The Global Programme to Enhance Reproductive Health Commodity Security - Annual Report 2012

Publication date: 2013

The Global Programme to Enhance Reproductive Health Commodity Security Annual Report 2012 All photos © UNFPA Cover photo: Solange is a volunteer Community Health Worker in her village of Sablogo, Burkina Faso. Photo credit: UNFPA Burkina Faso/Ollivier Girard Design by Phoenix Design Aid A/S, Denmark The sources of information in this report include (1) Special national surveys conducted with UNFPA support in GPRHCS Stream 1 countries; (2) Reports submitted by UNFPA Regional and Country Offices; (3) UNFPA’s donor support report; (4) national data sources including Ministry of Health (MOH) data, Demographic and Health Surveys (DHS); Multiple Indicator Cluster Surveys (MICS), and Reproductive Health Surveys (RHS); (5) global sources including databases and technical publications by UNFPA, UNICEF and WHO. This technical annual report was produced by Desmond Koroma, Technical Specialist for Planning, Monitoring and Reporting, and Susan Guthridge-Gould, writer and editor, with the guidance of Dr. Kechi Ogbuago and Jagdish Upadhyay of the Commodity Security Branch, Technical Division, UNFPA New York. Valuable input was provided by donors, partners and colleagues in UNFPA Regional and Country Offices engaged in the UNFPA flagship thematic fund, the Global Programme to Enhance Reproductive Health Commodity Security. IAnnual Report 2012 ConTEnTS ovERvIEw X EXECuTIvE SummaRy XII InTRoduCTIon XvI CHaPTER onE: TowaRdS unIvERSal aCCESS and uSE 1 1.1 Adolescent birth rate 2 1.2 Maternal mortality ratio 3 1.3 Youth HIV prevalence rate 4 1.4 Unmet need and CPR 5 1.5 Family planning method mix 10 CHaPTER Two: mEaSuRInG avaIlaBIlITy aT THE CounTRy lEvEl 16 2.1 Service delivery points offering at least 3 modern methods of contraceptives 17 2.2 Seven life-saving maternal/RH medicines available 20 2.3 Service delivery points with ‘no stock outs’ of contraceptives 23 2.4 Funding available for contraceptives including condoms 28 CHaPTER THREE: CaTalyzInG naTIonal PolITICal and FInanCIal CommITmEnT 33 3.1 RHCS strategy is integrated with national strategies 34 3.2 National strategy implemented 38 3.3 Functional co-ordination mechanism for RHCS 42 3.4 Contraceptives and life-saving maternal medicines in EML 46 3.5 Funding mobilized for GPRHCS on a reliable basis 50 3.6 UNFPA signed MOUs with Stream 1 country governments 53 3.7 RHCS mainstreamed in regional policies and strategies 53 3.8 RHCS priorities included in PRSP, health sector policy and SWAPs 54 3.9 Allocation within budget line for contraceptives 58 CHaPTER FouR: STREnGTHEnInG HEalTH SySTEmS: InTEGRaTIon, loGISTICS and maInSTREamInG 68 4.1 Using AccessRH for procurement of RHCS 69 4.2 Pre-qualified suppliers 71 4.3 No ‘ad hoc requests’ to UNFPA for commodities (non-humanitarian) 71 4.4 Forecasting using national technical expertise 74 4.5 Managing procurement process with national technical expertise 75 4.6 Functioning LMIS 76 4.7 Co-ordinated approach towards integrated health supplies management system 78 4.8 Adopting/adapting health supply chain management information tool 79 Global ProGramme to enhance reProductive health commodity SecurityII CHaPTER FIvE: maInSTREamInG RHCS wITHIn unFPa CoRE BuSInESS 83 5.1 Expenditure of UNFPA/CSB core resources for RHCS increased 84 5.2 GPRHCS planning takes into account lessons learned in RHCS mainstreaming 84 5.3 RHCS priorities included in CCA, UNDAF, CPD and CPAP 87 5.4 County Offices with increasing funds allocated to RHCS 90 5.5 Relevant joint UN programmes for SRH and MNH that include RHCS 90 5.6 Institutions providing RHCS training and workshops 90 5.7 Activities of Regional Offices and clusters 91 CHaPTER SIX: advoCaCy, PaRTnERSHIP and maRkET SHaPInG 96 6.1 London Summit on Family Planning 97 6.2 Family Planning 2020 97 6.3 UN Commission on Life-Saving Commodities for Women and Children 98 6.4 Meeting of the 46 countries of the GPRHCS to plan 2012-2018 98 6.5 Bill and Melinda Gates support for Strengthening Transition Planning and Advocacy at UNFPA 99 6.6 Joint Interagency Work on Priority Medicines for Mothers and Children 99 6.7 Emergency stock-outs and humanitarian response 100 6.8 Coordinated Assistance for Reproductive Health Supplies (CARhs) 100 6.9 Reproductive Health Supplies Coalition 101 6.10 Marie Stopes International (MSI) 101 6.11 International Planned Parenthood Federation (IPPF) 101 6.12 AccessRH 101 6.13 Prequalification of male and female condoms and IUDs; Quality Assurance Policy for RH Medicines 103 6.14 The UNFPA Family Planning Strategy: Choices Not Chance 104 6.15 Capacity building in procurement 105 6.16 Condom programming 106 CHaPTER SEvEn: By THE numBERS 110 7.1 Programme Management 110 7.2 Commodity Purchases and Benefits 113 7.3 Finance 119 ConCluSIon and way FoRwaRd 126 annEX 1: ConTRaCEPTIvES PRovIdEd To STREam 1, 2 and 3 CounTRIES 129 annEX 2: alloCaTIon and EXPEndITuRE 141 annEX 3: PERFoRmanCE monIToRInG FRamEwoRk 146 annEX 4: lIST oF aCRonymS 157 IIIAnnual Report 2012 TaBlES Table 1: Adolescent birth rate for GPRHCS Stream 1 countries Table 2: Unmet need for family planning for GPRHCS Stream 1 countries Table 3: Contraceptive prevalence rate (modern methods): Stream 1 countries Table 4: Family planning demand satisfied in GPRHCS Stream 1 countries Table 5: Per cent distribution of currently married women age 15-49 by contraceptive method currently used for selected GPRHCS Stream 1 countries Table 6: Percentage of service delivery points (SDPs) offering at least three modern methods of contraception in GPRHCS Stream 1 countries in 2008 to 2012 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 and 2012 Table 8: Percentage of SDPs with seven life-saving maternal/RH medicines (including magnesium sulfate and oxytocin) available in GPRHCS Stream 1 countries in 2012 Table 9: Percentage of SDPs by type with seven life-saving maternal/RH medicines (including magnesium sulfate and oxytocin) available in GPRHCS Stream 1 countries in 2012 Table 10: Percentage of SDPs reporting ‘no stock-out’ of contraceptives within the last six months in GPRHCS Stream 1 countries, 2008 to 2012 Table 11: Percentage of SDPs reporting ‘no stock-out’ of contraceptives within the last six months by type of SDP in GPRHCS Stream 1 countries, 2011 and 2012 Table 12: Percentage of SDPs reporting ‘no stock-out’ of contraceptives within the last six months by location of SDP in GPRHCS Stream 1 countries, 2011 and 2012 Table 13: RHCS strategy integrated into sectoral strategies in Stream 1 countries, 2010 to 2012 Table 14: RHCS strategy integrated into sectoral strategies in Stream 2 countries; 2010 and 2012 Table 15: RHCS strategies/action plans in Stream 1 countries, 2009 to 2012 Table 16: RHCS strategies/action plans in Stream 2 countries, 2010 and 2012 Table 17: RHCS coordinating mechanism in place in Stream 1 countries, 2009 to 2012 Table 18: RHCS coordinating committees in Stream 2 countries, 2010 to 2012 Table 19: Stream 1 countries with essential RH commodities (contraceptives and life-saving maternal/ RH medicines) in EML, 2011 and 2012 Table 20: Stream 2 countries with essential RH commodities (contraceptives and life-saving maternal/ RH medicines) in EML, 2011 and 2012 Table 21: Amount mobilized from donor countries in US$ for GPRHCS, 2007 to 2012 Table 22: Stream 1 countries with signed MOU between Government and UNFPA for GPRHCS implementation, 2011 and 2012 Table 23: RHCS issues included in PRSPs, health policies and SWAPs in Stream 1 countries, 2010 to 2012 Table 24: RHCS issues included in PRSPs health policies and SWAPs in Stream 2 countries, 2010 to 2012 Table 25: Existence of line item for contraceptives in national budget for GPRHCS Stream 1 countries, 2011 and 2012 Table 26: Existence of line item for contraceptives in national budget for GPRHCS Stream 2 countries, 2011 and 2012 Table 27: Government budget allocation for contraceptives in GPRHCS Stream 1 countries, 2008 to 2012 Global ProGramme to enhance reProductive health commodity SecurityIv Table 28: Government budget allocated and spent for procurement of contraceptives in GPRHCS Stream 1 countries, 2008 to 2012 Table 29: Stream 1 countries making ‘no ad hoc requests’ to UNFPA for commodities (non-humanitarian), 2011 and 2012 Table 30: Stream 2 countries making ‘no ad hoc requests’ to UNFPA for commodities (non-humanitarian), 2011 and 2012 Table 31: Stream 1 countries using national technical experts for forecasting, 2010 to 2012 Table 32: Stream 1 countries using national technical experts for procurement of RH commodities, 2009 to 2012 Table 33: Number of Stream 1 countries with functioning LMIS, 2011 and 2012 Table 34: Number of Stream 1 countries with co-ordinated approach towards integrated health supplies management system, 2011 and 2012 Table 35: Number of Stream 1 countries adopting/adapting a health supply chain management information tool Table 36: GPRHCS planning for Stream 1 countries takes into account lessons learned, 2011 and 2012 Table 37: GPRHCS planning in in 2012 for Stream 2 countries takes into account lessons learned, 2011 and 2012 Table 38: Stream 1 countries with RHCS priorities included in CCA, UNDAF, CPD, CPAP and AWP Table 39: Stream 2 countries with RHCS priorities included in CCA, UNDAF, CPD, CPAP and AWP Table 40: Programme management indicators, 2012 Table 41: Total contraceptives provided to all countries in 2012 Table 42: Total male and female condoms provided to all countries in 2012 Table 43: Total CYPs for contraceptives and condoms provided for all countries in 2012 Table 44: Breakdown of amount carried over from 2011 to 2012 Table 45: Breakdown of amount received in 2012 Table 46: Amount and per cent expended per component and per year (US$) Table 47: Breakdown of capacity building expenditure 2009 to 2012 annEX Table 48: Contraceptives provided to Stream 1 countries in 2012 Table 49: Contraceptives provided to Stream 2 countries in 2012 Table 50: Contraceptives provided to Stream 3 countries in 2012 Table 51: Male and female condoms provided to Stream 1 countries in 2012 Table 52: Male and female condoms provided to Stream 2 countries in 2012 Table 53: Male and female condoms provided to Stream 3 countries in 2012 Table 54: CYP from contraceptives provided to Stream 1 countries in 2012 Table 55: CYP from contraceptives provided to Stream 2 countries in 2012 Table 56: CYP from contraceptives provided to Stream 3 countries in 2012 Table 57: CYP from male and female condoms provided to Stream 1 countries in 2012 Table 58: CYP from male and female condoms provided to Stream 2 countries in 2012 Table 59: CYP from male and female condoms provided to Stream 3 countries in 2012 Table 60: Trends and composition of CYP provided to all countries for condoms and contraceptives, 2008 to 2012 Table 61: Breakdown of amount allocated, amounts expended by outputs and implementation rate for 2012 Table 62: 2012 Summary Updates for the UNFPA Global Programme to Enhance Reproductive Health Commodity Security vAnnual Report 2012 FIGuRES Figure 1: Trends in estimates of maternal mortality ratio (per 100,000 live births) by 5 year intervals, 1990 to 2010 Figure 2: HIV prevalence among young people aged 15-24 in selected GPRHCS Stream 1 countries by urban and rural residence Figure 3: Contraceptive prevalence rate (modern methods) for GPRHCS Stream 1 countries Figure 4: Family planning demand satisfied in GPRHCS Stream 1 countries Figure 5: Per cent distribution of currently married women age 15-49 by contraceptive method currently used, for selected GPRHCS Stream 1 countries Figure 6: Percentage of service delivery points (SDPs) offering at least three modern methods of contraception in GPRHCS Stream 1 countries, 2008 to 2012 Figure 7: Percentage of sampled SDPs by location, offering at least three modern methods of contraception in GPRHCS Stream 1 countries, 2011 and 2012 Figure 8: Percentage of SDPs with seven life-saving maternal/RH medicines (which includes magnesium sulfate and oxytocin) available in GPRHCS Stream 1 countries in 2012 Figure 9: Percentage of SDPs with seven life-saving maternal/RH medicines (which includes magnesium sulfate and oxytocin) available in GPRHCS Stream 1 countries in 2012 Figure 10: Percentage of rural SDPs reporting ‘no stock-out’ of contraceptives within the last six months in GPRHCS Stream 1 countries, 2011 and 2012 Figure 11: Percentage of SDPs reporting ‘no stock-out’ of contraceptives within the last six months by location of SDP in GPRHCS Stream 1 countries, 2011 and 2012 Figure 12: RHCS strategy integrated into sectoral strategies in Stream 1 countries, 2010 to 2012 Figure 13: RHCS strategy integrated into sectoral strategies in Stream 2 countries, 2010 to 2012 Figure 14: Number of Stream 1 countries with RHCS strategy being implemented Figure 15: Number of Stream 2 countries with RHCS strategy being implemented Figure 16: Number of Stream 1 countries with national coordinating mechanisms Figure 17: Number of Stream 2 countries with national coordinating mechanisms Figure 18: Stream 1 countries with essential RH commodities (contraceptives and life-saving maternal/ RH medicines) in EML, 2011 and 2012 Figure 19: Stream 2 countries with essential RH commodities (contraceptives and life-saving maternal/ RH medicines) in EML, 2011 and 2012 Figure 20: Resources mobilized for GPRHCS 2007 to 2012 Figure 21: Resources contributed by donors to GPRHCS, 2007 to 2012 Figure 22: Government has signed MOU for GPRHCS implementation Figure 23: RHCS issues included in PRSPs; health policies & plans; and SWAp in Stream 1 countries, 2010 to 2012 Figure 24: RHCS issues included in PRSPs; health policies & plans; and SWAp in Stream 2 countries, 2010 to 2012 Figure 25: Existence of line item for contraceptives in national budget for GPRHCS Stream 1 countries, 2011 and 2012 Figure 26: Existence of line item for contraceptives in national budget for GPRHCS Stream 2 countries, 2011 and 2012 Global ProGramme to enhance reProductive health commodity SecurityvI Figure 27: Government budget allocation for contraceptives in GPRHCS Stream 1 countries, 2008 to 2012 Figure 28: Government budget allocated and spent for procurement of contraceptives in GPRHCS Stream 1 countries in 2012 Figure 29: Cost of commodities (in US$) dispatched by AccessRH by destination of shipment, 2011 and 2012 Figure 30: Number of countries to which third party clients made shipments through Access RH by region/ sub-region in 2011 and 2012 Figure 31: Number of Stream 1 countries that made ‘no ad hoc request’ for commodities, 2011 and 2012 Figure 32: Number of Stream 2 countries that made ‘no ad hoc request’ for commodities, 2011 and 2012 Figure 33: Stream 1 countries using national technical experts for forecasting of RH commodities Figure 34: Stream 1 countries using national technical experts for procurement of RH commodities Figure 35: Amount allocated to UNFPA Commodity Security Branch (million $) Figure 36: GPRHCS Stream 2 countries take into account lessons learned for planning, 2011 and 2012 Figure 37: Percentage of participants reporting change in their understanding of key procurement issues before and after training sessions in selected countries Figure 38: Total CYP for contraceptives and condoms provided for all countries in 2012 Figure 39: Total CYP for contraceptives and condoms provided for all countries by Stream in 2012 Figure 40: CYPs for contraceptives and condoms provided by stream in 2012 Figure 41: Total CYP for contraceptives and condoms provided for all countries, 2008 to 2012 Figure 42: Trends in total CYP for contraceptives and condoms provided for all countries, 2008 to 2012 Figure 43: Percentage of distribution of CYP for the contraceptives and condoms provided for all countries, 2008 to 2012 Figure 44: Percentage GPRHCS expenditure for commodities and capacity building, 2007 to 2012 Figure 45: Percentage distribution of GPRHCS Stream 1 country expenditures per output for 2012 Figure 46: GPRHCS capacity building expenditures by output in 2012 Figure 47: GPRHCS resources expended by output and by stream for 2012 vIIAnnual Report 2012 FoREwoRd Universal access to reproductive health is a target that has been agreed to by world leaders, as part of the Millennium Development Goals, particularly the goal to improve maternal health. Family planning is at the heart of sexual and reproductive health, and is anchored on respect for human rights, for women’s empowerment, for informed choice, for social justice and equality and for increased access to information, education, quality health care, and life-saving commodities, including reproductive health commodities. In 2012, governments and partners in 46 developing countries took action to ensure that national health systems have the capacity and resources to provide a steady supply of quality, affordable reproductive health commodities. This symbolizes a strengthened commitment by countries with high unmet need for family planning so that all may exercise their right to voluntary quality family planning information and services. To date, some 220 million women and girls around the world have unmet need for family planning. As this 2012 annual report shows, UNFPA’s support for providing essential supplies has proven to be a practical and cost-effective means to achieve the vision echoed at the London Summit on Family Planning, which has inspired momentum since last year to create a change in the lives of at least an additional 120 million women in the coming years. With its 40 some years of experience and track record in sexual and reproductive health, and extensive geographical presence, UNFPA is proud to say that through our Global Programme to Enhance Reproductive Health Commodity Security (GPRHCS), we have enabled women, men and young people to make their own reproductive decisions within a framework of human rights. More broadly, the commitment expressed by many countries to RHCS has strengthened their health systems in ways that improve delivery of comprehensive sexual and reproductive health to their poorest and hardest-to- reach communities. This report highlights how UNFPA translates the framework for reproductive health commodity security into practice. In Burkina Faso and Lao PDR, community-based distribution agents have expanded access to contraceptives in places with high demand and unmet need for family planning. In Niger and Côte d’Ivoire, men have learned how to become champions for reproductive health through initiatives known as Husbands’ Schools. In Sierra Leone, independent monitoring by a community-based organization has dramatically improved supply security. In 2012, Ethiopia achieved the highest ‘no stock-out’ rate of the GPRHCS programme countries. Investments in computerized supply systems in Haiti and Madagascar have paid off with national-level increases in the use of modern methods of contraception. These and other results are reported here in the GPRHCS Annual Report 2012. In spite of this progress in some focus countries, we also recognize that much more needs to be done. As we all know, making reproductive health commodity security more widely available requires more than increasing supply and quality of contraceptives. It requires building an enabling environment for women, men and young people, especially girls, to exercise their rights. This requires more efforts to build national capacity, to strengthen health systems, to ensure appropriate policies and legislation, and to ensure that resources are in place to achieve these goals. And it means raising awareness about the positive impact of reproductive health commodity security as the key to voluntary and accessible family planning, HIV/STI prevention and maternal health services, which are all critical elements to sustainable development. With renewed – and unprecedented – support from donors, and with the renewed commitment of developing countries themselves to ensure reproductive health commodity security, UNFPA remains confident that it can deliver a world where every pregnancy is wanted, every birth is safe, and every young person’s potential is fulfilled. Progress in reproductive health commodity security is crucial to making this mission possible. dr. Babatunde osotimehin Executive director of unFPa Global ProGramme to enhance reProductive health commodity SecurityvIII IXAnnual Report 2012 This traditional birth attendant received training to become an advocate for reproductive health as part of a Community Wellness Advocacy Group (CAG) in Sierra Leone. CAGs incorporate men’s peer education, inspired by a study tour of the Husband’s School project in Niger. Photo: UNFPA Sierra Leone Global ProGramme to enhance reProductive health commodity SecurityX ovERvIEw A secure, steady and reliable supply of reproductive health commodities has an impact on teenagers too young to be mothers, couples seeking to space the births of their children, women whose lives could be saved by medication during childbirth, and people in need of protection from HIV and sexually transmitted infections. In 2007, UNFPA launched a thematic fund to strengthen country-driven efforts to provide essential supplies for their reproductive health programmes. In 2012, UNFPA continued to see real progress, and we are pleased to share good news especially at this exciting time of heightened global attention to issues of longstanding concern to UNFPA. This remarkable year placed the UNFPA at the centre of an unprecedented global commitment by governments in the South and in the North, donors, civil society organizations and philanthropic foundations – everyone was on board for family planning. In-house, there was a sense of UNFPA rising to deliver and lead in family planning, starting from the Executive Director and emanating throughout UNFPA offices across the developing world. The ground-breaking london Summit on Family Planning in July galvanized global support for the urgent acceleration of efforts to address the unmet family planning and reproductive health needs of an additional 120 million women and girls. UNFPA participated extensively with preparations starting early in the year, leadership at the event itself, and continued leadership in the initiative created to deliver on the commitments made at the Summit – a partnership called Family Planning 2020 or FP2020 that is chaired by UNFPA and the Bill & Melinda Gates Foundation. The launch of the un Commission on life-Saving Commodities for women and Children signaled heightened attention to underutilized reproductive health commodities. It was created and is chaired by the UN Secretary-General, with Nigeria’s President and Norway’s Prime Minister as co-chairs. The Executive Directors of UNFPA and UNICEF are co-vice chairs. Under the auspices of the Every Woman Every Child movement, the Commission seeks to increase access to life-saving medicines and health supplies for the world’s most vulnerable people. Working groups address market shaping, regulatory environment, and best practices and innovation. Most directly affecting the programme was a meeting of the 46 GPRHCS focus countries, held in Cotonou, Benin, in November. The meeting provided an opportunity to share information on key drivers for UNFPA’s integrated response to sexual and reproductive health and to finalize the design of the new programme. The GPRHCS 2013-2017 was launched at this event. The new programme, which aims to accelerate and consolidate the gains of the first five years, is introduced at the back of this publication. Another important event for the GPRHCS was the unFPa Global Consultation on Family Planning, held in Tanzania in June. The consultation gathered participants from the 18 countries of the Bill & Melinda Gates Foundation project ‘Strengthening Transition Planning and Advocacy at UNFPA’. Most countries were also part of the GPRHCS and the event provided a forum for the exchange of lessons learned. The agenda also focused on planning for the consolidation of UNFPA’s lead role in family planning through its reform process. Throughout much of 2012, then finalized in early 2013, the GPRHCS team contributed to the development of the first corporate-wide Family Planning Strategy 2012-2020. The team was fully involved in the process of conceptualizing and drafting the strategy, which aims to accelerate access to information, exercise of rights, services and supplies in the XIAnnual Report 2012 poorest countries where the need is greatest. The five measureable results areas are: enabled environments; increased demand; improved availability and reliable supply of quality contraceptives; improved services; and strengthened information systems for family planning. The GPRHCS is well-positioned to make a significant contribution to the strategy, working to maximize efficiency where objectives overlap. This report captures the results of the final year of the programme 2007-2012, and in so doing shows progress over its five full years of operation. It also sets the stage for the new programme 2013-2017. We are pleased to present our 2012 Annual Report and recommend several recent related publications including Ten Good Practices in Essential Supplies, the reports of the UNFPA Global Consultation on Family Planning and the Meeting of the 46 Countries of the Global Programme to Enhance Reproductive Health Commodity Security, and Increasing Access to Reproductive Health, the booklet showcasing key results over the past five years. The UNFPA Commodity Security Branch would like to acknowledge the contributions of all donors, without whom these accomplishments would not have been possible. Recognition for the results described in this report is also due to many valued partners in governments, other United Nations agencies and organizations, non-governmental organizations and civil society groups. Mr. Jagdish Upadhyay Chief, Commodity Security Branch, Technical Division Dr. Kechi Ogbuagu Technical Adviser/Coordinator Global Programme to Enhance Reproductive Health Commodity Security, Commodity Security Branch, Technical Division Global ProGramme to enhance reProductive health commodity SecurityXII EXECuTIvE SummaRy The Global Programme to Enhance Reproductive Health Security is the UNFPA flagship thematic fund to ensure access to a reliable supply of contraceptives, condoms, medicine and equipment for family planning, HIV/STI prevention and maternal health services. The Global Programme has mobilized approximately $565 million between its launch in mid- 2007 and the conclusion of its first five years in 2012. Support to reproductive health commodities through the GPRHCS 2008-2012 included contraceptives worth 86 million couple years of protection. UNFPA provided multi-year support to 12 Stream 1 countries and funded targeted initiatives in 34 Stream 2 countries through the Global Programme in 2012. Some additional ad hoc support was provided to Stream 3 countries. Total expenditure for 2012 was $129 million (provisional). Selected results and country highlights 2012 Results from the 12 Stream 1 countries and 34 Stream 2 countries showed continuing progress in 2012: 1. Use of modern methods of family planning has continued its positive upwards trend. In Burkina Faso, the contraceptive prevalence rate has increased 11.5 per cent from 8.6 per cent in 2003 to 13.3 in 2006 to 20.1 per cent in 2012. Ethiopia has nearly doubled its CPR from 13.9 per cent in 2005 to 27.3 per cent in 2011. Haiti, recovering from a devastating earthquake, has improved its CPR by 6 percentage points from 24.8 per cent in 2006 to 31.3 per cent in 2012. CPR in Lao PDR has increased by 8 percentage points from 35 per cent in 2005 to 43 per cent in 2012. In Madagascar, CPR has increased 11.2 percentage points from 18 per cent in 2004 to 29.2 per cent in 2009. CPR in Sierra Leone has increased by 4 percentage points from 7 per cent in 2008 to 11 per cent in 2011. 