provided to Stream 3 countries in 2010 Table 33: Estimates for adolescent birth rate, maternal mortality ratio, contraceptive prevalence rate and unmet need for family planning FIGURES Figure 1: Percentage of females aged 15 to 19 years who had children or were currently pregnant at the time of the survey by highest educational level for selected GPRHCS Stream 1 countries Figure 2: Maternal mortality ratio for GPRHCS Stream 1 countries Figure 3: HIV prevalence among young people aged 15 to 24 years for selected GPRHCS Stream 1 countries Figure 4: Contraceptive prevalence rate (modern methods) for selected Stream 1 countries Figure 5: Current use of contraception by highest educational level for selected GPRHCS Stream 1 countries Figure 6: Current use of contraception by household wealth index for selected GPRHCS Stream 1 countries Figure 7: Current use of contraception by urban/rural residence for selected GPRHCS Stream 1 countries Figure 8: Percentage of SDPs offering at least three modern methods of contraception in selected GPRHCS Stream 1 countries Figure 9: Percentage of SDPs within urban and rural areas with five life-saving maternal/RH medicines (including three UNFPA priority medicines) available in GPRHCS Stream 1 countries in 2010 Figure 10: Donor expenditure by commodities, 2005-2009 Figure 11: Total resource mobilized for the GPRHCS Figure 12: Expenditure by method, 2010 Figure 13: Couple years of protection (CYP) by method, 2010 Figure 14: Percentage of funds spent on commodity versus capacity Figure 15: Trends in Streams 1, 2 and 3 of expenditure related to provision of commodities and capacity development activities from 2008 to projected 2011 Figure 16: Trends in Stream 1 countries of expenditure related to provision of commodities and capacity development activities from 2008 to projected 2011 Figure 17: Trends in Stream 2 countries of commodity provision and capacity expenditure Figure 18: Linking results and resources by GPRHCS outputs abR adolescent birth rate aPRo asia and Pacific Region bCC behaviour Change Communication bKKbn Indonesia’s national Population and family Planning board CaRh Coordinated assistance for RH supplies CbDs Community-based family planning distributors CCa Common Country assessment CCM Country Commodity Manager CCP Comprehensive condom programming CIes Centro de Investigación y estudios de la salud CPaP Country Programme action Plan CPD Country Programme Document CPR Contraceptive prevalence rate Csb Commodity security branch Cso Civil society organizations CYP Couple year protection DaC Development assistance Committee DfID Department for International Development (UK) DHs Demographic and Health surveys DRC Democratic Republic of the Congo eMl essential Medicines list emoC emergency obstetric care emonC emergency obstetric and newborn Care GPRHCs UnfPa Global Programme to enhance Reproductive Health Commodity security HeW Health extension Workers HIV/aIDs Human immunodeficiency virus/acquired immunodeficiency syndrome HMIs Health management information system HRb Humanitarian Response branch ICPD International Conference on Population and Development IeC Information, education, and Communication IPPf International Planned Parenthood federation IUD Intra-uterine device laC latin american countries lMIs logistics Management and Information system MCH Maternal and Child Health MDGs Millennium Development Goals MHTf Maternal Health Thematic fund MMR Maternal mortality ratio MnCH Maternal, newborn and Child Health lIsT of aCRonYMs MnH Maternal and neonatal Health MoH Ministry of Health MoU Memorandum of Understanding MsI Marie stopes International na not available nGo non-governmental organization oC oral contraceptive oeCD organisation for economic Co-operation and Development PDR Peoples’ Democratic Republic PMnCH Partnership for Maternal, newborn and Child Health PPMR Procurement Planning and Monitoring Report PRIsMa asociación benéfica PRIsMa PRsP Poverty Reduction strategy Papers Psb Procurement services branch PsM Procurement and supply management Qa Quality assurance RbM Results-based management ReC’s Regional economic Communities RH Reproductive health RHCs Reproductive health commodity security Ro Regional office sDP service delivery point sRH sexual Reproductive Health sTI sexually transmitted infections sWaps sector-wide approaches TD Technical Division ToR Terms of Reference UbW Unified budget and Workplan UnaIDs Joint United nations Programme on HIV/aIDs UnDaf United nations Development assistance framework UnDG United nations Development Group UnfPa United nations Population fund UnHCR United nations High Commissioner for Refugees UnICef United nations Children’s fund UsaID United states agency for International Development WaHo West african Health organisation WHo World Health organization foReWoRD by Werner Haug – Director, Technical Division, UnfPa More than 100 countries worldwide have eliminated or nearly eliminated maternal mortality as a public health problem. In spite of this, there are still approximately 350,000 maternal deaths and over 1 million newborn deaths yearly in the world. For every woman who dies in childbirth, at least 20 more suffer injuries, infections or disabilities. This reality could be averted with highly cost-effective and feasible interventions to prevent maternal and newborn mortality and morbidity. These interventions include general access to reproductive health (including family planning), a skilled birth attendant present at every delivery, access to emergency obstetric and newborn care when needed and HIV prevention. When adopted and scaled up with a rights-based and equity-driven approach, these have led to tremendous gains, proving that rapid progress is indeed possible. UNFPA supports developing countries that are most in need of assistance — and furthest from achieving MDG 5 and universal access to reproductive health by 2015 — through two important initiatives: the Global Programme to Enhance Reproductive Health Commodity Security (GPRHCS) and the Maternal Health Thematic Fund (MHTF). Both initiatives, working together, are well-positioned to support the UN Secretary- General’s Global Strategy for Women’s and Children’s Health, an unprecedented global-level commitment to advance the well-being of women and children. The many achievements, outlined in this report, provide ample evidence that strong political commitment, adequate investments and partnerships are critical to achieving MDG 5 and universal access to reproductive health. UNFPA launched the GPRHCS in 2007 to address the urgent and ongoing need for a reliable supply of contraceptives, condoms, medicines and equipment in developing countries. Reproductive health commodity security is achieved when all individuals can obtain and use affordable, quality reproductive health commodities of their choice whenever they need them. Commodity security underpins UNFPA program- ming and is critical to accelerating progress towards internationally agreed development goals. The Global Programme is already yielding measurable results through a framework for assisting countries in planning for their own needs, with a focus on commodities as well as capacity development to strengthen health systems. Momentum is building around achieving MDG 5 and we face an unprecedented opportunity to tackle maternal mortality and morbidities head on. While much progress has been made, in many countries there is still a far way to go. I would like to take this opportunity to thank countries, donors, other partner organizations and all colleagues for the continued collaboration to reaching our shared goal. Werner Haug Director, Technical Division UNFPA ii exeCUTIVe sUMMaRY The Global Programme to Enhance Reproductive Health Commodity Security (GPRHCS) provided sustained multi-year support to 11 Stream 1 countries and funded targeted initiatives in 34 Stream 2 countries. In total, the Global Programme focused on 45 countries, a deliberately tighter focus than the previous year. Some additional ad hoc support was provided to Stream 3 countries. Expenditures (provisional) totaled $93,551,586 in 2010, up from $87,089,805 in 2009. Of that amount, $61,771,480 (66 percent) went to reproductive health commodities and $31,780,105 (34 percent) went to capacity development. Within UNFPA, the GPRHCS worked in collaboration with the Maternal Health Thematic Fund to provide programmatic support to ensure that life-saving maternal health drugs and supplies were available in all facilities. The GPRHCS also worked closely with the HIV/AIDS branch to increase the availability of contraceptives in countries with high HIV prevalence and among vulnerable populations. Selected results and country highlights from 2010 include the following: 1. Contraceptive prevalence rate (CPR) increased substantially in several Stream 1 countries (Ethiopia, Mozambique and Niger), continuing to build on notable increases in 2009; 2. In 10 out of 11 Stream 1 countries, three modern methods of contraceptives were available in at least 80 percent of service delivery points; 3. Nine out of 11 Stream 1 countries had the five essential maternal health drugs available in more than 60 percent of service delivery points; 4. There was a clear increase in the number of facilities without stock-outs of contraceptives in 5 out of 11 Stream 1 countries. Also, six Stream 1 countries had no stock-outs in more than 76 percent their service delivery points; 5. Ten out of 11 Stream 1 countries and 26 Stream 2 countries have national strategic plans in place for RHCS under government leadership and with the involvement of relevant stakeholders; 6. Functional coordinating mechanisms for RHCS exist in 10 out of 11 Stream 1 and most Stream 2 countries; 7. Essential medicines lists include reproductive health commodities in all Stream 1 and 26 Stream 2 countries as of 2010, with both life-saving medicines and modern methods of contraception, though not every list includes every method; 8. Ten out of 11 Stream 1 countries and 15 Stream 2 countries include RHCS within national Poverty Reduction Strategies, ensuring its priority at the highest levels; 9. Budget lines for RH commodities, a strong indicator of government commitment, are present in 10 out of 11 Stream 1 countries and at least 16 Stream 2 countries; allocations actually increased in Mongolia, Mozambique and Niger in 2010; 10. National technical expertise for commodity forecasting and for managing procurement processes is being used in 8 out of 11 Stream 1 countries, up from six countries in 2009; 11. Based on demand from countries, expenditure on capacity development increased from 19.3 percent in 2009 to 34 percent in 2010, reflecting intensified efforts to build capacity and strengthen systems; 12. Funding levels for the GPRHCS reached an all-time high of almost $100 million in 2010. iii Information used for the preparation of this report comes from a variety of sources. The main sources of information are reports submitted by UNFPA Country Offices in collaboration with country partners, and data analysed from the country reporting questionnaire. Information from other published and unpublished sources provides further explanation to make the discussion more meaningful. In 2010, implementation reached new levels in Stream 1 and 2 countries, and the added value of the Global Programme was demonstrated in many ways and captured in ‘results’. Using the GPRHCS monitoring and evaluation framework, the programme was able to track progress and achievements much more comprehensively. This improved understanding of progress is also contributing substantially to currently ongoing discussions both within and outside the organization on the future directions of the programme. The GPRHCS will continue to work with governments and partners to improve RHCS in a focused manner within the Stream 1 and Stream 2 countries receiving support. The focus will be on continuing to develop sustainable approaches to RHCS as part of overall health sector reform, and in building a stronger foundation for more permanent and lasting solutions to RHCS. Results-based management, lessons learned and monitoring will strengthen future efforts. Support to a few Stream 3 countries will continue to be necessary due to the unexpected and devastating nature of so many humanitarian situations and natural disasters, and the weak infrastructure in many countries. However, some Stream 3 countries are building up their capacity to achieve RHCS and may be selected for Stream 2 in the coming years. At the same time, however, the GPRHCS will finalize its gradual exit strategy for countries as they no longer need targeted support and become ready to graduate. Ensuring the availability and utilization of family planning information and services has always been a priority for UNFPA and continues to be a priority through the GPRHCS. In this regard, UNFPA has pledged to contribute to the HANDtoHAND Campaign of the Reproductive Health Supplies Coalition, supporting Stream 1 and Stream 2 countries to attain at least 2 percentage points increase in CPR per year. Evidence of increasing government commitment to RHCS is being seen in many countries and, it is hoped, will continue to rise so that the reliance on external funding can lessen. However, additional funding will continue to be required for the foreseeable future. The need for expanding the GPRHCS donor base remains a key priority and efforts in this regard will intensify in 2011. Substantial results of achievements from counties with the support of the GPRHCS will be documented and widely shared. The GPRHCS continues in line with UNFPA’s Strategic Plan to ensure access to and use of quality reproductive health commodities, supplies and medicines, as part of the overall effort to reduce the number of maternal and newborn deaths, halt the spread of HIV/AIDS and improve the sexual and reproductive health and rights of women, men and young people – particularly within countries most in need. iv The urgent and ongoing need for a reliable supply of contraceptives, condoms, medicines and equipment in developing countries is the challenge addressed by UNFPA’s Global Programme to Enhance Reproductive Health Commodity Security (GPRHCS). Reproductive health commodity security is of critical importance to reproductive health, and the critical importance of reproductive health to development is expressed in the Millennium Development Goals (MDGs), where universal access to reproductive health is a target for 2015, and in the International Conference on Population and Development (ICPD) Programme of Action. Without a secure, reliable supply of contraceptives and other essentials, countries will not be able achieve these goals. UNFPA established the Global Programme as a framework for assisting countries in planning for their own needs. At the request of governments, UNFPA helps to: • Integrate RHCS in national policies, plans and programmes through advocacy with policy makers, parliamentarians and partners in government; • Strengthen the delivery system 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; • In partnership with the Maternal Health Thematic Fund and HIV/AIDS Branch, 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. Since 1990, UNFPA has been considered to be the largest multilateral supplier of contraceptives and condoms, and the lead United Nations agency for reproductive health commodity security (RHCS). However, funding shortages and a tendency to look at reproductive health commodities in isolation from other issues meant that support in this area was often substantial but ad hoc. UNFPA launched the Global Programme to Enhance Reproductive Health Commodity Security 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. In only a few years, it is already yielding measureable results. Reporting on results Results-based management (RBM) is a priority for UNFPA. The GPRHCS Monitoring and Evaluation Framework was reviewed extensively in 2009 in a collaborative effort by UNFPA Country Offices, Regional Offices, donors and partners. Improvements in monitoring and reporting on indicators enabled the GPRHCS to gather valuable data on RHCS progress and results at the national, regional and global levels. It is possible to demonstrate specific achievements in this report because UNFPA has implemented results- based management—an approach that promotes more effective and efficient ways of working. Reproductive health commodity security (RHCS) is achieved when all individuals can obtain and use affordable, quality reproductive health supplies of their choice whenever they need them. InTRoDUCTIon v This report looks at the results (goal, outcome and output) and associated indicators that are used to measure progress in the Global Programme to Enhance RHCS. The results-based approach is based on the GPRHCS Monitoring and Evaluation Framework and the UNFPA Results and Resources Framework. Both aggregate data and specific examples to highlight achievements in 2010 are presented in this report. Section One states the main goal: UNFPA works at the request of governments to achieve universal access to reproductive health by 2015 and universal access to comprehensive HIV prevention by 2010 for improved quality of life. It also presents the programme’s main outcome: The Global Programme seeks results in increased availability, access and utilization of reproductive health commodities for voluntary family planning, HIV/STI prevention and maternal health services in the focus countries. Section Two looks at the programme’s four outputs: (1) Country RHCS strategic plans developed, coordinated and implemented by government with their partners; (2) Political and financial commitment for RHCS enhanced; (3) Capacity and systems strengthened for RHCS; (4) RHCS mainstreamed into UNFPA core business. Section Three presents selected areas of achievement and Section Four presents examples of activities in support of several ‘key issues’. Section Five summarizes the allocation of funds for commodities in 2010, and Section Six provides the financial overview. The report concludes with challenges, lessons learned and suggestions for next steps. The UNFPA Commodity Security Branch acknowledges the contributions of our donors, without whom these accomplishments would not have been possible. Recognition for the results described in this report is also due to valued partners in governments, other United Nations agencies and organizations, non- governmental organizations and civil society groups. vi Funding streams GPRHCS supports countries through three funding streams in order to address the specific needs of each country: Stream 1 provides multi-year funding to a relatively small number of countries. These predictable and flexible funds are used to help countries develop more sustainable, human rights-based approaches to RHCS, thereby ensuring the reliable supply of reproductive health commodities and the concerted enhancement of national capacities and systems. Stream 2 funding supports initiatives to strengthen several targeted elements of RHCS, based on the country context. Stream 3 is emergency funding for commodities in countries facing stock-outs for reasons such as poor planning, weak infrastructure and low in-country capacity. Stream 3 also provides support for countries facing humanitarian situations, including natural or man-made disasters. In these settings, the GPRHCS works closely with UNFPA’s Humanitarian Response Branch (HRB) and United Nations High Commissioner for Refugees (UNHCR) to deliver much-needed commodities in times of emergency. All funding through this stream is used for the provision of commodities. 2010 Stream 1 countries 2010 Stream 2 countries 1. Burkina Faso 1. Benin 21. Mauritania 2. Ethiopia 2. Bolivia 22. Namibia 3. Haiti 3. Botswana 23. Nigeria 4. Lao PDR 4. Burundi 24. Papua New Guinea 5. Madagascar 5. Central African Republic 25. Sao Tome and Principe 6. Mali 6. Chad 26. Senegal 7. Mongolia 7. Congo 27. Swaziland 8. Mozambique 8. Côte d'Ivoire 28. Timor Leste 9. Nicaragua 9. Democratic Republic of the Congo 29, Togo 10. Niger 10. Djibouti 30. Uganda 11. Sierra Leone 11. Ecuador 31. Yemen 12. Eritrea 32. Zambia 13. Gabon 33. Zimbabwe 14. Gambia 34. Sudan 15. Ghana 16. Guinea 17. Guinea-Bissau 18. Lesotho 19. Liberia 20. Malawi vii Young woman in Chad. Photo by Giacomo Pirozzi/Panos Pictures Goal anD oUTCoMe seCTIon one G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 1 Driving progress towards one global goal, UNFPA applies a strategic and structured framework1 for assisting countries establish a secure, reliable supply of contraceptives and other essential supplies. Each year, more countries are establishing RHCS as an integral part of their overall health sector plan and a key strategy in reducing maternal and newborn death and preventing the spread of HIV. In 2010, UNFPA worked in targeted ways through the Global Programme to Enhance Reproductive Health Commodity Security to contribute to progress towards this goal and the outcome against which progress is measured. Goal: Universal access to reproductive health by 2015 and universal access to comprehensive HIV prevention by 2010 for improved quality of life. Outcome: Increased availability, access and utilization of reproductive health commodities for voluntary family planning, HIV/STI prevention and maternal health services in the Global Programme to Enhance RHCS focus countries. This section looks at indicators associated with the goal and outcome, providing context for the activities supported by UNFPA throughout the year. 1.1 GOAL: Universal access to reproductive health by 2015 and universal access to comprehensive HIV prevention by 2010 for improved quality of life This goal of the Global Programme is derived from the UNFPA Strategic Plan 2008-2012. The indicators associated with this goal – adolescent birth rate, maternal mortality ratio and youth HIV prevalence rate – are used globally to measure progress in achieving MDG 5 to improve maternal health. Monitoring of progress by means of the goal and outcome indicators draws on quantitative data sources. In many countries these are often not readily and consistently available, thus making it difficult to demonstrate progress and adequately compare change among the countries. In spite of this, however, some progress has been made. The data presented here on progress should not be attributed as the achievement to GPRHCS alone, or indeed to UNFPA alone, but should be seen as outcomes of concerted efforts by all partners to address the development challenges in each country. 1.1.1 adolescent birth rate Adolescent birth rate (ABR) is a measurement of the number of births to women 15 to 19 years of age per 1,000 women in that age group. It represents the risk of childbearing. The indicator measures the incidence of childbirth among young people, which has implications for prevalence of unprotected sex, early marriage, early childbearing, teenage pregnancy and disruption of schooling among adolescents. In the Global Programme’s Steam 1 countries, adolescent birth rates (ABR) range from 18.5 per 1,000 women (15-19) in Mongolia to 199 per 1,000 women (15-19) in Niger. With the exception of Mongolia and Haiti, the Stream 1 countries have adolescent birth rates of more than 100 per 1,000 women. In Stream 2 countries, adolescent birth rates are within the same range as in Stream 1 countries. Among the Stream 2 countries only Ecuador has an ABR of less than 100 (see Annex 3). The 21 Stream 2 countries with an ABR of more than 110 are all in Africa. 