The Global Programme to Enhance Reproductive Health Commodity Security - Progress Report 2008

Publication date: 2008

Global Programme to Enhance Reproductive Health Commodity Security Progress Report 2008 United Nations Population Fund 2008 GPRHCS 2008 Progress Report Page 2 Table of Contents EXECUTIVE SUMMARY 3 INTRODUCTION 9 STREAM 1 – ETHIOPIA 10 STREAM 1 – BURKINA FASO 16 STREAM 1 – MOZAMBIQUE 20 STREAM 1 – NICARAGUA 23 STREAM 1 – MONGOLIA 29 STREAM 1 – MADAGASCAR 34 STREAM 1 – LAOS 38 STREAM 1 – NIGER 41 STREAM 1 – HAITI 44 STREAM 2 47 STREAM 2 – IN EASTERN AND SOUTHERN AFRICA 47 STREAM 2 – IN WEST AFRICA 50 STREAM 2 – IN ASIA AND THE PACIFIC 52 STREAM 2 – IN LATIN AMERICA AND THE CARIBBEAN 55 STREAM 3 59 GLOBAL INITIATIVES TO FACILITATE RHCS 60 GLOSSARY OF TERMS 63 GPRHCS 2008 Progress Report Page 3 Executive Summary Introduction and Objectives: Since 2007, the Thematic Fund for Reproductive Health Commodity Security [RHCS]—which finances the Global Programme to enhance RHCS—has helped UNFPA work with national governments to carry out the diverse and multi-faceted work needed to achieve Reproductive Health Commodity Security. Previous efforts responding to ad-hoc requests from countries for technical assistance and supplies failed to generate country-driven, sustainable approaches to commodity security. UNFPA developed the Global Programme, specifically to help countries plan for their own needs in the sphere of RHCS. The Global Programme is designed to act as a catalyst to national action and the prioritisation and subsequent mainstreaming of Reproductive Health Commodity Security into national health policies, programmes, budgets and plans. As a result, countries are beginning to move towards more predictable, planned and sustainable country-driven approaches to securing essential supplies and ensuring their use. Focus on Stream 1 Countries: To ensure these extra funds have a clear measurable impact, the Global Programme provides multi-year funding to a relatively small number of ‘Stream 1’ countries. These predictable and flexible funds are then used to help countries develop more sustainable approaches to RHCS: ensuring the reliable supply of RH commodities and the concerted enhancement of national capacities and systems. Of the nine current Stream 1 countries, receiving this country-defined package of medium-term support, Ethiopia, Burkina Faso, Mozambique, Nicaragua and Mongolia have been receiving support since 2007; with Madagascar, Laos, Niger and Haiti joining them in 2008. The selection of two further Stream 1 countries is currently underway. A key cross-cutting activity carried out in all Stream 1 countries in the final quarter of 2008 was the setting of the baseline for a number of key indicators against which progress and the impact of the Global Programme is to be measured over the coming years. This progress report focuses primarily on Stream 1 countries. A large number of other countries are receiving Global Programme funds from Streams 2 and 3. Stream 2: Stream 2 funding provides support to initiatives to strengthen several elements of RHCS in either one or more countries [providing the possibility of regional initiatives]. Though many countries have benefitted from this targeted support on what has until now been a more ad hoc basis, the formalisation of the selection of Stream 2 initiatives is currently underway. It is expected that during 2009, some 20 initiatives will be selected for funding and implementation will begin. Stream 3: In 2008, Stream 3 provided about US$20 million worth of RH commodities to some 60 countries to help them avoid RH commodity stockouts that would otherwise have occurred. The support included 196 million male condoms and 2.9 million female condoms in addition to other contraceptives and maternal health drugs. This emergency fund continues to support countries that face stockouts for reasons such as poor planning, weak infrastructure and low in-country capacity. Over time, UNFPA will seek to demonstrate that requests for funding are falling as in-country capacity and systems improve. Stream 3 also provides indispensable support to countries facing stockouts due to humanitarian crises caused by natural or man-made disasters – and as UNFPA’s role in disaster relief becomes better defined, the need for this crucial source of support is likely to endure in the medium-term and beyond. As part of specific support to refugees and internally displaced population, UNFPA provided UNHCR with nearly 7 million male condoms and 440,000 female condoms that were distributed in 26 conflict and post-conflict countries. GPRHCS 2008 Progress Report Page 4 Mainstreaming RHCS: The package of support defined in each of the Stream 1 countries by the government, with help from UNFPA and other key stakeholders, varies greatly as a function of specific RHCS-related needs and opportunities. In all countries, mindful of the need to mainstream this issue, the focus is less on the definition of a policy document with “RHCS” in the title than on the integration of RHCS into key health sector policies. The opportunities for such mainstreaming vary from country to country and so the policy vehicles by which the Global Programme promotes better RHCS also differ greatly. Progress is slower than desired in a number of cases and while efforts focus on keeping activities on schedule, the explicitly government-led approach of the Global Programme is one which UNFPA and its partners can promote, support and facilitate but not control. In Stream 1 