2. Access to a choice of appropriate methods is improving. The benchmark for this indicator was achieved in 11 Stream 1 countries where more than 75 per cent of service delivery points (SDPs) offered at least three modern methods of contraception, with Nigeria close at 74.1 per cent. In eight of these countries, there was availability at more than 90 per cent of SDPs. Compared to 2011, the percentage has improved in Burkina Faso, Lao PDR, Madagascar, Mali, Niger and Sierra Leone. 3. Supplies are more reliable. Seven Stream 1 countries had no stock-outs in more than 60 per cent their service delivery points, up one from the previous year. Ethiopia, Madagascar and Niger experienced no stock-outs in more than 90 per cent of SDPs for all levels of SDPs (primary, secondary and tertiary). 4. National strategic plans for RHCS are in place and being implemented under government leadership and with the involvement of relevant stakeholders in 11 of 12 Stream 1 countries (excepting Haiti) and 32 of 34 Stream 2 countries, as last year. 5. All Stream 1 and 2 countries have functional coordinating mechanisms for RHCS, consistent with last year. 6. Essential medicines lists exist in all 46 countries. The lists in all countries include life-saving maternal health and reproductive health medicines, and contraceptives. 7. All 46 countries include RHCS in their national Poverty Reduction Strategies and national health sector plans as of 2012, ensuring its priority at the highest levels. RHCS issues are also integrated into the Sector Wide Approaches for health in 11 XIIIAnnual Report 2012 Stream 1 and 31 Stream 2 countries, where there was an increase of four countries over last year. 8. Budget lines for RH commodities, a strong indicator of government commitment, are present in 11 countries, excepting Haiti, consistent with the previous year. Budget allocations increased in 2012 in Ethiopia, Lao PDR, Mali, Mongolia and Mozambique. Budget lines for contraceptives in Stream 2 countries increased from 20 countries in 2011 to 25 countries in 2012. 9. National technical expertise for commodity forecasting and for managing procurement processes is being used in 10 out of 12 Stream 1 countries. 10. Six Stream 1 countries had seven life-saving medicines available in more than 70 per cent of SDPs in 2012. A revision in the indicator tracking life-saving maternal health drugs increased the medicines from five to seven, adding Magnesium Sulfate and Oxytocin to the list. For reference, 11 Stream 1 countries had five essential maternal health drugs available in more than 70 per cent of SDPs in 2011. 11. Based on demand from countries, expenditure on capacity development compared to commodity procurement approached 50:50 in the common pool of funds. In addition, an earmarked contribution from DFID was directed to commodity procurement. 12. Funding levels for the GPRHCS reached an all-time high of $181 million, up from the previous high of $145 million in 2011. From its launch in mid-2007 to its conclusion in 2012, the GPRHCS mobilized $565 million from donor that have included over the years: Australia, Canada, Denmark, European Commission, Finland, France, Ireland, Liechtenstein, Luxembourg, Netherlands, Spain, Spain (Catalonia), United Kingdom, and private and individual contributors. Positive change in the face of complex global issues would be impossible alone, and in 2012 UNFPA continued to rely on and support a wide network of partnerships at global, regional, national and local levels. Nongovernmental organizations (NGOs) are among the many valued partners that engage with UNFPA through the Global Programme. These partners help national governments with advocacy, technical training, developing models, delivering services and exchanging information. The Global Programme procured supplies for many NGOs, and benefitted from close collaboration in many ways. Key partners in 2012 included International Planned Parenthood Federation (IPPF), Marie Stopes International (MSI), Population Services International (PSI), and the Universal Access to Female Condom Joint Programme. Selected countries with increased CPR Particularly strategic action in the priority countries receiving sustained UNFPA support through the Global Programme is moving an indicator at the national level, where it tends to be difficult to demonstrate progress. Increases in contraceptive prevalence rate (CPR) in the following five countries (all Stream 1), show increases in the number of women using modern methods of contraception. The indicator is linked not only to functional systems for RHCS but also to empowerment and the exercise of the right to reproductive health, including family planning. In Burkina Faso, the contraceptive prevalence rate has increased 11.5 per cent from 8.6 per cent in 2003 to 20.1 per cent in 2012. In 2009, the government engaged civil society organizations in a partnership for Global ProGramme to enhance reProductive health commodity SecurityXIv community-based distribution of contraceptives, with GPRHCS support. In addition, sustained commitment to a multi-media behaviour change communication campaign has reached up to 60 per cent of the population with information to inspire action for better reproductive health, including family planning. Other key data gathered by UNFPA tracked RHCS progress in 2012: The percentage of service delivery points offering at least three modern methods of contraception increased from 90.3 per cent in 2011 to 99.5 per cent in 2012. Only 24 per cent of SDPs had seven life-saving maternal/RH medicines available in 2012. The percentage of SDPs reporting ‘no stock-out’ of contraceptives increased from 12.8 per cent in 2011 to 25.1 per cent in 2012. Ethiopia has nearly doubled its CPR from 13.9 per cent in 2005 to 27.3 per cent in 2011. One important contributor has been the country’s investment in training Health Extension Workers, in particular focusing on the use of long-lasting contraceptive implants. Towards institutionalizing RHCS, the curriculum at the Public Health School and School of Pharmacy at Addis Ababa University has incorporated RHCS. In addition, five universities have launched training towards task shifting among middle-level health workers for maternal health. The GPRHCS has supported these and other efforts and tracked RHCS progress in 2012: National budget allocations for RH commodities increased in 2012. At least three modern contraceptive methods were available in 96.4 per cent of service delivery points. Seven life-saving maternal/ RH medicines were available in 54.6 per cent of SDPs in 2012. In the six months prior to the survey, some 97.6 per cent of SDPs reported ‘no stock-out’ of contraceptives – the highest ‘no stock-out’ rate among Stream 1 countries. Ethiopia experienced no stock-outs in more than 90 per cent of SDPs for all levels of SDPs (primary, secondary and tertiary). Haiti, recovering from a devastating earthquake, has improved its CPR by 6 percentage points from 24.8 per cent in 2006 to 31.3 per cent in 2012. The country has implemented CHANNEL for computerized supply management, created an RHCS technical committee, studied RHCS in Rwanda, and held workshops to address family planning and stock-outs at health facilities. A recent national survey on GPRHCS indicators at service delivery points found improvements in the availability of life- saving maternal health medicines and a more secure supply with fewer stock-outs. At least three modern contraceptive methods were available in 84.3 per cent of service delivery points. Seven life-saving maternal/ RH medicines were available in 73.6 per cent of SDPs in 2012. The percentage of SDPs reporting ‘no stock- out’ of contraceptives in the six months prior to the survey increased from 26.4 per cent in 2011 to 42.6 per cent in 2012. CPR in lao PdR has increased by 8 percentage points from 35 per cent in 2005 to 43 per cent in 2012. With GPRHCS support, the country has accelerated its development of human resources for health and an integrated logistics management information system. Use of radio and community outreach activities promoting reproductive health, including village Health Days, has grown. The success of community- based distribution agents serving the most rural areas with family planning supplies and services has been credited to a culturally-sensitive approach that builds capacity among local health workers who speak the same ethnic language and share the same cultural background. National budget allocations for RH commodities increased in 2012. At least three modern contraceptive methods were available in 91.4 per cent of service delivery points. Seven life-saving maternal/ RH medicines were available in 53.1 per cent of SDPs in 2012. In the six months prior to the survey, 71.1 per cent of SDPs reported ‘no stock-out’ of contraceptives. In madagascar, CPR has increased 11.2 percentage points from 18 per cent in 2004 to 29.2 per cent in 2009. The government’s adoption of computerized supply management using the UNFPA-developed CHANNEL software has enabled significant progress. Training workshops have engaged directors, inspectors and staff at central, regional and district levels. Stock- outs are down, more pharmacies and warehouses are functional, coordinating committees are meeting regularly, more women are using contraception, and more youth-friendly health centres have opened to XvAnnual Report 2012 provide access to this underserved population. The percentage of service delivery points offering at least three modern methods of contraception has increased steadily from 30.8 per cent in 2009 to 47.8 per cent in 2010 to 77.5 per cent in 2011 to 95 per cent in 2012. Madagascar experienced no stock-outs in more than 90 per cent of SDPs for all levels of SDPs (primary, secondary and tertiary). Seven life-saving maternal/RH medicines were available in 66.9 per cent of SDPs in 2012. In the six months prior to the survey, 88.9 per cent of SDPs reported ‘no stock-out’ of contraceptives. CPR in Sierra leone has increased by 4 percentage points from 7 per cent in 2008 to 11 per cent in 2011. This progress reflects a dynamic commitment to new approaches, such as managing contraceptives and other drugs and medical supplies through a contract with a civil society organization. The government has adopted a computerized supply management system using CHANNEL software, and has deployed monitors and community wellness advocates to see that essential supplies reach people who need them. Sierra Leone made its first budget allocation in 2011 for reproductive health commodities, a sign of commitment advocated by the GPRHCS. The number of service delivery points offering at least three modern methods of contraceptive increased from 80.5 per cent in 2011 to 89 per cent in 2012. Seven life-saving maternal/RH medicines were available in 71.7 per cent of SDPs in 2012. The percentage of SDPs reporting ‘no stock-out’ of contraceptives in the six months prior to the survey increased from 35.4 per cent in 2011 to 44 per cent in 2012. All of the above countries have a national strategic plan in place for RHCS, engage relevant stakeholders, have functional coordinating mechanisms for RHCS, include contraceptives on their essential medicines list, fund national budget lines for RH commodities, and (with the exception of Lao PDR), use national technical expertise for commodity forecasting and for managing procurement processes. major events of the year A number of events in 2012 reinforced the significance of RH commodity security and furthered UNFPA programming in this regard. The london Summit on Family Planning urged acceleration of efforts to address the unmet family planning and reproductive health needs of an additional 120 million women and girls. A newly created un Commission on life-Saving Commodities for women and Children advocated at the highest levels for the increased availability, affordability and accessibility of essential but underutilized commodities for maternal and child health. The unFPa Global Consultation on Family Planning reported on a Bill & Melinda Gates Foundation project and gathered many countries of the GPRHCS in Tanzania in June. In November, a meeting of the 46 GPRHCS focus countries, held in Cotonou, Benin, served to launch the new programme (2013-2018), which aims to accelerate and consolidate the gains of the first five years. There are many stories of success and of challenges, many of them interlinked with complex issues of poverty and equality, many in countries requiring strategic support for years to come. A number of these success stories are featured throughout this report. With the generous support of donors and the invaluable collaboration of our partners, the Global Programme to Enhance Reproductive Health Commodity Security will continue to support countries in their efforts to meet the reproductive health needs of their populations, especially the poor and underserved. Global ProGramme to enhance reProductive health commodity SecurityXvI InTRoduCTIon 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. It has a pivotal and strategic role in accelerating progress towards the Programme of Action of the International Conference on Population and Development and the Millennium Development Goals, especially MDG 5 to improve maternal health. UNFPA joins with a wide range of partners in governments, other agencies and civil society to work towards these goals. Background For decades, the international community had viewed supplies for reproductive health services in isolation from programming. Funding was sporadic, which meant procurement was ad hoc, leading to dangerous shortfalls at family planning clinics, maternity hospitals, pharmacies and other distribution points. In response, UNFPA developed a mechanism to advance the concept of reproductive health commodity security, providing a more comprehensive view of the problems and solutions. 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. Concluding its fifth full year of operation in 2012, the GPRHCS has provided support to countries for activities that have yielded measureable results. The GPRHCS has provided support in two key areas: (1) develop capacity to strengthen health systems; and (2) procure reproductive health commodities. This fund has been a catalyst for national efforts to build stronger health systems to procure essential supplies. It has provided a framework for assisting countries in planning for their own needs. At the request of governments, UNFPA has provided strategic and pivotal support seeking comprehensive RHCS by working with partners in several key areas: • Integrate RHCS in national policies, plans and programmes through evidence-based advocacy with policy makers, parliamentarians, partners in government and many other valued partners in each country, seeking to catalyze political and financial commitment; • Strengthen the delivery system to ensure a secure, steady and reliable supply through improved logistics management information systems, often with computer software and training, as well as RHCS mainstreaming in the national health system; • Provide training to build skills at every step of the supply chain, developing the human resources capacity of national staff for forecasting and procurement, pharmacists, warehouse managers, and health workers charged with providing RH information and services, among others; • Procure contraceptives and other essential reproductive health supplies and promote their use through various mechanisms such as community- based distribution and social marketing, seeking to increase timely access to a choice of quality, affordable reproductive health commodities; • Increase access and create demand by working within a rights-based approach that empowers individual choices and dignity, sharing information through behaviour change communication, and going the last mile to ensure access for underserved and hard-to-reach populations. The GPRHCS has supported countries through three funding streams in order to address the specific needs of each country. XvIIAnnual Report 2012 Stream 1 has provided multi-year funding to a relatively small number of countries. These predictable and flexible funds have been 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 has supported initiatives to strengthen several targeted elements of RHCS, based on the country context. Stream 3 has provided emergency funding for commodities in countries facing stock-outs for reasons such as poor planning, weak infrastructure and low in-country capacity. Stream 3 has also provided support for countries facing humanitarian situations, including natural or man-made disasters. In these settings, the GPRHCS has worked closely with UNFPA’s Humanitarian Response Branch and the United Nations High Commissioner for Refugees. The funding streams have helped to organize country selection criteria and the designation of the level of country support, though ‘streams’ will no longer be applied starting with the new programme in 2013. 2012 Stream 1 countries 2012 Stream 2 countries 1. Burkina Faso 2. Ethiopia 3. Haiti 4. lao PdR 5. madagascar 6. mali 7. mongolia 8. mozambique 9. nicaragua 10. niger 11. nigeria 12. Sierra leone 1. Benin 2. Bolivia 3. Botswana 4. Burundi 5. Central African Republic 6. Chad 7. Congo 8. Côte d’Ivoire 9. Democratic Republic of the Congo 10. Djibouti 11. Ecuador 12. Eritrea 13. Gabon 14. Gambia 15. Ghana 16. Guinea 17. Guinea-Bissau 18. Lesotho 19. Liberia 20. Malawi 21. Mauritania 22. Namibia 23. Papua New Guinea 24. Sao Tome and Principe 25. Senegal 26. South Sudan 27. Sudan 28. Swaziland 29. Timor Leste 30. Togo 31. Uganda 32. Yemen 33. Zambia 34. Zimbabwe Global ProGramme to enhance reProductive health commodity SecurityXvIII Structure of this report This report showcases results in the 46 countries of the UNFPA Global Programme to Enhance Reproductive Health Commodity Security, including 12 Stream 1 and 34 Stream 2 countries. The structure of the report follows the programme’s Performance Monitoring Framework. The results framework is intrinsically linked to the UNFPA Strategic Plan and is therefore one of the key platforms for delivering on the UNFPA mandate. • Goal: Universal access to reproductive health • Outcome: Increased availability, access and utilization of reproductive health commodities for voluntary family planning, HIV/STI prevention and maternal health services in the GPRHCS focus countries • Output 1: Country RHCS strategic plans developed, coordinated and implemented by government with their partners • Output 2: Political and financial commitment for RHCS enhanced • Output 3: Capacity and systems strengthened for RHCS • Output 4: RHCS mainstreamed into UNFPA core business • Programme management At the goal and outcome level, there is the goal of universal access to reproductive health by 2015. The outcome level seeks increased availability, access and utilization of reproductive health commodities for voluntary family planning, HIV/STI prevention and maternal health services in GPRHCS focus countries. The outcome indicators against which progress is monitored include contraceptive prevalence rate (CPR) and unmet need for family planning. At the output level GPRHCS activities are supported to achieve four results: (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. Progress towards the outcome on increasing availability, access and use is measured from several perspectives: For situational context, national data (mostly DHS or HMIS) is used to report on unmet need for family planning and contraceptive prevalence rate. National data sources include Ministry of Health (MOH) data, Demographic and Health Surveys (DHS); Multiple Indicator Cluster Surveys (MICS), and Reproductive Health Surveys (RHS). Country-level progress for RHCS is measured using data from special national surveys conducted every year with unFPa support for GPRHCS Stream 1 countries where such data is not otherwise available. The surveys look at representative samples of service delivery points (SDPs) that provide contraceptive methods or medicines. Reports are also submitted by UNFPA Regional and Country Offices. Progress is also measured by tracking donor resources available for contraceptives including condoms, with data from UNFPA’s donor support report published by the Commodity Security Branch based on donor databases. Other global sources include databases and technical publications by the United Nations, including by UNFPA, UNICEF and WHO, and by international development partners including Marie Stopes, IPPF and RH Supplies coalition and members of FP2020. 