1 See the annex for the Global Performance Monitoring Framework 2 Available data for Stream 1 countries indicate that the percentages of young women aged 15 to 19 years who had children or were currently pregnant at the time of various DHS surveys, were as high as 41 percent in Mozambique and 34 percent in Sierra Leone. Table 2 shows that the incidence of pregnancy and motherhood among women aged 15 to 19 years in all the countries was higher for young women in poor households, and lower for households with the highest wealth index. In Mozambique, while 60.5 percent of females 15 to 19 years in the lowest wealth quintile had children or were pregnant, only 24.6 percent of their counterparts in the highest wealth quintile had children or were pregnant at the time of the survey. Pregnancy and motherhood among women aged 15 to 19 years, as shown in Figure 1, was found to be significantly lower among young girls with secondary or higher education than their counterparts with no education. In Ethiopia, the figure was 28.9 percent for women with no education, compared to only 3 percent for women with secondary education. For Nicaragua, the percentage for women with no education (64.2 percent) is nearly twice as high as for women with primary education (34 percent). Adolescent birth rate* Percentage who had childrena or are currently pregnant** Country Year Per 1,000 women 15-19 Survey and year Percent Burkina Faso 2001 131.0 DHS 2003 23.3 Ethiopia 2003 109.1 DHS 2005 16.6 Haiti 2003 68.6 DHS 2005-06 14.0 Lao PDR 2005 110.0 - N/A Madagascar 2008 148.0 DHS 1992 29.0 Mali 2004 190.0 DHS 1995-96 41.5 Mongolia 2007 18.5 - N/A Mozambique 2001 185.0 DHS 2003 41.0 Nicaragua 2005 108.5 DHS 2006 25.2 Niger 2004 198.9 DHS 1992 36.2 Sierra Leone 2006 143.0 DHS 2008 34.0 Table 1: Adolescent birth rate and percentage of women aged 15 to 19 years who had children or were currently pregnant at the time of various surveys for GPRHCS Stream 1 countries Source: * Population and Development Branch, Have we progressed on MDG4b? The empirical evidence in advancing Universal Access to Reproductive Health, Technical Division, UNFPA New York, June 2010. ** Data from Macro International Inc, 2011. MEASURE DHS STATcompiler. http://www.measuredhs.com, March 16 2011 Household wealth index Burkina Faso (DHS 2003) Ethiopia (DHS 2005) Haiti (DHS 2005- 06) Mozambique (DHS 2003) Sierra Leone (DHS 2008) Lowest 26.0 23.8 21.5 60.5 49.4 Second 31.8 20.8 15.6 48.9 46.8 Middle 27.2 19.8 17.6 44.6 43.4 Fourth 26.8 18.3 13.4 42.0 31.6 Highest 12.2 8.2 7.1 24.6 16.1 Table 2: Percentage of females aged 15 to 19 years who had children or were currently pregnant at the time of the survey by household wealth quintile for selected GPRHCS Stream 1 countries Source: Data from Macro International Inc, 2011. MEASURE DHS STATcompiler. http://www.measuredhs.com, March 16 2011 G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 3 Reproductive health commodity security remains a key strategy for meeting young people’s reproductive health needs, including family planning. UNFPA works in many ways, including RHCS, to support countries in their efforts to address the problems associated with pregnancy and motherhood among young women, for preventing unwanted pregnancy, and for making maternal health safe. 1.1.2 Maternal mortality ratio Maternal mortality ratio (MMR) refers to the number of women who die from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, per 100,000 live births. With the exception of Sao Tome and Principe, for which data is not available, recent UN estimates2 show that MMR for GPRHCS Stream 1 countries range from 65 maternal deaths per 100,000 live births for Mongolia to 970 for Sierra Leone. The GPRHCs country with the highest MMR is Chad, with 1,200 maternal deaths per 100,000 live births. Only three countries (Ecuador, Mongolia and Nicaragua) have MMR of 100 or less. In contrast, 33 out of the 44 Stream 1 and 2 countries that submitted reports have MMR of more than 300 maternal deaths per 100,000 live births. Most maternal deaths are preventable using well-known, cost-effective strategies including the provision life-saving maternal health medicines; ensuring skilled health workers are at hand to assist at every delivery; providing access to essential obstetric care, especially when complications arise; and providing family planning information and services to prevent unwanted pregnancies and unsafe abortions. Activities of the Global Programme to Enhance RHCS directly support efforts to reduce maternal deaths, which require the provision of contraceptives to prevent unwanted pregnancy and life-saving maternal health medicines to make pregnancy and childbirth safer. 2 Trends in Maternal Mortality: 1990 to 2008; Estimates developed by WHO, UNICEF, UNFPA and the World Bank; WHO 2010 Figure 1: Percentage of females aged 15 to 19 years who had children or were currently pregnant at the time of the survey by highest educational level for selected GPRHCS Stream 1 countries Source: Demographic and Health Surveys (DHS) data from Macro International Inc, 2011. MEASURE DHS STATcompiler. http://www.measuredhs.com, March 16 2011 0 10 20 30 40 50 60 70 Sierra Leone (DHS 2008) Nicaragua (CDC-RHS Survey 2006) Niger (DHS 1992) Mali (DHS 1995-96) Mozambique (DHS 2003) MadagascarHaiti (DHS 2005-06) Ethiopia (DHS 2005) Burkina Faso (DHS 2003) Secondary or higherPrimaryNo Education Selected GPRHCS Stream 1 countries (survey & date) Pe rc en ta ge o f fe m al es 1 5- 19 y ea rs (DHS 1992) 4 1.1.3 Youth HIV prevalence rate The percentage of young people aged 15-24 who are living with HIV out of total population in this age group is one of the Millennium Development Goal indicators that seeks to measure the incidence of the HIV epidemic among young people. This indicator gives the potential effect of the disease on the youth population, which has current and future development implications. Available data for this indicator, sourced from national survey results, show that HIV/AIDS is more prevalent among young females than young males. Country Maternal mortality ratio (per 100,000 live births) Burkina Faso 560 Ethiopia 470 Haiti 300 Lao PDR 580 Madagascar 440 Mali 830 Mongolia 65 Mozambique 550 Nicaragua 100 Niger 820 Sierra Leone 970 Table 3: Maternal mortality ratio for GPRHCS Stream 1 countries Source: Trends in Maternal Mortality: 1990 to 2008; Estimates Developed by WHO, UNICEF, UNFPA and the World Bank; Annex 1, page 23 Source: Trends in Maternal Mortality: 1990 to 2008; Estimates developed by WHO, UNICEF, UNFPA, World Bank; Annex 1, page 23 Figure 2: Maternal mortality ratio for GPRHCS Stream 1 countries 0 100 200 300 400 500 600 700 800 900 1000 Sierra LeoneNigerNicaraguaMozambiqueMongoliaMaliMadagascarLao PDRHaitiEthiopiaBurkina Faso GPRHCS Stream 1 country M at er na l d ea th s (p er 1 0 0 ,0 0 0 li ve b ir th s) G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 5 Figure 3 shows that HIV/AIDS prevalence is often higher among urban females than rural females. In most of the countries represented in the figure, HIV prevalence among young females is twice as high when compared to their male counterparts. HIV prevalence among young people is higher in southern African countries than elsewhere. In Swaziland (DHS 2006-07) the prevalence among young people was 5.9 percent for male and 22.7 percent for female and in Zimbabwe (DHS 2005-06) the prevalence among young males 15 to 19 years was 4.2 percent compared to 11.0 percent for young females 15 to 19 years. The urban-rural disparities, the differences observed between the sexes, and the high prevalence in southern Africa call for focused strategies to scale up interventions, including comprehensive condom programming. There is also the important need to address the vulnerability of young women to HIV infection. In recognition of this need, a cluster of countries in southern Africa are supported by the GPRHCS within the Stream 2 funding modality and targeted support is provided particularly for HIV/AIDS prevention and comprehensive condom programming. 1.2 Outcome: Increased availability, access and utilization of reproductive health commodities for voluntary family planning, HIV/STI prevention and maternal health services in the Global Programme focus countries A measureable outcome enables UNFPA to measure progress towards the global goal. The outcome is measured using the following indicators: Two outcome indicators of the GPRHCS are derived from the UNFPA Strategic Plan 2008-2012. They are also indicators for MDG 5, improve maternal health: • contraceptive prevalence rate; • unmet need for family planning; Figure 3: HIV prevalence among young people aged 15 to 24 years for selected GPRHCS Stream 1 countries Source: Demographic and Health Surveys (DHS) data from Macro International Inc, 2011. MEASURE DHS STATcompiler. http://www.measuredhs.com, March 16 2011 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 Rural femaleRural maleUrban femaleUrban male Haiti (Mortality and Morbidity Survey 2005-06) Sierra Leone Niger (DHS 2006) Mali (DHS 2006) Ethiopia (DHS 2005) Burkina Faso (DHS 2003) H IV P re va le nc e (% ) (DHS 2008) 6 In addition, the GPRHCS monitors the following three outcome indicators to measure progress for commodity security: • number of GPRHCS Stream 1 countries with service delivery points (SDPs) offering at least three modern methods of contraceptives; • number of GPRHCS Stream 1 countries where five life-saving maternal/RH medicines from the list of UNFPA priority medicines are available in all facilities providing delivery services; and • number of Stream 1 countries with service delivery points with ‘no stock-outs’ of contraceptives within last six months. Achieving reproductive health commodity security is manifested in the availability of contraceptive commodities and life-saving and essential maternal health medicines within service delivery points where clients, irrespective of background, could have access to them. It is with this in mind that the GPRHCS supports countries in addressing shortfalls and stock-outs of essential medicines and contraceptives. GPRHCS is engaged in the actual procurement and delivery of these commodities to the countries and, significantly, the programme assists in strengthening storage, distribution and service provision systems in support of family planning and maternal and neonatal health. The GPRHCS provides funds for an annual survey in Stream 1 countries to obtain data for three important outcome indicators specific to the programme. In situations where the health management information system (HMIS) is regularly updated, data for these indicators could be easily obtained. However, as a result of the weak statistical systems in all the GPRHCS countries, data for three additional GPRHCS outcome indicators have to be sourced from special surveys. The 2010 surveys in Stream 1 countries were carried out according to a standardized methodology and survey guidelines. The guideline recommended a framework for choosing representative sample of service delivery points (SDPs) that provide modern contraceptive methods and maternal/reproductive health (RH) services in each country. The service delivery points of the countries were categorized into primary Level SDPs (health posts and health centres); secondary level SDPs (rural, zonal and regional hospitals/general hospitals); tertiary level SDPs (referral/specialized hospitals); or as defined by national protocols. In practice, the ability to compare figures for 2010 and previous years is limited by the fact that ccountries adopted methods that not only varied widely but also differed from the standardized methodology adopted for 2010. 1.2.1 Unmet need for family planning This indicator is measured by the percentage of women currently married, or in a consensual union, aged 15-49 who want to stop having children or to postpone the next pregnancy for at least two years, but who are not using contraception. As a result of lack of recent DHS survey data, most countries have not reported any change in unmet need for family planning. Table 4 shows that unmet need for family planning in Stream 1 countries ranges from 10.7 percent for Nicaragua to 34 percent in Ethiopia. With the exception of Lao PDR in Southeast Asia, all the Stream 1 countries with unmet need higher than 25 percent are in Africa. For Stream 2 countries, unmet need ranges from 3.8 percent for Timor Leste to 40.3 percent for Uganda (see Annex 3). Unmet need is higher than 25 percent for 22 programme countries, and this includes five of the 11 Stream 1 countries. High unmet need for family planning is an indication of the existence of barriers, including social, economic and physical barriers that limit women’s access to and utilization of family planning services, and limit quality of care. This carries attendant risk of unintended pregnancies and early childbearing. Barriers are also related to quality of care. Support is required for country-led family planning efforts-through the provision of commodities; strengthening health systems; removing social, economic and physical barriers; scaling up demand creation efforts; and improving quality of care—all necessary for reducing unmet need and improving contraceptive use. G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 7 1.2.2 Contraceptive prevalence rate - modern methods Contraceptive prevalence rate (CPR) - modern methods - refers to the proportion of women aged 15-49 who are using, or whose sexual partners are using, any modern method of contraception. The indicator is useful in tracking progress towards health, gender and poverty goals. It also serves as a proxy measure of access to reproductive health services. Though new data for CPR for 2010 was not available for most of the Stream 1 countries, the conclusions made about improvement in CPR in 2009 still remains valid; that is nine original Stream 1 countries have a CPR greater than 10 percent and seven countries have a CPR of 25 percent or higher. Over 70 percent of the Stream 1 countries are within 10 percentage points of their target CPR for 2013 or 2015 as set in their national health strategies. In the new Stream 1 countries (Mali and Sierra Leone), the baseline CPR was established at 7 percent in 2009. Table 4: Unmet need for family planning for GPRHCs stream 1 countries, percentage Country Baseline (2008) 2009 2010 Target (2013) Burkina Faso 31.3 (MOH) 28.0 (MOH) 28.8 (MOH) NA Ethiopia 34.0 (DHS 2005) 34.0 (DHS 2005) 34.0 (DHS 2005) Less than 10% Haiti 37.5 (DHS 2005- 06) 37.5 (DHS 2005- 06) 37.5 (DHS 2005- 06) NA Lao PDR 27.3 (LRHS 2005) 27.3 (LRHS 2005) 27.3 (LRHS 2005) NA (CPR target is set in MNCH Strategy rather than unmet need) Madagascar 24.0 (DHS 2004) 19.0 (MOH) 19.0 (MOH) NA Mali 31.2 (DHS 2006) 31.2 (DHS 2006) 31.2 (DHS 2006) NA Mongolia 14.4 (ENDSA 2008) 14.4 (ENDSA 2008) 14.4 (ENDSA 2008) 10% Mozambique 18.4 (DHS 2003) 18.4 (DHS 2003) 18.4 (DHS 2003) NA Nicaragua 10.7 (DHS 2006- 07) 10.7 (DHS 2006- 07) 10.7 (DHS 2006- 07) 8% Niger 22.0 (MOH 2007) NA NA NA Sierra Leone 28.0 (DHS 2008) 28.0 (DHS 2008) 28.0 (DHS 2008) 40% reduction Source: Compiled from 2010 GPRHCS country reports and related documents 8 While CPR continued to increase in 2010 in countries supported by the Global Programme, analysis of disaggregated data revealed that in all Stream 1 countries, current use of contraception was higher in urban areas and amongst those with higher education, and also increased with higher wealth quintiles. This finding is consistent with the longstanding situation in developing countries regarding use, access, availability, affordability and other factors that help or hinder the use of modern methods of contraception. A focus on those most in need in poor and rural areas is called for, along with efforts to enhance awareness and knowledge to generate demand. Table 5: Contraceptive prevalence rate (modern methods): Stream 1 countries, percentage Country Baseline 2009 2010 Target Burkina Faso 8.6 (DHS 2003) 13.3 (MICS 2006) 13.3 (MICS 2006) 35% (2013) Ethiopia 13.9 (DHS 2005) 30.0 (MOHS) 32.0 (MOHS) 65% (2015) Haiti 24.8 (DHS 2005-06) 24.8 (DHS 2005-06) 24.8 (DHS 2006) 35% (2013) Lao PDR 35.0 (LRHS 2005) 35.0 (LRHS 2005) 35.0 (LRHS 2005) 55% (2015) Madagascar 18.0 (DHS 2004) 29.2 (MOHS) 29.2 (DHS 2008-09) 36% (2012) Mali 6.9 (DHS 2006) 6.9 (DHS 2006) 6.9 (DHS 2006) 15% (2013) Mongolia 40.0 (RHS) 52.8 (RHS 2008) 52.8 (RHS 2008) 55% (2012) Mozambique 11.7 (DHS 2003) 11.7 (DHS 2003) 12.2 (MOH) 34% (2015) Nicaragua 69.8 (DHS 2007) 69.8 (DHS 2007) 69.8 (DHS 2007) 72% (2013) Niger 11.7 (DHS 2006) 16.5 (MOH) 21.0 (National Health Information System) 18% (2012) Sierra Leone - 7.0 (DHS 2008) 7.0 (DHS 2008) 10.5% (2013) Source: Compiled from 2010 GPRHCS country reports and related documents Figure 4: Contraceptive prevalence rate (modern methods): Stream 1 countries Source: Compiled from 2010 GPRHCS country reports and related documents 0 10 20 30 40 50 60 70 80 Target20102009Baseline Sierra LeoneNigerNicaraguaMozambiqueMongoliaMaliMadagascarLao PDRHaitiEthiopiaBurkina Faso GPRHCS Stream 1 country Pe rc en ta ge G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 9 Figure 4 shows that the significant increase in CPR witnessed in 2009 in several Stream 1 countries (Ethiopia, Mozambique and Niger) continued in 2010. Specifically for Niger, the target set for 2012 in the country’s national health strategy has already been surpassed. Figures from Mongolia and Nicaragua indicate that the targets are close to being achieved. Disaggregated data compiled from various DHS and other national surveys conducted in Stream 1 countries give insight into the disparities that exist in use of contraceptives. As shown in Figure 5, current use of contraceptives is higher among women with secondary or higher levels of education in all the countries. In Nicaragua, the difference between respondents with no education and those with secondary or higher level is narrower than for the other countries. Current use of contraceptives is also highly related to household wealth index. Data presented in Figure 5 shows that for most of the countries, the percentage of current users of contraceptives are disproportionately higher among married women in the highest wealth quintile. In the case of Burkina Faso, Ethiopia, Mali, Niger and Sierra Leone, the percentage of women who are current users of contraceptives in the highest wealth quintile is higher than all the other categories put together. Haiti appears to have the least disparity between the poorest and the richest quintiles. Information provided by this disaggregated data will be used by countries and partners in targeting the underserved and devising strategies to better address their needs. Figure 5: Current use of contraception by highest educational level for selected GPRHCS Stream 1 countries Source: Demographic and Health Surveys (DHS) data from Macro International Inc, 2011. MEASURE DHS STATcompiler. http://www.measuredhs.com, March 16 2011 0 10 20 30 40 50 60 70 80 Secondary or higherPrimaryNo education Sierra Leone (DHS 2008) Nicaragua (DHS 2006) Niger (DHS 2006) Mali (DHS 2006) Madagascar (DHS 2008-09) Haiti (Mortality and Morbidity Survey 2005-06) Ethiopia (DHS 2005) Pe rc en ta ge Selected GPRHCS Stream 1 countries (survey & date) 10 Figure 7 shows that the percentage of contraceptive users in all the countries shown appears to be higher for urban dwellers than for rural dwellers. In the case of Burkina Faso, Ethiopia, Mali, Niger and Sierra Leone, there appears to be four times more current users in urban centres than in rural areas. Source: Demographic and Health Surveys (DHS) data from Macro International Inc, 2011. MEASURE DHS STATcompiler. http://www.measuredhs.com, March 16 2011 Figure 6: Current use of contraception by household wealth index for selected GPRHCs stream 1 countries Selected GPRHCS Stream 1 countries (survey & date) 0 5 10 15 20 25 30 35 40 HighestFourthMiddleSecondLowest Sierra Leone (DHS 2008) Niger (DHS 2006) Mozambique (DHS 2003) Mali (DHS 2006) Madagascar (DHS 2008-09) Haiti (Mortality and Morbidity Survey 2005-06) Ethiopia (DHS 2005) Burkina Faso (DHS 2003) Pe rc en ta ge Figure 7: Current use of contraception by urban/rural residence for selected GPRHCs stream 1 countries Selected GPRHCS Stream 1 countries (survey & date) Source: Demographic and Health Surveys (DHS) data from Macro International Inc, 2011. MEASURE DHS STATcompiler. http://www.measuredhs.com, March 16 2011 0 10 20 30 40 50 60 70 80 RuralUrban Sierra Leone (DHS 2008) Niger (DHS 2006) Nicaragua (DHS 2006) Mozambique (DHS 2003) Mali (DHS 2006) Madagascar (DHS 2008-09) Haiti (Mortality and Morbidity Survey 2005-06) Ethiopia (DHS 2005) Burkina Faso (DHS 2003) Pe rc en ta ge G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 11 1.2.3 number of GPRHCs stream 1 countries with service delivery points (sDPs) offering at least 3 modern methods of contraceptives3 This indicator assesses the percentage of service delivery points (SDPs) that report the availability of at least three types of modern methods of contraceptives. It allows a country to better understand the extent to which quality contraceptive services are being made available and accessible to their population, which will impact CPR in the long run. Ensuring the availability of contraceptives and choice of methods at every facility that offers health services is the foundation for improving reproductive health and rights. As had been mentioned before, to ensure standardisation and comparability among countries, a standardised methodology was designed for the conduct of this survey in the 11 Stream 1 countries for 2010. Summaries of data from the individual survey reports, as shown in Table 6 show that the number of service delivery points (SDPs) offering at least three modern contraceptive methods varied from country to country – but had shown a steady increase in 2010 for all Stream 1 countries (except Sierra Leone where the survey the year before had been on availability of two rather than three modern methods of contraception). Three modern contraceptive methods were available in more that 80 percent of primary-level SDPs surveyed in Stream 1 countries, the disaggregated data revealed. The exceptions were Madagascar and Sierra Leone (50 and 70 percent, respectively) as shown in Table 7. In Ethiopia, Mongolia and Mozambique, three modern methods of contraceptives were available in 100 percent of the tertiary-level SDPs. In general higher level facilities appear to be better stocked with contraceptives than the lower level facilities. The Haiti survey report indicates that male condoms, pills and injectables were offered in more than 90 percent of SDPs but female condom, vasectomy and the IUD were provided in less than 35 percent of SDPs. In the south-east, north, north-west and west of Haiti, over 10 percent of SDPs offer less than three methods. Public SDPs offer more contraceptives in Haiti than private SDPs. The same can be said about SDPs located in urban areas which provide far more methods than those located in rural area. 3 The modern methods under consideration are i) Male condoms, ii) Female Condoms , iii) Oral Pills , iv) Injectables , v) IUDs , vi) Implants, vii) Sterilisation for Females and viii) Sterilisation for Male Table 6: Percentage of service delivery points (SDPs) offering at least three modern methods of contraception in GPRHCS Stream 1 countries Country Baseline 2009 2010 Target (2013) Burkina Faso NA 80.4 (2009) 93.5 100 (2012) Ethiopia 60.0 (2006) 90.0 98.0 100 (2010) Haiti 0 NA 93.0 90.0 (2013) Laos 96.0 (2006) 91.0 93.0 100 (2012) Madagascar - 30.8 47.8 100 (2012) Mali - 100 97.0 NA Mongolia 98.0 NA 93.5 100 Mozambique 95.7 (HIS 2008) NA 96.5 100 Nicaragua 66.6 (2008) 92.0 99.5 100 Niger 56.0 (2008) NA 80.9 90.0 Sierra Leone - 88.0* 87.2 100 Source: GPRHCS 2010 country and related sample survey reports Note: 2010 data from sample surveys reports of each country conducted using standardized methodology * Proportion with at least two modern methods available 12 Target (2013) Sierra LeoneNicaragua Figure 8: Percentage of SDPs offering at least three modern methods of contraception in GPRHCS selected Stream 1 countries Source: GPRHCS 2010 country and related sample survey reports 0 20 40 60 80 100 120 20102009Baseline (2008) MadagascarLaosEthiopiaBurkina Faso Selected GPRHCS Stream 1 countries (survey & date) Pe rc en ta ge Table 7: Percentage of sampled SDPs by type of facility, offering at least three modern methods of contraception in GPRHCS Stream 1 countries in 2010 Country Primary Secondary Tertiary Burkina Faso 92 100 100 Ethiopia 97.6 98.4 100 Haiti 91.0 94.0 93.0 Laos 89.0 95.0 94.0 Madagascar 50.0 50.6 61.8 Mali 88.0 88.0 73.0 Mongolia 92.0 100 100 Mozambique 96.7 95.0 100 Nicaragua 99.5 100 - Niger 80.0 100 100 Sierra Leone 70.0 76.0 78.0 Source: GPRHCS 2010 country and related sample survey reports * Tertiary facilities are cardiology, dermatology and physical medicine and these do not stock essential maternal health medicines. G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 13 1.2.4 number of GPRHCs stream 1 countries where 5 life-saving maternal/RH medicines4 from the list of UnfPa priority medicines are available in all facilities providing delivery services Reducing the maternal mortality ratio (MMR) is a key goal for all Stream 1 countries supported by the GPRHCS. High rates of maternal mortality continue to plague most of the Stream 1 countries. Women, particularly in rural areas, die in high numbers from lack of access to quality maternal health services. Situation analyses such as national Emergency Obstetric and Newborn Care (EmONC) needs assessments often reveal that facilities which provide delivery services are not adequately stocked with the necessary supplies and medicines to save a woman’s life during childbirth. UNFPA, in collaboration with WHO and other partners, has identified 10 priority and essential medicines that must be available in all facilities where births take place, to decrease the number of maternal and infant deaths. The GPRHCS is working to ensure that these medicines are routinely available in adequate quantities and quality at all maternal health facilities. This indicator is a measure of the functionality of the health system, and the ability of countries to forecast their needs and then procure and manage commodities to efficiently meet those needs. Given the inherent difficulty in tracking all 10 essential medicines, the number of medicines has been restricted to five in this indicator. Table 8 shows the results of the survey conducted in 2010 on the availability of five life-saving maternal/ RH medicines (including three UNFPA priority medicines) in GPRHCS Stream 1 countries. The results show that most Stream 1 countries (10 out of 11) had these medicines available in 50 percent or more of facilities. Availability was low in Lao PDR (13%), probably because for Lao PDR the sample contained a disproportionate number of health centres that did not have these medicines available. For the other Stream 1 countries, the percentage ranged from 51.4 percent in Burkina Faso to 99.5 percent in Nicaragua – showing that Nicaragua has already achieved the target set for 2011. 