1Annual Report 2012 CHaPTER onE: TowaRdS unIvERSal aCCESS and uSE Members of a civil society group monitor and load RH supplies in Bo, Sierra Leone. Photo: UNFPA Sierra Leone UNFPA supports interventions that catalyze country-driven efforts towards a steady, secure and reliable supply of essential reproductive health commodities. The aim is to help countries achieve RHCS outcomes as an integral part of their overall health sector interventions. UNFPA is contributing towards the Millennium Development Goals, notably the MDG 5 target to achieve, by 2015, universal access to reproductive health. Goal and context Strategic interventions in commodity security have been catalytic for the implementation of sexual and reproductive health interventions, including family planning, maternal health and HIV prevention. Action in this area contributes to the achievement of universal access to reproductive health – which is the highest- level goal in the framework of the Global Programme to Enhance Reproductive Health Commodity Security. Since goal-level results are contributed to by all actors, Global ProGramme to enhance reProductive health commodity Security2 presentation of progress here should not be attributed alone to the GPRHCS or indeed UNFPA. This section is meant to provide information on current levels of achievement and place in context some of UNFPA support through its flagship thematic fund for reproductive health commodity security. Goal: Universal access to reproductive health by 2015 At the top of the Global Programme’s Performance Monitoring Framework is the goal of universal access to reproductive health. At this ‘goal level’ progress is measured through three indicators: adolescent birth rate, maternal mortality ratio and youth HIV prevalence rate. These indicators also are used globally to measure progress in achieving MDG 5. 1.1 adolescent birth rate The 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 relates to assessing the impact of various interventions being implemented to address the incidence of childbearing among adolescent women. The levels and trends of ABR could represent measures of success in addressing early marriage and early childbearing, family planning for young girls, and sexuality education and awareness raising interventions for young people to make informed choices. All of these have implications for the well-being of adolescent girls. In most countries, including GPRHCS Stream 1 countries, adolescent birth rate (ABR) remains very high. According to the Millennium Development Goals Report 2011, sub-Saharan Africa has the highest adolescent birth rate – which has barely changed from 124 per 1,000 women 15-19 in 1990 to 122 in 2008.1 GPRHCS Stream 1 countries in sub-Saharan Africa have higher ABR than the countries from other regions (Table 1). ABR is highest in Niger at 198.9 per 1,000 women 15-19, followed by Mozambique at 193 per 1,000 women 15-19 and Mali at 189 per 1,000 women 1 United Nations, The Millennium Development Goals Report 2011, UN, New York 2011, p.31 15-19. Globally, the number of women aged 15 to 19 will reach 300 million very soon and most of them will be in developing countries, especially sub-Saharan Africa, according to population estimates. The GPRHCS provides a platform for helping countries design and implement family planning and maternal health programmes that address the special needs of adolescents. Specific activities implemented in 2012 will be presented in appropriate sections of this report. Table 1: adolescent birth rate for GPRHCS Stream 1 countries Country year Per 1,000 women 15-19 Burkina Faso 2009 130 Ethiopia 2010 79 Haiti 2003 68.6 Lao PDR 2005 110 Madagascar 2006 147.1 Mali 2004 189.6 Mongolia 2008 19.8 Mozambique 2007 193 Nicaragua 2005 108.5 Niger 2003 198.9 Nigeria 2006 123 Sierra Leone 2006 113 http://mdgs.un.org/unsd/mdg/SeriesDetail.aspx?srid=761 as on 20th March 2013 3Annual Report 2012 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. Pregnancy remains a major health risk for women in most countries despite evidence of proven interventions that could prevent disability and death related to pregnancy, according to the Millennium Development Goals Report 2011. Maternal mortality has declined globally from 400 maternal deaths per 100,000 live births in 1990 to 210 maternal deaths per 100,000 live births in 2010,2 recent maternal mortality ratio estimates show. Among countries of the GPRHCS, Mongolia and Nicaragua had the lowest MMR estimates among the GPRHCS Stream 2 Trends in Maternal Mortality: 1990 to 2010; Estimates developed by WHO, UNICEF, UNFPA and the World Bank; WHO 2012 1 countries 2009 to 2010 (Figure 1). Generally, MMR has declined in all the Stream 1 countries. The rate declined faster in Lao PDR than all the other countries: MMR in Lao PDR declined from an estimated 1,600 maternal deaths per 100,000 live births in 1990 to 470 maternal deaths per 100,000 live births in 2010. Although there has been improvement, MMR estimates for Sierra Leone continue to be the highest among the Stream 1 countries. The GPRHCS serves as one of the main channels through which UNFPA works with countries to provide health care services and information for prevention and management of pregnancy-related complications. Specific interventions include the provision life-saving maternal health medicines, supporting the distribution mechanisms so that medicines and supplies are available at service delivery points and stock-outs are averted, training of skilled birth attendants, and provision of family planning information and services to prevent unwanted pregnancies and unsafe abortions. Other critical interventions such as provision of essential obstetric care are supported largely through the other strategic funding mechanisms. Figure 1: Trends in estimates of maternal mortality ratio (per 100,000 live births) by 5 year intervals 1990 to 2010 Source: Trends in Maternal Mortality: 1990 to 2010; Estimates Developed by WHO, UNICEF, UNFPA, World Bank; See Annex. 0 500 1000 1500 2000 Es ti m at es o f m at er na l m or ta lit y ra ti o Lao PDR 1990 Year (5-year intervals) 1995 2000 2005 2010 Sierra Leone Niger Nigeria Mali Ethiopia Mozambique Burkina Faso Madagascar Haiti Nicaragua Mongolia Global ProGramme to enhance reProductive health commodity Security4 1.3 youth HIv prevalence rate The percentage of young people aged 15 to 24 years who are living with HIV out of total population in that age group provides a measure of the effect of HIV among young people and its ramifications for socio-economic development, and the impacts of interventions. Globally, nearly 23 per cent of all people living with HIV are under the age of 25 and young people 15 to 24 account for 41 per cent of new infections among those aged 15 or older, according to the Millennium Development Goals Report 2011. HIV prevalence in most of the Stream 1 countries is higher in urban areas than in rural settings. In Ethiopia (DHS 2011), young people living in urban areas accounted for 75 per cent of the total HIV prevalence among young people 15 to 24 years compared to 25 per cent for rural residence. The pattern was the same in Sierra Leone (DHS 2008), where HIV prevalence among young people in urban areas accounted for 73 per cent of the total prevalence for that age group compared to 27 per cent for rural residence. In almost all the countries, HIV is more prevalent among young women in urban areas than for males in urban or rural areas or females in rural areas (Figure 2). The surveys consistently show a higher prevalence among females. HIV prevalence is disproportionately higher among young women in both rural and urban settings than their male counterparts in rural and urban settings. Young women aged 15 to 24 years accounted for 85 per cent of the HIV prevalence among young people in that age group in Ethiopia; 75 per cent in Mozambique and 52 per cent in Mali. Figure 2: HIv prevalence among young people aged 15–24 in selected GPRHCS Stream 1 countries by urban and rural residence Source: HIV/AIDS Survey Indicators Database. http://www.measuredhs.com/hivdata/, March 23 2012. H IV P re va le nc e Urban Male Ethiopia (DHS 2011) Country Mali (DHS 2006) Mozambique (HIV/AIDS Indicator Survey 2009) Niger (DHS 2006) Sierra Leone (DHS 2008) Niger Mali Mozambique 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 5Annual Report 2012 Generally, HIV prevalence has fallen by more than 25 per cent among young people in 15 of the most severely affected countries, mostly in sub-Saharan Africa, as they continue to adopted safer sexual practices – and progress in this direction is urgently needed. To address the HIV prevalence among young people, GPRHCS has worked with governments and other partners to implement strategies such as comprehensive condom programming and supporting integrated sexual and reproductive health services delivery at country level. Linking HIV responses with these services is an overarching strategy for reaching more people cost- effectively and moving towards universal access to prevention, treatment, care and support – including wider access for people living with HIV. As one of ten co-sponsors of UNAIDS, UNFPA works to intensify and scale up HIV prevention efforts using rights- based and evidence-informed strategies, including attention to the gender inequalities that add fuel to the epidemic. Reproductive health commodity security supports the strengthening of efforts to prevent HIV. 1.4 unmet need and CPR Unmet need points to the gap between women’s reproductive intentions and their contraceptive behaviour. Contraceptive prevalence rate (CPR) refers to the use of modern methods of contraception. Together, these national-level indicators provides context about the situation as reported at the national level by national sources. Both indicators are directly related to an outcome of the GPRHCS: increased availability, access and utilization of reproductive health commodities for voluntary family planning, HIV/STI prevention and maternal health services in the GPRHCS focus countries. outcome: Increased availability, access and utilization of reproductive health commodities for voluntary family planning, HIV/STI prevention and maternal health services in the GPRHCS focus countries 1.4.1 unmet need for family planning Women with unmet need are fecund and sexually active women who are not using any method of contraception, and who report not wanting any more children or wanting to delay the birth of their next child. The updated information on unmet need for family planning for 2012 is presented in Table 2.3 The information has been updated for Burkina Faso, Haiti, Lao PDR, Mali, Mozambique, Niger, Nigeria and Sierra Leone. Unmet need has remained fairly constant in most of the countries, the exceptions being Lao PDR 3 For unmet need and CPR, data are sourced from national survey results (mostly DHS) or from national HMIS where available. Since surveys are conducted infrequently updates for these indicators are presented when they are available. where it decreased from 27.3 per cent in 2005 to 20 per cent in 2012, and Mozambique where it increased from 18.4 per cent in 2003 to 22.3 per cent in 2011. Through the GPRHCS, UNFPA works with governments to addressing unmet need for family planning. This is done through the broader framework of sexual reproductive health but specifically in the context of commodity security. Specific actions include the provision of commodities, advocacy for an enabling environment for family planning, logistics management, training of staff, raising awareness and generating demand and working to address barriers women have in accessing family planning services. Global ProGramme to enhance reProductive health commodity Security6 Table 2: unmet need for family planning for GPRHCS Stream 1 countries, percentage Country Baseline (2008) 2009 2010 2011 2012 Target (2013) Burkina Faso 31.3 (MOH) 28.8 (MOH) 28.8 (MOH) 28.8 (MOH) 24.5 (DHS 2010) NA Ethiopia 34 (DHS 2005) 34 (DHS 2005) 34 (DHS 2005) 25 (DHS 2011) 25 (DHS 2011) Less than 10% Haiti 37.5 (DHS 2005-06) 37.5 (DHS 2005-06) 37.5 (DHS 2005-06) 37.5 (DHS 2005-06) 38 (DHS 2012) NA Lao PDR 27.3 (LRHS 2005) 27.3 (LRHS 2005) 27.3 (LRHS 2005) 27.3 (LRHS 2005) 20 (Social Indicator Survey 2012) NA (CPR target is set in MNCH Strategy rather than unmet need Madagascar 24 (DHS 2004) 19 (MOH) 19 (MOH) 19 (DHS 2009) 19 (DHS 2009) NA Mali 31.2 (DHS 2006) 31.2 (DHS 2006) 31.2 (DHS 2006) 31.2 (DHS 2006) 32 (MICS 2009/2010) NA Mongolia 14.4 (RHS 2008) 14.4 (RHS 2008) 14.4 (RHS 2008) 14.4 (RHS 2008) 14.4 (RHS 2008) 10% Mozambique 18.4 (DHS 2003) 18.4 (DHS 2003) 18.4 (DHS 2003) 18.4 (DHS 2003) 22.3 (DHS 2011 Preliminary) NA Nicaragua 10.7 (DHS 2006-07) 10.7 (DHS 2006-07) 10.7 (DHS 2006-07) 10.7 (DHS 2006-07) 10.7 (DHS 2006-07) 8% Niger 22 (MOH 2007) NA NA NA 20 (DHS 2012 Prelim) NA Nigeria       20 (DHS 2008) 18.9 (MICS 2011)   Sierra Leone 28 (DHS 2008) 28 (DHS 2008) 28 (DHS 2008) 28 (DHS 2008) 27.4 (MICS 2011) 40% reduction Source: Compiled from various sources as indicated in the table 1.4.2 Contraceptive prevalence rate - modern methods Contraceptive prevalence rate (CPR) is a very important measure of the outcome of family planning interventions. With respect to modern methods, this measure refers to the proportion of women aged 15-49 who are using, or whose sexual partners are using, any modern method of contraception. The measure provides an indication of progress made in improving family planning and meeting the needs of women. For a better understanding of progress, the measure can be disaggregated to show 7Annual Report 2012 prevalence for different areas of the country, different age groups, background characteristics such as household wealth and level of education. The updates provided in Table 3 and Figure 3 show that CPR has increased in Lao PDR, by 8 percentage points from 35 per cent in 2005 to 43 per cent in 2012; in Haiti by more than 6 percentage points from 24.8 per cent in 2005-2006 to 31.3 per cent in 2012; in Nigeria by 4 percentage points from 9.7 per cent in 2008 to 14.0 per cent in 2011; and in Sierra Leone by four percentage point from 7 per cent in 2008 to 11 per cent in 2011. Preliminary results of a KAP study conducted in Burkina Faso showed that CPR has increased by 5 percentage points over last to 20.1 per cent in 2012. Table 3: Contraceptive prevalence rate (modern methods): Stream 1 countries, percentage Country Baseline 2009 2010 2011 2012 Target Burkina Faso 8.6 (DHS 2003) 13.3 (MICS 2006) 16.2 (DHS 2010) 16.2 (DHS 2010) 20.1 (KAP 2012 Preliminary) 35% (2013) Ethiopia 13.9 (DHS 2005) 30 (MOHS) 32 (MOHS) 27.3 (DHS 2011) 27.3 (DHS 2011) 65% (2015) Haiti 24.8 (DHS 2005-06) 24.8 (DHS 2005-06) 24.8 (DHS 2005-06) 24.8 (DHS 2005-06) 31.3 (DHS 2012) 35% (2013) Lao PDR 35 (LRHS 2005) 35 (LRHS 2005) 35 (LRHS 2005) 35 (LRHS 2005) 43 (Social Indicator Survey 2012) 55% (2015) Madagascar 18 (DHS 2004) 29.2 (MOHS) 29.2 (DHS 2008-09) 29.2 (DHS 2008-09) 29.2 (DHS 2008-09) 36% (2012) Mali 6.9 (DHS 2006) 6.9 (DHS 2006) 6.9 (DHS 2006) 6.9 (DHS 2006) 8 (MICS 2009/2010) 15% (2013) Mongolia 40 (RHS 2008) 40 (RHS 2008) 40 (RHS 2008) 40 (RHS 2008) 40 (RHS 2008) 55% (2012) Mozambique 11.7 (DHS 2003) 11.7 (DHS 2003) 12.2 (MOH) 12.2 (MOH) 11.3 (DHS 2011 Preliminary) 34% (2015) Nicaragua 69.8 (DHS 2007) 69.8 (DHS 2007) 69.8 (DHS 2007) 69.8 (DHS 2007) 69.8 (DHS 2007) 72% (2013) Niger 11.7 (DHS 2006) 16.5 (MOH) 21 (HMIS) 21 (HMIS) 12.1 (DHS 2012 Preliminary) 18% (2012) Nigeria – – – 9.7 (DHS 2008) 14 (MICS 2011) – Sierra Leone – 7 (DHS 2008) 7 (DHS 2008) 7 (DHS 2008) 11.1 (MICS 2011) 10.5% (2013) Source: Compiled from various sources as indicated in the table Global ProGramme to enhance reProductive health commodity Security8 Figure 3: Contraceptive prevalence rate (modern methods) for GPRHCS Stream 1 countries Even with improvements in CPR, disparities in contraceptive use among women based on education levels, household income and urban rural location continue to exist. CPR is disproportionately higher among married women in the highest wealth quintile than those in lower wealth quintiles. In all GPRHCS countries, the percentage of women who are current users of contraceptives increases with the level of education of the women. 1.4.3 Family planning demand satisfied Computation of ‘total demand for family planning’ uses data for CPR and unmet need for family planning. The total demand for family planning constitutes those who are currently using a family planning method and those who need family planning but are not currently using any family planning method. The percentage of family planning demand satisfied is arrived at by computing contraceptive prevalence rate as a percentage of total demand for family planning – % of demand satisfied = [(CPR ÷ (CPR + Unmet Need)) x100]. Based on the updated information, shown in Tables 4 and Figure 4, the percentage of demand satisfied is highest in Nicaragua (86.7 per cent) followed by Mongolia (73.5 per cent) and Lao PDR (68.3 per cent); it is lowest in Sierra Leone (28.8 per cent). Total demand satisfied has increased from 2011 to 2012 in Lao PDR from 56.2 per cent to 68.3 per cent, Burkina Faso from 36 per cent to 45 per cent, Haiti from 39.8 per cent to 45 per cent and Sierra Leone from 20 per cent to 28.8 per cent (Table 4). C on tr ac ep ti ve P re va le nc e % Burkina Faso Ethiopia Haiti Lao PDR Madagascar Mali Mongolia Mozam- bique Nicaragua Niger Nigeria Sierra Leone Country 0 10 20 30 40 50 60 70 80 Baseline (2008) 2009 2010 2011 2012 Target 9Annual Report 2012 Table 4: Family planning demand satisfied in GPRHCS Stream 1 countries Country unmet need CPR Total demand for FP Percentage of total demand satisfied Percentage of total demand noT satisfied Burkina Faso 24.5 20.1 44.6 45.1 54.9 Ethiopia 25 27.3 52.3 52.2 47.8 Haiti 38 31.3 69.3 45.2 54.8 Lao PDR 20 43 63. 68.3 31.7 Madagascar 19 29.2 48.2 60.6 39.4 Mali 32 8 40 20 80 Mongolia 14.4 40 54.4 73.5 26.5 Mozambique 22.3 11.3 33.6 33.6 66.4 Nicaragua 10.7 69.8 80.5 86.7 13.3 Niger 20 12.1 32.1 37.7 62.3 Nigeria 18.9 14 32.9 42.6 57.4 Sierra Leone 27.4 11.1 38.5 28.8 71.2 Figure 4: Family planning demand satisfied in GPRHCS Stream 1 countries Pe rc en ta ge Percentage of Total Demand Satisfied Bu rk in a Fa so Et hi op ia H ai ti La o PD R M ad ag as ca r M al i M on go lia M oz am bi qu e N ic ar ag ua N ig er N ig er ia Si er ra L eo ne CountryPercentage of Total Demand NOT Satisfied 0% 20% 40% 60% 80% 100% Global ProGramme to enhance reProductive health commodity Security10 1.5 Family planning method mix Family planning method mix is used to look at whether users of family planning are concentrated on a few methods or are fairly spread among a number of methods. One way of assessing this is by computing the difference in prevalence between the most prevalent modern method in a country and the third-most prevalent method and dividing it by the total CPR for modern methods.4 Countries 4 USAID | DELIVER PROJECT, Task Order 1. 2010. Contraceptive Security Index Technical Manual. Arlington, Va.: USAID | DELIVER PROJECT, Task Order 1; Page 9 with high method mix scores are said to have even spread of users among the methods – which could be conducive for contraceptive security. On the other hand, countries with low scores may have high concentrations of users on limited methods – a scenario that is though not to be conducive for contraceptive security. Table 5 shows data for four countries with two recent surveys for which method mix scores are presented. Table 5: Per cent distribution of currently married women age 15-49 by contraceptive method currently used for selected GPRHCS Stream 1 countries modern FP method Burkina Faso Haiti Sierra leone lao PdR niger dHS 2010 2012 kaP preliminary results dHS 2005- 06 dHS 2012 Preliminary report dHS 2008 mICS 2011 lRHS 2005 lao Social indicator Survey 2012 dHS 2006 Preliminary dHS-mICS 2012 Female Sterilization 0.2 0.0 2.1 1.5 0.0 0.0 4.6 4.6 0.3 0.1 Male Sterilization 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 IUD 0.3 0.2 0.0 0.1 0.2 0.0 2.8 1.6 0.1 0.1 Implant 3.4 3.8 1.6 1.9 0.0 0.6 0.0 0.1 0.0 0.3 Pill 3.2 3.6 3.3 2.8 2.3 4.0 15.2 21.2 3.0 5.6 Injectable 6.2 8.9 11.0 19.4 2.9 4.6 10 13.6 1.5 2.1 Male Condom 1.6 1.7 5.3 5.1 0.6 0.1 0.8 1.1 0.0 0.0 Others 1.3 1.9 1.5 0.4 0.7 1.8 0.0 0.6 0.1 3.9 Total for Modern FP Methods 16.2 20.1 24.8 31.3 6.7 11.1 33.4 42.8 5.0 12.1 Method Mix Score on a 10-point scale 8.1 7.4 6.9 4.7 6.7 7.5 6.8 6.1 4.6 7.1 11Annual Report 2012 In Burkina Faso, the three methods with the highest prevalence accounted for 79 per cent of modern CPR in 2010, which increased slightly to 81.1 per cent in 2012. Similarly in Haiti, the three methods with the highest prevalence accounted for 79 per cent of modern CPR in 2005-2006 and increased to 87.3 per cent in 2012. For Lao PDR, the concentration of users on limited methods increased from 67.7 per cent in 2005 to 92.1 per cent of users in 2012. For Niger, even with improvement in method mix score, the concentration on the three most prevalent methods has remained very high at around 96 per cent. In the case of Sierra Leone, even with a slight improvement in method mix score, the three most prevalent methods accounted for 93.7 per cent of CPR in 2011 compared to 88.1 per cent in 2008. The injectable is the most popular method in Haiti (61.9 per cent of CPR in 2012) and Sierra Leone (41.4 per cent of CPR in 2011); and the pill is the most popular method in Niger (49.5 per cent of CPR in 2012) and Lao PDR (46.3 per cent of CPR in 2012). Preference for long-term and permanent methods Figure 5: Per cent distribution of currently married women age 15–49 by contraceptive method currently used for selected GPRHCS Stream 1 countries Pe rc en ta ge Female Sterilization DHS 2010 Burkina Faso Haiti Sierra Leone Lao PDR Niger 2012 KAP preliminary results DHS 2005-06 DHS 2012 Prelim. Report DHS 2008 MICS 2011 LRHS 2005 Lao Social indicators 2012 DHS 2006 DHS-MICS 2012 Prelim. Report CountryMale Sterilization IUD Implant Long-term and permanent methods Pill Injectable Male Condom Others 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Global ProGramme to enhance reProductive health commodity Security12 For the new set of countries with updated data, the prevalence of long-term and permanent methods (e.g. sterilization, IUD and implants) decreased in Burkina Faso from 24 per cent to 19 per cent of CPR, decreased in Haiti from 14.9 per cent to 11.5 per cent of CPR, decreased in Lao PDR from 22.2 per cent to 14.7 per cent of CPR and decreased in Niger from 8 per cent to 4.1 per cent of CPR (Figure 5). In contrast, for Sierra Leone, prevalence of long term and permanent methods increased from 3 per cent to 5.4 per cent of CPR. While the implant is the most popular long-term permanent method in Haiti, Niger and Sierra Leone, in Lao PDR the most popular method is female sterilization. Box 1: Procure contraceptives and promote their use The Global Programme to Enhance RHCS works to procure contraceptives and other essential reproductive health supplies and promote their use through various mechanisms such as community-based distribution and social marketing, seeking to increase timely access to a choice of quality, affordable reproductive health commodities. Burkina Faso’s community-based distribution The predominantly rural country of Burkina Faso has initiated an innovative approach to community- based distribution of condoms and contraceptives, as well as health information, in a project spearheaded by UNFPA and involving a wide range of partners, from volunteer health workers and community-based organizations to government ministries. Although Solange Lamoussa Sawadogo (pictured at right) has no medical training, the 28-year-old mother of two is fondly called ‘loctoré’ – doctor in English – in her village 200 kilometres east of Ouagadougou. With the nearest health centre in Moaga, eight kilometres away, Solange, a volunteer Community Health Worker, promotes reproductive health, encourages couples to seek family planning counselling – something rather new in this traditional community – and dispenses condoms and some contraceptives. Well respected by both the men and women of Sablogo, she seizes every opportunity to talk to people wherever she finds them – by the well, 13Annual Report 2012 on the farm, in the market place, at places of worship, and attending village events. “Here, women are willing to use contraceptive pills,” says Solange. Some are also starting to use longer- acting injectables, such as Norplant, but an increasing number prefer pills, she says. After going to the Health and Social Promotion Centre in Moaga, women can buy contraceptive supplies from Solange, upon presentation of the booklet given them by a health worker, to whom they must return on a quarterly basis for a check-up. Solange also makes it a point to encourage men to take an active role in their wives’ pregnancies, including by going with them to the clinic for antenatal consultations. And she is getting results: In this village, about 20 men have already accompanied