4 The 10 UNFPA Priority medicines are i) Amoxicillin , ii) Azithromycine, iii) Benzathine Penicillin, iv) Cefexime, v) Clotrimazole, vi) Ergometrine, vii) Iron/Folate, viii) Magnesium Sulfate, ix) Metronidazole and x) Oxytocine Table 8: Percentage of SDPs with five life-saving maternal/RH medicines (including three UNFPA priority medicines) available in GPRHCS Stream 1 countries Country 2010* Target (2013) Burkina Faso 51.4 Y** Ethiopia 76.1 100 Haiti 60.8 NA Lao PDR 13.0 Y** Madagascar 66.6 100 Mali 92.0 NA Mongolia 76.8 98.0 Mozambique 68.4 NA Nicaragua 99.5 100 Niger 60.6 100 Sierra Leone 75.5 100 *Source: GPRHCS 2010 country and related sample survey reports ** National average 80%, Prov: 100%, Dist: 90% HC: 30% 14 In terms of urban and rural disparities, the results of the survey as shown in the Figure 9 indicate that in Mongolia more rural SDPs had the required life-saving maternal health medicines available than in urban areas. The opposite is the case in Ethiopia, Haiti, Lao PDR, Madagascar and Mozambique, where more SDPs in urban areas had the required medicines than those in the rural areas. The disparity was found to be higher in Ethiopia with 93.9 percent of urban SDPs compared to 45 percent of rural SDPs having available 5 life- saving maternal/RH medicines (including three UNFPA priority medicines. 1.2.5 number of stream 1 countries with service delivery points with ‘no stock-outs’ of contraceptives within last 6 months The GPRHCS supports governments in making sure that reproductive health commodities and services are available on a consistent and reliable basis with no stock-outs. These efforts involve the timely response to reproductive health commodity requirements to avert shortfalls; capacity development to improve procurement and management systems for reproductive health. For many countries, supply management systems are still not fully functional at every level of the health system. The number of stock-outs experienced in a country reflects the level of functioning of the Logistics Management System (LMS) at central and district levels. Table 9 indicates that ‘no stock-out’ rates improved for most Stream 1 countries. In 2010, ‘no stock-out’ rates higher than 80 percent were reported for Nicaragua (99.7%), Ethiopia (99.2%), Niger (99.1%), Mongolia (97.6%) and Burkina Faso (81.3%). On the other hand, four countries experienced ‘no stock out’ rates of less than 50% in the six months preceding the survey. These were Mozambique (24.1%), Lao PDR (36%), Sierra Leone (41.4%) and Mali (46%). In terms of types of service delivery points, and in Lao PDR, 100 percent of the national hospitals and 80 percent of the provincial hospitals and MCH clinics, all of which are urban-based, had stocks of all contraceptives at the time of the survey. About 72 percent of SDPs at district level had at least three modern contraceptive methods. For Ethiopia, in the six months prior to the survey, no stock-outs of modern contraceptive methods were reported in all of the primary and tertiary level SDPs, and only 3.2 percent of secondary level SDPs experienced stock-out. Regarding urban rural stock status, only 2.6 percent of rural Figure 9: Percentage of SDPs within urban and rural areas with five life- saving maternal/RH medicines (including three UNFPA priority medicines) available in GPRHCS Stream 1 countries in 2010 Source: GPRHCS 2010 country and related sample survey reports 0 10 20 30 40 50 60 70 80 90 100 NicaraguaMozambiqueMongoliaMaliMadagascarLaosHaitiEthiopia RuralUrban Selected GPRHCS Stream 1 countries (survey & date) Pe rc en ta ge G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 15 SDPs experienced stock-out of any modern contraceptive method in the six months prior to the survey. In Sierra Leone, two districts – the Western Urban Area (where the capital Freetown is located) and Bombali district – experienced no stock-out of any contraceptive commodity or service that they offer in the six months prior to the survey. This was said to be attributable to the fact that these two geographic subdivisions of the country were the model districts for UNFPA reproductive health interventions for the Country Programme (2007-2010). In addition, female and male condoms, followed by IUDs were the methods most regularly in stock. Injectables and female sterilization techniques experiences the most stock-outs. In Mozambique, 64.8 percent of primary level SDPs had no stock-out of male condoms; 53.8 percent had no stock-out of oral pills; 46.2 percent had no stock-out of IUDs; 54.9 percent had no stock-out of injectables; and, 39.6 percent had no stock-out of female condoms. The most frequently cited reasons for stock-out were inadequate logistics management (e.g. shortage of supply, delay in placing orders and delivery of commodities), and the lack of resources to procure commodities. For certain contraceptive methods like IUDs, there were limited numbers of trained personnel to provide this service in some SDPs. On the whole, the steady reduction in the number of facilities experiencing stock-outs of contraceptive commodities amongst the Stream 1 countries is very encouraging, and attests to system improvements which in the long run will contribute to the availability and accessibility of commodities in many of these countries. 1.2.6 funding available for contraceptives including condoms Funding available globally for contraceptives and condoms is shown Table 10 (figures for 2010 were still being calculated at the time this report was finalized). This indicator, which focuses on trends in commodity support among major donors, measures the level of external assistance to countries and the availability of donor funds for procurement of contraceptives, including condoms. UNFPA has been tracking donor support for contraceptives and condoms for STI/HIV prevention since 1997. From its donor database, the UNFPA Commodity Security Branch publishes an annual report with information on the trends and gaps between estimated needs and actual donor support. Table 9: Percentage of SDPs reporting ‘no stock-out’ of contraceptives within the last six months in GPRHCS Stream 1 countries Country Baseline 2009 2010**** Target (2013) Burkina Faso NA 29.2 (2009) 81.3 100 (2012) Ethiopia 60.0 (2006) 90.0 (2009) 99.2 100 (2010) Haiti NA NA 52.5 NA Lao PDR NA 20.0* 36.0 80.0 Madagascar 63.3 (2008) 74.4(2009) 79.6 96.0 (2012) Mali - 100 46.6 NA Mongolia 100 100 97.6** 100 Mozambique NA NA 24.1 NA Nicaragua 66.6 (2008) 81.0 (2009) 99.7 92.0 Niger 0 100 (2009) 99.1*** 100 (2012) Sierra Leone - 77.0 41.4 100 * For Lao PDR, the break down were as follows in 2009; national = 20%, provincial hospitals = 50% district hospitals = 19% and health centre = 15% ** 100% in both tertiary and secondary facilities but 92 % in primary facilities *** 100% for tertiary institutions and 95.2% for secondary and 99.3% for primary ****GPRHCS 2010 country and related sample survey reports 16 This report highlights trends in support from bi-lateral donors, multi-lateral donors and social marketing organizations. The report is intended mainly for use in planning contraceptive supply, advocacy and resource mobilization. The ‘value added’ by publishing this annual document is its significant impact on issues related to RHCS in the areas of policy dialogue, advocacy, contribution to advancing the MDGs and interagency work. Table 10: Trends in donor expenditure by commodities, 2005-2009 expenditure, in millions of Us$ Donors 2005 2006 2007 2008 2009 USAID 68.8 62.8 80.9 68.9 87.5 UNFPA 82.6 74.4 63.9 89.3 81.1 PSI 28.8 30.6 24.9 14.1 17.9 BMZ/KFW 13.1 23.6 24.6 15.5 16.2 DFID 4.6 12.1 22.5 11.1 13.0 Others* 9.6 5.1 6.4 14.9 23.0 Total 207.5 208.6 223.2 213.7 238.8 * Includes IPPF, MSI, Japan, Netherlands, and others Table 11: Trends in commodity support among major donors, 2005-2009 expenditure, in millions of Us$ Method 2005 2006 2007 2008 2009 Male condoms 75.7 68.9 83.5 65.7 72.6 Oral contraceptives 55.9 58.2 52.3 52.8 45.8 Injectables 58.9 58.4 53.3 53.2 52.6 Implants 5.5 7.2 16.2 23.3 33.4 Female condoms 5.3 9.0 12.8 14.3 29.2 IUDs 4.3 4.0 2.5 1.7 3.2 Other* 1.8 2.8 2.6 2.7 2.1 Total 207.5 208.6 223.2 213.7 238.8 *Includes emergency contraceptives, vaginal tablets, foams/jellies, and sampling/testing G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 17 Tables 10 and 11 illustrate trends in commodity expenditures among major donors from 2000 to 2009. Together, USAID and UNFPA account for about 70 percent of overall donor support for contraceptives and condoms for STI/HIV. Some highlights of the 2009 donor report include: • Donor support in 2009 was $238.8 million, approximately an 11 percent increase from 2008; • There was a more diversified commodity mix in 2009. Male condoms led (30%), followed by injectables (22%), oral contraceptives (19%), implants (14%), and female condoms (12%). By comparison in 2008, 80 percent of donor support was allocated to only three types of commodities (male condoms, oral contraceptives and injectables); • Donor support for female condoms more than doubled (from 14 million in 2008 to 29 million in 2009), while there were notable increases for IUDs and implants; • Donor share requirements would nearly need to double in order to meet projected contraceptive need (estimated at $408 million) in 2015. Although funding is increasing, it still has not met the need that exists. At least 215 million women in the developing world want to delay or avoid pregnancy but are not using family planning. The demand for modern contraception continues to far outstrip supply. It is estimated that to meet current unmet need and keep pace with population growth, numbers of contraceptive users will increase by over 30 per cent during the next 15 years. 0 10 20 30 40 50 60 70 80 90 100 OtherIUDsFemale condomsImplants InjectablesOral contraceptivesMale condoms 20092008200720062005 Figure 10: Donor expenditure by commodities, 2005-2009 Year D on or E xp en di tu re ( pe rc en ta ge ) 18 Health worker keeps records in Niger. Photo by Giacomo Pirozzi/Panos Pictures oUTPUT-leVel ResUlTs seCTIon TWo G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 19 Section Two looks at the programme’s four outputs: (1) Country RHCS strategic plans developed, coordinated and implemented by government with their partners; (2) Political and financial commitment for RHCS enhanced; (3) Capacity and systems strengthened for RHCS; (4) RHCS mainstreamed into UNFPA core business. 2.1 Output 1: Country RHCS strategic plans developed, coordinated and implemented by government with their partners Supporting government-led processes to formulate and implement RHCS activities as an integral part of health sector interventions, and putting in place structures that will institutionalize such processes are key strategies of the GPRHCS, especially in Stream 1 countries. The GPRHCS therefore helps government to prepare and implement RHCS strategies and action plans, and to integrate RHCS issues into key sectoral strategies. It also helps to establish functional coordinating bodies under the leadership of government and with the participation of key stakeholders as per country requirement. These bodies help to ensure resource mobilization and implementation of activities, as well as their government’s recognition of the need to put RHCS high on the national agenda. Essential in all this is to strive to include RH commodities, including contraceptives, on the Essential Medicines List (EML) of each country. 2.1.1 number of countries where RHCs strategy is integrated with national RH/sRH,HIV/aIDs, Gender & Reproductive Rights strategies This indicator seeks to assess the holistic approach adopted by each country (Streams 1 and 2) in implementing RHCS and other closely related and complementary interventions in the areas of RH health, HIV/AIDS and gender. The indicator assesses the existence of the three thematic strategies and most importantly the inclusion of appropriate RHCS issues in each of the thematic strategies. Sectoral strategies Countries RH/SRH HIV/AIDS Gender Burkina Faso Y Y Y Haiti Y Y N Ethiopia Y Y Y Lao PDR Y Y N Madagascar Y Y N Mali Y Y Y Mongolia Y Y Y Mozambique Y Y Y Nicaragua Y N N Niger Y Y Y Sierra Leone Y Y Y Total for ‘Yes’ 11 10 7 Table 12: RHCS strategy integrated into sectoral strategies in Stream 1 countries Source: * Population and Development Branch, Have we progressed on MDG4b? The empirical evidence in advancing Universal Access to Reproductive Health, Technical Division, UNFPA New York, June 2010. ** Data from Macro International Inc, 2011. MEASURE DHS STATcompiler. http://www.measuredhs.com, March 16 2011 20 All of the Stream 1 countries have RHCS integrated into RH/SRH Strategies. Ten out the 11 Stream 1 countries have RHCS issues integrated into HIV/AIDS strategies, and only seven of them have RHCS key issues integrated into gender strategies. For the Stream 2 countries, with the exception of Djibouti, all the other countries have integrated GPRHCS key issues into at least one of the three sectoral strategies. Among Stream 2 countries, 23 indicated that they have integrated RHCS key issues into HIV/AIDS strategies, while in the case of the gender strategy 14 had done so. Sectoral strategies Countries RH/SRH HIV/AIDS Gender Benin Y Y N Bolivia Y Y N Botswana Y Y Y Burundi Y Y N Central African Republic Y Y Y Chad Y Y NA Congo Y Y Y Côte d’Ivoire Y Y Y Democratic Republic of the Congo Y Y Y Djibouti N N N Ecuador Y Y Y Eritrea Y Y Y Gabon Y Y Y Gambia Y Y NA Ghana N Y Y Guinea Y N N Guinea-Bissau Y N N Lesotho Y Y N Liberia Y Y N Malawi Y Y N Mauritania Y Y Y Namibia Y Y Y Nigeria Y NA Y Sao Tome and Principe N N N Senegal Y Y Y Swaziland Y Y N Uganda Y Y Y Zambia Y Y N Zimbabwe Y N N Total for ‘Yes’ 26 23 14 Table 13: RHCS strategy integrated into sectoral strategies in Stream 2 countries G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 21 There are several reasons why RHCS issues are not integrated in sectoral strategies, including the absence of such a strategies (Chad, Liberia and Swaziland indicated that there was no gender mainstreaming strategy); lack of resources or funds as indicated by Benin; the need to revise an existing strategy often regarded as obsolete in Burundi and Djibouti; and, limited human capacity as noted by Democratic Republic of Congo, Malawi and Namibia. 2.1.2 number of countries with strategy implemented (national strategy/action plan for RHCs implemented) In addition to ascertaining the existence of a RHCS strategy, this indicator seeks to determine whether actions were taken during the year to implement aspects of the strategies and action plans especially in the GPRHCS Stream 1 and 2 countries. The number of Stream 1 countries that have developed RHCS strategies or action plans increased to 10 out of 11 countries in 2010, compared to 9 out of 11 countries in 2009. Mali now has an RHCS strategy/ plan but Haiti has not yet developed one. Regarding implementation, RHCS strategies/action plans were implemented in 10 countries in 2010, up from seven in 2009, as shown in Table 14. Table 15 shows that an RHCS strategy/action plan exists in 26 Stream 2 countries. With the exception of two countries (Uganda and Côte d’Ivoire) all the other countries reported the implementation of RHCS strategies/action plans. The focus in 2011 is to support the formulation and implementation of RHCS strategies in Stream 2 countries such as Congo, Gambia, Lesotho, Liberia, Mauritania and Zambia, where in some cases though plans exist, they are to a larger extent not being implemented. Have RHCS strategy/ action plan If yes, elements being implemented National country coordinating mechanism exists If yes, RHCS issues included in institutional mechanism If yes, does mechanism have TOR Countries 2009 2010 2009 2010 2009 2010 Burkina Faso Y Y Y Y Y Y Y Y Ethiopia Y Y Y Y Y Y Y Y Haiti N N N N N N N N Lao PDR Y Y Y Y Y Y Y Y Madagascar Y Y Y Y Y Y Y Y Mali N Y N Y Y* Y Y Y Mongolia Y Y Y Y Y Y Y Y Mozambique Y Y N Y Y Y Y Y Nicaragua Y Y N Y Y Y Y Y Niger Y Y Y Y Y Y Y Y Sierra Leone Y Y Y Y Y Y Y Y 2010 Total for ‘Yes’ - 10 - 10 10 10 10 10 2009 Total for ‘Yes’ 9 - 7 - 9 - - - ** For contraceptives only Table 14: RHCS strategies/action plans and coordinating committees in Stream 1 countries 22 2.1.3 number of countries with functional coordination mechanism on RHCs or RHCs is included in broader coordination mechanism This indicator determines the existence of a coordinating mechanism and also assesses the existence and the effectiveness of the mechanism used to bring country-level partners together to work on RHCS issues. It provides an indication of GPRHCS countries with bodies or entities that facilitate the interaction of stake- holders and oversees joint planning and decision making on RHCS issues. Countries Have RHCS strategy/ action plan If yes, elements being implemented National country coordinating mechanism exists If yes, RHCS issues included in institutional mechanism If yes, does mechanism have TOR Benin Y Y Y Y N Botswana Y Y Y Y Y Burundi Y Y N - - Central Africa Republic Y Y Y Y Y Chad Y Y Y Y Y Congo Y Y Y Y Y Côte d’Ivoire Y N Y Y Y DRC Y Y Y Y Y Djibouti Y Y N N N Eritrea Y Y Y Y Y Gabon Y Y Y Y Y Ghana Y Y Y Y Y Guinea Y Y N N N Guinea Bissau Y Y Y Y - Lesotho Y N Y N Y Liberia N NA Y Y Y Malawi Y Y Y Y Y Mauritania N NA Y Y Y Namibia Y Y Y Y - Nigeria Y Y Y Y Y Sao Tome and Principe Y Y N N N Senegal Y Y Y N N Swaziland Y Y Y Y Y Gambia N NA Y Y N Uganda Y Y Y Y N Zambia Y Y Y Y Y Zimbabwe Y Y Y Y Y Bolivia Y Y Y Y Y Ecuador Y Y Y Y Y Total for ‘Yes’ 26 24 25 23 20 Table 15: RHCS strategies/action plans and coordinating committees in Stream 2 countries G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 23 Ten of the 11 Stream 1 countries have mechanisms in place for coordinating RHCS issues with terms of references and with broad-based memberships (see Table 14). Haiti does not have such a mechanism. At least four meetings were held in the countries, with the exception of Burkina Faso where no meetings were held and Mali where only one meeting was held in 2010. This is an improvement compared to 2009, when three out of the 11 Stream 1 countries had no functional coordinating mechanisms on RHCS or had RHCS issues included in a broader coordination mechanism. For the Stream 2 countries, Table 15 further shows that national country coordinating mechanisms are reported to exist, with RHCS issues included as part of their core business, in 25 countries. However, two countries (Benin and Gambia) indicated that these committees have no terms of reference (TOR). Also, in 11 of the Stream 2 countries with coordination mechanisms, no meetings have been held. The lack of TORs and meetings not being held indicate that the committees are less functional. 2.1.4 number of countries with essential RH commodities in eMl (Contraceptives and life-saving maternal/RH medicines in eMl) The indicator provides a measure for the progress made by GPRHCS countries in establishing an essential medicines list (EML) and, most importantly, in ensuring that all the modern contraceptives and the 10 priority reproductive health medicines are included on the EML for each country. Essential medicines lists exist in all the Stream 1 countries and the lists contain all UNFPA and WHO essential and life-saving maternal health medicines. Two countries, Mozambique and Nicaragua, reported that the EMLs do not contain all the modern contraceptive methods. This is because in the case of Nicaragua, female condoms are not included on the list and in the case of Mozambique the list does not include implants. All of the Stream 2 countries that provided reports (26 countries), indicated the existence of an EML, and that the list contained essential life-saving maternal health medicines. Namibia reported it does not have an EML. Only four countries (Congo, DRC, Djibouti and Gambia) reported that the list did not contain all the modern contraceptive methods. 2.2 Output 2: Political and financial commitment for RHCS enhanced In moving towards a more sustainable approach, progress can be measured by several indicators that symbolize the commitment of national governments to support and finance RHCS. This second GPRHCS output seeks to measure the political and financial commitment particularly of the national governments to RHCS issues at the country level. The GPRHCS strongly supports countries that are implementing broad- based efforts to reform and improve health systems and services, and advocates for the mainstreaming of RHCS into such processes. Inclusion of RHCS in the national planning process is an important step in ensuring that reproductive health issues are national priorities and budgeted for accordingly. Key indicators identified to gauge the achievement of this output include availability of funding for GPRHCS through multi-year pledges, signing of MOUs with Stream 1 country governments, mainstreaming of RHCS issues in policies and strategies at the regional level, inclusion of RHCS priorities in national and sectoral policies and plans, and the maintenance of allocation within SRH/RHCs budget line for contraceptives at country level. While the establishment of a budget line for RH commodities is considered to be a powerful indication of the fact that a government has chosen to prioritize RHCS, maintaining the funds allocated within the budget is an indication of sustained commitment particularly during this period of global economic downturn. 2.2.1 funding mobilized for GPRHCs on a reliable basis (e.g. multi-year pledges) This indicator provides information on actual resources mobilized from pledges made by donors for the implementation of the GPRHCS. It ascertains the results of resource mobilization efforts undertaken by UNFPA Commodity Security Branch to support countries for the implementation of the GPRHCS. 24 Since 2008, over $223 million has been mobilized by UNFPA from various donors. As shown in Figure 11, this amount has increased steadily from $55.3 million in 2008 to $95.5 million in 2010. The amount mobilized for 2010 was from six donors countries; with the Netherlands and the United Kingdom accounting for nearly 82 percent of the resources mobilized for the year. Although there has been a significant increase in recent years, prospects for the future funding of the GPRHCS, in line with other aid/ donor dependent funds, is likely to decrease in spite of the encouraging results being clearly documented in this and other reports. This is a largely attributable to the global financial crisis, which has limited the ability of many funding governments to commit resources to aid as used to be the case. The GPRHCS is fully aware of this and efforts are being intensified in 2011 to expand the donor base, demonstrate and disseminate results, and also secure the interest of non-traditional partners in order to ensure that support to countries, particularly those in most need, continues uninterrupted. 0 10,000,000 20,000,000 30,000,000 40,000,000 50,000,000 60,000,000 70,000,000 80,000,000 90,000,000 100,000,000 201020092008 Figure 11: Total Resources for the GPRHCS (2008 to 2010) A m ou nt m ob ili se d (U S$ ) Year Funding Source 2008 2009 2010 Total Canada - 1,996,805 - 1,996,805 Finland 2,590,674 - - 2,590,674 France - - 272,109 272,109 Ireland 1,557,632 - - 1,557,632 Luxembourg 557,103 591,716 544,218 1,693,037 Netherland 34,114,379 45,831,976 39,807,880 119,754,235 Spain 7,772,021 7,396,450 - 15,168,471 Spain (Catalonia) - 563,471 420,168 983,639 UK 8,695,652 16,474,465 54,464,816 79,634,933 Total 55,287,461 72,854,883 95,509,191 223,651,535 Table 16: Amount mobilized from donor countries in US$ G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 25 2.2.2 UnfPa signed MoUs with stream 1 country governments The indicator assesses the existence of an agreement between government and UNFPA on the implementation of GPRHCS. The MOU spells out the expectations of each party and therefore provides a formal basis for cooperation and commitment for the achievement of the GPRHCS goals in Stream 1 countries. All the 11 Stream 1 countries indicated that an MOU has been signed between UNFPA and government. The signing of MOUs provides a formal basis for ensuring governments’ commitment to the implementation of GPRHC. LOUs/MOUs have also been formalized with many Stream 2 countries in 2010. Experiences with Stream 1 countries have shown that this serves to formalize the arrangement and commit governments to prioritizing programmes in this area and, indeed, committing their domestic resources towards the achievement of identified common goals and objectives. 2.2.3 RHCs mainstreamed in regional policies and strategies through UnfPa work with global, bilateral and regional organizations/partners The indicator assesses the outcome of efforts made by UNFPA, especially at the regional level to infuse RHCS issues into the policies, plans and activities of global, bilateral and regional organizations/partners. It also focuses on the role of UNFPA through the GPRHCS in building RHCS capacities in for instance regional economic communities or commissions. Partners such as the Regional Economic Communities (RECs) are making RHCS their own by including it in policies and strategies at the regional level. For several years, the GPRHCS has been working very closely with the following institutions: West African Health Organisation (WAHO), East African Community (EAC), the Intergovernmental Authority on Development (IGAD), and the South African Development Community Parliament (SADC/PF). Most have established their regional and strategic action plans for RHCS and SRH. Examples include the West African RHCS Strategy developed and implemented by WAHO, the East Africa RHCS/SRH strategic plan being developed by EAC, and the RHCS/SRH plan developed by IGAD. This collaboration has continued, as in the examples below from 2010. In Johannesburg in May 2010, a joint planning meeting of the Regional Economic Communities led to development of joint action plans, which were agreed upon and will be implemented in 2011. In a formal Communiqué signed by the RECs, various actions points were agreed upon at regional and sub-regional levels, among which were need for UNFPA to support with capacity building and evidence based data; promoting the production and utilisation of data for evidence based sub regional interventions; promoting and/or conducting regular inter REC-fora for exchange and sharing of experiences. Representatives of IGAD, a regional development organization in East Africa, and EAC, a regional intergovernmental organization, held a meeting with UNFPA management to discuss future areas of collaboration with UNFPA. The GPRHCS also provided significant support to IGAD in support of their work with vulnerable populations in IGAD hot spots, including support to service providers on SRH/HIV with training and provision of RH kits. UNFPA provided technical support for WAHO for developing comprehensive and harmonized RH Action Plans in ECOWAS member states, and welcomed WAHO staff to a training-of-trainers session on LMIS and computer software. Support was provided in 2010 to the SADC Executive Secretariat for developing regional guidelines for sustained access, availability, acceptability and use of condoms – along with development of an inter- agency roster of consultants for comprehensive condom programming (CCP). The work is related to a grant received by SADC from the African Development Bank. 26 2.2.4 number of countries that have included RHCs priorities in; a) PRsP and b) Health sector policy and plan and sWaPs For RHCS issues to be given priority in plans programmes and budgets, stakeholders should advocate for and work towards their inclusion in key country level strategic planning documents, including Poverty Reduction Strategy Papers (PRSPs); national health sector policies and plans; and health sector wide approaches for the health sector. The level of inclusion of RHCS issues in these documents provides a clue about the level of commitment and importance attached to RHCS issues in the country. In 2010, RHCS issues were integrated into PRSPs in 10 Stream 1 countries (with the exception of Mozambique), compared to eight Stream 1 countries in 2009. For Stream 2 countries, only 12 out of the 27 countries have RHCS issues integrated into PRSPs or national development plans. As mentioned before, inclusion of RHCS in the national planning process is an important step in ensuring that reproductive health issues are national priorities and budgeted for accordingly. Inclusion within the PRSPs and processes is of particular strategic importance given that this is at the highest level of national planning. This is often difficult to achieve, however, and opportunities to intervene in this national process come but once every five years. It is therefore of singular interest to note the progress made amongst Stream 1 countries in this area in 2010. Two additional Stream 1 countries (Ethiopia and Nicaragua) succeeded in having RHCS included in their PRSPs. In the case of Stream 2 countries, 14 have RHCS issues integrated in their PRSPs. Reasons why RHCS issues are not integrated into PRSPs include the nonexistence of PRSPs in some countries (as indicated by Benin, Mauritania and Zambia), and the minimal involvement of RHCS technical experts in the formulation of PRSPs as indicated by Malawi and Nigeria. Table 17 shows that in 2010, all Stream 1 countries, as was the case in 2010, have RHCS issues included in health policies and plans; eight countries responded that RHCS issues were included in sector-wide approaches (SWAp) in health. Haiti, Mozambique and Sierra Leone reported the nonexistence of a SWAP for the health sector. All Stream 2 countries have RHCS key issues included in their health sector policies and plans, with the exception of Burundi, Djibouti and Namibia. Also, 21 Stream 2 countries have RHCS issues in their SWAps, as shown in Table 18. Countries RHCS issues in PRSP RHCS issues in health policy & plan RHCS issues in SWAp (for health) Burkina Faso Y Y Y Ethiopia Y Y Y Haiti Y Y N Laos Y Y Y Madagascar Y Y Y Mali Y Y Y Mongolia Y Y Y Mozambique N Y N Nicaragua Y Y Y Niger Y Y Y Sierra Leone Y Y N 2010 Total for ‘Yes’ 10 11 8 Table 17: RHCS issues included in PRSPs, health policies and SWAps in Stream 1 countries G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 27 2.2.5 number of countries maintaining allocation within sRH/RHCs budget line for contraceptives This indicator is used to assess the willingness of governments to consistently allocate resources for the procurement of contraceptives. Analysis is mindful of the fact that the inclusion of RHCS issues into key national planning documents alone is not the only requirement for actions to be taken to address RHCS concerns, and that a budgetary allocation for the procurement of RHCS including contraceptives is also a strong indication of government commitment. Table 18: RHCS issues included in PRSPs health policies and SWAPs in Stream 2 countries Countries RHCS issues in PRSP RHCS issues in health policy & plan RHCS issues in SWAP (for health) Benin N Y Y Bolivia N Y Y Botswana Y Y Y Burundi N Y N Central Africa Republic Y Y Y Chad Y Y - Congo Y Y - Côte d’Ivoire N Y Y Democratic Republic of Congo Y Y Y Djibouti N N N Ecuador Y Y Y Eritrea Y Y Y Gabon Y Y Y Gambia N Y Y Ghana Y Y Y Guinea N Y Y Guinea Bissau N Y Y Lesotho N Y Y Liberia N Y N Malawi N Y Y Mauritania N Y N Namibia - - - Nigeria N Y Y Sao Tome and Principe Y Y Y Senegal Y Y Y Swaziland Y Y - Uganda Y Y Y Zambia Y Y Y Zimbabwe Y Y Y Total for ‘Yes’ 15 27 21 28 Ten Stream 1 countries indicated that their government budget contains line item for the procurement of contraceptives, the exception being Sierra Leone. The amount allocated was reported to have increased, compared to last year, in Mozambique, Mongolia and Niger; it was said to have decreased in Burkina Faso, Mali and Nicaragua. For Ethiopia, Lao PDR and Madagascar the amount was said to have remained unchanged. For Stream 2 countries, 17 countries have contraceptives included in the in national budget line. Six Stream 2 countries (Guinea Bissau, Liberia, Mauritania, Swaziland, Uganda and Zambia) reported that the budget line increased. The amount allocated remained same in nine countries and decreased for two countries (Central African Republic and Botswana) compared to last year. 2.3 Output 3: Capacity and systems strengthened for RHCS It is only by strengthening country capacity that reproductive health commodity security can be assured. Building in-country capacity allows for sustainable progress and helps ensure that commodities procured can be distributed in an efficient and effective manner. It also helps to ensure that issues of demand and equity are given due cognizance in the provision of services. It is for this reason that GPRHCS funds country efforts to train staff and strengthen systems and institutions. The achievement of this output is measured by examining efforts relating to strengthened forecasting and procurement systems as well as the existence of a well-adapted and functioning logistics management information system within GPRHCS countries. 2.3.1 number of countries using accessRH for procurement of RHCs The indicator measures the extent to which AccessRH has been adopted by countries for the procurement of RHCs and the extent to which this has reduced the lead time by 20 percent (time between ordering the commodity and its arrival in the country). It therefore assesses the effectiveness of the new procurement modality that is expected to address delays in procurement. AccessRH, is an innovative procurement mechanism supported by key global partners working in the area of procurement. The GPRHCS provided $6 million for this initiative in 2010. AccessRH is expected to commence support to countries and partners in April 2011. Since the initiative is yet to be functional, no country reported using AccessRH for the procurement of reproductive health commodity supplies. The AccessRH project, aims to improve access to quality, affordable reproductive health commodities and enhance delivery performance for low- and middle-income public sector entities and NGO clients. It also aims to increase information sharing and supply chain visibility for all reproductive health stakeholders. UNFPA was selected by the Reproductive Health Supplies Coaltion to implement this initiative as part of the operations of the Procurement Services Branch (PSB), and donors provided funding to cover 2010-2013. 2.3.2 number of pre-qualified suppliers of IUDs and condoms for use by UnfPa and partners The indicator measures the efforts of UNFPA-WHO partnership for ensuring quality supplies of IUDs and condoms from a set of prequalified and re-qualified manufactures. This exercise, carried out on a continuous basis, provides countries with a certified list of manufacturers for the procurement of the two commodities. To support national and global efforts to increase access and availability of reproductive health commodities, GPRHCS in collaboration with UNFPA’s Procurement Service Branch continued to ensure that RH commodities meet international quality standards at all times. Based on evaluation of products and equipment previously delivered, PSB with support from the GPRHCS, in the last few years has worked at strengthening quality assurance procedures in collaboration with major partners and stakeholder such as WHO, UNICEF, Global Fund and Family Health International. UNFPA continues to ensure reproductive health commodity security by the prequalification process for manufacturers of IUDs and condoms in line with WHO’s prequalification standards. By the end of 2010, 23 manufactures of condoms and eight manufacturers of IUDs had been assessed and services retained for use by UNFPA and partners. G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 29 2.3.3 number of stream 1 countries making ‘no ad hoc requests’ to UnfPa for commodities (non-humanitarian) This indicator assesses the extent to which countries effectively prepare procurement plans for their RH commodity needs at the beginning of the year such that no requests are made outside the plans (except for humanitarian situations). When countries are able to make good annual procurement plans and, most importantly, carry out actual procurement according to the plan , RH commodities will be expected to be always available for provision of services to clients (except in the case of humanitarian situations). Therefore, as countries are assisted to strengthen national systems for commodity security, one of the key expected results is the occurrence of ‘no stock-out’ for RH commodities, including contraceptives. Eight Stream 1 countries made no ad hoc requests for commodities; only Haiti, Mali and Mongolia reported that they made requests for RHCs in 2010. These three countries further indicated that steps such as training of government staff in procurement, putting in place and implementing procurement and distribution plans have helped to reduce the ad hoc requests they made during the year. Seventeen Stream 2 countries made no ad hoc requests for commodities in 2010, and about 24 countries have taken measures during 2010 to reduce ad hoc requests for RH commodities. Gabon indicated that stock-outs are averted by ensuring that there is a national budget line for the medicines and that estimation of three years needs for RH products are prepared. In Ghana, medium-term forecasting for three years; annual forecasting for each year, bi- annual review meetings and regular pipeline monitoring are carried out to avert stock-outs. In Liberia, Burundi, Central African Republic and Congo the measures taken to avert stock-out includes strengthening of forecasting, procurement and distribution systems for RH commodities. 2.3.4 number of stream 1 countries forecasting for RH commodities using national technical expertise Training of national experts to carry out forecasting for RHCS is an important strategy of building country capacity for reproductive health commodity security. The indicator therefore assesses the existence of national staff, in government institutions, that are responsible for forecasting RH commodity needs for their respective countries. Of the 11 Stream 1 countries, seven indicated that they had national technical expertise in the Ministry of Health or in other government agency for forecasting RH commodities for the respective countries. The following four countries did not indicate the existence of a national expert for forecasting for RH commodities: Lao PDR, Mongolia, Mozambique and Niger. Countries Expertise forecasting in MOH Expertise for procurement of RH commodities 2010 2009 2010 Burkina Faso Y Y Y Ethiopia Y Y Y Haiti Y N N Lao PDR N N Y Madagascar Y Y Y Mali Y N Y Mongolia Y N Y Mozambique N N N Nicaragua Y Y Y Niger N Y Y Sierra Leone Y Y Y Total for ‘Yes’ 7 6 8 Table 19: Stream 1 countries using national technical experts for forecasting and procurement of RH commodities 30 2.3.5 number of stream 1 countries managing procurement process with national technical expertise For each Stream 1 country, the indicator ascertains the existence of nationals responsible for procurement of RH commodities in a government agency. The indicator contributes to ascertaining the extent to which capacities of nationals have been built for managing procurement. This use of national for managing procurement processes is a key step to ensuring sustainability and country ownership and institutionalization of skills and capacities for RHCS. Nine Stream 1 countries reported that national technical expertise was present in the Ministry of Health or in another government agency for procurement of RH commodities in 2010. Two countries (Haiti and Mozambique) indicated that they did not have national technical experts for managing procurement. This was an improvement from 2009 when only six countries indicated that there was national technical expert for managing procurement processes for RH commodities. 2.3.6 number of stream 1 countries with functioning lMIs The Global Programme to Enhance RHCS provides capacity building support to countries for the strengthening of logistics management information systems (LMIS) for managing procurement and distribution of RH commodities. The indicator therefore measures the effectiveness of the LMIS in providing relevant information about the procurement and distribution of the RH commodities in terms of the ability of the system to provide data on current and up-to-date stock levels; data on distribution of essential life-saving medicines; data on distribution of modern contraceptives; number of users for each modern contraceptive method; and, product particulars including expiry date. Seven out of the 11 Stream 1 countries indicated that they had functioning LMIS. The seven countries indicated that the LMIS can provide figures on distribution of contraceptives, while five countries (Haiti, Ethiopia, Nicaragua, Niger and Sierra Leone) indicated that the system was capable of provide figures on distribution of essential life-saving medicines. Furthermore, four of the countries (Lao PDR, Madagascar, Mali and Nicaragua) with functional LMIS indicated that the system is capable of providing inventory and monthly consumption data. Five Stream 1 countries reported that the system can readily provide information on stock at all levels, five can readily provide information on the expiry dates of all products, and, two can readily provide information on number of users of each product. 2.3.7 number of stream 1 countries with co-ordinated approach towards integrated health supplies management system The indicator assesses the existence of a unified procurement and distribution system for health supplies that includes RH commodities, including modern methods of contraception and priority medicines. In many countries, contraceptive commodity logistic systems were largely parallel systems in response to donor demands and to the need for timely data for addressing logistic needs. To ensure efficiency and sustainability, there is a need for unified procurement and distribution systems that would cater for all commodities within the health system. The indicator therefore assesses the existence of such a unified mechanism for managing all health supply systems that takes into account the procurement and distribution of RH commodities. The responses provided by the countries indicated that six out of the 11 Stream 1 countries have coordinated and integrated health supplies management system; five countries do not (Burkina Faso, Haiti, Lao PDR, Monoglia and Mozambique). In five out of the six countries with a coordinated and integrated health supplies management system, the system contains (a) an integrated procurement mechanism for contraceptives and RH medicines and (b) an integrated supply/distribution mechanism for contraceptives and RH medicines (Ethiopia, Madagascar, Nicaragua and Niger). For Sierra Leone, the system contains an integrated supply/ distribution mechanism for contraceptives and RH medicines only. G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 31 2.3.8 number of stream 1 countries adopting/adapting a health supply chain management information tool Adopting or adapting a health supply chain management information tool into the national system is critical for the achievement of RH commodity security. The GPRHCS promotes computer-based logistics management information systems. Various types of computer software are in use, and the indicator assesses the existence of a computerized health supply chain management information system in the country through the use of any relevant software, including CHANNEL or PIPELINE, for example. All Stream 1 countries have adapted or adopted a computerized tool. CHANNEL software continues to be the most popular tool for adaption and, in some countries, use is being made of its web version. 2.4 Output 4: RHCS mainstreamed into UNFPA core business (UN reform environment) This output and related indicators focus on steps taken by UNFPA (Headquarters, Country and Regional Offices) to integrate RHCS issues into important United Nations planning documents and processes at the country level. The integration of key RHCS issues, into UN planning processes enables country offices mobilize resources, support programme planning, build capacity and provide technical assistance - all in support of assisting governments to achieve outcomes for reproductive health commodity security. 