their pregnant wives at least once to the Moaga health clinic, something virtually unheard of in the past. The community-based distribution system has increased family planning: The Moaga health centre was able to increase the contraceptive prevalence rate from 11 per cent in 2009 to 30 per cent in 2011 among the 7,000 people it serves in six villages. Source: UNFPA news story by Boureima Sanga Community-based distribution of contraceptives in Burkina Faso was launched in 2009 as a partnership of government, civil society and UNFPA’s GPRHCS involving outsourcing for efficiency. Agents have served 94 per cent of health districts including more than 1,000 health facilities. Women accounted for nearly half of the 1,443 facilitators and 4,954 distributors trained from 2009 to 2011. In 2012, contraceptives distributed provided 8,184 couple years of protection from unwanted pregnancy. Progress in the country is moving forward on several fronts, including training of staff at more than 200 service delivery points, developing capacity for forecasting and procurement and, specifically, training of district health practitioners in every region on the use of computerized logistics management information system to avoid supply stock-outs. Also, an extensive multi-media public outreach campaign using film, radio and theatre has reached an estimated audience of 60 per cent of the population with family planning messages since 2008. Reaching rural and ethnic women in lao PdR In Lao People’s Democratic Republic (Lao PDR), specially trained ‘community-based distribution agents’ are the reason why more hard-to-reach women are using modern methods of contraception and why local family planning services are providing better care and serving more clients. In areas where they work, family planning uptake has increased from 12 per cent in 2007 to 45 per cent in 2011. Developing the capacity of community service providers to deliver culturally appropriate services has demonstrated positive results. In some districts, the level or extent of family planning services provided by special family planning providers now exceeds that of district hospitals. At the national level, the contraceptive prevalence rate has increased in Lao PDR by 8 percentage points from 35 per cent in 2005 to 43 per cent in 2012. Global ProGramme to enhance reProductive health commodity Security14 Community wellness advocacy Groups launched in Sierra leone Traditional Birth Attendants have become a powerful force for family planning community advocacy at community level. They have received training and formed Community Wellness Advocacy Groups (CAGs) to address public gatherings at markets, meetings and move from door to door. The CAGs programme was officially launched in 2012 in Sierra Leone. CAGs conduct various outreach activities, such as mobilizing and referring pregnant women for antenatal care, accompanying women and girls for reproductive health services including family planning services, making sure that women benefit from the Free Health Care Initiative and dispelling the wide spread myths and misconceptions that hamper access to RH/FP services. Of particular importance in the community advocacy programme is the inclusion of Men’s Peer Educator Networks (MPENs) that were established as an adaptation of the Husband schools in Niger, following a study tour to that country. CAGs aim to reach individuals like Fatmata Kamara, a young mother of three, whose husband does not know that his wife takes contraceptive pils. “After our third kid, I told him I do not want any more kids, and asked him to use a condom but he wouldn’t listen to me,” she says. Asked if she’d like to know more about long- acting implants, she voices a concern:, “I have heard of it, but my friends are saying that if I take them, I will develop a bad sickness and will eventually bleed to death”. Addressing misconceptions is a frequent task for the CAGs. Marian Foday, a Community Wellness Advocate in Bo, says this case is not an exception: “There are many women like Ms. Kamara who want to practice long term family planning methods but are afraid to use methods like implants due to the local myths and misconceptions associated with them”. She believes that attitudes are changing. “With the support received from UNFPA and other partners I hope we can continue to change attitudes in the community and I am confident that soon young women like Ms. Kamara will voluntarily access long-term methods like implants”. Source: Annual UNFPA country report to GPRHCS more country examples The Condomize Campaign reached thousands of participants at two events in Ethiopia in 2012: the 13th World Congress on Public Health in April attended by 168 countries and a family planning symposium in November. UNFPA supported the National Family Planning Symposium attended by 500 high-level government officials, policy advisers, and representatives from development partners and community service organizations. nigeria, which moved from Stream 2 to Stream 1 in 2011, committed $3 million and signed an MOU with UNFPA to procure contraceptives in 2012. The Government also enacted a policy to dispense contraceptives in public health facilities free of charge. Community-based provision of family planning information, services and supplies expanded to two additional districts in Rwanda in 2012, Karongi and Rubavu, accompanied by training at the village level 15Annual Report 2012 of 2,172 community health workers. Expansion to Nyamasheke district in early 2013 included training for another 1,206 community health workers. For more information, view this video: http://youtu.be/EiKeHOttLeo. In Cameroon in 2012, monitoring was conducted for the implementation of the pilot project on pre-placement of obstetric kits for safer birth and Caesarian sections. After 10 months of implementation, the number of women delivering in the participating health facilities had increased by 70 per cent. The Government initiated the scale- up of the strategy to other health districts using its own funds. For the first time, Cameroon’s Ministry of Health included a budget line for the procurement of contraceptives in its budget, as of 2013. A pilot plan to introduce modern methods of contraception in Peru increased use of injectables and implants right from the start: in the first month, use increased from zero to 341 implants and 679 monthly injectables across five pilot sites. For many years, the mix of contraceptive has been limited to only four alternatives and has not reached the neediest populations. The Government and UNFPA are committed to expanding access to and choice of methods. In Bolivia, a proposal was submitted to the Ministry of Health and Sports to amend the legal framework of the bid process for reproductive health commodities and drugs. Presently, CEASS (the national distribution centre for health supplies) is at a legal disadvantage in the process of bidding on against private entities for such supplies; the proposed amendment would level the playing field. CEASS has also undertaken negotiations for purchase of reproductive health commodities and drugs including contraceptives from other countries including Canada, Cuba and India. Although South Sudan is a new nation, the government with UNFPA support distributed over 911,600 condoms in 2012 through a network of partners in the country and as part of the emergency programme response through the distribution of RH kits. UNFPA South Sudan and the Ministry of Health also participated in the UNFPA-funded workshop in Rwanda on strengthening comprehensive condom programming. Staff members and MoH focal point came back with increased knowledge and skills to strengthen condom programming in the country. Global ProGramme to enhance reProductive health commodity Security16 CHaPTER Two: mEaSuRInG avaIlaBIlITy aT THE CounTRy lEvEl A warehouse dispatcher in Tenkodogo, Burkina Faso, uses CHANNEL computer soft ware to track stocks of reproductive health supplies. Photo: Ollivier Girard/ UNFPA Burkina Faso Reporting on results The GPRHCS is able to demonstrate specific achievements in this report because UNFPA uses results-based management (RBM) - an approach for more effective and efficient ways of working. The results-based approach applies the GPRHCS Performance Monitoring Framework and the UNFPA Results and Resources Framework. The robust Performance Monitoring Framework enables the GPRHCS to measure progress and report results. Reviewed extensively in 2009 in a collaborative effort by UNFPA Country Offices, Regional Offices, donors and partners, the framework focuses on valuable data about RHCS progress and results at the national, regional and global levels. Headings represent the framework’s indicators. Sources of data in the remainder of the report include national surveys conducted with UNFPA support in GPRHCS Stream 1 countries, reports submitted by UNFPA Regional and Country Offices, and UNFPA’s donor support report. 17Annual Report 2012 2.1 number of GPRHCS Stream 1 countries with service delivery points (SdPs) offering at least 3 modern methods of contraceptives5 This outcome indicator is a measure of the efficiency of commodity distribution networks in a country and the ability of government and its partners to sustain achievements made in making services available to clients. Since 2010, information for this indicator is derived from annual surveys conducted in all GPRHCS Stream 1 countries using a special tool designed for the purpose. 5 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 Recent survey results shown in Table 6 and Figure 6 track the percentage of service delivery points (SDPs) offering at least three modern contraceptive methods. The benchmark for this indicator has been achieved in all Stream 1 countries where more than 75 per cent of SDPs offered at least three modern contraceptives. Eight out of the 12 Stream 1 countries had at least three modern contraceptive methods available in more than 90 per cent of SDPs as per national protocols and guidelines. The percentage was highest in Burkina Faso (99.5 per cent). Compared to 2011, the percentage has improved in five countries (Burkina Faso, Lao PDR, Madagascar, Mali, Niger and Sierra Leone). Table 6: Percentage of service delivery points (SdPs) offering at least three modern methods of contraception in GPRHCS Stream 1 countries, 2008 to 2012 Country Baseline (2008) 2009 2010 2011 2012 Target (2013) Burkina Faso NA 80.4 (2009) 93.5 90.3 99.5 100 (2012) Ethiopia 60 (2006) 90 98 97.2 96.4 100 (2010) Haiti - NA 93 91.8 84.3 90 (2013) Lao PDR 96 (2006) 91 93 67 91.4 100 (2012) Madagascar - 30.8 47.8 77.5 95 100 (2012) Mali - 100 97 83 99 NA Mongolia 98 NA 93.5 98.2 97.6 100 Mozambique 95.7 (HIS 2008) NA 96.5 97.1 96.6 100 Nicaragua 66.6 (2008) 92 99.5 100 98.6 100 Niger 56 (2008) NA 80.9 79 91.1 90 Nigeria 89 88.9 NA Sierra Leone - 88* 87.2 80.5 89 100 Source: GPRHCS 2010 country and related sample survey reports Note: 2010 to 2012 data from sample surveys reports of each country conducted using standardized methodology * Proportion with at least two modern methods available Global ProGramme to enhance reProductive health commodity Security18 Figure 6: Percentage of service delivery points (SdPs) offering at least three modern methods of contraception in GPRHCS Stream 1 countries, 2008 to 2012 In 2012, five countries, (Burkina Faso, Lao PDR, Madagascar, Mali, and Niger) showed improvements in the availability of contraceptives at the primary SDP level (Table 7) and nine countries showed improvements at secondary level. 0% 20% 40% 60% 80% 100% Pe rc en ta ge Burkina Faso Ethiopia Haiti Lao PDR Madagascar Mali Mongolia Mozam- bique Nicaragua Niger Nigeria Sierra Leone CountryBaseline (2008) 2009 2010 2011 2012 Target 19Annual Report 2012 Table 7: Percentage of sampled SdPs by type of facility, offering at least three modern methods of contraception in GPRHCS Stream 1 countries, 2010 to 2012   Primary Secondary Tertiary 2010 2011 2012 2010 2011 2012 2010 2011 2012 Burkina Faso 92 89.6 100 100 92.7 96.8 100 100 100 Ethiopia 97.6 96.4 95.8 98.4 98.4 96.6 100 100 100 Haiti 91 90.9 80.2 94 93.5 91.2 93 100 100 Lao PDR 89 67 87.1 95 92 97.9 94 93 94.3 Madagascar 50 78.5 95 50.6 45.3 96.3 61.8 45.5 100.0 Mali 88 77 99 88 95 100 73 82 100 Mongolia 92 98.2 96 100 97.8 100 100 100 100 Mozambique 96.7 98.9 95.5 95 92.1 97.4 100 100 100 Nicaragua 99.5 100 98.5 100 100 100 - - 100 Niger 80 78 90.7 100 97.0  100 100 100 100 Nigeria - 84 83.3 - 94.3 96 - 97.1 100 Sierra Leone 70 90.2 88.9 76 58.2 86.4 78 50 100 Source: GPRHCS 2010 to 2012 country and related sample survey reports In line with their national protocols and guidelines, 100 per cent rural SDPs in Mali and Niger had at least three modern methods of contraceptives available; while in Burkina Faso and Mongolia, 100 per cent of urban SDPs had at least 3 modern methods available (Figure 7). Global ProGramme to enhance reProductive health commodity Security20 Figure 7: Percentage of sampled SdPs by location offering at least three modern methods of contraception in GPRHCS Stream 1 countries, 2011 and 2012* Survey reports cited several factors that could account for SDPs not offering three modern methods of contraceptives. In Sierra Leone, for example, the lack of trained staff and equipment limited the provision of long-term and permanent methods. In Mozambique, delays in transportation systems made it difficult for some SDPs to offer three modern methods. In Lao PDR, there was a lack of appropriately trained staff to provide services such as IUD insertion and male and female sterilization; in addition, the capacity of the supply chain system was too limited to ensure a constant flow of supplies to all facilities. In Mali, infrequent demand by clients was cited as the reason why some methods, including female condoms and male sterilization, were not available in SDPs. 2.2 number of GPRHCS Stream 1 countries with seven life-saving maternal/RH medicines (including magnesium sulfate and oxytocin) available The list of priority life-saving medicines for women and children was revised in 2012, directly affecting this indicator on maternal health medicines6. Two 6 According to the WHO Priority life-saving medicines, for changes occurred: The number of life-saving maternal health medicines increased from five to seven, and inclusion of two medicines was specified. The revision requires that magnesium sulfate and oxytocin must be among the seven, subject to the provisions of national protocols and guidelines regarding the level of SDPs and their mandates to provide certain medicines. In 2012, six out of the 12 Stream 1 countries had seven life-saving medicines (including magnesium sulfate and oxytocin) available in more than 70 per cent of SDPs (Table 8 and Figure 8). The survey results of 2012 are not comparable to the other years. women and children, 2012; the priority medicines are: i) Oxytocin, ii) Misoprostol, iii) Sodium chloride, iv) Sodium lactate compound solution, v) Magnesium sulphate, vi) Calcium gluconate, vii) Hydralazine, viii) Methyldopa, ix) Ampicillin, x) Gentamicin, xi) Metronidazole, xii) Mifepristone, xiii) Azithromycin, xiv) Cefixime, xv) Benzathine Benzylpenicillin, xvi) Nifedipine, xvii) Dexamethasone, xviii) Betamethasone, and ixx) Tetanus toxoid. For further information please see to the updated list at http://apps. who.int/iris/bitstream/10665/75154/1/WHO_EMP_MAR_2012.1_ eng.pdf. Please note that for this survey a) Sodium chloride and Sodium lactate compound solution are alternates; and that b) Dexamethasone is an alternate to Betamethasone Pe rc en ta ge Burkina Faso Ethiopia Haiti Lao PDR Madagascar Mali Mongolia Mozam- bique Nicaragua Niger Nigeria Sierra Leone Country2011 Urban 2012 Urban 2011 Rural 2012 Rural 0% 20% 40% 60% 80% 100% 21Annual Report 2012 Table 8: Percentage of SdPs with seven life-saving maternal/RH medicines (including magnesium sulfate and oxytocin) available in GPRHCS Stream 1 countries in 2012 Country Percentage Country Percentage Burkina Faso 24.4 Mongolia 82.3 Ethiopia 54.6 Mozambique 84.8 Haiti 73.6 Nicaragua 88.5 Lao PDR 53.1 Niger 68.5 Madagascar 66.9 Nigeria 47.0 Mali 91.0 Sierra Leone 71.7 *Source: GPRHCS 2012 Survey reports of GPRHCS Stream 1 countries Figure 8: Percentage of SdPs with sevel life-saving maternal/RH medicines (which includes magnesium sulfate and oxytocin) available in GPRHCS Stream 1 countries in 2012 Pe rc en ta ge Burkina Faso Ethiopia Haiti Lao PDR Madagascar Mali Mongolia Mozam- bique Nicaragua Niger Nigeria Sierra Leone Country 0% 20% 40% 60% 80% 100% Global ProGramme to enhance reProductive health commodity Security22 The percentage of SDPs with seven life-saving maternal health medicines (including magnesium sulfate and oxytocin) was higher in tertiary SDPs than for secondary SDPs in 10 countries (except in Madagascar and Mongolia). Also in Burkina Faso, Lao PDR, and Sierra Leone less than 35 per cent of primary SDPs had the seven life-saving medicines available in 2012. Table 9: Percentage of SdPs by type with seven life-saving maternal/RH medicines (including magnesium sulfate and oxytocin) available in GPRHCS Stream 1 countries in 2012 Country By type of SdP Primary Secondary Tertiary Burkina Faso 14.2 68.3 90.9 Ethiopia 25.4 92.2 100 Haiti 53.8 79.4 100 Lao PDR 31.4 75.7 87.1 Madagascar 65.4 61.5 40.0 Mali 89.0 96.0 100 Mongolia 76.2 96.3 83.3 Mozambique 73.0 100 100 Nicaragua 88.5 85.7 100 Niger 67.6 84.6 100 Nigeria 32.7 64.8 87.0 Sierra Leone 67.4 79.2 100 *Source: GPRHCS 2012 Survey reports of GPRHCS Stream 1 countries 23Annual Report 2012 Figure 9: Percentage of SdPs with seven life-saving maternal/RH medicines (including magnesium sulfate and oxytocin) available in GPRHCS Stream 1 countries in 2012 The challenges of providing the full range of maternal health medicines varied from country to country in 2012. In Lao PDR, some SDPs did not meet the requirements of this indicator because some medicines were not included on the facility’s drug list, and also because they lacked refrigerators or proper storage systems. In Mongolia, the main reason for not offering oxytocin or magnesium sulfate was because SDPs had limited or no supply of these commodities. Medicines such as clotrimazol and metronidazole were prescribed by doctors but clients were required to buy them at drug stores. For Haiti, medicines were not readily available because of weakness in the supply chain system, which was in some cases plagued by delays. There is an ongoing need to address the challenges faced by countries as they strive to maintain quality of care and deliver services closer to the people. One step is building the capacity of the health authorities of SDPs. It also is important to ensure that at least some methods are provided when needed, which calls for improvement in storage, transportation and inventory management to improve availability of maternal health medicines especially in hard to reach areas. Overall, effective planning and monitoring systems are essential in order to ensure the consistent supply of medicines. 2.3 number of Stream 1 countries with service delivery points with ‘no stock-outs’ of contraceptives within last 6 months The aim is to ensure that service delivery points always have contraceptives in stock to serve clients, in line with national protocols. UNFPA supports countries to procure and distribute contraceptives and train staff to make the methods available to women who need them. Averting shortfalls or ‘stock-outs’ entails making logistics management systems fully functional. It also requires addressing issues related to policies, building infrastructure and in some cases ensuring political stability. Seven out of 12 countries (Ethiopia, Lao PDR, Madagascar, Mongolia, Mozambique, Nicaragua and Niger) experienced no stock-out of contraceptives in 60 per cent or more SDPs in 2012 (Table 10). This is an increase of one country from 2011. Ethiopia (97.6 per cent), Niger (97.1 per cent) and Madagascar (88.9 per cent) have very high ‘no stock-out’ rates. Pe rc en ta ge Burkina Faso Ethiopia Haiti Lao PDR Madagascar Mali Mongolia Mozam- bique Nicaragua Niger Nigeria Sierra Leone CountryPrimary Secondary Tertiary 0% 20% 40% 60% 80% 100% Global ProGramme to enhance reProductive health commodity Security24 Table 10: Percentage of SdPs reporting ‘no stock-out’ of contraceptives within the last six months in GPRHCS Stream 1 countries, 2008 to 2012 Country Baseline (2008) 2009 2010**** 2011**** 2012**** Target (2013) Burkina Faso NA 29.2 (2009) 81.3 12.8 25.1 100% (2012) Ethiopia 60 (2006) 90 (2009) 99.2 98.8 97.6 100% (2012) Haiti NA NA 52.5 26.4 42.6 NA Lao PDR NA 20* 36 84 71.1 80% Madagascar 63.3 (2008) 74.4 (2009) 79.6 90.3 88.9 96% (2012) Mali - NA 46 31 57 NA Mongolia 100 100 97.6** 37.7 64.4 100% Mozambique NA NA 24.1 81 64.7 NA Nicaragua 66 (2008) 81 (2009) 99.7 64.5 63.1 92% Niger 0 100 (2009) 99.1*** 85 97.3 100% (2012) Nigeria       44 67.4  NA Sierra Leone - 77.0 41.4 35.4 44 100% * 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, 2011 and 2012 country and related sample survey reports Ethiopia, Madagascar and Niger experienced no stock-outs in more than 90 per cent of SDPs for all levels of SDPs (primary, secondary and tertiary). This was accomplished in Ethiopia in 2011 and in 2012. 25Annual Report 2012 Table 11: Percentage of SdPs reporting ‘no stock-out’ of contraceptives within the last six months by type of SdP in GPRHCS Stream 1 countries, 2011 and 2012 Country Primary 2011 Primary 2012 Secondary 2011 Secondary 2012 Tertiary 2011 Tertiary 2012 Burkina Faso 10 25.5 23.7 22.6 10 27.3 Ethiopia 98.2 99.4 100 91.9 100 100 Haiti 29.9 40.7 19.4 50 0 0 Lao PDR 80 69.1 89 76.8 94 65.7 Madagascar 62.9 92.9 74.4 94.1 69.5 94.1 Mali 33 59 28 57 36 0 Mongolia 37.3 64.2 44.4 67.5 20 50 Mozambique 90.9 68.6 78.9 61.5 100 50 Nicaragua 63.9 63.2 73.9 57.9 NA 100 Niger 85 96.9 85 100 100 100 Nigeria 45.2 63 39.8 72.8 58.3 78.3 Sierra Leone 35.2 39.5 30.7 57.1 29.2 0 *Source: GPRHCS 2011 and 2012 Survey reports of GPRHCS Stream 1 countries Global ProGramme to enhance reProductive health commodity Security26 Figure 10: Percentage of rural SdPs reporting ‘no stock-out’ of contraceptives within the last six months in GPRHCS Stream 1 countries, 2011 and 2012 ‘No stock-out’ rates at primary SDPs have improved since last year in many countries, with the exception of Lao PDR, Mozambique and Nicaragua (Figure 10). The ‘no stock-out’ rate at the primary level remained above 60 per cent for 2011 and 2012 in six countries: Ethiopia, Lao PDR, Madagascar, Mozambique, Nicaragua and Niger. ‘No stock-out’ rates for 2012 were higher in rural areas in 9 of the 12 Stream 1 countries (Burkina Faso, Ethiopia, Lao PDR, Madagascar, Mali, Mongolia, Nicaragua, Nigeria and Sierra Leone) than in urban areas (Table 12). In contrast, for Haiti, Niger and Nigeria the ‘no stock-out’ rates are higher in urban areas. Pe rc en ta ge Burkina Faso Ethiopia Haiti Lao PDR Madagascar Mali Mongolia Mozam- bique Nicaragua Niger Nigeria Sierra Leone CountryPrimary 2011 Primary 2012 0% 20% 40% 60% 80% 100% 27Annual Report 2012 Table 12: Percentage of SdPs reporting ‘no stock-out’ of contraceptives within the last six months by location of SdP in GPRHCS Stream 1 countries, 2011 and 2012 Country Rural urban 2011 2012 2011 2012 Burkina Faso 9.3 26.8 17.9 20.6 Ethiopia 98.2 97.8 99 97.6 Haiti 27.4 38.8 25 47.3 Lao PDR 80 69.9 89 25.4 Madagascar 61.8 94.2 74.2 92.6 Mali 31 61.0 32 50.0 Mongolia 37.7 67.7 37.8 58.3 Mozambique 80.2   85.7   Nicaragua 63.7 66.6 65.8 61.7 Niger 87 96.9 76 100 Nigeria 45.1 58.4 42.5 79.8 Sierra Leone 35.5 44 31.5 34.4 *Source: GPRHCS 2011 and 2012 Survey reports of GPRHCS Stream 1 countries ‘No stock-out’ rates improved in SDPs in urban and rural areas from 2011 to 2012 (Figure 11). Rural rates improved in 8 of the 12 GPRHCS Stream 1 countries (Burkina Faso, Haiti, Madagascar, Mali, Mongolia, Nicaragua, Niger and Sierra Leone). Urban rates also improved in 8 of the 12 Stream 1 countries (Burkina Faso, Haiti, Madagascar, Mali, Mongolia, Niger, Nigeria and Sierra Leone). Global ProGramme to enhance reProductive health commodity Security28 Figure 11: Percentage of SdPs reporting ‘no stock-out’ of contraceptives within the last six months by location of SdP in GPRHCS Stream 1 countries, 2011 and 2012 The stock-out situation has improved in the Stream 1 countries, yet many challenges still persist. In Sierra Leone, for example, weakness in the supply and distribution system affects the availability of all the methods. Lack of trained staff and equipment contributed to the stock-out level of long-term and permanent methods such as IUDs, implants and sterilization (male and female). In Mongolia, shortage of supply due to weak distribution systems contributed to the stock-out level for male condoms, oral pills, IUDs and emergency pills. In Burkina Faso, demand exceeded the limited quantity of supplies and caused stock-outs for male and female condoms, pills and injectables. Also, due to errors in inventory management, some SDPs were not able to predict the occurrence of stock-outs and could not order for replenishment in time. Results of the annual surveys conducted as part of the GPRHCS show that capacity development challenges, including problems associated with national supply chain systems, continue to impede the effective functioning of the health system at all levels. The stock-outs experienced in the countries continue to reflect the level of functioning of the logistics management system from central to district levels. 