2.4.1 expenditure of UnfPa/Csb core resources for RHCs increased In addition to mobilizing resources from donors, UNFPA provides support to the branch that manages its commodity security functions. The indicator therefore provides information on the amount that UNFPA provides from core resources for implementing RHCS functions and activities Each year, UNFPA allocates core resources to its Commodity Security Branch principally as matching fund for the management and implementation of the GPRHCS. The amount increased from $1.33 million in 2008 to $2.12 million in 2009 and decreased slightly to $2.10 million in 2010. The slight decrease was due to reduction in resources mobilized as core funds as a result of the global financial downturn. 2.4.2 GPRHCs planning takes into account lessons learned in RHCs mainstreaming To improve the implementation of programme activities, lessons learned must be taken into account so as to ensure efficient use of resources for the achievement of outputs. This indicator assesses whether countries make use of key lessons learned for the previous year in the implementation of activities for the present year. In addition to all the Stream 1 countries, 17 out of the 27 responding Stream 2 countries indicated that they took into account lessons learned in 2009 for GPRHCS planning in 2010. Examples of lessons learned in Stream 1 countries include the following: In, Burkina Faso, some facilities has been found to lack sufficient life-saving maternal medicines in 2010 and, therefore, steps are being taken in 2011 to strengthen the capacity for procurement and distribution of essential maternal medicines. In Nicaragua, review of the previous year’s implementation revealed that adequate oversight was not being provided by existing coordination mechanisms and, in response, Nicaragua is establishing and strengthening coordination mechanisms, including at the sub-national level. In Niger, because of the low uptake of services by communities in the hard-to-reach areas, NGOs are being used to create demand for family planning and maternal health services within these areas. Similarly, lessons learned are being used in Stream 2 countries to improve on programme results. For example; to address the persistent commodity stock out situations in Central Africa Republic, surveillance mechanisms are being put in place to gather data and monitor stock levels and movement of commodities from warehouses to service delivery points. In the Gambia, where accurate forecasting of contraceptive 32 needs remain a persistent problem, plans are being made to build the capacity of government staff to carry out forecasting and procurement functions more effectively. The lessons learned by each country are important for selecting activities to include in the work plans and for ensuring continuity in GPRHCS planning and programme implementation. The results achieved in the implementation of these activities are expected to strengthen the contribution of RHCS interventions towards the achievement of RH outcomes. 2.4.3 number of countries with RHCs priorities included in: a) CCa, b) UnDaf, c) CPD and d) CPaP This indicator gauges extent to which UNFPA Country Offices have been able to have RHCS issues included in country programming frameworks and hence provide a platform within the UN for leveraging resources and advocating with government and other partners to advance RHCS at country level. Table 20 shows that only three Stream 1 countries (Burkina Faso, Mali and Mongolia) stated that RHCS issues were included in CCA documents. With the exception of Mali, all the other Stream 1 countries indicated that they have included RHCS issues in the UNDAF. Most importantly, all the 11 GPRHCS Stream 1 countries have included RHCS issues in their CPD, CPAP and AWP documents. Table 21 shows that among the Stream 2 countries, 21 have included RHCS in CCAs, 25 in UNDAF, 25 in CPDs, and 29 in CPAPs and AWPs documents of their country. The results show that efforts have been made by the country offices to include RHCS issues into core planning documents especially those documents for which the country offices take direct responsibility in working with governments to formulate i.e. CPD, CPAP and AWPs. Country RHCS included in CCA RHCS included in UNDAF RHCS included in CPD RHCS included in CPAP RHCS included in AWP Burkina Faso Y Y Y Y Y Ethiopia N Y Y Y Y Haiti N Y Y Y Y Lao PDR N Y Y Y Y Madagascar N Y Y Y Y Mali Y N Y Y Y Mongolia Y Y Y Y Y Mozambique N Y Y Y Y Nicaragua N Y Y Y Y Niger N Y Y Y Y Sierra Leone N Y Y Y Y Total for ‘Yes’ 3 10 11 11 11 Table 20: Stream 1 countries with RHCS priorities included in: a) CCA, b) UNDAF, c) CPD, d) CPAP and e) AWP G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 33 2.4.4 number of UnfPa Country offices with increasing funds allocated to RHCs Each country office is expected to allocate, and even mobilize additional resources for the programme, in addition to resources provided for the implementation of RHCS-related activities. The indicator therefore assesses the extent to which countries have been supporting the implementation of RHCS activities with additional resources. Ten Stream 1 countries reported an increase in country office allocation for RHCS in 2010. In the case of Haiti, the amount allocated was the same as the previous year. Of the Stream 2 countries, 19 increased their allocation for RHCS, six country offices indicated a decrease in their funding for RHCS in 2010, and three maintained the same level of funding for RHCS. Country RHCS included in CCA RHCS included in UNDAF RHCS included in CPD RHCS included in CPAP RHCS included in AWP Benin Y Y N Y Y Bolivia Y Y Y Y Y Botswana Y Y Y Y Y Burundi N N N Y Y Central Africa Republic Y Y Y Y Y Chad Y Y Y Y Y Congo N Y Y Y Y Côte d’Ivoire Y Y Y Y Y DRC Y Y Y Y Y Djibouti Y Y Y Y Y Ecuador Y Y Y Y Y Eritrea Y Y Y Y Y Gabon Y Y Y Y Y Gambia Y N N Y Y Ghana Y Y Y Y Y Guinea N Y Y Y Y Guinea Bissau N Y Y Y Y Lesotho Y Y Y Y Y Liberia Y Y Y Y Y Malawi Y Y Y Y Y Mauritania N Y Y Y Y Namibia N N N Y Y Nigeria Y Y Y Y Y Sao Tome and Principe N Y Y Y Y Senegal Y Y Y Y Y Swaziland Y Y Y Y Y Uganda Y Y Y Y Y Zambia N Y Y Y Y Zimbabwe Y Y Y Y Y Total for ‘Yes’ 21 25 25 29 29 Table 21: Stream 2 countries with RHCS priorities included in: a) CCA, b) UNDAF, c) CPD, d) CPAP and e) AWP 34 2.4.5 number of countries with all the relevant joint Un programmes for sRH and MnH that include RHCs In situations where joint UN programmes are formulated for the health sector, especially on sexual and reproductive health and maternal and newborn health, it is important to ensure that RHCS issues are part of the joint programmes. This enables the provision of support to make available maternal health medicines, including contraceptives, and to build capacities and strengthen systems for improved maternal health. The indicator assesses the extent to which UNFPA Country Offices, with joint UN Programmes, have been able to have RHCS issues included in relevant thematic programmes. The six Stream 1 countries that have a UN Joint Programme on SRH or MNH, indicated that they have key RHCS issues included in the programmes (Burkina Faso, Ethiopia, Madagascar, Mali, Niger and Sierra Leone). Also, 14 Stream 2 countries indicated that RHCS key issues are included in their UN Joint Programmes. 2.4.6 number of national/regional institutions providing quality technical assistance on RHCs in the areas of Training and Workshops In addition to providing support for country-level interventions, the GPRHCS also provide support for building capacities of regional organizations so that they can offer technical assistance for GPRHCS in each of the UNFPA geographic regions. This is done in support of the regionalization and capacity building strategies of UNFPA. The UNFPA sub-regional office in Johannesburg conducted a capacity building activity on computerized LMIS for 36 programme managers and logisticians from 13 countries in the eastern and southern part of Africa in collaboration with the Mauritius Institute of Health. The capacity of the Mauritius Institute of Health was strengthened to provide annual courses in supply chain management for national health systems of African countries. The need to develop capacity for sub-regional institutions to provide integrated programmatic and technical support for RHCS prompted the UNFPA sub-regional office in Johannesburg to identify seven consultants in the field of RHCS and provided training on UNFPA programming and strategies. The UNFPA Asia and Pacific Regional Office (APRO) has been providing technical support to the BKKBN in order to strengthen the technical capacity of its faculty, and support the periodic review, revision and update of the training curriculum. In 2010 APRO conducted a training of trainers from the faculty at BKKBN (including selected UNFPA CO staff) for the international training programme on RHCS; and to guide the follow-up actions aimed at ensuring a qualitative improvement in the content and presentation of the training programme. In support of south-south cooperation, APRO also facilitated the participation of two trainers from BKKBN, Indonesia and one trainer from ICOMP, Malaysia in the training of trainers in the Mauritius Institute of Health. In Latin America and the Caribbean, the Global Programme provided evidence-based information for advocacy, policy development, incorporation of RH drugs at public health services, and medical protocol development. In addition, the GPRHCS contributed to the establishment of regional strategic alliances between the Latin American Federation of. Obstetrics and Gynaecology Societies (FLASOG) and a range of organizations including IPAS, Latin American Consortium against Unsafe Abortion (CLACAI) and the Consortium on Emergency Contraception (CLAE). UNFPA continued to strengthen the Sexual and Reproductive Rights FLASOG Committee and to work with this regional group in a number of ways, from training programmes to strategic alliance to reduce unsafe abortion and improve access to emergency contraception to development of SRH content for university medical curricula (see section 4.4 for additional information about activities in the region in 2010). Alliances with FLASOG and with the Legal Advisory Committee of Emergency Contraception served to reach new audiences such as health professionals and lawyers, and to identify advocacy strategies to reach the young and the poor. The GPRHCS supported collaboration with the CLAE for the promotion of emergency contraceptives in the countries of Latin America and the Caribbean. It also supported development of CLAE’s Index, a tool which is an indicator on the status of the availability of emergency contraceptives in each LAC country. UNFPA also worked with civil society representatives to develop a paper on misoprostol with the CLACAI that was presented in regional fora and used in advocacy efforts. G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 35 Also in Latin America, UNFPA expanded partnership and networking with two nongovernmental organizations, CIES (Centro de Investigación y Estudios de la Salud) and PRISMA, in the area of commodity security to produce south-south cooperation between academic and technical institutions to provide technical assistance to countries, develop research, enhance training options, and extend knowledge sharing best practices in the region. The PRISMA CIES programme has directly contributed to strengthening the capacities of professionals working in commodity security from public and private sector in Argentina, Dominican Republic, Nicaragua, Panama, Peru, Uruguay and other countries. 2.5 Cluster achievements Some countries that are in need of assistance but are too small to be considered for individual support have been grouped, or clustered, to receive support. The Global Programme provides support, largely technical and not RH commodities, through their respective regional office. The countries jointly report to the GPRHCS. They include the Pacific Island countries, Eastern European and Central Asian countries, and countries of the Caribbean. 2.5.1 Pacific Island countries The specific needs of small island states were reflected in 2010 RHCS training in FSM, Kiribati, Tuvalu, Tonga and Vanuatu. Within months of the training, there were no stock-outs reported by any facility and the entire medicines supply system was running better. For Vanuatu and Papua New Guinea, the development of RHCS supply management training materials for first referral health facilities included a competency map for RHCS and the wider medicine supply. The materials will be used a course, and University of Canberra will award a certificate to participants who complete the course. In Fiji in August, senior staff (including many pharmacists) attended a training session aimed at improving skills in higher-level procurement. Wastage and overstocking of RH supplies were linked to an inconsistent flow of data in Vanuatu and Papua New Guinea, where a 2010 mission studied the need for more accurate forecasting. A baseline against which to measure progress in Vanuatu was one result of the RH commodity availability mission. Also in 2010, training for health service providers focused on long-lasting implants and non-scalpel vasectomy. In Micronesia, the Government endorsed evidence-based service guidelines and draft policy guidelines on family planning. High-level representatives from five countries attended the Asia and Pacific Regional Family Planning Advocacy Workshop, which received technical support from UNFPA Pacific Sub- regional Office. The focus was on re-positioning family planning in the development agenda, which was also promoted in national advocacy with parliamentarians in 2010. There was progress for maternal health as eight Pacific Island countries finalized and updated RHCS Strategic Plans (Cook Islands, Micronesia, Kiribati, Nauru, Niue, Tuvalu, Tonga and Vanuatu). UNFPA provided support for RHCS focal points to coordinate and integrate RHCS within existing supply systems (Micronesia, Papua New Guinea, Samoa, Solomon Islands, Tuvalu and Vanuatu). In the Solomon Islands, the inter-agency RH Supplies Coalition conducted an RHCS assessment. 2.5.2 eastern europe and Central asian countries These countries belong to a cluster of Central Asian countries where CPR ranges from 26.4 in Tajikistan to 59.3 in Uzbekistan. Tajikistan has highest unmet need of 25 percent and for others it is around 10 percent; however, data from Turkmenistan is not available. All of these countries, except Kazakhstan, has a national strategy on reproductive health where RHCS issues have been included and has a national coordination mechanism coordinated largely by the MOH. In 2010, three out of five of these countries made ad hoc requests for contraceptives. In 2010, these countries received modest amount of contraceptive supply. All the countries received oral pills, and requests were made for IUDs, implants and female condoms. All four countries reported that they 36 have well-developed LMIS. UNFPA’s software CHANNEL and Country Commodity Manager (CCM) have been in use in their systems. In Kazakhstan, 50 staff members from healthcare facilities from six districts were trained to assess family planning needs and 20 were trained on logistics management including use of the CHANNEL software. A strong LMIS in Tajikistan has helped keep even district-level warehouse with stable and reliable supplies and distribution. In Turkmenistan in 2010, GPRHCS support is strengthened national RH commodity security through annual procurement of contraceptives, training of the RH care providers on family planning and IEC activities to raise awareness about family planning. The new LMIS system was initially piloted in the selected regions of Uzbekistan. 2.5.3 Caribbean countries UNFPA undertook a number of activities and advocacy for RHCS integration, co-financing, harmonized procurement processes, and implementation of computerized LMIS. Workshops in four regions provided CHANNEL training. Posters, pamphlets, TV sports and other IEC materials on RHCS, including family planning, were produced for nine Caribbean countries jointly with the Caribbean Family Planning Affiliation and IPPF. Brochures on RHCS were translated into Dutch. Belize developed audio visuals on the use of male and female condoms as part of their awareness programme to reduce HIV infections and unwanted pregnancies. Humanitarian response and RHCS was the focus of training with the MOH and NGOs in Barbados, Grenada and Surinam, with a stronger focus on issues of gender-based violence in a workshop in Trinidad. Preparations were made in Jamaica to establish an RHCS coordinating committee. To support the re-positioning of family planning as a development and rights issue in countries especially Guyana and Suriname, funding from the RHCS programme supported two workshops with 93 participants to strengthen family planning programme delivery. 2.6 Programme management To assess key aspects of the management of the GPRHCS ten indicators are included in the monitoring and evaluation framework. These indicators help to assess the adherence to programme guidelines, timely completion of tasks and also support the tracking of activities in regions. The Table shows the performance levels relating to the ten management indicators. For 2010 the GPRHCS countries achieved an overall implementation rate of 88 percent, with stream one countries reaching 98 percent. By mid-December 2010, over 90 percent of the countries submitted budgeted work plans to their respective regional offices. Most of these work plans were reviewed and finalized by January/February 2011. Also, all the 11 GPRHCS Stream 1 countries submitted midyear progress reports. The reports were discussed, peer- reviewed and experiences shared in a midyear review meeting held in Addis Ababa in June 2010. Stream 2 countries are expected to provide midyear reports for 2011. By December 2010, over 90 percent of GPRHCS countries submitted both programme report for review by the regional offices with copies to CSB. The countries finalized the reports based on advice given by both ROs and CSB on the joint reporting format to use, alignment of report with the year’s work plan, and the need to report on results rather than activities. Most countries were unable to submit financial reports in mid-December due to the fact that financial closure continues until the end of March. The deadline for this indicator will therefore be reviewed accordingly. By mid-January 2010, GPRHCS focal points in five out of the seven regional offices prepared and submitted budgeted annual work plans for by CSB. As is the case for country offices, regional offices are also required to submit midyear reports. The reports submitted were discussed and reviewed at the midyear review meeting held in Addis Ababa in June 2010. G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 37 The 2010 work plans submitted by countries were reviewed by both CSB and regional offices. The review process included telephone discussions and emails. By 1st week of March, over 80 countries had their work plans approved. For the other countries, approval was pending due to various reasons including the need to submit AWPs in the correct format; and, the need to finalize and submit previous year’s narrative and financial report. In 2010, CSB organized two meetings – a joint planning meeting at the beginning of the year and a progress review at mid-year. The joint planning meeting in 2010 was jointly organized in January 2010 by the Thematic Trust funds of the Technical Division: GPRHCS, MHTF (including Fistula and Midwifery and UBW). Participation was therefore broader in scope, to include countries supported by the MTHF. The 11 Stream 1 countries and the regional offices participated at the mid-year review meeting organized in Addis Ababa in July 2010. In addition to focusing on the peer review of planning and reporting documents, the meetings encouraged south-south exchange of ideas and good practices, identification of technical assistance needs of countries, and the formulation of joint actions. This consolidated Annual GPRHCS 2010 Report (programmatic and financial) responds to the last indicator in this section. In addition to being aligned to the GPRHCS Monitoring and Evaluation Framework, the report provides information on other areas of intervention including capacity development, partnerships, family planning, and resource mobilization and allocation for capacity development and procurement of commodities. It also addresses the challenges, lessons learned and way forward for the GPRHCS in the coming years. Programme Management Indicator Achievement for 2010 Number of countries Percentage 1 Number of countries achieving at least 60% of work plan outputs 40 out of 45 countries (11 Stream 1 countries) (29 Stream 2 countries) 88.9% 100% 85.3% 2 Number of Country Offices with completed and budgeted annual work plan by end of December each year 42 out of 45 countries (11 Stream 1 countries) (31 Stream 2 countries) 93.3% 100% 91.2% 3 Number of Country Offices submitting mid-year progress report to respective regional offices by 15 June each year 11 out of 11 Stream 1 countries 100% 4 Number of Country Offices submitting completed annual narrative programme report to respective Regional Offices by 15 December 42 out of 45 countries (11 Stream 1 countries) (31 Stream 2 countries) 93.3% 100% 91.3% 5 Number of Country Offices submitting completed financial report to respective Regional Offices by 15 December 5 out of 45 countries 10% 6 Number of Regional Offices submitting reviewed AWPs to Technical Division/HQ by mid-January 5 out of 7 regional offices 71.4% 7 Number of Regional Offices submitting mid-year report by mid- July and annual report by mid-January to Technical Division/HQ 5 out of 7 regional offices 71.4% 8 Country work plans reviewed and allocation made by HQ by 1st week of March 37 out of 45 countries (10 Stream 1 countries) (27 Stream 2 countries) 82.2% 90.9% 79.4% 9 Semi-annual and annual progress review/planning meeting organized for all GPRHCS Stream 1 counties by CSB/TD 2 meetings held 100% 10 Consolidated annual GPRHCS report (programmatic and financial) prepared by end of March of following year by HQ 1 consolidated annual report prepared 100% Table 22: Programme management indicators, 2010 38 Outreach worker in Ethiopia talks to young women. Photo by Peter Barker/Panos Pictures seleCTeD aReas of aCHIeVeMenT seCTIon THRee G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 39 3.1 Prequalification and Quality Assurance policy / WHO Quality assurance of reproductive health commodities, technical cooperation with relevant stakeholders and building national capacity have been key features of work on behalf of RHCS in 2010. Quality assurance efforts were undertaken to help maintain and increase the supplier base for male condom and IUD manufacturers who meet the quality standards as set out by the WHO Prequalification standards and guidelines. Thirteen male condom and seven IUD factories were re-inspected in 2010. As of 31 December, 25 male condom and eight IUD factories are on the UNFPA ‘prequalified’ list of manufacturers. This list serves as a resource for all UN agencies, NGOs and government institutions procuring male condoms and IUDs that meet requirements for international quality standards. The factories are re-inspected every three years to maintain their prequalification status and all orders purchased by UNFPA are pre-shipment tested. Currently there is only one female condom factory that is prequalified. As a result, the price of the female condom has remained high, due to one manufacturer being the sole source for procurement. A lot of work in 2010 has been towards addressing this issue by initiating the development of specifications and guidelines for other female condom designs to come on to the market. A successful workshop was conducted with manufacturers interested in taking part in female condom production, researchers, technical experts and other public sector and social marketing procurers. Generally, there is great support and interest from manufacturers for the development of this market. Work is in progress to finalize the specifications and guidelines and support the technical review process to identify other female condom factories to be approved for public sector procurement. This work has been in collaboration with WHO. In the area of policy, a quality assurance policy was developed in collaboration with WHO, UNICEF and other agencies involved in procurement of medicines, The QA Policy for pharmaceuticals is to guide PSB on procurement of contraceptives and other medicines that meet international quality standards. The policy outlines quality assurance activities that support procurement of contraceptives and other reproductive health medicines from manufacturers who adhere to good manufacturing practices in accordance with international standards. Technical cooperation and collaborations with key partners (WHO Depts. of Medicines, Quality Assurance and Safety; Reproductive Health and Research, FHI, UNICEF, other NGOs) and relevant stakeholders to strengthen partnerships continued in 2010 with special focus on strategic areas. This included quality assurance, development of guidelines and tools, capacity building of national entities involved in commodity security, for example, national quality control laboratories, regulatory authorities and manufacturers. In the area of national capacity building, there was a need to respond to the increasing number of countries undertaking post-shipment quality testing of reproductive health commodities. Guidance and harmonization is required in this area. The aim is to promote the use of international specifications, guidelines, procedures and testing protocols to prevent rejection of acceptable batches. Use of inappropriate testing standards, equipment and procedures has contributed greatly to increasing shortages of reproductive health products at country level when product release is delayed or products are destroyed. Workshops in collaboration with WHO and FHI in the Latin American and Caribbean region were conducted with laboratories that perform post-shipment testing to encourage use of international guidelines, techniques and decision processes. Similar work is envisioned for Africa in 2011. 40 3.2 Partnership for Maternal, Newborn and Child Health (PMNCH) UNFPA’s Commodity Security Branch was co-chair with UNICEF in Priority Action 3 of PMNCH, which focuses on essential commodities for maternal, newborn and child health. In 2010 a number of key activities were carried out. A resource library on MNCH commodity research and information was developed for the Partnership’s website. A mapping exercise conducted on the available MNCH-related procurement and supply management (PSM) tools helped to identify publicly available PSM tools and to develop an exhaustive list of these tools. These MNCH related procurement and supply management tools will be added to the PMNCH Knowledge Gateway portal. Tools are defined as software, spreadsheets, websites, fact sheets, guides, guidelines, manuals, standard operating procedures, databases, check lists, price lists, catalogues and training course material. Also in 2010, a draft list of priority/essential MNH commodities (medicines including contraceptives) was developed in line with existing WHO guidance. A survey conducted in 2010 will contribute to a publication on existing funding sources for MNCH commodity security. 3.3 National capacity on procurement Building national capacity in the sphere of procurement focused on three main areas: materials development, human resources and strategies. In materials development, the training package was translated to Mongolian and adapted for two training sessions, one at the central level in May and one at the aimag (province) level in November. In the case of the latter, an audience of pharmacists performing procurement for the hospitals in the regions. In the same manner, materials were adapted for the Pacific Island Countries, 14 in total who attended training in Fiji, to a mixed audience of pharmacists, logisticians, procurement officers, programme and RH coordinators, and central medical store managers. Africa was again hesitant to receive similar trainings and come forward in 2010. However, current indications show growing improvement. To address this challenge and promote more interest, a marketing brochure was developed that highlights the benefits such as economic gains, reduction in stock-outs and quality products. Finally, in seeking to assist country offices with the human resource challenge of preparing this activity, Terms of Reference have been prepared for consultants to undertake the assessment process at two levels, be it for Situation Analysis for which to build strategies, or for Fact Finding assessment in advance of the training workshops. In terms of human resources, the strategy from the outset has been not to train unless the option to train trainers has been agreed upon. Securing transfer of knowledge is essential to strengthening systems and the progress in this regard has been steady. Some 70 participants and 15 trainers have received training during the year, with additional trainers in the case of Mongolia, co-facilitating in a second session as a result of the first. Mongolia established an MOU with the University of Health Science School of Pharmacy faculty. The education unit of the MOH acknowledged the training’s worth by accrediting it through their development programme. Finally, the outcome of the November training produced numerous recommendations from the pharmacists to the MOH in remedying flaws in the current system. Using examples of what they had learned and pointing to better solutions from the tools and templates of the training, they succeeded in making a case to convince the MOH to review the current documents and laws. In total some 85 individuals were trained in 2010, 15 of which were trained as trainers though this number could be seen as greater considering additional contributions from government personnel in Mongolia and one interpreter-turned-trainer. Activities developed national capacity in 15 countries and produced numerous additional requests ranging from quality assurance technical assistance to developing tailor- made workshops, training and operational manuals. 3.4 Reproductive Health Supplies Coalition UNFPA fully supports and collaborates with the Reproductive Health Supplies Coalition. Since 2004, this innovative and effective partnership forum has worked towards building global coordination among G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 41 different stakeholders to enhance RHCS. Three innovative mechanisms have already been adopted and they are contributing effectively. Although the Coalition does advocate for more money, it is not always “more money” but “better money” through these innovative mechanisms that help international development. The three innovative mechanisms are: CARh, AccessRH and Pledge Guarantee. UNFPA is operating AccessRH and is fully involved in the other two. UNFPA together with other partners support the HANDtoHAND campaign in support of the UN Secretary- General’s Global Strategy for Women’s and Children’s Health. The campaign aims at achieving 100 million new users of modern contraception by 2015 – meeting the needs of 80 percent of women in low- and middle-income countries. UNFPA would like to contribute through RHCS to enhance CPR in Stream 1 and Stream 2 countries by 2 percentage points per year more. The Reproductive Health Supplies Coalition is a global partnership of some 125 public, private, and non- governmental organizations dedicated to ensuring that all people in low- and middle-income countries can access and use affordable, high-quality supplies to ensure their better reproductive health. The Coalition brings together diverse agencies and groups with critical roles in providing contraceptives and other reproductive health supplies. These include multilateral and bilateral organizations, private foundations, governments, civil society, and private-sector representatives. 3.5 Coordinated Assistance for RH Supplies (CARh) Members of CARh include the UNFPA Commodity Security Branch, UNFPA Procurement Services Branch, USAID, the RH Interchange Secretariat, and the USAID | DELIVER Project. Other members participate on an ad hoc basis according to need, including the World Bank, KfW, the UN Foundation (Pledge Guarantee for Health staff), the Reproductive Health Supplies Coalition Secretariat, and Marie Stopes International. The group focuses on contraceptives and condoms in countries on the verge of a shortage or stock-out. The main objective of CARh is to coordinate the efforts and response of the global donor community during a commodity crisis5. CARh holds a monthly meeting where key global-level partners for the funding and procurement of contraceptives meet to share the latest information. The group seeks to identify shortages and their causes, to seek solutions, and to coordinate action. As of September 2010, CARh has provided data on 21 countries. The main source of data is the monthly Procurement Planning and Monitoring Report (PPMR) produced by USAID. Between October 2009 and September 2010, the CARhs group addressed 184 distinct commodity issues, of which 103 required action (the remaining required information). Most of the group’s work is directed towards averting future stock-outs. Other areas of activity include addressing existing stock-outs or handling existing overstocks. CARhs also assists countries in creating new shipments or expediting existing shipments. The group has found that female condoms and progestin-only pills have been most prone to stock-out, whereas emergency contraception and combined oral pills have been least likely to stock-out. More specifically, between October 2009 and September 2010, in both Kenya and Ghana, six contraceptive methods provided by the public sector faced multiple or recurrent stock crises. Two or more products faced stock crises for multiple months in Bangladesh, Liberia, Mali, Mozambique and Tanzania. CARhs is seeking to streamline the process now that data is making contraceptive supply challenges ever more visible. Future challenges for CARhs include expanding the available supply of data, assuring the involvement of more stakeholders, and streamlining and automating processes. CARhs also seeks greater impact on policy issues affecting reproductive health commodity security. 3.6 Emergency/humanitarian response Reproductive health kits for disasters and conflicts areas were provided by GPRHCS. To reduce reproductive health mortality and morbidity, particularly among women during the disaster situation, UNFPA has assembled the essential drugs, equipment and supplies into a set of pre-packaged kits specifically designed 5 The group changed its name in May 2010 from Countries-At-Risk (CAR) to Coordinated Assistance for Reproductive Health Supplies (CARh). 42 for these purposes – ‘Reproductive Health Kits’. Under the GPRHCS programme during 2010, RH kits were procured and delivered to Ethiopia, Haiti, Kenya, Djibouti, Sudan, Somalia, Uganda and Afghanistan to meet the needs for vulnerable populations, displaced persons and refugees. The total expenditure for RH kits was $1.9 million which is part of the total $61.7 million . In addition kits were provided as part of the collaborative activities with the Intergovernmental Authority on Development (IGAD) in eastern Africa in support of SRH activities targeted at their ‘hotspots’ and cross- border populations. The UNFPA-UNHCR Commodities Initiative provided male and female condoms, RH Kits and other essential RH commodities for refugees and displaced populations in 26 conflict and post-conflict countries, in collaboration between CSB, Humanitarian Response Branch and Procurement Services Branch. 3.7 UNFPA and WHO collaboration The UNFPA-WHO Collaborative Initiative on Critical Life-saving Medicines was launched in 2008 to review access to a core set of critical, life-saving maternal/RH medicines. Joint fact finding missions have been carried out in selected countries during 2008, 2009 and 2010 (Lao PDR, Mongolia, Nepal, Philippines, the Democratic People’s Republic of Korea and Solomon Islands). Suggestions were then made by the joint team on the basis of country specific findings, many of which are being implemented by the governments with the technical assistance from UNFPA and other in-country key stakeholders. In 2010, a UNFPA-WHO joint mission was conducted in the Solomon Islands. Also during 2010, countries implementing some of the key recommendations from these fact-finding studies benefited from specific follow up actions; two are Stream 1 countries (Mongolia and Lao PDR) and one (Solomon Islands) falls within the South Pacific Cluster of Stream 2 countries. 3.8 Collaboration with MSI and IPPF Partnership makes progress possible, and the GPRCHS values its collaboration with many important partners at the local, national, regional and global level who are working together to achieve shared goals. The Global Programme provides commodities to two leading non-governmental organizations and, beyond products, engages in ongoing collaboration to promote efficiency and effectiveness in programming and to make the most of limited resources. A brief overview of the successful partnerships with Marie Stopes International (MSI) and the International Planned Parenthood Federation (IPPF) is provided below. The GPRHCS and MSI, one of the largest international family planning organizations in the world, are partners with an MoU. MSI provides high-quality family planning and sexual healthcare in more than 40 countries. In 2010, UNFPA supported MSI country programmes in Africa, Asia, Latin America and the Middle East by providing family planning commodities worth $2,500,000 over the period 1 October 2009 to 30 September 2010. In total, 28 MSI country programmes have benefitted from UNFPA commodities to avoid shortages, increase their service delivery or remove price barriers for poor clients. MSI is using the contraceptive supplies to provide women and men, in particular from poor and underserved communities, with access to much needed quality, family planning services. The largest amounts were for 19.3 million male condoms followed by nearly 1.2 million oral contraceptive cycles. The GPRHCS also works closely with IPPF, the leading international non-governmental organization dealing with sexual and reproductive health and rights, and another MoU partner. In September 2010, UNFPA approved the donation of commodities worth $2,000,000 to support IPPF in the delivery of family planning and reproductive health programmes across the world. Oral contraceptives, injectables, IUDs, female condoms, male condoms and implants were among the RH commodities delivered to IPPF’s warehouse in the UK and distributed by IPPF to recipient countries. The support helped to enable IPPF Member Associations to avoid some of the commodity security problems that have, in the past, undermined their ability to deliver effective family planning and reproductive health programmes. It also provided an opportunity for IPPF to promote long-acting methods to Member Associations who are more reliant on short-term methods of contraception, which IPPF considers an important area of growth for the Federation. G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 43 44 Teenagers in Madagascar at a talk about safer sex practice. Photo by Piers Benatar/Panos Pictures KeY IssUes In RHCs seCTIon foUR G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 45 This section showcases examples of 2010 activities related to four ‘key issues’ of importance to the Global Programme to Enhance RHCS: Comprehensive condom programming, family planning, building capacity for logistics management, and advocacy and resource mobilization. This is not a systematic analysis of action, but a collection of examples from country reports where some detail was provided. The aim is to suggest the range and scope of activity associated with the GPRHCS. 4.1 Support to family planning The need for voluntary family planning is growing fast, and it is estimated that the ‘unmet need’ will grow by 40 percent during the next 15 years. UNFPA is committed to closing the gap between the number of individuals who use contraceptives and those who would like to space or limit their families. UNFPA supports family planning services that: • offer a wide selection of methods • reflect high standards of medical practice • are sensitive to cultural practices • provide sufficient information about proper use or possible side effects • address women’s other reproductive health needs The Husbands’ School: Where men learn about reproductive health Groups of men are learning about reproductive health in “Husbands’ Schools” and taking the lessons home. Increases are being seen in the use of family planning and the numbers of antenatal consultations, skilled health workers at births, and vaccinations. The innovative initiative was developed and carried out in Niger’s Zinder region. Cited as a ‘best practice’ it is now being scaled up in Niger and in the sub-region. The aim of the Husbands’ School initiative is to improve the involvement of men in the promotion of reproductive health. In villages where it has been implemented, use of family planning has increased dramatically and antenatal consultations have tripled within three years. It has given communities responsibility for improving the supply of services, from building a delivery room to building housing for a midwife. Following the establishment of a Husbands’ School in Bandé, several indicators related to the use of reproductive health services illustrate the level of results experienced in the initiative. From 2006 to 2010, family planning use increased from 1.7 percent to 17.20 percent; antenatal consultation increased from 28.62 percent to 87.30 percent; delivery with qualified person present increased from 8.39 percent to 25.02 percent and vaccination increased from 45.6 percent to 107 percent. “Before [the project], we feared motherhood like people fear death. Now, we are enthusiastic about it,” said a woman in Bandé. 46 The Global Programme supports government efforts to implement a comprehensive approach to reproductive health commodity security. Such an approach not only delivers supplies but addresses related needs such as demand generation, innovative financing mechanisms, consideration for market segments, and outreach to vulnerable populations – with due attention to the reproductive rights of individuals. Progress at the level of the two main indicators of results in this area (unmet need and CPR) takes time. Small changes in these indicators can reflect progress and impact, and in countries where leadership and focused support are provided, significant progress can be made. A number of examples have been selected from country reports to illustrate the range of family planning activities in 2010. Community outreach activities were scaled up in Benin, reaching 28,818 adolescents and young people through person-to-person interviews and educational sessions led by community volunteers and community nurse counsellors. With partners including PSI, training sessions for leaders of social promotion centre leaders were organized, with a focus on men’s involvement in family planning. A campaign in Burkina Faso conveyed the benefits of family planning to communities via IEC/BCC activities using mass, interpersonal and social media. Thirteen activities in 2010 helped to raise awareness, including a mobile media service, forum theatres, radio and TV advertisements, radio and TV broadcasts in local languages (“Burkina variétés”), film screenings and the distribution of posters and leaflets. Grassroots communication activities reached many people, in particular through 450 theatre performances that carried messages about the benefits of family planning, existing methods and the location of family planning service providers. Performances in local villages directly involved some 366,705 individuals, including 142,567 women, 108,386 men and 115,752 young people. Tribal leaders were extensively involved in these performances. In addition, 100 film screenings followed by discussions about the benefits of family planning were organised in villages by local partners, reaching more than 150,000 men, women and young people. In response to rising demand for family planning in Mongolia, an extensive training and re-training programme on family planning was implemented in 2010 in collaboration with the University of Mongolia. The training programme involved 223 primary health care providers from urban and rural health facilities. The Global Programme supported a ‘demand creation’ campaign focused on preventing unwanted pregnancy among young people, and also provided reproductive health commodities that helped to fill the gap in contraceptive supply in a country where stock-outs are a challenge. Also in 2010, a social marketing initiative was implemented by Mongol Em Impex Company (MEIC) and MSI Mongolia. The latter also partnered with UNFPA to train trainers from NGOs working with sex workers on female condom use. Photo: Broadcasting the benefits of family planning in a community theatre performance. G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 47 Community radio in Niger broadcasts reproductive health information in a series of short sketches called “The Adventures of Foula.” Named for a brand of condoms, Foula, the campaign was launched last year by Niger’s former first Lady Mrs. Laraba Tandja. In 2010 it expanded not only in coverage but also in partnerships. Radio is crucial in a country with a 15 percent literacy rate for women. Five-minute sketches with themese, stories and characters from the lives of the local population address reproductive health topics such as family planning, prevention of unwanted pregnancy, female genital cutting/mutilation, sexually transmitted infections and HIV/AIDS. The sketches are broadcast in several languages on radio throughout the country. A local social marketing organization, Animas Sutura, produces the IEC/BCC campaign with the involvement of UNFPA, World Bank and the Global Fund. With UNFPA funding, coverage rose from 140 villages to 197 villages and neighbourhoods in the Maradi region, with 1,764 broadcasts of these sketches on community radio. The broadcasts reached around 72,000 people, including 5,400 women and 1,800 men in discussion sessions led by 180 women. Communication activities that began in 2008 have contributed to significant results, including increased use of contraception. In Madagascar, a rapid results strategy known as ‘Quick Wins’ was adopted by MINSANP to improve reproductive health indicators in six of the poorest regions by improving provision of reproductive health commodities and services, including family planning, to communities. A strategy guide was produced to standardise the implementation of outreach work, and Behaviour Change Communication (BCC) activities were carried out. In Chad, GPRHCS supported the effort to increase access and availability of long-term family planning methods such as implants. In 2010, some 20 health workers participated in training on how to properly insert implants, going on to provide this service to 165 women within a three-month period. Photo: Women in Niger’s Maradi region listen to ‘The Adventures of Foula’ on a Lifeline radio. Photo: Participants at an RHCS training in Madagascar. 