2.4 Funding available for contraceptives including condoms The indicator tracks the donor resources available for contraceptives, including condoms, as another way of measuring progress towards RHCS. The source of the data for this indicator is the UNFPA Report on Donor Support for Contraceptives and Condoms, a report compiled from donor databases and published annually by the Commodity Security Branch. In 2012, data was only available for DFID, Global Fund, IPPF, MSI, PSI, UNFPA and USAID but not for DKT and KFW, a change from 2011. The report will be posted on the UNFPA website as soon as it becomes available at www.unfpa.org. Pe rc en ta ge Burkina Faso Ethiopia Haiti Lao PDR Madagascar Mali Mongolia Mozam- bique Nicaragua Niger Nigeria Sierra Leone CountryRural 2011 Rural 2012 Urban 2011 Urban 2012 0% 20% 40% 60% 80% 100% 29Annual Report 2012 Box 2: Increase access and create demand Countries are increasing access and creating demand by working within a human rights-based approach that empowers individual choices and dignity, sharing information through behaviour change communication, and going the last mile to ensure access for underserved and hard-to-reach populations. Four new Husbands’ Schools in Côte d’Ivoire Men can learn to become champions for reproductive health and help to reduce maternal mortality: This is the idea behind the School for Husbands (École des Maris), a project that started in Zinder, Niger, and with UNFPA support is expanding in that country and others, including Burkina Faso and Côte d’Ivoire in 2012. In Côte d’Ivoire, men from four pilot Schools for Husbands are talking about change. “Now, I am happy to help my wife with the loads on our way back from the field. Something has changed because everybody in the village is doing so,” says a man from Djangomenou who joined the new school in his village. His neighbor admits: “I cannot stand seeing my wife go to the hospital alone; that’s why I always go with her.” A man from Ousso says the husbands put their new knowledge to work. “Upon our return from training, we cleaned the whole village to make it healthy because we now know that dirt gives us a lot of diseases,” he said. Members of the Schools are becoming role models in their communities. The Chief of Sakassou is trusted for advice by more young people, he says: “Young people in my village now easily come to see me when they have problems in their homes (couple) because I give them good advice since the School for Husbands was put in place. I feel closer to them.” Côte d’Ivoire’s Ministry of Health and AIDS is working with UNFPA on many fronts to accelerate progress towards the Millennium Development Goals, including a strategy to boost the use of reproductive health services in the district of Toumodi by involving men and boys. The action responds to high rates of maternal mortality and unmet need for family planning. In August 2012, the partners established four pilot sites for the School for Husbands in the Health District of Toumodi, with a total population of 22,775. Each school is run by 10 to 12 people, for a total of 45 members, eight Coaches or Community Agents, and four health workers (all nurses). Monthly reports of activities at the Schools are reported to the health center supervisor, then transmitted to the district level, where they are compiled using health information management software. Results in the first six months of the pilot phase show promising progress. Four health centers, one in each of the four villages where a School for Husbands operates, report increased use of reproductive health services between 2011 and the six months of 2012 following project implementation in August 2012: • Use of key reproductive health services increased at all four health facilities, including maternal health and family planning; • New users of family planning increased by five times; • Assisted delivery at birth increased. Men’s involvement contributed to a substantial increase in attendance and use of maternal as well as child health services. The pilot phase has demonstrated that men’s involvement of men promotes access to information and services for family Global ProGramme to enhance reProductive health commodity Security30 planning and other aspects of reproductive health, removes barriers, and improves awareness among families and communities. Further, the involvement of administrative, political and community leaders enhances success and local ownership, especially when traditional village chiefs are themselves participants in the schools. Early results from this experience also confirm a high level of interest in modern contraception by women, consistent with high unmet need across the country. Requests are already coming in from neighboring villages to start schools of their own. Schools for Husbands and demand generation through behaviour change in niger In niger, where the Schools for Husbands initiative originated, the number of schools has grown from 11 test schools in 2007 in the Zinder region to a total of 284 schools in four regions as of 2012, including Dosso, Maradi, Tahoua and Zinder. As of 2012, an estimated 3,250 men are participating. Traditional leaders (chefs traditionnels) expressed their support for efforts to sensitize the public about the importance of family planning in the “Déclaration de Niamey” issued 24 November 2012. Documented results include behaviour changes in men in favour of reproductive health, improvements in RH indicators such as more post-natal consultations, and dramatic increases in the use of family planning. Also in niger and expanding with GPRHCS support, an NGO-led radio programme called ‘The Adventures of Foula’ has reached hundreds of villages with thousands of broadcasts and discussions sessions reaching tens of thousands of women and men. This IEC/BCC campaign continues today, reporting 7,884 dramatic sketches, 3,300 discussion session, creation of committees and training on family planning – all for community-level initiatives on sexual and reproductive health. more country examples In mali, demand creation activities and supply of RH commodities were at the heart of implementation, particularly in response to the 2012 socio-political and humanitarian crisis marked by a coup in March. A collaborative forecasting activity was instrumental in developing an emergency procurement plan for contraceptives. ‘Mobile Teams’ in rural areas fostered demand for long-acting contraceptive methods and built understanding of the importance of birth spacing, messages echoed in media spots, sketches and radio shows. A youth-led organization, Y.E.S. Salone, is the driver of a multi-sectoral programme launched nationally in Sierra leone in 2012 by UNFPA, five Ministries, UN agencies and NGOs. The acronym stands for ‘Young, Empowered and Safe’. The programme provides a single framework for all partners, including the Strategic Planning Unit in the President’s Office; during Parliament’s opening session in December, the President himself announced a new programme on teenage pregnancy. The programme aims to scale up demand for family planning and sexual and reproductive health services for adolescents and youth. Activities this year included development of minimum standards for services; a mobile minibus ‘Poda Poda’ campaign with music, drama sketches, debates and discussion; and roll-out of a 31Annual Report 2012 peer-to-peer grassroots education programme in 13 districts. Adolescent health was also a priority for GPRHCS- supported action in nicaragua, including development and validation of a National Comprehensive Adolescent Health and Development Strategy, advocacy with government and donors to launch an inter-sectorial approach to prevent adolescent pregnancy, dissemination of youth care guidelines, and information and awareness campaigns in 43 municipalities. The number of youth-friendly service delivery points increased from three in 2011 to 10 in 2012 working with PROFAMILIA and AMNLAE. The national budget line for contraceptives in Nicaragua has increased from $321,935 in 2010 to $1,669,042 in 2012. Youth-friendly services, including access to contraceptives, were the focus of a Ministry of Health training course for 70 health professionals in uruguay. Also, UNFPA partner Reprolatina developed an action research project with adolescents to link SRH and HIV services and sexuality education in schools. In mozambique, demand creation activities for long- acting contraceptive implants increased significantly in 2012, with emphasis on the use of implants overall and, more specifically, promotion of the IUD during National Health Week in Nampula Province. In lao PdR, repositioning of family planning included messages that show positive health benefits to mothers and children by better birth spacing and delaying onset of first pregnancy. With GPRHCS funds, UNFPA supported national and sub-national awareness raising using TV and radio spots, posters, leaflets and other materials in local language, plus production, training and dissemination of IEC/BCC materials to promote increased use of modern family planning and attendance at births by a professional midwife. New in 2012 was condom promotion for dual protection among young people. As a strategy to reach remote communities in Lao PDR, UNFPA supports the Government and other stakeholders to conduct regular Health Promotion Days. In each event, doctors, midwives and nurses provide free family planning services, nutrition counseling and antenatal care check-ups to the villagers from the surrounding areas. Advocacy efforts encourage each village to make an action plan to assist women with transportation if complications occur in childbirth. CPR in Rwanda increased from 10 per cent in 2005 to 45 per cent in 2010, accompanied by improvement in maternal health. HIV prevalence has remained constant at 3 per cent, however, and in 2012 UNFPA Global ProGramme to enhance reProductive health commodity Security32 increased its support to partners to increase HIV awareness and prevention measure, and to ensure condoms are widely available at hot spots where people meet. In Ghana, advocacy work in 2012 seeking governmental support for contraceptive procurement led to the Minister of Health declaring a free family planning service. UNFPA and its stakeholders undertook advocacy work to win government support for contraceptive procurement. The modalities for implementing this initiative are presently under consideration. In Benin, five advocacy campaigns were organized aimed at the involvement of men and youth, local elected officials and opinion leaders in the promotion of family planning. This helped to foster and reinforce membership and engagement around family planning. The strong involvement of men and youth in the social mobilization campaigns helps to facilitate free access to family planning services in rural health districts. Togo has also emphasized the critical role of men as Champions of Reproductive Health, forming committees of men throughout the country in 2012 to discuss family relationships and support women’s access to reproductive health services. In namibia, information, education and communication family planning materials which had been developed during 2011 for demand creation were translated and aired on nation and community radios in 2012. The Republic of the Congo (Brazzaville) embarked on a unique programme for distribution of female condoms in 2012 through hairdressers, clothing stores, and other places where women gather. The results of these innovative efforts will be tallied in 2013. In the Congo, UNFPA also developed non- traditional private-sector partnerships, including those with Total EP, la Congolese Industrielle du Bois, and the Rotary Club International, to mobilize financial and human resources to advance family planning and reproductive health programme goals. Gabon intensified its efforts to increase demand for contraceptive supplies in 2012, particularly among the youth and adolescents who comprise more than 60 per cent of the population. Large-scale information display boards on the central highways around Libreville (home of over 50 per cent of the population of the country) and radio and television spots have been targeted to reach young people, and will continue on through 2013. Leaders of each of Gabon’s religious communities also entered into a resolution in 2012 to promote reproductive health. 33Annual Report 2012 CHaPTER THREE: CaTalyzInG naTIonal PolITICal and FInanCIal CommITmEnT Young women in Ecuador, where evidence-based advocacy garnered high-level support for RHCS. Credit: UNFPA Ecuador Many countries are taking action to mobilize political will and financial resources for RHCS. Vigorous and committed support at the highest national levels is an important factor in achieving sustainable results. Reproductive health commodity security is a powerful platform for reducing unmet need and achieving reproductive rights, but it is largely dependent on donors at the present time. Outputs that speak to political and financial commitment to RHCS are presented in this section: (1) Country RHCS strategic plans developed, coordinated and implemented by government with their partners; (2) Political and financial commitment for RHCS enhanced. output 1: Country RHCS strategic plans developed, coordinated and implemented by government with their partners Global ProGramme to enhance reProductive health commodity Security34 The GPRHCS provides support to countries to formulate and implement RHCS strategies, and to integrate those strategies into health sector interventions, providing evidence-based advocacy and assistance to ensure that RHCS strategies in place. This process includes ensuring country ownership and country leadership in the area of RHCS and family planning. Countries are assisted to formulate and implement RHCS strategies and action plans; integrate RHCS issues into key sectoral strategies; establish functional coordinating bodies under the leadership of government; and ensure RH commodities, including contraceptives, are included in the Essential Medicines List (EML) of each country. Both Stream 1 and 2 countries made progress in these areas in 2012. 3.1 number of countries where RHCS strategy is integrated with national RH/SRH, HIv/aIdS, gender & reproductive rights strategies Many countries have successfully integrated RHCS issues into national sectoral strategies for reproductive health or sexual and reproductive health (RH/ SRH), HIV/AIDS and gender strategies (Table 13 and Figure 12). All Stream 1 countries have integrated reproductive health commodity security into their RH/ SRH strategies and HIV/AIDS strategies. Eleven of the 12 countries have integrated RHCS issues into their gender strategy, the exception being Nicaragua where a gender strategy does not exist. Table 13: RHCS strategy integrated into sectoral strategies in Stream 1 countries, 2010 to 2012 Countries RH/SRH HIv/aIdS Gender 2010 2011 2012 2010 2011 2012 2010 2011 2012 Burkina Faso Y Y Y Y Y Y Y Y Y Haiti Y Y Y Y Y Y N N Y Ethiopia Y Y Y Y Y Y Y Y Y Lao PDR Y Y Y Y Y Y N Y Y Madagascar Y Y Y Y Y Y N N Y Mali Y Y Y Y Y Y Y Y Y Mongolia Y Y Y Y Y Y Y Y Y Mozambique Y Y Y Y Y Y Y Y Y Nicaragua Y Y Y N Y Y N N NA Niger Y Y Y Y Y Y Y Y Y Nigeria* NA Y Y NA Y Y NA Y Y Sierra Leone Y Y Y Y Y Y Y Y Y Total for ‘Yes’ 11 12 12 10 12 12 7 9 11 * Nigeria was designated as a Stream 1 Country in 2011, thus information for 2010 is in the Stream 2 Table 35Annual Report 2012 Figure 12: RHCS strategy integrated into sectoral strategies in Stream 1 countries, 2010 to 2012 Figure 13: RHCS strategy integrated into sectoral strategies in Stream 2 countries, 2010 to 2012 N um be r of C ou nt ri es 2010 2011 RH/SRH HIV/AIDS Gender 2012 2010 2011 2012 2010 2011 2012 Strategies and Year 0 2 4 6 8 10 12 N um be r of C ou nt ri es 2010 2011 RH/SRH HIV/AIDS Gender 2012 2010 2011 2012 2010 2011 2012 Strategies and Year 0 5 10 15 20 25 30 35 Global ProGramme to enhance reProductive health commodity Security36 Table 14: RHCS strategy integrated into sectoral strategies in Stream 2 countries, 2010 to 2012 Countries RH/SRH HIv/aIdS Gender 2010 2011 2012 2010 2011 2012 2010 2011 2012 Benin Y Y Y Y Y Y N Y Y Bolivia Y Y Y Y Y Y N Y Y Botswana Y Y Y Y Y Y Y Y Y Burundi Y Y Y Y Y Y N Y Y Central African Republic Y Y Y Y Y Y Y Y Y Chad Y Y Y Y Y Y N N N Congo Y Y Y Y Y Y Y Y Y Côte d’Ivoire Y Y Y Y Y Y Y Y Y Democratic Republic of the Congo Y Y Y Y Y Y Y Y Y Djibouti N Y Y N Y Y N Y Y Ecuador Y Y Y Y Y Y Y Y Y Eritrea Y Y Y Y Y Y Y Y Y Gabon Y Y Y Y Y Y Y Y Y Gambia Y Y Y Y Y Y N N N Ghana N Y Y Y Y Y Y Y Y Guinea Y Y Y N Y Y N N N Guinea-Bissau Y Y Y N Y Y N N N Lesotho Y Y Y Y Y Y N N N Liberia Y Y Y Y Y Y N Y Y Malawi Y Y Y Y Y Y N Y Y Mauritania Y Y Y Y Y Y Y Y Y Namibia Y Y Y Y Y Y Y Y Y 37Annual Report 2012 Countries RH/SRH HIv/aIdS Gender 2010 2011 2012 2010 2011 2012 2010 2011 2012 Nigeria* Y NA NA N NA NA Y NA NA Papua New Guinea N Y Y N Y Y N N Y Sao Tome and Principe N Y Y N N N N N Y Senegal Y Y Y Y Y Y Y Y Y South Sudan - Y Y - N Y - N N Sudan N Y Y N N N N N N Swaziland Y Y Y Y Y Y N N N Timor Leste N Y Y N Y Y N N Y Togo N Y Y N Y Y N Y Y Uganda Y Y Y Y Y Y Y Y Y Yemen N Y Y N N N N N Y Zambia Y Y Y Y Y Y N Y Y Zimbabwe Y Y Y N Y Y N Y Y Total for ‘Yes’ 26 34 34 23 30 30 14 22 26 * Nigeria was designated as a Stream 1 Country in 2011, thus updates for 2011 and 2012 are in the Stream 1 Table The number of GPRHCS Stream 2 countries where RHCS issues were integrated into sexual and reproductive health strategies was 32 out of 34, remaining the same in 2011 and 2012 (Table 14 and Figure 13). Likewise, the number of countries with RHCS issues integrated into the sectoral strategy on HIV/AIDS remained at 30. The number of countries with RHCS issues integrated into the sectoral strategy on Gender increased from 22 countries in 2011 to 26 countries in 2011. There are several reasons why RHCS issues are not integrated in some sectoral strategies. In some cases, no comprehensive strategies exist, which means that implementation is usually ad hoc. Another reason is that existing strategies are very old and yet to be revised, which is the case of in Chad, Gambia, Guinea and Sudan, where actions are not guided by updated protocols and guidelines. Global ProGramme to enhance reProductive health commodity Security38 3.2 number of countries with strategy implemented (national strategy/action plan for RHCS implemented) The GPRHCS assists countries in the implementation of their RHCS action plans. Table 15 shows progress made in implementing RHCS strategies/action plans in the GPRHCS Stream 1 countries from 2009 to 2012. As was the case in 2011, only Haiti did not have an action plan for RHCS in 2012. The number of countries implementing elements of RHCS strategy and action plan increased from 7 in 2009 to 11 in 2011 and 2012 (Figure 14). In Lao PDR, the plan is implemented as part of an integrated MNCH strategic and planning framework of the Ministry of Health. Thirty two of the 34 GPRHCS Stream 2 countries have action plans for reproductive health commodity security and are implementing aspects of the plan. Papua New Guinea and Sudan do not have an action plan for implementation (Table 16 and Figure 15). Table 15: RHCS strategies/action plans being implemented in Stream 1 countries, 2009 to 2012 Country Have RHCS strategy/action plan If yes, elements being implemented 2009 2010 2011 2012 2009 2010 2011 2012 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 Y Y N Y Y Y Mongolia Y Y Y Y Y Y Y Y Mozambique Y Y Y Y N Y Y Y Nicaragua Y Y Y Y N Y Y Y Niger Y Y Y Y Y Y Y Y Nigeria* - - Y Y - - Y Y Sierra Leone Y Y Y Y Y Y Y Y Total for ‘Yes’ 9 10 11 11 7 10 11 11 * Nigeria was designated as a Stream 1 Country in 2011, thus information for 2010 are in the Stream 2 Table 39Annual Report 2012 Figure 14: number of Stream 1 countries with RHCS strategy being implemented Figure 15: number of Stream 2 countries with RHCS strategy being implemented N um be r of C ou nt ri es 20102009 2011 Have RHCS strategy/action plan 2012 20102009 2011 Elements being implemented 2012 Strategy Implementation 0 2 4 6 8 10 12 2010 2011 Have RHCS strategy/action plan 2012 2010 2011 If yes, elements being implemented 2012 0 5 10 15 20 25 30 35 N um be r of C ou nt ri es Strategy Implementation Global ProGramme to enhance reProductive health commodity Security40 Table 16: RHCS strategies/action plans implemented in Stream 2 countries, 2010 to 2012 Countries Have RHCS strategy/action plan If yes, elements being implemented 2010 2011 2012 2010 2011 2012 Benin Y Y Y Y Y Y Bolivia Y Y Y Y Y Y Botswana Y Y Y Y Y Y Burundi Y Y Y Y Y Y Central Africa Republic Y Y Y Y Y Y Chad Y Y Y Y Y Y Congo Y Y Y Y Y Y Côte d’Ivoire Y Y Y N Y Y DRC Y Y Y Y Y Y Djibouti Y Y Y Y Y Y Ecuador Y Y Y Y Y Y Eritrea Y Y Y Y Y Y Gabon Y Y Y Y Y Y Ghana Y Y Y Y Y Y Guinea Y Y Y Y Y Y Guinea Bissau Y Y Y Y Y Y Lesotho Y Y Y N Y Y Liberia N Y Y N N Y Malawi Y Y Y Y Y Y Mauritania N Y Y N Y Y Namibia Y Y Y Y Y Y Nigeria* Y NA  NA Y NA NA  41Annual Report 2012 Countries Have RHCS strategy/action plan If yes, elements being implemented 2010 2011 2012 2010 2011 2012 Papua New Guinea N N  N N N  N Sao Tome and Principe Y Y Y Y Y Y Senegal Y Y Y Y Y Y South Sudan - Y Y - Y Y Sudan N N N N N N Swaziland Y Y Y Y Y Y Timor Leste N Y Y N Y Y Togo N Y Y N Y Y Gambia N Y Y N Y Y Uganda Y Y Y Y Y Y Yemen N Y Y N N Y Zambia Y Y Y Y Y Y Zimbabwe Y Y Y Y Y Y Total for ‘Yes’ 26 32 32 24 30 32 * Nigeria was designated as a Stream 1 Country in 2011, thus updates for 2011 are in the Stream 1 Table Global ProGramme to enhance reProductive health commodity Security42 3.3 number of countries with functional co-ordination mechanism for RHCS, or RHCS is included in broader coordination mechanism All the GPRHCS Stream 1 countries had a coordination mechanism in place that included RHCS issues and had Terms of Reference in 2012, as in the previous year. Efforts in this area aimed to bring partners together for joint decision making and action on RHCS under the leadership of government. All of the 34 Stream 2 countries reported that they have coordinating committees which include RHCS in their frameworks (Table 18 and Figure 16). More specifically, these mechanisms have Terms of Reference (TORs) in 33 countries, up from 32 in 2011, with Senegal being the country where action was taken. The TORs address country-specific issues that need to be coordinated and the modality to do so. Table 17: RHCS coordinating mechanism in place in Stream 1 countries, 2009 to 2012 Country national country coordinating mechanism exists If yes, RHCS issues included in institutional mechanism If yes, does mechanism have ToR 2009 2010 2011 2012 2010 2011 2012 2010 2011 2012 Burkina Faso Y Y Y Y Y Y Y Y Y Y Ethiopia Y Y Y Y Y Y Y Y Y Y Haiti N N Y Y N Y Y N Y Y Lao PDR Y Y Y Y Y Y Y Y Y Y Madagascar Y Y Y Y Y Y Y Y Y Y Mali Y* Y Y Y Y Y Y Y Y Y Mongolia Y Y Y Y Y Y Y Y Y Y Mozambique Y Y Y Y Y Y Y Y Y Y Nicaragua Y Y Y Y Y Y Y Y Y Y Niger Y Y Y Y Y Y Y Y Y Y Nigeria* - - Y Y - Y Y - Y Y Sierra Leone Y Y Y Y Y Y Y Y Y Y Total for ‘yes’ 10 10 12 12 10 12 12 10 12 12 * Nigeria was designated as a Stream 1 Country in 2011, thus information for 2010 are in the Stream 2 Table ** For contraceptives only 43Annual Report 2012 Figure 16: number of Stream 1 countries with national coordinating mechanisms Figure 17: number of Stream 2 countries with national coordinating mechanisms N um be r of C ou nt ri es 20102009 2011 National country coordinating