48 A first in family planning in Mali was the training of clinicians from the Army’s Central Health Services Directorate (ASDAP) in 2010. ASDAP organised training for 23 army clinicians from the eight military regions of Mali in contraceptive technology. Reaching another audience, a meeting involving 80 imams in Tombouctou, and meetings involving leaders of Muslim women’s associations and imams in Bamako, demonstrated that Islamic leaders are interested in family planning. Mali moved forward on family planning on several fronts. More than 5,000 people were reached through 147 IEC sessions carried out by MSI Mali with UNFPA support. Of this number, 899 were referred for reproductive health services. Four major events of 2010 included mass demonstrations on the themes of birth spacing and family planning in Fana, Kangaba, Koulikoro and Kati. In some areas of Mali, use of modern methods of contraception by married women is very low. From July through November 2010, with support from UNFPA and MSI Mali, two mobile teams provided 2,347 women with a long-term method of family planning (implant or IUD) in partner community health centres (CSCOMs) where these methods had not been previously available. In the Koulikoro region, 38 partner CSCOMs are now offering these services. In April, 110 qualified services providers participated in a training session on long-term contraceptive technology. Many women in Ethiopia would like to avoid or delay pregnancy. A key role is played by the country’s Health Extension Workers (HEWs), who bring family planning information and services closer to communities. They are contributing to the increase in the contraceptive prevalence rate (CPR) from 13.9 percent in 2005 to 30 percent in 2009 (as indicated by the L10K baseline in 2009) in the four most populous regions. Ethiopia’s Ministry of Health has responded to a growing demand for long-acting methods of contraception by expanding access to voluntary family planning methods such as Implanon. UNFPA’s Global Programme to Enhance Reproductive Health Commodity Security has contributed by providing RH commodities and allocating funds for advocacy and for capacity building of the HEWs. Since the start of the initiative, 15,000 Health Extension Workers have been trained on Implanon insertion procedures. In 2010, more than 400 HEWs were trained on Implanon insertion and 200,000 sets of Implanon and consumables were procured and delivered to the Federal Ministry of Health. An estimated 1.7 million mothers (clients) have benefited from the programme thus far. The GPRHCS has contributed more than 60 percent of commodities and covered 25 percent of training costs. Ethiopian women have, on average, more than five children, but more than a third say they would like to avoid or delay pregnancy, according to the Demographic and Health Survey (2005). Community-based distribution is a successful model for reaching the most vulnerable and remote communities of Lao PDR with family planning services, finds a 2010 evaluation study. MCHC, with technical and financial support from UNFPA, is implementing a community-based family planning service provision programme in eight provinces in Lao PDR. The study finds an overall increase in the number of family planning clients in remote and ethnic communities. The data further shows significant increase in CPR in the catchment areas of community-based family planning distributors (CBDs), from 12 percent baseline (2005 LRHS) to 41.2 percent in 2010. The study shows CBDs to be a highly cost-effective channel for delivering quality services and family planning products such as condoms, oral contraceptive pills and injectable to remote populations. Through engaging and investing in the capacity building of local community members, this CBD model is proving to be an effective intervention for increasing knowledge, access, availability, and Photo: This woman in Mali chose an implant, now covered by a patch, as a long-term method. G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 49 demand for FP products and services. The findings of the CDB evaluation were overwhelmingly positive and evaluators recommended further scaling up of the community-based distribution model to deliver selected MNCH services, such as micronutrients and health messages, thus making them as CBD+. On the basis of this evaluation, the Government of Lao PDR has agreed with UNFPA and World Bank to expand the scope and coverage of this programme to the maximum possible nationwide. In coordination with Bolivia’s Ministry of Health, 10 intermediate ‘Centers for Reproductive Health Training’ were selected. UNFPA is helping to upgrade these facilities by providing technical assistance to review printed materials and procuring furniture, medical equipment and anatomical models. Training of health nurses and doctors has started in two Centers for Reproductive Health Training (Trinidad and Tarija), giving priority to health providers coming from rural areas. The Government of Ecuador committed in 2010 to guarantee effective access to information, counselling, and quality reproductive health services that include modern family planning methods based on Constitutional norms. The Ministry of Health worked with UNFPA in a consultative process to develop Ecuador’s first national family planning strategy. UNFPA also assisted the MoH to develop a RHCS plan that includes procurement of modern family planning methods through GPRHCS and procurement of anatomic and pelvic models for training in obstetric care, and intrauterine aspiration kits. UNFPA also helped to procure contraceptives third party. Training on norms, protocols, quality standards and other issues for family planning providers was carried out with 150 national facilitators and providers from the MoH. Also, at the request of the Ministry, it was agreed that studies will be conducted on family planning and maternal health costs, and demographic and social impact. Religious and political leaders in Mauritania are using an advocacy tool called ‘Islam and Family Planning/ Birth Spacing’ to help increase knowledge and use of family planning among the Mauritian population. It In Sierra Leone, access has increased and service uptake has trebled in some cases following a major commitment to reproductive health services. The key was the launch of the Sierra Leone section of the Campaign for Accelerated Reduction of Maternal Mortality in Africa (CARMMA). This kicked off the roll out of demand creation activities including mass media campaigns promoting the use of reproductive health services including family planning. Next, in April 2010, there was the launch of free health care services for pregnant women, lactating mothers and children under 5 years, by His Excellency the President of Sierra Leone. UNFPA made substantive and timely support to both the preparations and launch of the Free Health Care Initiative, which the President of Sierra Leone acknowledged in a national radio interview. At community level, 400 community members (TBAs, traditional and religious leaders) were empowered through training on RH, family planning promotion, prevention of teenage pregnancy and fistula in order to raise awareness and demand for RH services. Photo: Participants at an RH and family planning training session, 2010. 50 was created by the Mauritanian Ulama Association with UNFPA and other partners. First used in 2010, the strategy includes identifying ‘champions’ to act as trainers, especially of Imams in Mosques. More than 100 imams were involved in Nouakchott and Nouadhibou, using their Friday sermons to raise awareness of family planning. Three studies in Nigeria will help to guide government decisions about funding for contraceptives. UNFPA provided a forum for coordination of the studies, which focused on RCHS issues such as willingness to pay for contraceptives by clients, ability to pay, and supply chain cost assessment. In Sao Tome and Principe, new distribution points expanded access to RH commodities, including male and female condoms. Booklets, posters and other materials promoted the female condom. Services providers received training in logistics management information systems. In Senegal, 727 new ASBC were trained and equipped to offer reproductive health services including family planning and another 55 midwives were trained to provide long-lasting modern methods of contraception such as implants and IUDs. Training in CHANNEL also increased capacity for procurement. Training in Togo in 2010 reached 60 service providers with learning on contraceptive technology, organized into three sessions lasting 21 days each. Also, 79 service providers participated in week-long workshops to learn how to insert and remove Implanon. A practical introduction used anatomical models and a second phase took the training to selected clinics. A study in Togo found that mobile strategies for family planning are cost-effective compared to the administration of contraception at fixed facilities. Also in 2010, two worshops explored audio materials for broadcasts about maternal health and family planning. Four broadcasts were produced in the 12 most widely-spoken languages in Togo. Photo: Training participants in Tsévié - Maritime Region Photo: Training participant in Uruguay. G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 51 In Uruguay, training of 113 health professionals supported the country’s decree on comprehensive sexual and reproductive health services. The training, carried out by the MoH with the GPRHCS support, helped to build institutional capacity. 4.2 Support to condom programming UNFPA is the largest public-sector procurer of male condoms and the second largest of female condoms in the world. Within the UN System, UNFPA is the lead agency for all aspects of condom programming. Condoms must be universally available - either free or at low cost - and marketed widely to motivate people to use them. They are the only method available that offers dual protection from sexually transmitted infections, including HIV, and unintended pregnancy. UNFPA promotes comprehensive condom programming (CCP), which seeks to ensure that those at risk of STIs, including HIV, and unintended pregnancy: • are motivated to use male and/or female condoms; • have access to quality condoms; • have accurate condom information and knowledge; • use condoms correctly and consistently. Comprehensive condom programming is an integrated approach consisting of leadership and coordination of partners, demand, supply and support functions. In UNFPA, support for CCP is provided by the HIV/AIDS Branch, in close collaboration with the GPRHCS, the Humanitarian and Procurement Services Branches. These four entities have distinct but complementary roles and responsibilities to have a maximum impact at country level. UNFPA plays a key role in the Global Condom Initiative. The Initiative was launched in 2005 and works in 74 countries to increase both demand for, and supply of, condoms at the national level. CCP activities include support for governments of low- and middle-income countries to advocate for the removal of laws and policies that prevent condom access and utilization by key populations, such as young people, men who have sex with men, to establish a budget line for male and female condoms, and to allocate adequate national financial and human resources to procure and programme these commodities. This includes motivating users, strengthening service providers and developing educational materials to promote consistent and correct condom use. In 2010, UNFPA’s Global Programme on RHCS continued to contribute to this initiative. The following activities are selected examples of support to condom programming. Countries Male Condoms Female Condoms Burkina Faso 7,294,032 - Haiti 5,760,000 - Lao PDR 1,000,080 Mali 4,268,600 135,500 Mongolia 3,636,000 - Mozambique 30,780,000 1,500,000 Nicaragua 965,000 - Niger - 525,256 Sierra Leone 7,200,000 400,000 Total 60,903,712 2,560,756 Table 23: Male and female condoms provided to Stream 1 countries in 2010 See Annex for Stream 2 and 3 countries 52 In Lesotho, findings of a comprehensive condom programming needs assessment were presented to stakeholders for use in developing a CCP strategy. UNFPA also teamed up with PSI to produce 93,000 packages containing three female condoms each – a response to research showing that women who use female condoms at least three times are more likely to continue using them than women who use them only once. With support from UNFPA, PSI printed 20,000 leaflets for insertion into free-issue male condom packages, to increase knowledge about male condom use. In Ethiopia, the nationwide ‘Wise Up’ Programme continued to promote condom use to prevent HIV and other STIs among commercial sex workers, their clients and at-risk groups. They are reached day and night by outreach workers bringing information about the proper and consistent use of condoms. Peer education, mass campaigns and other IEC/BCC activities amplify the safer-sex message. Ethiopia is also reaching university students with new condom kiosks at five schools, a documentary film titled ‘Accessing Condoms in Higher Education Institutions’, and an FAQ booklet for young people. To reduce teen pregnancy and STIs in Nicaragua, workshops engaged 617 adolescents and young people in nine of the country’s 17 local health systems (SILAIS) in learning about the prevention of dangerously early pregnancy, prevention of STIs including HIV, and violence. On the national level, the MOH added indicators for adolescent fertility rate sexual and ‘actions’ of sexual and reproductive health targeting adolescents and young people into its 2011-2015 plan, along with inclusion of an indicator on the HIV prevalence rate among people 15 to 24 years old. Sensitization workshops developed with ‘Voz Joven’ on issues of adolescent SRH targeted mayors and personnel from 43 city halls. Also a logistics study on young people’s access to modern methods of contraception was carried out with partners PRISMA and CIES. Condom programming to combat HIV infection, which has tripled in the last six years especially among women, included a donation of male condoms to the MoH, technical and financial support to the national sex workers’ network, and inclusion of antiretroviral drugs and HIV rapid texts in the logistics system, SIGLIM. Demand for the female condom increased dramatically in Mozambique following expanded and higher- quality training, promotional events, and the close collaboration of the National Aids Council, UNFPA and other partners. Female condom programming was initiated for the first time in 2009. In 2010, training was expanded to district providers and civil society organizations (including networks of women’s group, men’s engagement, and youth and adolescents). Some 1150 female and 600 male anatomical models were acquired to improve training. Female condoms featured in events throughout the year, e.g. international Days, openings of new health facilities, activities of Ministries, sporting and school events, and at youth centres. In Sierra Leone, 27 trainers attended a workshop on condom programming and will next undertake cascade training for staff; 25 parliamentarians attended an event designed to gain their support for inclusion of condom promotion in secondary schools; and 38 focal points were nominated at ministry development agencies to promote CCP. Photo: Students at Jimma University, Ethiopia, attending an educational event on reproductive health G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 53 In South Africa, UNFPA’s support to condom programming assisted the Government of South Africa to close the shortfall of female condoms during the 2010 World Cup, including 3.5 million female condoms, which provided women with an additional tool to negotiate protected sex. The GPRHCS provided technical support for the distribution and management of condoms, and the HIV/AIDS Branch provided funding for the procurement of female condoms. The major focus in South Africa’s condom programming was related to a special event: Millions of soccer fans attended the FIFA World Cup. South Africa’s National Department of Health launched the Condom Distribution Project, focusing on the sporting events in June and July. “This was a period of festivities,” explain UNFPA staff in South Africa, “and an increase in unprotected and casual sex with the risk of HIV infection was anticipated.” The aim was to maximize the national distribution of male and female condom commodities around the World Cup, together with HIV counseling and education. Youth Ambassadors specially trained to distribute condoms and health information helped to make the project a success, along with local volunteers, cleaning staff at the sporting venue and mobile health clinics. Photo: Condom kiosk at the World Cup, South Africa. Capacity development in Botswana focused on developing a National Condom Strategy with an operational plan, working closely with the Ministry of Health and partners such as PSI. Supply and demand issues were considered, as well as the need for social marketing, partnership and capacity building, especially regarding the female condom. Training for health service providers and members of the media emphasized the dual protection offered by female condoms, especially for prevention of sexually transmitted infections including HIV/AIDS. Development of a Comprehensive Condom Programming (CCP) Training manual was also initiated. In Burkina Faso, 420 young people participated in training in adolescent reproductive health and other capacity-building activities related to life skills, IEC for HIV prevention, and the ARH response of youth organization in times of humanitarian crisis. About 420 young people, half young women and half young men, participated. In Burundi, the introduction of the CHANNEL software module in the national reproductive health programme (PNSR) facilitated needs assessment for male and female condom programming. One of the challenges is the lack of self-sufficiency in terms of stockpiling. The Ministry of Health and other partners are being approached to find a sustainable solution, in particular through the mobilization of funds to extend the central drug and medical supplies purchasing agency (CAMEBU). In Congo, the Comprehensive Condom Programming committee has been set up and is preparing to carry out an analysis of the existing situation and draw up a strategic Comprehensive Condom Programming plan for 2011. Media and arts professionals in Côte d’Ivoire joined UNFPA in a strong effort to raise awareness and share information about the benefits of condom use. UNFPA signed a memorandum of understanding with the Network of Media and Arts Professionals against AIDS (Réseau des Professionnels des Medias et des arts contre le sida, REPMASCI). The MoU is a commitment to build capacity amongst the network’s members Photo: Condom kiosk at the World Cup, South Africa. 54 to communicate and raise awareness about reproductive health problems and to increase understanding of UNFPA’s mandate. Female condoms were promoted in 18 messages to be used in awareness raising, in a collaborative process with the MoH, Ministry for Combatting Aids, and other civil society partners including young people, sex worker and social marketing experts. A total of 1,996 radio advertisements were broadcast compared with the 935 planned, and three different radio programmes were produced. In addition, a training programme for 25 press, radio and television journalists on reproductive health lead to a competition for the best article or best radio or television programme on a reproductive health topic. Eleven news articles were written: the most frequent topic covered was female condoms, followed by family planning. A TV report and nine radio reports were produced, with articles and broadcasts covering family planning the prevention of sexually transmitted infections, including HIV. In addition to a strong emphasis on raising awareness, CCP activities in Côte d’Ivoire included a review of CCP in preparation for a scale-up, training for service providers, and an 18-month forecast of contraceptive product needs, including condoms. In Ecuador, UNFPA continued to assist the MoH to design strategies related to a comprehensive condom programming initiative that includes overcoming social and cultural barriers in the access and use, design and implement a communications strategy aimed at addressing condom use barriers. Ecuador is in the process of elaborating a national strategy and related sensitization, including information materials and anatomical models for use in training and education. Regional Health workers in the Gambia were trained on RHCS and comprehensive condom programming at a training funded by GPHCS, with personnel from National AIDS Secretariat National AIDS Control Programme. Procuring and distributing condoms has been a challenge in Madagascar. In May 2010, it was confirmed that the National AIDS Programme, a department within the new ministerial structure, will be responsible for managing condoms. UNFPA will provide assistance to improve comprehensive condom programming in 2011. In Malawi, male involvement programmes continued in to 2010 to engage former perpetrators of violence in activities related to SRH in general, and to condom programming in particular. New activities are spinning off, and men are now engaging in the social marketing of female condoms and educating fellow men on issues of masculinity and their role in gender-based violence and SRH. Men’s travelling conferences around The 16 Days of Violence campaign spurred increased interest in condom use. A group of men developed interactive media tools (CD Rom) for engaging men in these issues. Building on established groups, Mozambique embarked on the process of compiling best practices through the nationally-led Prevention Reference Group and continued to look to the Multi-Sectorial Condom Working Group for leadership, partnership and coordination of condom programming in the country. Very good coordination was noted between the Condom Programming Coordination Group (CPCG) and the RHCS Task Force. The development of a condom strategy by Namibia’s government received financial and technical support from UNFPA in 2010. The process was strengthened by South-South cooperation. The strategy complements existing strategies and is aimed at increasing both the availability of, and the demand for condoms in the Namibia. It outlines the strategic priorities and key interventions needed to ensure the availability of and access to male and female condoms for all in Namibia. 2010 marked the second year that the Mongolian Government allocated money in the national budget for procurement of contraceptives, including condoms, and UNFPA supported procurement, provision, and distribution of 9,000 female and 24,856 male condoms. In Tajikistan, interviews were conducted to determine if condom programming would benefit specific groups. In a country where it is generally socially and culturally unacceptable for a woman to acquire condoms outside of a health clinic, only 3.4 percent of women and their partners use condoms. Interviews were conducted with health professionals and staff in private pharmacies, pointing to the importance of privacy, confidentiality and convenience to men when acquiring condoms. G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 55 UNFPA strengthened the capacity of CCP Focal Points from 15 African countries to integrate CCP and reproductive health commodity security, resulting in the development of national integrated plans in Benin, Burkina Faso and Côte d’Ivoire; the implementation of a situation analysis to inform strategic plan development in Equatorial Guinea and Guinea; and the establishment of a National Condom Task Team in the Republic of Congo. UNFPA supported mapping of organizations in the Caribbean region involved in condom programming that revealed the need for greater investment and partnerships to address supply management of condoms. Female condom programming was focus in Uganda, where orders have increased from 100,000 in 2007, to 200,000 in 2009 and to 600,000 female condoms ordered in December 2010 for procurement by UNFPA. Partnerships have been established, and trainings conducted with anatomical models also procured by UNFPA. There is much more to do in CCP to ensure that sexually active people feel free to demand for and access the means to protect themselves. Motivating users; strengthening service providers; and developing information, education and other promotional materials are actions needed in addition to the commodities themselves. Promotion is key to creating demand for male and female condoms, along with the design of attractive packages, sensitive messages, awareness campaigns, and efforts to engage the media. Promotion is often costly, however, and funds are limited. 4.3 Building capacity for logistics management Ensuring access to essential reproductive health supplies is a complex process. An effective logistics management information system (LMIS) can collect data about how much of each commodity has been used (consumption) and how much is left at each level of the supply chain (stock status). This data can be used to forecast future needs, determine financing requirements, procure supplies in a timely manner, and manage their distribution in order to avoid shortages. The GPRHCS promotes good logistics management information systems that are computerized. Various types of computer software are in use, including CHANNEL, a user-friendly software developed by UNFPA with the active participation of local governments. CHANNEL helps countries to manage their RH supplies through the public health distribution system by allowing individual warehouses to track their supply stock as soon as commodities enter or leave storage, and to generate simple reports and requests. Tracking and forecasting supplies is the key to avoiding shortages. Typically, use of CHANNEL starts at one location and expands to other regions or districts. After two or three years, users may wish to customize it to the country context or to advance to a more extensive program. Countries that have successfully launched this software at home often send trainers to neighboring countries to share skills. In deploying CHANNEL, UNFPA seeks to engage partners and local institutions and to use South-South collaboration for greater sustainability. The installation of CHANNEL software in 50 percent of Benin’s health care delivery points served to kick- start the computerisation of contraceptive supply management. It was an opportunity to build the capacities of a number of individuals responsible for RHCS management, set up RHCS-related databases and ensure the logistics management of these supplies such as to secure their availability. Training on RHCS, including LMIS, was conducted for 32 trainers, 240 service providers, 16 staff form the central medicine purchasing agency; 53 trainers trained in CHANNEL then provided software training to 56 service providers. Donor updates, monitoring visits and other activities accompanied the CHANNEL rollout. Botswana encountered obstacles to improving LMIS and the supply chain in 2010, due in part to restructuring at the MoH. Three training-of-trainer sessions and sensitization activities set the stage for improvements in 2011. In Burkina Faso, the aim in 2010 was to build the competencies of grassroots actors and improve quality monitoring of data input. CHANNEL software is now in the final stages of rollout across all of Burkina Faso’s 56 health regions and districts and regional and national hospitals. Development of an LMIS training module supported training of 174 pharmacists and health workers in the use of CHANNEL software, which was installed in 63 health districts, nine regional hospitals, two university hospitals – adding the 13 regional health services equipped last year. Assessment visits and a review of data collection practice helped to ensure quality and planning throughout. Collaboration with UNFPA’s partner KfW is considered a ‘best practice’ in the rollout of CHANNEL software to manage essential RH supplies in Burundi. UNFPA covered all contraceptive and life-saving maternal medicines/drugs needs over a period of two years, while KfW supplied computing equipment to the country’s 45 Ministry of Health districts. Thematic funds then enabled individuals responsible for the management of medicines and contraceptives at health district level to be initiated in system software and the use of CHANNEL. CHANNEL, which is fast becoming the standard programme for the management of all medicines, has been installed in the office of the KfW focal point to monitor RH commodity supply management at the national reproductive health programme warehouse, the central warehouse, and in 36 health district warehouses. Training for pharmacists and national procurement supervisors in Côte d’Ivoire, an LMIS training-of-trainers workshop, contributed to efforts to scale up the use of CHANNEL and improve LMIS. In Eritrea, efforts to improve the referral system for emergency obstetric care (EmOC) include upgrading and installing CHANNEL and CCM in 10 hospitals and six zonal medical stores, on-the-job training and refresher courses, procurement of 17 printers, development of a software stock catalogue for pharmaceuticals, and several visits for monitoring and evaluation. Stock-outs in the Gambia brought the need for better logistics systems to the forefront in 2010. Efforts to assess and quantify supplies and systems energized the commitment to RH commodity security. The supply chain management of contraceptives and other RH supplies is being merged into the CMS system. Participants from all health regions attended a workshop on RHCS and the effective use of the logistics management information system. Hands-on training and a university course enhance LMIS These before-and-after photos show a warehouse in Ethiopia that was reorganized following training for store managers and pharmacists working on the distribution and supply of RH commodities. In Ethiopia in 2010, UNFPA and SNNPR, with technical support from USAID/ DELIVER, organized three training sessions for a total of 107 health professionals. Also, automating LMIS record-keeping was initiated. UNFPA also worked with the School of Public Health at Addis Ababa University to institutionalize RHCS, successfully creating a two-credit training course for postgraduate students. Topics for course, planned to start in early 2011, will include logistics management, assessing stock status, quantification, inventory control systems and warehousing. G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 57 Following training in 2009 and 2010, health professionals in Kazakhstan are more prepared to assess contraceptive needs and use the CHANNEL software. This knowledge will support efforts to advocate for the procurement of RH commodities in the near future, as existing supplies come to an end. Building the capacity of reproductive health and family planning institutions is important in Kyrgyzstan, where specific needs include updating the LMIS, establishing a RHCS Committee, and developing an effective RHCS national strategy and programme. In 2010, UNFPA assisted with training programmes, technical support and improvement of the reporting system. Collaboration with the Republican Medical Information Centre strengthened forecasting, distribution and evaluation. Lao PDR undertook the design of a pilot unified logistics system for the health sector through the Medical Products and Supplies Centre, which also received GPRHCS support to conduct a survey on stock availability. In Madagascar, UNFPA signed an MOU with the Department for Information Systems with regard to maintaining the computers using CHANNEL in the health districts and regions, conducted to workshops to asses RH commodity needs, and designed a software interface to facilitate data transfer. In Malawi, LMIS training improved the data-capturing skills of 172 health staff, including members of the District Management Health Team. The role of LMIS as a system for data for use in decision making, Procurement of quality products in Mongolia Training has become a central feature of RHCS action in Mongolia, a country committed to RHCS with a national strategy and a budget line, yet faced with problems related to its market for illegal and poor-quality medicines, weaknesses in procurement laws and practices and even, occasionally, stock-outs. The country is addressing these problems by equipping pharmacists in the aimags (provinces) with training, and the tools and systems they need to ensure a safe and secure supply of reproductive health commodities. Through GPRHCS in May and November 2010, more than 50 procurement personnel, pharmacists and NGO partners received training along with trainers to carry the initiative forward. The initiative was institutionalized with the University of Health Science, School of Pharmacy faculty. Trainers trained in May helped to facilitate the November training session, thereby strengthening ownership and continuity. The training sessions addressed solutions through pre-qualification, quality verification, exclusion of manufacturers not meeting criteria, tendering, evaluating and pricing strategies as well as other effective and efficient approaches. The institutionalization of the training was further guarded through recognition by the Ministry of Health’s Education Unit, which granted certified credits to health procurement personnel attending the training. Implementation of the good practices in their entirety is currently being undertaken through the editing of official tendering and evaluation documents. 58 for capturing data, and for supply chain management was emphasized. The training contributed to the improved quality of data at district level, with an increase from a 45 percent reporting rate to an average of 80 percent. Also, training on CHANNEL and approval by the MoH of its installation in seven central warehouses and several other key locations are expected to improve data for RHCS. Conditions at Mozambique’s central warehouse in Maputo have improved with UNFPA support, removing one constraint in a country with weak capacity to procure RH supplies. The LMIS at the warehouse is functioning, and its expansion to others is planned for 2010. For the first time, Mozambique is undertaking a survey on the availability of modern methods of contraception. Tools provided by the GPRHCS were translated into Portuguese by UNFPA and Eduardo Mondlane University, which is leading the survey. A total of 293 Ministry of Health staff in Nicaragua participated in LMIS training in 2010, for implementation of PASIGLIM software. At service delivery points, the LMIS implementation has helped to reduce stock-outs, increase the availability of medicines, and enhanced monitoring. Also in 2010, a strategic plan for medical supplies was developed and approved by the MoH with UNFPA and many partners. A number of training programmes further strengthened quality control, forecasting and supply chain management. In Nigeria, a total of 634 health managers and providers received training on logistics management information systems in an effort to develop human resources capacity. Sessions were held in Abuja and the six states of Abia, Adamawa, Akwa Ibom, Benue, FCT, Kebbi and Lagos. Numerous activities were undertaken in Panama to manage the distribution of supplies, taking steps to fulfill recommendations of an assessment of the logistics management information system by PRISMA. The advocacy, leadership, collaboration and involvement of the MOH staff provided better inputs to understand the situation, identify scenarios and provide recommendations to decision makers. Areas of activity included: (1) technical assistance for the implementation of two workshops addressed to 45 health professionals on Logistics Management and Monitoring and Evaluation the LMIS; (2) technical assistance to create a RHCS Technical Group at central level responsible of training, supervising monitoring and evaluating regional and local levels; and (3) participation in regional training on RHCS and costing, including international workshops on estimating supply needs and monitoring and evaluation for strengthening the chain of health supplies. Swaziland prepared for a 2011 pilot of CHANNEL in cooperation with the Central Medical Stores, with support in 2010 to develop capacity in reproductive health commodity security, particularly logistics management information systems using CCM and CHANNEL. At the regional level, the systems and software were introduced to the Health Directorate and nurse managers of health facilities. Also, a pool of LMIS trainers was developed. Photo: A workshop on logistics management information systems in Panama G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 59 Leakages in Sierra Leone’s commodity supply and distribution system were drastically reduced through a collaborative effort of UNFPA and civil society organizations (CSOs), focusing on monitoring from the port to the end users. CSO monitors at the national, district and community level are present as supply and distribution points and, frequently, submit reports to the Anti-Corruption Commission for further action. The initiative is contributing to strengthening accountability in the use of health commodities. Also in 2010, Sierra Leone engaged in the revision of its national procurement and supply management (PSM) system, with the Government working in collaboration with UNFPA, UNICEF and other development partners. With CHANNEL implemented as the national inventory control and management software, three training sessions prepared 94 participants for a series of cascade trainings. Training on results-based management was organized for 30 implementing partners. Also, 50 computers and 30 printers were supplied to district medical stores and to hospitals. In 2010 in Tajikistan, monitoring visits to Khamadoni, Vose and Muminabad districts found that the top RH facilities are well-informed and trained on the LMIS system, and knowledgeable about RHCS and tasks such as registration and distribution of contraceptives to patients, maintenance of log books, patients’ cards. However, rural health centers and health houses require urgent measures and attention on these matters. The monitoring visits also suggest that CHANNEL software would provide substantial benefits at all Oblast- and Rayon- level facilities, yet the system has not been supported to reach its potential. Gaps and challenges in LMIS in Zambia were identified through visits to 14 pharmacies and facilities, with support from GPRHCS. Ministry of Health staff participated in a regional training of trainers on LMIS and CHANNEL software. As a result of the reviews, available stocks were assessed, procurement plans were developed, and commitments from partners were sought. Photo: CHANNEL training in Sierra Leone. Photo: Warehouse in Tajikistan. 60 In Zimbabwe, UNFPA procured a lorry to facilitate distribution of RH commodities to the service delivery points. Warehousing for storage of commodities was also secured. A logistics assistant was recruited to strengthen logistics and supply chain management of RH commodities. 4.4 Capacity development of institutions for technical assistance The Mauritius Institute of Health undertakes training and research in the health sector under the aegis of the Government’s Ministry of Health & Quality of Life. In 2010, UNFPA and MIH organized a 10-day regional training of trainers workshop on RHCS with 30 delegates from 11 African and Asian countries: Cameroon, Egypt, Ethiopia, Indonesia, Kenya, Lebanon, Madagascar, Mauritius, Morocco, Nepal and Senegal. The aim of the workshop was to improve capacity in RHCS so that each country can forecast, finance, procure and distribute quality reproductive health commodities such as contraceptives, maternal health drugs and HIV commodities. Collaboration between UNFPA and MIH dates back to 1982; as many as 1,200 health professionals from the sub-Saharan region have since been trained in reproductive health. A 10-day training of trainers workshop on RHCS was carried out in 2010 for senior officials of Bhutan, Lao PDR, Mongolia, Myanmar, Timor Leste and Yemen as a joint effort of BKKBN’s Centre for International Training and Collaboration, the UNFPA Country Office in Indonesia, and the UNFPA Asia Pacific Regional Office. APRO has been providing technical support to the BKKBN in order to strengthen the technical capacity of its faculty, as also in the periodic review, revision and update of the training curriculum. BKKBN is the Government of Indonesia’s National Family Planning Coordination Board. The Indonesian family planning program is internationally recognized for its success in lowering average family size, increasing contraceptive use, and improving the health of women and children. Photo (left): A truck was procured to address problems in distribution of RH commodities. Photo (right): In Zimbabwe, warehousing for storage of RH commodities like these anaesthetic machines, was secured in 2010. G lo ba l P ro gr am m e to E nh an ce R ep ro du ct iv e H ea lt h C om m od it y Se cu ri ty A nn ua l R ep or t 20 10 61 The UNFPA Sub Regional Office for the Caribbean carried out advocacy and sensitization activities to promote RHCS as part of the development agenda at the Caribbean Community and Common Market (CARICOM), the Organisation of Eastern Caribbean States (OECS), Ministers of Health, chief procurement officers at Pharmaceutical Procurement Services (PPS), and among local leaders including NGOs and health providers. In 2010, UNFPA worked in partnership with PSI, IPPF, CFPA affiliates, USAID, local NGOs and government to ensure sustainable work in RHCS and increase the demand for RH commodities through social marketing at the community level and a wider appreciation of the supply needs by the Government and the local NGOs. CFPA produced brochures, television spots and other IEC materials for use throughout the sub region. The GPRHCS also supported three brochures on RHCS contributions to the MDGs as well as the benefits of family planning. Training workshops to build capacity focused on RH in disaster response, RHCS and contraceptive technology, HIV/AIDS prevention, and legal and ethical aspects of RH and emergency contraception. Developing institutional capacity in Latin America The Latin American Federation of Obstetrics and Gynaecology Societies (FLASOG) is a key implementing partner of the UNFPA Regional Office in Latin America and the Caribbean. In 2010, UNFPA supported the training of 10 trainers and some 100 health professionals in sexual and reproductive health and rights, as well as promoting a proposal for SRH contents in university curricula. A specialized FLASOG team received training on how to improve access to emergency contraception. With support from UNFPA, FLASOG also produced a publication on studies and intervention to prevent sexual violence, and supported the development of a document on misoprostol for use in advocacy with governments for the drugs incorporation into public health systems. GPRHCS also supported activities in 2010 with the Consortium on Emergency Contraception (CLAE), enabling the group to enhance strategic alliances, develop tools to monitor the supply of emergency contraception, and to produce an advocacy kit. Also in 2010, UNFPA supported activities by REPROLATINA, an SRH NGO based in Brazil, to continue to promote family planning guidelines and tools developed by WHO and UNFPA in the past two years as part of a regional initiative. A training programme for family planning from Social Security Institutes was implemented, with an emphasis on quality counselling and services. South-south cooperation between academic and technical institutions was promoted through UNFPA’s partnership with CIES and PRISMA. Training programmes in 2010 included a series of week-long courses, each with 15 to 27 participations from at least five countries, on topics including RHCS principles and practice, strengthening the supply chain through monitoring and evaluation, and forecasting and procurement planning. Photo: PRISMA facilitators assisting in small group work. 62 4.5 Advocacy and resource mobilization A more sustainable approach to funding for reproductive health commodities is a GPRHCS priority (see section 2.2 on Output 2). Such funding in most countries has long depended on aid from external partners. GPRHCS strongly supports countries that are implementing broad-based efforts to reform and improve health systems and services, and advocates for the mainstreaming of RHCS into such processes – especially into the national budget line. The establishment of a national budget line is a clear sign that the government has chosen to prioritize RHCS, demonstrating that reproductive health issues are national priorities and budgeted for accordingly. Other steps that symbolize the commitment of national governments to support and finance RHCS is the inclusion of RHCS in national planning and policy documents related to the overall health sector programme, and in key strategies such as the Poverty Reduction Strategy Papers (PRSP). The following examples suggest the range of activities undertaken with the support of the GPRHCS in 2010 to advocate for RHCS and to mobilize resources. Several countries reported high-level support in 2010. The President of Niger announced a formal commitment to the United Nations Secretary-General’s maternal and child health initiative, and met with the UNFPA Executive Director. Sierra Leone’s President visited district hospitals and medial stores in all 13 districts of the country, accompanied by UNFPA and UNICEF, to promote reproductive and child health services. Sierra Leone’s First Lady supported the new Campaign for Accelerated Reduction of Maternal Mortality in Africa (CARMMA), on the theme ‘repositioning family planning’. The Ministry of Health can also show support for RHCS. Niger’s Minister of Public Health met with the Director of UNFPA’s Technical Division and Head of the Commodity Security Branch. Commitments were made to a budget line for the purchase of contraceptives and a system of storage and distribution. Burkina Faso’s Minister of Health chaired a national consensus workshop on the country’s strategic plan for RHCS, an event attended by directors of central and regional directorates, technical and financial partners, civil society partners and the media. From conferences to workshops, events can lead to concrete action and raise RHCS higher as a national priority. Mongolia welcomed over 500 participants to its sixth conference on national policy and essential medicines, with a focus on RHCS and the private sector. In Burkina Faso, a national consensus workshop featured a new RHCS strategic plan was held in March, chaired by the Minister of Health, brought together family planning stakeholders (directors of central and regional directorates, technical and financial partners, partner civil society organizations, med

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