mechanism exists Mechanism have TOR 2012 2010 2011 2012 RHCS issues included in institutional mechanism 2010 2011 2012 0 2 4 6 8 10 12 Existence of coordinating mechanism N um be r of C ou nt ri es 2010 2011 National RHCS country coordination mechanism If yes, RHCS issues included in institutional mechamism If yes, does mechanism have TOR 2012 2010 2011 2012 2010 2011 2012 Existence of coordinating mechanism 0 5 10 15 20 25 30 35 Global ProGramme to enhance reProductive health commodity Security44 Table 18: RHCS coordinating committees in Stream 2 countries, 2010 to 2012 Country national country coordinating mechanism exists If yes, RHCS issues included in institutional mechanism If yes, does mechanism have ToR 2010 2011 2012 2010 2011 2012 2010 2011 2012 Benin Y Y Y Y Y Y N Y Y Bolivia Y Y Y Y Y Y Y Y Y Botswana Y Y Y Y Y Y Y Y Y Burundi N Y Y N Y Y N Y Y  Central Africa Republic Y Y Y Y Y Y Y Y Y Chad Y Y Y Y Y Y Y Y Y Congo Y Y Y Y Y Y Y Y  Y Côte d’Ivoire Y Y Y Y Y Y Y Y Y DRC Y Y Y Y Y Y Y Y Y Djibouti N Y Y N N N N Y Y Ecuador Y Y Y Y Y Y Y Y Y Eritrea Y Y Y Y Y Y Y Y Y Gabon Y Y Y Y Y Y Y Y Y Gambia Y Y Y Y Y Y Y Y Y Ghana Y Y Y Y Y Y Y Y Y Guinea N Y Y N Y Y N Y Y Guinea Bissau Y Y Y Y Y Y N Y Y Lesotho Y Y Y N Y Y Y Y Y Liberia Y Y Y Y Y Y Y Y Y Malawi Y Y Y Y Y Y Y Y  Y Mauritania Y Y Y Y Y Y Y Y Y 45Annual Report 2012 Country national country coordinating mechanism exists If yes, RHCS issues included in institutional mechanism If yes, does mechanism have ToR 2010 2011 2012 2010 2011 2012 2010 2011 2012 Namibia Y Y Y Y Y Y N Y Y Nigeria* Y NA  NA Y NA NA Y NA  NA Papua New Guinea N Y Y N Y Y N Y Y Sao Tome and Principe N Y Y N Y Y N N N  Senegal Y Y Y N Y Y N N Y South Sudan - Y Y - Y Y - Y Y Sudan N Y Y N Y Y N Y Y Swaziland Y Y Y Y Y Y Y Y Y Timor Leste N Y Y N Y Y N Y Y Togo N Y Y N Y Y N Y Y Uganda Y Y Y Y Y Y N Y Y Yemen N Y Y N Y Y N Y Y Zambia Y Y Y Y Y Y Y Y Y Zimbabwe Y Y Y Y Y Y Y Y Y Total for ‘Yes’ 25 34 34 23 34 34 19 32 33 * Nigeria was designated as a Stream 1 Country in 2011, thus updates for 2011 are in the Stream 1 Table Global ProGramme to enhance reProductive health commodity Security46 3.4 number of countries with essential RH commodities in Eml (contraceptives and life- saving maternal/RH medicines in Eml) All Stream 1 countries had Essential Medicines Lists (EML) in place as of 2012, and all of these lists contained the UNFPA and WHO essential and life- saving maternal health medicines. Also, all the Stream 1 countries reported that their EMLs have maternal health medicines and contraceptives (Table 19 and Figure 18). Among Stream 2 countries, all had EMLs in place, with contraceptives included on the list for 32 countries in 2012, up from 30 in 2011 (Table 20). The number of Stream 2 countries with maternal health medicines included in the EML increased from 32 countries in 2011 to 34 countries in 2012 (Figure 19). Table 19: Stream 1 countries with essential RH commodities (contraceptives and life-saving maternal/RH medicines) in Eml, 2011 and 2012 Country Eml exists in the country If yes, does Eml contains contraceptives If yes, does Eml contains maternal drugs 2011 2012 2011 2012 2011 2012 Burkina Faso Y Y Y Y Y Y Ethiopia Y Y Y Y Y Y Haiti Y Y Y Y Y Y Lao PDR Y Y Y Y Y Y Madagascar Y Y Y Y Y Y Mali Y Y Y Y Y Y Mongolia Y Y Y Y Y Y Mozambique Y Y Y Y Y Y Nicaragua Y Y Y Y Y Y Niger Y Y Y Y Y Y Nigeria Y Y Y Y Y Y Sierra Leone Y Y Y Y Y Y Total for ‘Yes’ 12 12 12 12 12 12 47Annual Report 2012 Figure 18: Stream 1 countries with essential RH commodities (contraceptives and life-saving maternal/RH medicines) in Eml, 2011 and 2012 Figure 19: Stream 2 countries with essential RH commodities (contraceptives and life-saving maternal/RH medicines) in Eml, 2011 and 2012 N um be r of C ou nt ri es 2011 EML Exists 2012 2011 EML Contains contraceptives 2012 2011 EML Contains RH/ Maternal Medicines 2012 Existence of EML 0 2 4 6 8 10 12 N um be r of C ou nt ri es 2011 EML Exists 2012 2011 EML Contains Contraceptives 2012 2011 EML Contains RH/ Maternal Medicines 2012 Existence of EML 0 5 10 15 20 25 30 35 Global ProGramme to enhance reProductive health commodity Security48 Table 20: Stream 2 countries with essential RH commodities (contraceptives and life-saving maternal/RH medicines) in Eml, 2011 and 2012 Eml exists in the country If yes, does Eml contains contraceptives If yes, does Eml contains maternal drugs Country 2011 2012 2011 2012 2011 2012 Benin Y  Y Y Y Y Y Bolivia Y Y Y Y Y Y Botswana Y Y Y Y Y Y Burundi Y Y Y Y Y Y Central Africa Republic Y Y Y Y Y Y Chad Y Y Y Y Y Y Congo Y Y Y Y Y Y Côte d’Ivoire Y Y Y Y Y Y Democratic Republic of Congo Y Y Y Y Y Y Djibouti Y Y Y Y Y Y Ecuador Y Y N Y Y Y Eritrea Y Y Y Y Y Y Gabon Y Y Y Y Y Y Gambia Y Y Y Y Y Y Ghana Y Y N Y Y Y Guinea Y Y Y Y Y Y Guinea Bissau Y Y Y Y Y Y Lesotho Y Y Y Y N Y Liberia Y Y Y Y Y Y Malawi Y Y N N Y Y Mauritania Y Y Y Y Y Y 49Annual Report 2012 Eml exists in the country If yes, does Eml contains contraceptives If yes, does Eml contains maternal drugs Country 2011 2012 2011 2012 2011 2012 Namibia Y Y N N Y Y Nigeria* NA  NA NA NA NA NA Papua New Guinea Y Y Y Y Y Y Sao Tome et Principe Y Y Y Y Y Y Senegal Y Y Y Y Y Y South Sudan Y Y Y Y Y Y Sudan Y Y Y Y Y Y Swaziland Y Y Y Y Y Y Timor Leste Y Y Y Y Y Y Togo Y Y Y Y N Y Uganda Y Y Y Y Y Y Yemen Y Y Y Y Y Y Zambia Y Y Y Y Y Y Zimbabwe Y Y Y Y Y Y Total for ‘Yes’ 34 34 30 32 32 34 * Nigeria was designated as a Stream 1 Country in 2011, thus updates for 2011 are in the Stream 1 Table Global ProGramme to enhance reProductive health commodity Security50 output 2: Political and financial commitment for RHCS enhanced Ensuring RHCS requires commitment country, regional and global from governments and their partners. It is for this reason that the GPRHCS supports country initiatives to advocate for commitments from both donors and governments. Under this output evidence of commitments are gauged by the availability of funding for the GPRHCS through multi-year donor pledges, signing of MOUs with Stream 1 country governments, mainstreaming of RHCS issues in policies and strategies in the work of global and regional organizations and partners, inclusion of RHCS priorities in national and sectoral policies and plans, and the allocation of resources within SRH/RHCs budget line for contraceptives at country level. 3.5 Funding mobilized for GPRHCS on a reliable basis The purpose of this indicator is to track and report on resource mobilization efforts undertaken by UNFPA for the implementation of the GPRHCS, in particular on multi-year pledges. Funds mobilized in 2012 came from five sources (European Commission, UK, Netherlands, Liechtenstein and from donations received from private individuals) amounting to $181.4 million (Table 23). Although the European Union has supported RHCS interventions implemented by UNFPA in the past, the 2012 contribution of $34.6 million from the European Commission was the first such donation to the GPRHCS. The 46 countries of the GPRHCS were represented at a November 2012 meeting in Cotonou, Benin. Photo: UNFPA Benin 51Annual Report 2012 Table 21: amount mobilized from donor countries in uS$ for GPRHCS, 2007 to 2012 donor partner 2007 2008 2009 2010 2011 2012 Total Australia 0 0 0 0 10,893,246 0 10,893,246 Canada 0 0 1,996,805 0 0 0 1,996,805 Denmark 0 0 0 0 3,586,157 0 3,586,157 European Commission 0 0 0 0 0 34,598,541 34,598,541 Finland 0 2,590,674 0 0 0 0 2,590,674 France 0 0 0 272,109 0 0 272,109 Ireland 1,440,922 1,557,632 0 0 0 0 1,557,632 Liechtenstein 0 0 0 0 0 32,002 32,002 Luxembourg 544,959 557,103 591,716 544,218 569,800 0 2,262,837 Netherland 6,024,096 34,114,379 45,831,976 39,807,880 33,783,783 39,596,300 193,134,318 Spain 6,637,168 7,772,021 7,396,450 0 0 0 15,168,471 Spain (Catalonia) 0 0 563,471 420,168 0 0 983,639 UK 0 8,695,652 16,474,465 54,464,816 96,092,987 107,215,048 282,942,968 Private/ Individual Contributors 0 0 0 0 3,949 3,284 7,233 Total 14,647,145 55,287,461 72,854,883 95,509,191 144,929,922 181,445,175 564,673,777 The total contribution received from donors, as shown in Figure 20, increased by about 25 per cent; from $144.9 million in 2011 to $181.4 million in 2012. The total contribution received from the launch of the programme in mid-2007 to 2012 was $564.7 million. (In comparison, the same table in the 2011 annual report, p.40, shows a total of $365 million for a shorter timespan). Global ProGramme to enhance reProductive health commodity Security52 Figure 20: Resources mobilized for GPRHCS, 2007 to 2012 Two donors continued to be the two highest contributors to the GPRHCS: the UK accounted for 59.1 per cent and The Netherlands accounted for 21.8 per cent. Together, the two contributed 80.9 per cent of the resources in 2012. The other major contribution to the GPRHCS in 2012, amounting to 19 per cent of the resources, was from the European Commission. Figure 21: Resources contributed by donors to GPRHCS, 2007 to 2012 A m ou nt ( U S$ ) 2007 2008 2009 2010 2011 2012 Year 0 50,000,000 100,000,000 150,000,000 200,000,000 Pe rc en ta ge Denmark Year 200920082007 2010 2011 2012 UK Liechtenstein European Commission Netherlands Spain Private / Individual Contribution Canada Ireland Spain (Catalonia) Finland Luxembourg Australia 0 25% 50% 75% 100% 53Annual Report 2012 3.6 mou signed with unFPa and Stream 1 country governments UNFPA Country Offices in the Stream 1 countries sign a Memorandum of Understanding with their respective governments to ensure each party understands the actions that are to be taken and the commitments that must be met to ensure successful programme implementation. All Stream 1 countries had signed MOUs as a basis of cooperation and partnership in the implementation of the GPRHCS as of 2012 (Table 24 and Figure 22). Although it is not compulsory for Stream 2 countries to sign MOUs with their respective governments, the country offices are encouraged explore the possibility of doing so, in order to formalize the working relationship around GPRHCS interventions. Table 22: Stream 1 countries with signed mou between Government and unFPa for GPRHCS implementation, 2011 and 2012 Country 2011 2012 Burkina Faso Y Y Ethiopia Y Y Haiti Y Y Lao PDR Y Y Madagascar Y Y Mali Y Y Mongolia Y Y Mozambique Y Y Nicaragua Y Y Niger Y Y Nigeria Y Y Sierra Leone Y Y Total for ‘yes’ 12 12 Figure 22: Government has signed mou for GPRHCS implementation 3.7 RHCS mainstreamed in regional policies and strategies through unFPa work with global, bilateral and regional organizations and partners UNFPA, through its regional offices, works with global, bilateral and regional organizations/partners to build capacities and ensure their policies, plans and activities reflect RHCS key issues. Over the years, UNFPA has worked with different regional economic communities or commissions; providing support through the GPRHCS for the institutions to scale up actions relating to RHCS. In 2012, capacity assessments were conducted with the Intergovernmental Authority on Development (IGAD) as part of technical assistance provided by UNFPA Regional Offices with support from the GPRHCS. The assessments identified specific strategic areas for sexual and reproductive health and RHCS programming within the various mandates of IGAD Member States. Capacity assessments were undertaken using the guidelines of the UNFPA Policies and Procedures Manual (PPM). The assessments provided evidence regarding areas of strengths and weaknesses as well as opportunities for UNFPA collaboration. Letters of Understanding N um be r of C ou nt ri es 2011 2012 Year 0 2 4 6 8 10 12 Global ProGramme to enhance reProductive health commodity Security54 (LOUs) were subsequently signed, with partnership arrangements established and areas of technical collaboration agreed. The assessments focused on contextual issues, institutional commitment to RHCS coordination mechanisms, clientele of the institutions and implementation capacity of the institutions. Also this year, IGAD Member States nominated a senior programme staff member to serve as the IGAD-RHCS focal point within the departments of reproductive health to support the IGAD UNFPA RHCS initiative. (This action followed a recommendation made at the 2011 regional meeting of RH experts at the IGAD secretariat.) IGAD countries received support to implement family planning demand creation/generation, training of family planning service providers, building national capacity for procurement. Efforts were made to integrate family planning with PMTCT interventions for cross-border and mobile populations, and to integrate sexual and reproductive health into existing HIV/AIDS services for these populations and surrounding communities in selected hot spots in IGAD countries. 3.8 number of countries that have included RHCS priorities in PRSP and Health sector policy and plan and SwaPs This indicator tracks results achieved in working with governments and other partners to ensure that RHCS issues are part of national planning and country programming processes – specifically within documents such as Poverty Reduction Strategy Papers (PRSPs); national health sector policies and plans; and sector wide approaches for the health sector. Table 23: RHCS issues included in PRSPs, health policies and SwaPs in Stream 1 countries, 2010 to 2012 Countries RHCS issues in PRSP RHCS issues in health policy & plan RHCS issues in SwaP (for health) 2010 2011 2012 2010 2011 2012 2010 2011 2012 Burkina Faso Y Y Y Y Y Y Y Y Y Ethiopia Y Y Y Y Y Y Y Y Y Haiti Y Y Y Y Y Y N N N Laos Y Y Y Y Y Y Y Y Y Madagascar Y Y Y Y Y Y Y Y Y Mali Y Y Y Y Y Y Y Y Y Mongolia Y Y Y Y Y Y Y Y Y Mozambique N Y Y Y Y Y N Y Y Nicaragua Y Y Y Y Y Y Y Y Y Niger Y Y Y Y Y Y Y Y Y Nigeria - Y Y - Y Y - Y Y Sierra Leone Y Y Y Y Y Y N Y Y Total for ‘yes’ 10 12 12 11 12 12 8 11 11 * Nigeria was designated as a Stream 1 Country in 2011, thus information for 2010 are in the Stream 2 Table 55Annual Report 2012 As of 2012, RHCS issues were integrated in the PRSPs and national development strategies of all the Stream 1 countries (Table 23 and Figure 23). RHCS issues were also integrated in their existing health sector policies. RHCS issues were integrated in the Sector- Wide Approaches for the health sector in 11 Stream 1 countries, the exception being Haiti, as in 2011. Figure 23: RHCS issues included in PRSPs; health policies & plans; and Swap in Stream 1 countries, 2010 to 2012 Among Stream 2 countries, RHCS issues were integrated in the PRSPs, national development plans, and health sector policies and plans of all 34 countries as of 2012, as in 2011 (Table 24 and Figure 29). The number of Stream 2 countries that have integrated RHCS issues into their Sector-Wide Approaches for the health sector increased from 21 in 2010 to 27 in 2011 to 31 in 2012. The integration of RHCS issues into key national development strategies and plans indicated commitment and desire to prioritize RHCS at country level. N um be r of C ou nt ri es 2010 RHCS issues in PRSP 2011 2010 RHCS issues in health policy & plan 2011 2010 RHCS issues in SWAp (for health) 2011 Year and National Plan/Policy 0 2 4 6 8 10 12 Global ProGramme to enhance reProductive health commodity Security56 Table 24: RHCS issues included in PRSPs, health policies and SwaPs in Stream 2 countries, 2010 to 2012 RHCS issues in PRSP RHCS issues in health policy & plan RHCS issues in SwaP (for health) Countries 2010 2011 2012 2010 2011 2012 2010 2011 2012 Benin N Y Y Y Y Y Y Y Y Bolivia N Y Y Y Y Y Y Y Y Botswana Y Y  Y Y Y Y  Y Y  Y Burundi N Y Y Y Y Y N Y Y Central Africa Republic Y Y Y Y Y Y Y Y Y Chad Y Y Y Y Y Y - N Y Congo Y Y Y Y Y Y - Y Y Côte d’Ivoire N Y Y Y Y Y Y Y Y Democratic Republic of Congo Y Y Y Y Y Y Y Y Y Djibouti N Y Y N Y Y N N N Ecuador Y Y Y Y Y Y Y Y Y Eritrea Y Y Y Y Y Y Y Y Y Gabon Y Y Y Y Y Y Y Y Y Gambia N Y Y Y Y Y Y Y Y Ghana Y Y Y Y Y Y Y Y Y Guinea N Y Y Y Y Y Y Y Y Guinea Bissau N Y Y Y Y Y Y Y Y Lesotho N Y Y Y Y Y Y Y Y 57Annual Report 2012 RHCS issues in PRSP RHCS issues in health policy & plan RHCS issues in SwaP (for health) Countries 2010 2011 2012 2010 2011 2012 2010 2011 2012 Liberia N Y Y Y Y Y N Y Y Malawi N Y Y Y Y Y Y Y Y Mauritania N Y Y Y Y Y N Y Y Namibia - Y Y - Y Y - Y Y Nigeria N -  - Y -  - Y -  - Papua New Guinea - Y Y - Y Y - Y Y Sao Tome and Principe Y Y Y Y Y Y Y Y Y Senegal Y Y Y Y Y Y Y Y Y South Sudan - Y Y - Y Y - N Y Sudan - Y  Y - Y  Y - N  N Swaziland Y Y Y Y Y Y - N Y Timor Leste - Y Y - Y Y - Y Y Togo - Y Y - Y Y - N N Uganda Y Y Y Y Y Y Y Y Y Yemen - Y  Y - Y Y - N Y Zambia Y Y Y Y Y Y Y Y Y Zimbabwe Y Y Y Y Y Y Y Y Y Total for ‘yes’ 15 34 34 27 34 34 21 27 31 * Nigeria was designated as a Stream 1 Country in 2011, thus updates for 2011 are in the Stream 1 Table Global ProGramme to enhance reProductive health commodity Security58 Figure 24: RHCS issues included in PRSPs; health policies & plans; and Swap in Stream 2 countries, 2010 to 2012 3.9 number of countries maintaining allocation within SRH/RHCs budget line for contraceptives This indicator assesses the commitment to RHCS by the willingness of governments to allocate resources for the procurement of contraceptives and to fund family planning and maternal health interventions, with or without assistance from donors. Budget lines for contraceptives were present in 11 out of 12 Stream 1 countries in 2012, excepting Haiti. The amount allocated increased from 2011 to 2012 in Ethiopia, Lao PDR, Mali, Mongolia and Mozambique. The allocated remained the same in Burkina Faso, Nigeria and Sierra Leone. Resources decreased from 2011 to 2012 in Madagascar, Nicaragua and Niger. Table 25: Existence of line item for contraceptives in national budget for GPRHCS Stream 1 countries, 2011 and 2012 Country 2011 2012 Burkina Faso Y Y Ethiopia Y Y Haiti N N Lao PDR Y Y Madagascar Y Y Mali Y Y Mongolia Y Y Mozambique Y Y Nicaragua Y Y Niger Y Y Nigeria* Y Y Sierra Leone Y Y Total for ‘yes’ 11 11 N um be r of C ou nt ri es 2010 RHCS issues in PRSP 2011 2010 RHCS issues in health policy & plan 2011 2010 RHCS issues in SWAp (for health) 2011 Year and National Plan/Policy 0 5 10 15 20 25 30 35 59Annual Report 2012 Figure 25: Existence of line item for contraceptives in national budget for GPRHCS Stream 1 countries, 2011 and 2012 The number of Stream 2 countries with line items in the national budget for the procurement of contraceptives increased from 20 in 2011 to 25 in 2012 (Table 26 and Figure 26). Table 26: Existence of line item for contraceptives in national budget for GPRHCS Stream 2 countries, 2011 and 2012 Country 2011 2012 Benin Y Y Bolivia Y Y Botswana Y Y Burundi Y Y Central Africa Republic Y Y Chad N N Congo Y Y Côte d’Ivoire N N Democratic Republic of Congo N N Country 2011 2012 Djibouti N N Ecuador Y Y Eritrea Y Y Gabon N Y Gambia Y Y Ghana N Y Guinea Y Y Guinea Bissau N Y Lesotho Y Y Liberia Y Y Malawi N Y Mauritania N N Namibia N Y Papua New Guinea Y Y Sao Tome and Principe Y Y Senegal Y Y South Sudan N N Sudan N N Swaziland Y Y Timor Leste N N Togo Y Y Uganda Y Y Yemen N N Zambia Y Y Zimbabwe Y Y Total for ‘yes’ 20 25 N um be r of C ou nt ri es 2011 2012 Year 0 2 4 6 8 10 12 Global ProGramme to enhance reProductive health commodity Security60 Figure 26: Existence of line item for contraceptives in national budget for GPRHCS Stream 2 countries, 2011 and 2012 Resources allocated in Ethiopia increased from $6.7 million in 2011 to $16.3 in 2012 (Table 27 and Figure 27). The allocation remained the same as last year in Nigeria at $3 million, Burkina Faso at $1 million, Mozambique at $753,523 and Sierra Leone at $165,000. Table 27: Government budget allocation for contraceptives in GPRHCS Stream 1 countries, 2008 to 2011 Country amount allocated in uS$ 2008 2009 2010 2011 2012 Burkina Faso 978,261 1,326,087 652,174 1,000,000 1,000,000 Ethiopia 1,745,213 3,200,000 3,581,849 6,659,500 16,267,585 Haiti 0 0 0 0 0 Laos 18,500 0 0 18,750 25,000 Madagascar 109,524 119,168 121,126 68,501 47,273 Mali 0 0 0 218,917 274,081 Mongolia 0 47,000 41188 55,000 57,095 Mozambique 510,000 333,079 392,913 379,962 753,523  Nicaragua 110,158 208,723 321,935 765,940 611,320 Niger 103,734 103,734 122,222 122,222 108,481 Nigeria 0 0 0 3,000,000 3,000,000 Sierra Leone 0 0 0 165,0000 165,0000  Source: Data provided by UNFPA CO in Stream 1 countries from information obtained from the Ministries of Health of their respective countries, March 2012 N um be r of C ou nt ri es 2011 2012 Year 0 5 10 15 20 25 61Annual Report 2012 Figure 27: Government budget allocation for contraceptives in GPRHCS Stream 1 countries, 2008 to 2012 Regarding allocations by programme country governments, Nicaragua spent more on contraceptives than it allocated in its national budget line (with the exception of 2010); expenditures were more than double allocations in 2011 and 2012 (Figure 28 and Table 28). Seven countries (Burkina Faso, Ethiopia, Lao PDR, Madagascar, Mongolia, Niger and Nigeria) spent 100 per cent of their allocated resources for the procurement of contraceptives in 2012. In Mali, the amount allocated was not spent due to the conflict situation in the country. Mozambique is the only country reporting that the amount allocated was not spent for any of the years 2008 to 2012. Also, no allocations were made in Haiti from 2008 to 2012. A m ou nt A llo ca te d (m ill io n §) Mongolia 2008 Year (5-year intervals) 2009 2010 2011 2012 Haiti Niger Nicaragua Laos Mali Mozambique Burkina Faso Madagascar Nigeria Sierra Leone Ethiopia 0 5 10 15 20 Global ProGramme to enhance reProductive health commodity Security62 Figure 28: Government budget allocated and spent for procurement of contraceptives in GPRHCS Stream 1 countries in 2012 Source: Data provided by UNFPA CO in Stream 1 countries from information obtained from the Ministries of Health of their respective countries, April 2013. A m ou nt in M ill io n U S$ Burkina Faso Ethiopia Lao PDR Haiti MaliMadagascar Mongolia Mozam- bique Nicaragua Niger Nigeria Sierra Leone Country 0 5 10 15 20 63Annual Report 2012 Ta bl e 28 : G ov er nm en t bu dg et a llo ca te d an d sp en t fo r pr oc ur em en t of c on tr ac ep ti ve s in G PR H C S St re am 1 t o 20 12 C ou nt ry 20 0 8 20 0 9 20 10 20 11 20 12 a m ou nt a llo ca te d a m ou nt Sp en t % ag e sp en t a m ou nt a llo ca te d a m ou nt Sp en t % ag e sp en t a m ou nt a llo ca te d a m ou nt Sp en t % ag e sp en t a m ou nt a llo ca te d a m ou nt Sp en t % ag e sp en t a m ou nt a llo ca te d a m ou nt Sp en t % ag e sp en t Bu rk in a Fa so 97 8 ,2 6 1 9 37 ,0 51 9 5. 8 1,3 26 ,0 8 7 1 ,5 4 3, 16 1 11 6 .4 6 52 ,17 4 6 52 ,17 3 10 0 .0 1 ,0 0 0 ,0 0 0 1,0 0 0 ,0 0 0 10 0 .0 1,0 0 0 ,0 0 0 1,0 0 0 ,0 0 0 10 0 .0 Et hi op ia 1,7 4 5, 21 3 1,7 4 5, 21 3 10 0 .0 3, 20 0 ,0 0 0 3, 20 0 ,0 0 0 10 0 .0 3, 58 1,8 4 9 3, 58 1,8 4 9 10 0 .0 6 ,6 59 ,5 0 0 6 ,6 59 ,5 0 0 10 0 .0 1 6 ,2 67 ,5 8 5 16 ,2 67 ,5 8 5 10 0 .0 H ai ti - - - - - - - - - - - - - - - La o PD R 18 ,5 0 0 16 ,3 0 0 8 8 .1 - - - - - - 1 8 ,7 50 1 8 ,3 9 6 9 8 .1 25 ,0 0 0 25 ,0 0 0 10 0 .0 M ad ag as ca r 10 9 ,5 24 10 9 ,5 24 10 0 .0 11 9 ,16 8 75 ,8 0 5 6 3. 6 12 1,1 26 12 1,1 26 10 0 .0 6 8 ,5 0 1 6 8 ,5 0 1 10 0 .0 4 72 72 4 72 72 10 0 .0 M al i - - - - - - - - - 21 8 ,9 17 21 8 ,9 17 10 0 .0 27 4 ,0 8 1 0 0 .0 M on go lia 0 0 - 4 7, 0 0 0 4 6 ,0 22 97 .9 4 1,1 8 8 4 1,1 8 8 10 0 .0 55 ,0 0 0 52 ,3 37 9 5. 2 5 7, 0 9 5 5 7, 0 9 5 10 0 .0 M oz am bi qu e 51 0 ,0 0 0 0 0 .0 33 3, 0 79 0 0 .0 39 2, 9 13 0 0 .0 37 9 ,9 6 2 0 .0 0 0 .0 7 53 ,5 23   N ic ar ag ua 11 0 ,15 8 59 1,6 6 5 53 7. 1 20 8 ,7 23 22 7, 50 0 10 9. 0 32 1,9 35 32 1,9 35 10 0 .0 76 5, 9 4 0 2, 0 25 ,8 9 1 26 4 .5 6 11 ,3 20 1,6 6 9 ,0 4 2 27 3. 0 N ig er 10 3, 73 4 10 3, 73 4 10 0 .0 10 3, 73 4 10 3, 73 4 10 0 .0 12 2, 22 2 12 2, 22 2 10 0 .0 12 2, 22 2 12 2, 22 2 10 0 .0 1 0 8 ,4 8 1 1 0 8 ,4 8 1 10 0 .0 N ig er ia - - - - - - - - - 3, 0 0 0 ,0 0 0 3, 0 0 0 ,0 0 0 10 0 .0 3, 0 0 0 ,0 0 0 3 ,0 0 0 ,0 0 0 1 0 0 .0 Si er ra L eo ne - - - - - - - - - 1 6 5, 0 0 0 1 6 5, 0 0 0 10 0 .0 1 6 5, 0 0 0 - - So ur ce : D at a pr ov id ed b y U N FP A C O in S tr ea m 1 c ou nt rie s fr om in fo rm at io n ob ta in ed fr om t he M in is tr ie s of H ea lth o f t he ir re sp ec tiv e co un tr ie s, A pr il 20 13 . Global ProGramme to enhance reProductive health commodity Security64 Box 3: Integrating RHCS in national policies, plans and programmes Integrating RHCS into national policies, plans and programmes has been a process of fostering commitment at all levels. Advocacy with partners in government, parliamentarians and other policy makers has helped to ensure national ownership and sustainability. Many countries have taken action to mobilize political will and financial resources for RHCS, both international donors and the governments of developing countries. New national budget lines and allocations for contraceptives are striking signs of commitment when limited resources are further strained by the global economic crisis. High-level support in Ecuador Evidence-based advocacy in Ecuador won high-level support for the national family planning strategy, along with Government support of $8 million for the strategy plus $7 million to procure modern contraceptives through UNFPA in 2011. The country also centralized the procurement of reproductive health commodities for a more efficient system. With catalytic funding of $700,000 over three years, results were achieved through the process of building understanding and technical capacity among government health staff at the national and regional level. Results of national and local dialogue processes were presented at a special committee meeting of the Latin American Economic Commission (CEPAL) and UNFPA in July. At the Ministry of Health’s request, UNFPA developed training for health staff nationwide, holding the first session in September for 100 health providers on contraceptives and other RH issues. In 2012, evidence-based advocacy and policy dialogue continued to engage government and civil society, influencing rights and norms. Institutionalizing RHCS training in Ethiopia and mongolia In Ethiopia, a curriculum on reproductive health commodity security has evolved over time, from orientation and training, to an ongoing collaboration with the Public Health School and School of Pharmacy. Health Extension Workers have received training to deliver RH and family planning to rural communities. GPRHCS commodity procurement supported the government’s plan to make long-lasting contraceptive implants widely available throughout the country to women who want to delay pregnancy. One sign of improved RHCS, the percentage of service delivery points offering at least three modern methods of contraception increased from 60 per cent in 2006 to 96.4 in 2012, and uptake in the use of long-lasting implants is increasing significantly. 65Annual Report 2012 In seeking to build a sustainable system for RHCS in Mongolia, UNFPA focused on institutional capacity building rather than short- term training. The strategy helped to build national ownership while ensuring UNFPAs eventual exit from the process. Hundreds of pharmacists graduate each year in Mongolia with special training in family planning services and supplies. In addition to quality of care, they learn how to manage a computerized supply chain for a steady flow of essential supplies from warehouses to the couples who need them. Training in reproductive health commodity security is now part of the curriculum at Health Sciences University of Mongolia’s School of Pharmacy. Previously, a lack of know-how caused shortfalls in essential supplies. The government and UNFPA started by training 12 health professionals in 2008 and quickly expanded to 150 in 2009, 222 in 2010 and 367 in 2011. In 2012, the School of Pharmacy in collaboration with department of obstetrics and gynaecology conducted refresher training on RHCS for RH managers of all provinces. Even in remote rural areas, access to contraceptives and the availability of a choice of methods are improving. RHCS indicators for contraceptive method choice and availability of life-saving medicines have improved consistently to reach high levels. The commitment of the MOH and the university, and dedication of the faculty of the School of Pharmacy played a major role in the success. The availability of a web-based CHANNEL programme in Mongolian language was also useful in the training. more country examples Institutionalizing RH indicators in nicaragua in three spheres of commitment – an RHCS committee, sector-wide cooperation agreement, and the Common Basket Fund – has fostered a positive environment for increased RH commodities access. Change came through development of an advocacy strategy, with GPRHS support, which helped win inclusion of RHCS indicators in the national health plan and recognition of adolescents and youth as a priority group in RH, particularly for pregnancy prevention. The percentage of service delivery points in Nicaragua offering at least three modern methods of contraception increased from 66.6 per cent in 2008 to 98.6 in 2012. mozambique’s leaders affirmed commitments made at the London Summit on Family Planning in July 2012, with the overall goal of increasing the Mozambican population’s utilization of family planning services and contraception. The Government provides free integrated sexual and reproductive health services and commodities in all health facilities, and committed to increasing funding for contraceptive procurement. The Minister of Health again pledged the country’s commitment at a National Workshop on Family Planning in November 2012, noting the need to explore new innovative approaches and partnerships to improve universal access to family planning and increase CPR in Mozambique. More than 150 young people participated in a workshop for dialogue and discussion prior to the national workshop. The RHCS Technical Working Group expanded its scope in nigeria in 2012, ensuring RHCS as national, state and community levels. Led by the Federal Ministry of Health, the Group inaugurated a Procurement Supply Management (PSM) sub- committee in January 2012 for monitoring, tracking and problem-solving with meetings every two weeks. Procurement lead time was reduced from nine months to 3.5 months, social marketing continued to grow, and the total market for contraceptives increased in 2012. The cumulative effect of the advocacy efforts, resource mobilization and implementation of RHCS Strategic Plan led to a three-fold increase in CYP for contraceptives provided to States based on requests made between 2011 and 2012. Demonstrating its commitment to family planning, Rwanda pledged nearly $1 million ($909,685) to Global ProGramme to enhance reProductive health commodity Security66 procure contraceptives in 2012. The President of Rwanda delivered a speech at the family planning summit in London in November. With UNFPA partner PRISMA in uruguay, a new RHCS committee was established in 2012 with two delegates from each member of the Health Public Providers Comprehensive Network (RIEPS), with the government and UNFPA as part of the team. The committee analyzed the logistics system and initiated training. The percentage of health institutions in Uruguay with a Sexual and Reproductive Health Coordinator Team increased from 40 per cent in 2011 to 78 per cent in 2012. Also this year, the National Observatory on Gender and Sexual and Reproductive Health received UNFPA GPRHCS support to track progress and produce reports for advocacy in policy and planning. The tool includes a database and indicators and has produced status reports on SRH standards, a study on health human resources, and a study in 2012 on the sexual and reproductive health of women and men 15 to 49 years old. kyrgyzstan’s decision in 2012 to include contraceptives in the list of medicines and supplies under the Additional Drug Benefit List financed by the Mandatory Health Insurance Fund was an important step towards meeting the family planning requirement of women in poor and vulnerable groups. Kyrgyzstan also revised its EML this year so that contraceptives, IUD and condoms are now included in the national list. In other progress this year, a budget line for contraceptives was also created as a first step in a wider strategy to meet demand for RH commodities. The country has already installed and introduced Country Commodity Manager (CCM) and the CHANNEL software programme to strengthen supply management. An in-depth analysis of access to reproductive health services in Tajikistan, led by the MoH with UNFPA support, has contributed data for evidence- based advocacy. Data from five regions will support the integration of reproductive health into health services and other RHCS goals. The process has included reporting back to local health authorities, institutions and the MOH on indicators, obstacles and recommendations. It involved staff of regional RH centres to improve transparency while building capacity in monitoring and assessment. As a result, health care authorities demonstrate increased sensitivity to reproductive health and family planning, given them higher priority at the primary care level, increased method choice and availability, reorganized and improved access to RH commodities at primary health care level, and introduced a top-up system to stock contraceptives at facilities. Ecuador has taken action to mobilize political support and resources for RHCS on both international and local levels. In 2012, UNFPA facilitated dialogue between authorities from the Ministries of Health of Ecuador and Uruguay in regard to comprehensive sexual and reproductive health care which resulted in an exchange of experiences between the two Ministries. This led to the initiation of South-South development cooperation to strengthen sexual and reproductive health services by level of health care and complexity. A partnership between UNFPA and the Municipality of Quito has strengthened other medium and small municipalities within the country regarding reproductive health programmes and access to family planning services. Youth, civil society, and citizenship participation, and educational and communicational strategies have established the creation of zone dialogue spaces to improve reproductive health service delivery. Students of the national medical university attend a family planning training course. Photo: UNFPA/Parviz Boboev 67Annual Report 2012 The Government of South Sudan adopted its first UNFPA Country Programme in April 2012. South Sudan continued work already started in 2011 by ensuring that RHCS was integrated in the family planning policy and strategy which was revised in 2012. This document integrated key issues related to RHCS, midwifery and maternal health. The Ministry of Health strengthened capacity for managing RH commodities through participation of key staff in several meetings related to RHCS and condom programming including the Intergovernmental Authority on Development (IGAD) meeting on RHCS in Djibouti. The Ministry of Health also led the nation-wide Reproductive Health Coordination Forum in holding six working sessions with 15 partners to enhance the political and social environment for sexual and reproductive health through the engagement of civil society. In djibouti, the Ministry of Health initiated a series of activities with UNFPA in 2012 to implement the national strategy for reproductive health commodity security. A thematic group has been established within the Ministry to coordinate RHCS activities. Senegal created a line in the national budget for contraceptive acquisition. Senegal is mid-way through implementation of a 2011-2015 Strategic Plan for Reproductive Health Commodity Security, acting on its government’s commitment to ensure that every person can chose, obtain and use high-quality contraception and reproductive health supplies. In 2012, youth training sessions prepared peer educators to share accurate information about modern family planning. Global ProGramme to enhance reProductive health commodity Security68 CHaPTER FouR: STREnGTHEnInG HEalTH SySTEmS: InTEGRaTIon, loGISTICS and maInSTREamInG An outsourcing strategy through contracting is part of the government’s plan to secure RH supplies in Burkina Faso. Photo: UNFPA/Ollivier Girard Strengthening national health systems through capacity building continued to a priority for countries participating in the GPRHCS in 2012. This work encompassed diverse aspects of reproductive health commodity security, including the procurement and distribution of RH commodities, training of staff in a wide range of positions from pharmacists to warehouse managers, addressing institutional capacity, improving the delivery of health services, and ensuring a functional logistics management information system. output 3: Capacity and systems strengthened for RHCS 69Annual Report 2012 4.1 number of countries using accessRH for procurement of RHCS AccessRH is an innovative procurement mechanism supported by key global partners working in the area of procurement. This indicator measures the extent to which AccessRH has been adopted by countries for the procurement of RH commodities. It also assesses the extent to which the use of AccessRH has reduced the lead time by 20 per cent (time between ordering the commodity and its arrival in the country). The goal of AccessRH is to improve access to quality, affordable reproductive health commodities and reduce delivery times for government and NGO clients and to provide enhanced information for planning and tracking. The Procurement Services Branch (PSB) continued to implement the AccessRH project under the auspices of the Reproductive Health Supplies Coalition (RHSC). In 2010, the Commodity Security Branch allocated $10 million to PSB to build inventory of reproductive health commodities (at manufacturers’ warehouses) for easy and faster shipments to countries as and when orders are placed; this was followed by an additional $4 million in 2012. Of the $13.16 million spent in 2012, about $12.7 5 million was for procurement of 53mm standard male condoms and $68,000 was for 200,000 pieces of IUD CUT380A (which will be shipped in 2013). The balance of about $345,000 was spent on stock insurance and sampling and testing. Figure 29: Cost of commodities (in uS$) dispatched by accessRH by destination of shipment, 2011 and 2012 Source: “Table 2: AccessRH Project dispatched quantities as at 31st Dec 2012” in PSB Update on CSB Funded Access RH Revolving Fund Quarterly Update 31st December 2012 Acess RH training for 27 specialists in medications procurement from five Central Asian countries was held October 2012 in Ashgabat, Turkmenistan A m ou nt in U S$ GPRHCS Stream 1 countries GPRHCS Stream 2 countries Others Destination of Shipment 0 1,000,000 2,000,000 3,000,000 4,000,000 5,000,000 2011 2012 Global ProGramme to enhance reProductive health commodity Security70 To date AccessRH has made 138 shipments to 79 countries. The number of GPRHCS and non-GPRHCS countries to which shipments were made increased in 2012 (Figure 29). Shipments to countries participating in the GPRHCS continued to account for a larger percentage of procurement through AccessRH. GPRHCS countries accounted for 78 per cent of the total procurement (of male condoms) in 2012, up from 71 per cent in 2011. Shipments were also made on behalf of Third Party Clients (those that are not UNFPA Country Offices) including Ministries of Health, National AIDS Control Councils, international NGOs and United Nations agencies. Third Party Client shipments reached 57 countries by end of 2012 (Figure 30). The four major destinations of shipments on behalf of Third Party Clients were Africa (up from 29 per cent of the countries in 2011 to 32 per cent in 2012), Asia (down to 16 of the countries in 2012 compared to 18 in 2011), Eastern Europe and Central Asia (up to 19 per cent of the countries in 2012 compared to 18 in 2011) and Latin America (up to 11 per cent of the countries in 2012 compared to 4 per cent in 2011). The increased use of AccessRH by third parties was an encouraging show of confidence in the efficiency of the procurement process. Figure 30: number of countries to which third party clients made shipments through access RH by region/sub-region in 2011 and 2012 Source: PSB datasheet N um be r of C ou nt ri es Africa Arab States Asia Pacific Caribbean Island Countries Eastern Europe and Central Asia Latin America Pacific Island Countries Others (NGO) Region/Sub-region 2011 2012 0 5 10 15 20 13 2 8 6 8 5 2 1 18 9 6 3 11 6 2 2 71Annual Report 2012 Reports from UNFPA’s Procurement Services Branch indicate that clients with standard 53mm condom orders fulfilled from inventory receive their goods 10 to 14 weeks faster than clients ordering condoms which need to be produced when the order is placed. This indicates that AccessRH has is contributing to the reduction in Lead-time for the procurement of condoms. Additional information on AccessRH is available: www.myAccessRH.org. 4.2 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. Seventeen male latex condom manufacturing sites were evaluated for prequalification or re-assessment for prequalification in 2012. No IUD evaluations carried out. As of 31 December 2012, 25 male condom factories and seven IUD factories had successfully completed the process. Additional factories were expected to be added to the list in the first half of 2013, following closure of inspection observations pending from 2012 inspections. The prequalification lists are dynamic and factories are added and removed accordingly; as such, the list changes multiple times during the year. 4.3 number of Stream 1 countries making ‘no ad hoc requests’ to unFPa for commodities (non-humanitarian) This indicator provides a proxy measurement of 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). The capacity to make accurate long-term forecasts and establish procurement plans is a sign of stronger systems. Countries should then be able to accurately predict their commodity needs and place orders to avert stock-outs, or at least to eliminate the need to make ad hoc procurements. Table 29: Stream 1 countries making ‘no ad hoc requests’ to unFPa for commodities (non- humanitarian), 2011 and 2012 Country 2011 2012 Burkina Faso N N Ethiopia Y Y Haiti Y N Lao PDR Y N Madagascar Y N Mali N Y Mongolia Y N Mozambique N Y Nicaragua Y N Niger Y N Nigeria N N Sierra Leone Y N Total for ‘yes’ 8 3 Global ProGramme to enhance reProductive health commodity Security72 Figure 31: number of Stream 1 countries that made ‘no ad hoc request’ for commodities, 2011 and 2012 In 2010 and 2011, eight Stream 1 countries made no ad hoc requests for RH commodities. In other words, these countries made procurement requests according to plans and forecasts made at the beginning of the year. In 2012, only three countries made no ad hoc request for RH commodities (Table 35). The reasons for the increase in ad hoc requests vary from country to country. In Mali, armed conflict in the northern part of the country created an emergency situation which required adjustments in national budgets and procurement of goods. For Mozambique, ad hoc requests were the result of an increase in need created by awareness raising and demand generation activities undertaken during national health weeks. Also, service provider training of health professionals in family planning techniques triggered demand for additional quantities of IUDs; Mozambique experienced a shortage of IUDs and requested an additional 9,000 IUDs. Key actions taken to prevent ad hoc requests include annual contraceptive forecasting led by government and with participation of all partners including UNFPA in Ethiopia; technical assistance provided by UNFPA to the Ministry of Public Health in Haiti for forecasting and quantification; strengthening of supply chain management and establishing monitoring and reporting system in Lao PDR; use of LMIS software (CHANNEL) to monitor stock distribution and having a functional logistics committee in place that provides forecasts for RH commodity needs; in Nigeria technical support received from USAID | DELIVER PROJECT has greatly enhanced stock monitoring to advert stock outs; and, in Sierra Leone an autonomous procurement and supply chain agency (crown agent) has been recruited to build and transfer skills to government personnel to ensure sustainability. N um be r of C ou nt ri es 2011 2012 Year 0 1 2 3 4 5 6 7 8 73Annual Report 2012 Table 30: Stream 2 countries making ‘no ad hoc requests’ to unFPa for commodities (non- humanitarian), 2011 and 2012 Country made ‘no ad hoc request’ 2011 2012 Benin N Y Bolivia Y N Botswana Y Y Burundi Y N Central Africa Republic N Y Chad N N Congo Y N Côte d’Ivoire N N Democratic Republic of Congo N Y Djibouti N N Ecuador Y N Eritrea N Y Gabon Y N Gambia N Y Ghana Y N Guinea Y N Guinea Bissau Y N Lesotho Y N Country made ‘no ad hoc request’ 2011 2012 Liberia Y N Malawi Y N Mauritania Y Y Namibia Y N Nigeria N N Papua New Guinea - Y Sao Tome and Principe N Y Senegal N Y South Sudan N N Sudan N N Swaziland Y Y Timor Leste N N Togo N Y Uganda Y N Yemen N Y Zambia Y Y Zimbabwe Y N Total for ‘Yes’ 18 14 Global ProGramme to enhance reProductive health commodity Security74 Figure 32: number of Stream 2 countries that made ‘no ad hoc request’ for commodities, 2011 and 2012 The number of Stream 2 countries making ‘no ad hoc request’ decreased from 18 in 2011 to 14 in 2012 (Table 30 and Figure 32). There were several reasons for the increase in ad hoc requests. Botswana requested male condoms because there were issues with the quality of condoms produced by a local manufacturer. Gambia requested implants when the number of clients requesting implants increased. Mauritania requested Noristerat and Depo-Provera when they were on the verge of stock-out. Papua New Guinea stocks ran so low an emergency procurement was made. In Senegal, a flood displaced over 280 families and required emergency procurement of RH commodities including contraceptives to serve their needs. In Democratic Republic of Congo, the humanitarian situation in parts of the country required RH kits to respond to the emergencies. 4.4 number of Stream 1 countries forecasting for RH commodities using national technical expertise This indicator assesses the existence of trained national staff, in government institutions, who are responsible for forecasting RH commodity needs for their respective countries. UNFPA works with governments and other partners to ensure that human capacity is built to carry out forecasting for RHCS as part of the overall strategy for contraceptive security. Table 31: Stream 1 countries using national technical experts for forecasting, 2010 to 2012 Country Expertise forecasting in moH 2010 2011 2012 Burkina Faso Y Y Y Ethiopia Y Y Y Haiti Y Y Y Lao PDR N N N Madagascar Y Y Y Mali Y Y Y Mongolia Y Y Y Mozambique N Y Y Nicaragua Y Y Y Niger N Y Y Nigeria - N N Sierra Leone Y Y Y Total for ‘yes’ 8 10 10 N um be r of C ou nt ri es 2011 2012 Year 0 5 10 15 20 75Annual Report 2012 Figure 33: Stream 1 countries using national technical experts for forecasting of RH commodities Ten Stream 1 countries had national technical expertise in the Ministry of Health or in other government agency for forecasting for RH commodities in 2012 – up from 8 in 2010 (Table 31 and Figure 33). The exception were Lao PDR and Nigeria, as in the previous year. In Nigeria, the actual process of forecasting was carried out by the USAID | DELIVER PROJECT with the participation of national staff. In Lao PDR, the process benefitted from technical assistance by UNFPA and UNICEF for RH commodity needs; and by the Global Funds through the Centre for HIV/STI (CHAS) for the forecast and procurement of condoms. 4.5 number of Stream 1 countries managing procurement process with national technical expertise This indicator assesses the existence of national human resource capacity for procurement of RH commodities in a government agency. It also provides an indication of steps taken to ensuring sustainability and country ownership and institutionalization of skills and capacities for RHCS. Table 32: Stream 1 countries using national technical experts for procurement of RH commodities, 2009 to 2012 Country Expertise for procurement of RH commodities 2009 2010 2011 2012 Burkina Faso Y Y Y Y Ethiopia Y Y Y Y Haiti N N Y N Lao PDR N Y N N Madagascar Y Y Y Y Mali N Y Y Y Mongolia N Y Y Y Mozambique N N Y Y Nicaragua Y Y Y Y Niger Y Y Y Y Nigeria - - N N Sierra Leone Y Y Y Y Total for ‘yes’ 6 9 10 9 N um be r of C ou nt ri es 2010 2011 2012 Year 0 2 4 6 8 10 Global ProGramme to enhance reProductive health commodity Security76 Figure 34: Stream 1 countries using national technical experts for procurement of RH commodities The number of Stream 1 countries with national technical expertise increased from 9 in 2010 to 10 in 2011 and then to 9 countries in 2012, a decrease due to the lack in Haiti of such skilled national staff last year (Table 24). 4.6 number of Stream 1 countries with functioning lmIS This indicator seeks to ascertain the effectiveness of the logistics management information systems for tracking the distribution of RH commodities. It is expected that a functional logistics management information system will provide information 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 expiration date. N um be r of C ou nt ri es 2009 20112010 2012 Year 0 2 4 6 8 10 77Annual Report 2012 Ta bl e 33 : n um be r of S tr ea m 1 c ou nt ri es w it h fu nc ti on in g lm IS , 2 0 11 a nd 2 0 12 C ou nt ry C ou nt ry h as fu nc ti on in g lm IS lm IS p r o vi de s Fi gu re s on m od er n co nt ra ce pt iv es lm IS p r o vi de s fi gu re s on lif es av in g m ed ic in es lm IS h as in fo rm at io n on In ve nt or y an d m on th ly co ns um pt io n lm IS h as In fo rm at io n on st oc k st at us a t al l l ev el s lm IS h as In fo rm at io n on ex pi ry d at es o f al l p ro du ct s lm IS h as In fo rm at io n on n um be r of us er s of a ll pr od uc ts 20 11 20 12 20 11 20 12 20 11 20 12 20 11 20 12 20 11 20 12 20 11 20 12 20 11 20 12 Bu rk in a Fa so Y Y Y Y N Y Y Y Y Y Y Y Y Y Et hi op ia Y Y Y Y Y Y N Y Y Y Y Y N N H ai ti Y Y Y Y Y Y Y Y N N Y Y Y Y La o PD R Y Y Y Y N N Y Y Y Y N Y N Y M ad ag as ca r Y Y Y Y Y Y Y Y Y Y Y Y Y Y M al i Y Y Y Y Y Y Y Y Y Y N Y N N M on go lia Y Y Y Y Y Y Y Y Y Y Y Y Y Y M oz am bi qu e Y Y N Y Y Y N N N N Y Y Y Y N ic ar ag ua Y Y Y Y Y Y Y Y Y Y Y Y N N N ig er Y Y Y Y Y Y N N Y Y Y Y N N N ig er ia Y Y Y Y N N N Y Y Y Y Y N N Si er ra L eo ne Y Y Y Y Y Y Y Y Y Y Y Y N N To ta l f or ‘Y es ’ 12 12 11 12 9 10 8 10 10 10 10 12 5 6 Global ProGramme to enhance reProductive health commodity Security78 All Stream 1 countries had a functional LMIS in place in 2011 as well as in 2012, which was an improvement from 7 in 2010 (Table 33). There were variations in the level of functionality of the systems with respect to the ability of the system to provide data on modern contraceptives, lifesaving medicines, monthly consumption data, stock status at all levels and information on expiration dates of all products. Improvements in the functionality of the system in various areas were noted, yet overall only 6 of the 12 Stream 1 countries had systems capable of provide information on number of users of all products: Burkina Faso, Haiti, Lao PDR, Madagascar, Mongolia and Mozambique. 4.7 number of Stream 1 countries with co- ordinated approach towards integrated health supplies management system The indicator assesses the existence of a unified mechanism for managing all health supply systems that takes into account the procurement and distribution of RH commodities. This an important step in strengthening systems for RHCS. The aim is to integrate contraceptive commodity logistic systems into national systems that address the needs of the health system. Table 34: number of Stream 1 countries with co-ordinated approach towards integrated health supplies management system, 2011 and 2012 Country Integrated supply management system exists System includes an integrated procurement mechanism for contraceptives and RH medicines System includes an integrated supply/distribution mechanism for contraceptives and RH medicines 2011 2012 2011 2012 2011 2012 Burkina Faso Y Y Y Y Y Y Ethiopia Y Y Y Y Y Y Haiti N N na na na Y Lao PDR N N na na na na Madagascar Y Y N N Y Y Mali Y Y N N Y Y Mongolia Y Y Y Y Y Y Mozambique Y Y N Y Y Y Nicaragua Y Y Y Y Y Y Niger Y Y Y Y Y Y Nigeria N Y na Y na N Sierra Leone Y Y N Y Y Y Total for ‘yes’ 9 10 5 8 9 10 79Annual Report 2012 Ten Stream 1 countries had some form of a coordinated and integrated health supplies management system in 2012, not including Haiti and Lao PDR (Table 34). The number of countries with systems that included integrated procurement mechanisms for contraceptives and RH medicines increased from five in 2011 to eight in 2012: Burkina Faso, Ethiopia, Mongolia, Mozambique, Nicaragua, Niger, Nigeria and Sierra Leone. Ten countries in 2012 had systems that included integrated supply/ distribution mechanisms for contraceptives and RH medicines (the exceptions being Lao PDR and Nigeria). In 2012, the supply management systems were more integrated regarding supply and distribution than for procurement mechanisms. The number of countries with systems that included integrated procurement mechanisms and integrated supply and distribution mechanisms for RH commodities (contraceptives and RH medicines) increased from five in 2011 to seven in 2012: Burkina Faso, Ethiopia, Mongolia, Mozambique, Nicaragua, Niger and Sierra Leone. 4.8 number of Stream 1 countries adopting/ adapting a health supply chain management information tool Use of an information management tool has strengthened the health supply management system in many countries. It has often entailed adopting or adapting a computer-based programme to serve the needs of the country and at a higher level, ensuring that it is web-based and available to a wider audience and updated regularly. Table 35: number of Stream 1 countries adopting/adapting a health supply chain management information tool Country Country adopted supply management tools 2010 2011 2012 Burkina Faso Y Y Y Ethiopia Y Y Y Haiti Y Y Y Lao PDR Y Y Y Madagascar Y Y Y Mali Y Y Y Mongolia Y Y Y Mozambique Y Y Y Nicaragua Y Y Y Niger Y Y Y Nigeria - Y Y Sierra Leone Y Y Y Total for ‘yes’ 11 12 12 In Stream 1 countries, GPRHCS continued to support countries to improve on their supply management systems. The number of Stream 1 countries that have adopted and are using some form of computerized health supply chain management information system increase from 10 in 2010 and to 12 in 2011 and 2012 (Table 35). Ten countries adopted CHANNEL, the computer software developed by UNFPA, and two countries adopted PIPELINE (Mozambique and Nigeria). Global ProGramme to enhance reProductive health commodity Security80 Box 4: Strengthening the delivery system To ensure a secure, steady and reliable supply of RH commodities, countries make it a priority to improve their logistics management information systems, often with computer software and training, and to mainstream RHCS within their national health systems. a civil society partnership for monitoring health supplies in Sierra leone Members of a civil society organization (CSO) are closely monitoring health commodities in Sierra Leone – from the quay and airport to the central medical store, district medical stores and peripheral health units. Theft of drugs is down, availability of supplies at facilities is up, and access to health services and medicines has improved. The Government introduced the civil society component to enhance its newly computerized system for tracking and managing essential supplies. It also made a first-ever budget allocation to RH commodities in 2011 and pursued inclusion of family planning in national policies. logistics management information systems – and warehouses that work in madagascar Before and after photos of a warehouse in Taolagnaro, Madagascar, are representative of improvements at five warehouses in 2012. Such investment in the national health system infrastructure is part of a wide variety of RHCS actions in 2012 – from a new manual on family planning to revision of the national RHCS strategy, to inclusion of RH issues in medical and pharmaceutical schools, to the acquisition of trucks to transport essential supplies. In Madagascar, the government adopted CHANNEL computer software for control, transparency and follow-up in the management of health supplies. This supported improvement across the board. CPR in Madagascar rose by 11 percentage points from 2004 to 2009, to reach 29.2 per cent. This remarkable increase stands in contrast to the country’s relatively stagnant rates during the years leading up to strategic GPRHCS support. Unmet need declined from 24 per cent in 2004 to 19 per cent in 2009 and 2010. Access to appropriate methods is improving: The percentage of service delivery points (SDPs) offering at least three modern contraceptive methods improved in Madagascar from 30.8 per cent 2009 to 47.8 per cent in 2010 to 97.2 per cent in 2011. More shelves are reliably stocked: Clinics and other service delivery points reported ‘no stock-out’ of contraceptives at 63.3 per cent in 2008, 74.4 per cent in 2009, 79.6 per cent in 2010 and 90.8 per cent of SDPs in 2011. Choice of method is better assured, with the 81Annual Report 2012 availability of three modern methods from 50 per cent in 2010 to 97.3 per cent in 2011 at primary-level SDPs. Key medicines are available: All the tertiary- level SDPs (100 per cent) in Madagascar had the five life-saving medicines for maternal and reproductive health available in 2011. After major investment in its logistic management information system over the previous two years, by the end of 2010 Madagascar had a functional LMIS capable of providing inventory and monthly consumption data. In Haiti, three monitoring missions covering a sample of 14 of a total 34 sites using computer software (CHANNEL) in their logistics management information system were conducted in 2012, finding challenges due to the mobility of trained personnel and electrical outages. The Ministry of Health called on regional pharmacists to be more committed and for the strengthening of all CHANNEL sites to serve as the national system providing monthly stock information to the central level. An RHCS Technical Monitoring Committee of key donors and the Ministry’s partners was created to oversee the annual national survey for tracking the GPRHCS indicators, holding a November workshop to improve coordination at the institutional and MOH departmental levels. In mali, laboratory and medical equipment aided services in community health centers in the Kayes region, along with hundreds of family planning counseling cards to raise awareness. A new national comprehensive condom programming work plan, partnership between UNFPA and NGOs resolved an implant stock-out early in the year, and UNFPA accelerated procurement of RH supplies that helped to compensate for the withdrawal of donor during the crisis and helped to keep shelves stocked with contraceptives. The central warehouse in nicaragua is at the centre of efforts to strengthen the entire logistics management system. Overloaded by increasing demand, the Health Supplies Center (CIPS) benefitted from technical assistance from PRISMA, a regional partner: diagnostic analysis, development of a comprehensive plan, reorganization, operational manuals, information system design, staff capacity building training, and funding mobilization. In Ethiopia in 2012, the Pharmaceuticals Fund Supply Agency continued to improve the integration of family planning commodities in its overall supply management, and its hubs are taking over storage, distribution and inventory management – a dramatic improvement over formerly lengthy and uncoordinated supply lines. The GPRHCS also supported procurement of computers, printers and inventory control cards as part of logistics and information management systems. A situational diagnostic of the logistics system in Panama in 2012 provided a starting point for a plan to close gaps that currently lead to supply shortfalls. Support for these efforts was retained despite a change in MOH leadership. Efforts to secure more health personnel trained in the implementation of the family planning decision-making tool focused on two regions. A national inventory was conducted as part of an analysis of the availability of contraceptives and reproductive health essential medicines in Panama MOH facilities. In El Salvador, the reorganization and systematization of supplies and basic medicines for sexual and reproductive health care was one result of an RH commodity security strategy implemented with UNFPA support at the Santa Gertrudis Hospital of San Vicente, under the MoH. Limited access to medicines Global ProGramme to enhance reProductive health commodity Security82 for maternity services had caused dangerous delay in obstetric emergencies, and daily and monthly monitoring was implemented to ensure availability. In Boliva in 2012, four training sessions in the operation of the logistic management information system and the storage of contraceptives were held for personnel of health facilities and FIMs. In Sao Tome and Principe, 17 new reproductive health service providers were trained and 28 reproductive health service providers were refreshed on LMIS, ensuring that LMIS is functioning at all levels to maintain the availability of reproductive health commodities. Training three central-level managers as trainers in CHANNEL has increased the capacity of national institutions to deliver high-quality, integrated sexual and reproductive health services. Despite severe budgetary restrictions since 2011, Sudan invested in both its physical and human resource infrastructure in 2012 to enhance reproductive health commodity service and supply networks. With regards to physical improvements of service delivery points, four health centers were rehabilitated and equipped in Blue Nile state, and warehouses in two states—Kassala and Gadarif— were rehabilitated to improve their storage capacity. LMIS capacity was strengthened in these three states through training of 190 RH and pharmaceutical staff. Forty MoH staff pariticpating in supply chain management training. Guinea (Conakry) faced significant challenges in operating LMIS/CHANNEL for reproductive health commodity security and distribution: outlying areas lacked sufficient electrical service to run the computers. With funding from Catholic Relief Services, 19 of 33 prefectures were equipped with solar energy sources, allowing UNFPA-supported CHANNEL software to be put into place for reproductive health supply management while CRS utilized CHANNEL to aid in distribution of health- protecting mosquito netting. 83Annual Report 2012 CHaPTER FIvE: maInSTREamInG RHCS wITHIn unFPa CoRE BuSInESS Andrea, owner of a street garments stall in Uruguay, shows condoms she received for free through a nationwide agreement of the Ministry of Health and UNFPA. Photo: UNFPA/Manuela Aldabe The indicators under the output ‘RHCS mainstreamed into UNFPA core business’ keep track of progress made by UNFPA to integrate RHCS issues into the organization’s programming processes. The output also focuses efforts made by UNFPA to make RHCS a priority issue within the United Nations planning documents and partnership processes at the country level. Through the GPRHCS, UNFPA supports advocacy for resource mobilization and mobilizes resources, provides technical and other capacity building support to government and other partners and helps to build partnership in support of RHCS activities. output 4: RHCS mainstreamed into UNFPA core business (UN reform environment) Global ProGramme to enhance reProductive health commodity Security84 5.1 Expenditure of unFPa/CSB core resources for RHCS increased UNFPA support to the Commodity Security Branch (CSB) – the branch within the agency that manages its RH commodity security functions continued to ensure UNFPA’s continuous engagement on RHCS in 2012. The amount that UNFPA provided from its core resources for implementing RHCS activities in CSB decreased in 2012, reflecting an overall reduction in total core funds available to UNFPA this year, and the need to sustain programme delivery in other areas. The amount allocated to CSB has fluctuated somewhat over time, with $1.33 million in 2008, $2.12 million in 2009, $2.1 in 2010, $1.45 million in 2011 and $1.45 million in 2012 (Figure 40). The reduction is largely the cause of reduced total core funds available to UNFPA and the need to sustain programme delivery in other areas. Figure 35: amount allocated to unFPa Commodity Security Branch (million $) 5.2 GPRHCS planning takes into account lessons learned in RHCS mainstreaming Sustained programming requires building on achievements and scaling up lessons learned. This indicator is used to look at the areas in which the countries are using lessons learned from previous implementations to build on current and future interventions. In both 2011 and 2012, 11 Stream 1 countries (except Haiti) took into account lessons learned in the previous year for the implementation of the programme in the current year (Table 36). Table 36: GPRHCS planning for Stream 1 countries takes into account lessons learned, 2011 and 2012 name Country 2011 2012 Burkina Faso Y Y Ethiopia Y Y Haiti N Y Lao PDR Y Y Madagascar Y Y Mali Y Y Mongolia Y Y Mozambique Y N Nicaragua Y Y Niger Y Y Nigeria Y Y Sierra Leone Y Y Total for ‘yes’ 11 11 Examples of activities in 2012 included building on procurement training to strengthen capacity in Burkina Faso; strengthening partnerships with stakeholders through regular meetings to share information develop strategies for problem solving in Ethiopia; and providing support to the Food and Drug Department (chair of the FDD Technical Working Group) to initiate the Supply Task Force led by MPSC to meet regularly and to ensure mainstreaming of RHCS in Lao PDR. Madagascar equipped health districts with IT equipment and then installed solar energy equipment N um be r of C ou nt ri es 20092008 20112010 2012 Year 0.0 0.5 1.0 1.5 2.0 2.5 85Annual Report 2012 to ensure that work flow was not interrupted by power outages, improving timely reporting on commodities. In Sierra Leone, CHANNEL was adapted to suit local needs, which has resulted in better commodity management and forecasting. Additional efforts were also put into developing the low capacity of government staff to use and manage CHANNEL, which was identified as a major issue last year. In Stream 2 countries, the number of countries taking lessons learned in into account increased from 27 in 2011 to 30 in 2012 (Table 39 and Figure 41). In the Central African Republic, problems posed by the weak logistics system were addressed when UNFPA helped to bring together partners, including NGOs, to improve the system, contributing to a stronger distribution network and better communications between warehouses and health facilities in project areas. Table 37: GPRHCS planning in in 2011 for Stream 2 countries takes into account lessons learned, 2011 and 2012 name Country 2011 2012 Benin Y Y Bolivia Y Y Botswana Y Y Burundi Y Y Central Africa Republic Y Y Chad Y Y Congo Y Y Côte d’Ivoire Y Y Democratic Republic of Congo Y Y Djibouti N Y Ecuador Y Y Eritrea N  N name Country 2011 2012 Gabon N Y Gambia Y Y Ghana Y Y Guinea Y Y Guinea Bissau Y Y Lesotho Y Y Liberia Y Y Malawi Y Y Mauritania Y Y Namibia N  N Nigeria   Papua New Guinea Y Y Sao Tome et Principe Y Y Senegal Y Y South Sudan Y Y Sudan N Y Swaziland Y Y Timor Leste N N Togo Y Y  Uganda Y Y Yemen N N Zambia Y Y Zimbabwe Y Y Total for ‘yes’ 27 30 Global ProGramme to enhance reProductive health commodity Security86 Figure 36: GPRHCS Stream 2 countries take into account lessons learned for planning, 2011 and 2012 The implementation of the lessons learned into succeeding programing years has enabled each country to build on successes and to address challenges. The issues for Stream 2 included intensification of the monitoring of RHCS activities in Benin to track stock levels and respond to needs. In Chad, CHANNEL was introduced to improve the logistic information management system and a procurement plan was formulated to respond to country needs. In the area of logistics management, Democratic Republic of Congo used CHANNEL to strengthen weaknesses in the supply chain management of essential drugs, to enhance distribution and reporting on availability of commodities. Côte d’Ivoire addressed logistics management challenges by efforts to strengthen national capacity to ensure government leadership and sustainability. Many countries strengthened partnerships for RHCS. In Burundi, partnership with KFW was strengthened for the procurement of contraceptives to ensure sustained availability. In Ecuador, GPRHCS funds were used to build on policy dialogue, advocacy and national capacity building efforts that continued in 2012 to enhance credibility with high-level Government officials as well as technical MoH staff. The RHCS coordinating committee in Guinea was supported to ensure better information sharing among partners and coordination with partners including the World Bank. Liberia continued to collaborate with USAID on RHCS issues, improving timely forecasting for RHCs and ensuring joint funding of interventions, which has helped to minimize ad-hoc requests for normal programme activities in recent years. In the area of programme planning, an acute shortage of condoms in 2012 in Uganda provided useful lessons that later ensured the allocation of funds for condom procurement in the Joint Program on Population in Uganda for 2013. In Sudan, lessons learned about the need for early planning and engagement of partners were applied to timely preparations for 2013, and plans and estimates of RHCs needs were developed with involvement and consultations of partners. In the Central African Republic, evaluation of the 2008- 2012 Strategic Plan provided recommendations that were used to improve RHCS interventions for 2013-2017. In Guinea Bissau, joint planning activities increased participation by the Government and strengthened its leadership in programme planning and implementation. Lessons learned about scaling up community outreach enabled Lesotho to work more effectively with NGOs, which have been shown to be quicker and have a comparative advantage in reaching communities with condom messages. In 2012, Lesotho’s partnership with PSI was scaled up and engagement of additional NGO partners was planned for 2013 and beyond. In Ghana, continuous and active community engagement continued to help generate demand for contraceptives. Distribution of RHCS through mobile networks was identified for scaling up in Togo based on positive results achieved last year in ensuring that communities in hard-to-reach areas can access services. N um be r of C ou nt ri es 2011 2012 Year 0 5 10 15 20 25 30 87Annual Report 2012 5.3 number of countries with RHCS priorities included in CCa, undaF, CPd and CPaP UNFPA Country Offices work within partnership frameworks in each country, including UN Country Teams, to ensure that RHCS issues are included into strategic initiatives. Each year UNFPA Country Offices are asked to report on their efforts to ensure RHCS priorities are integrated into UN programming processes. Table 38: Stream 1 countries with RHCS priorities included in CCa, undaF, CPd, CPaP and awP, 2010 to 2011 Country RHCS included in CCa RHCS included in undaF RHCS included in CPd RHCS included in CPaP RHCS included in awP 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 Burkina Faso Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Ethiopia N N Y Y Y Y Y Y Y Y Y Y Y Y Y Haiti N N Y Y Y Y Y N Y Y Y Y Y Y Y Lao PDR N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Madagascar N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Mali Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Mongolia Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Mozambique N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Nicaragua N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Niger N N N Y Y Y Y Y Y Y Y Y Y Y Y Nigeria - Y Y - Y Y - Y Y - Y Y - Y Y Sierra Leone N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Total for ‘yes’ 3 9 11 10 12 12 11 12 12 11 12 12 11 12 12 * Nigeria was designated as a Stream 1 Country in 2011, thus information for 2010 are in the Stream 2 Table Global ProGramme to enhance reProductive health commodity Security88 Ta bl e 39 : S tr ea m 2 c ou nt ri es w it h R H C S pr io ri ti es in cl ud ed in C C a , u n d a F, C Pd , C Pa P an d a w P, 2 0 10 t o 20 12 C ou nt ry R H C S in cl ud ed in C C a R H C S in cl ud ed in u n d a F R H C S in cl ud ed in C Pd R H C S in cl ud ed in C Pa P R H C S in cl ud ed in a w P 20 10 20 11 20 12 20 10 20 11 20 12 20 10 20 11 20 12 20 10 20 11 20 12 20 10 20 11 20 12 Be ni n Y Y Y Y Y Y N Y Y Y Y Y Y Y Y Bo liv ia Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Bo ts w an a Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Bu ru nd i N N Y N N Y N Y Y Y Y Y Y Y Y C en tr al A fr ic a Re pu bl ic Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y C ha d Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y C on go N Y Y Y Y Y Y Y Y Y Y Y Y Y Y C ôt e d’ Iv oi re Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y D RC Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y D jib ou ti Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Ec ua do r Y Y Y Y Y Y Y Y Y Y

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