countries where broad-based efforts to reform and improve health systems and services are on-going, UNFPA has advocated mainstreaming RHCS into such processes and is using Global Programme funds to complement these larger efforts to strengthen elements of the health system. In Ethiopia, Global Programme funds are covering previously neglected RHCS-related elements to complement an ambitious, US$110 million, five-year Ministry of Health initiative to implement a new health commodity supply system nationwide. In Nicaragua, a National Sexual and Reproductive Health Strategy was finalised in 2007 and Global Programme funds have been used to support the integration of an RHCS component within this broad Ministry of Health strategy. Promoting the mainstreaming of RHCS within the governments own principal policy vehicles also helps ensure the institutionalisation and national ownership of the issue. In Nicaragua, where RHCS-related activities were part of the Ministry of Health annual workplan, it was easier to ensure that the activities were completed. Coordination and strategic in-country support: With national treasuries already severely overstretched in their efforts to up-grade national health systems and services, there is the ever-present risk that RHCS and related issues will become marginalised and neglected once again. At country level, UNFPA is engaged with a small number of partners [who vary from country to country] to keep the issue on the national agenda. In many cases, a national coordination mechanism [NCM] exists which has within its remit/TORs the issue of RHCS. Challenges abound however and much effort is devoted to addressing them. At national level, the coordination mechanism often faces one or more of the following problems: [•] there are too few active members of the NCM and they tend to be drawn from those few organisations that have traditionally been most involved in RHCS and related issues; [•] members tend to be operational level with a technical background and little decision-making power; [•] the focus tends to be concentrated on one or more of the following – [i] technical logistics and procurement issues, [ii] contraceptives, [iii] reproductive health; [•] public sector involvement tends to be drawn from the [S]RH team in the Ministry of Health and the team responsible for RH commodity logistics and procurement; [•] there is little or no involvement of those in-country stakeholders involved in the fight against HIV/AIDS; [•] there is no complementary higher level forum with decision-makers in which RHCS is systematically debated, progress reviewed and strategic direction given. To address these issues, UNFPA is working to ensure that RHCS is on the agenda of higher level fora periodically at national level [two to three times per year would seem reasonable] and that on such occasions key donor partners are able to provide strategic support for RHCS and related issues prioritised by the Global Programme. Challenges of the new aid environment: The Global Programme is experiencing first-hand some of the challenges inherent in implementing a harmonised, country-driven approach that adheres to the guiding principles of the Paris Declaration on Aid Effectiveness. With a focus on alignment and harmonisation and government leadership, stakeholder control on events is somewhat reduced. For example, some governments try to emphasise harmonisation and government-led processes. It should be stressed though that the delays in implementation of activities which sometimes result are well compensated over the longer-term by the fact that government priorities are being implemented and governments set the priorities. Over time, implementation of policies where donors align with government and national priorities runs a better chance of being sustainable than previous more donor-driven approaches. GPRHCS 2008 Progress Report Page 5 The reasons for under-utilisation of funds is sometimes more straightforward. Though Haiti became a Stream 1 country in 2008, no Global Programme funds were used in the sphere of RHCS due to severe weather conditions in the country which hampered progress. This was compounded by the United States decision to substantially reduce funding to the Ministry of Health. It is interesting to note, however, that the crisis which followed pushed the government to undertake to reduce its reliance on foreign aid and to create a budget line for RH commodities. On a related note, it is also worth mentioning that in the context of health sector reform, where decentralisation of authority to provincial level is set to take place and mindful of how this can disrupt RH commodity supply in reforming countries, UNFPA increasingly recommends maintaining and strengthening centralised procurement functions. Monitoring progress – GPRHCS baseline and RHCS dashboard: Monitoring performance of Stream 1 countries in particular but also the overall impact of the GPRHCS has been a key priority in 2008. In order to ensure a strong results focus in addressing reproductive health, a baseline for RHCS has been established in Stream 1 countries [and a number of other countries]. This will enable measurement of progress made on indicators such: as number of stockouts of supplies; number of service delivery points offering three or more contraceptive options; and levels of national capacity in forecasting and procurement. Additionally, an extensive online monitoring tool was developed in 2008 which facilitates a periodic survey of RHCS-related process indicators. The RHCS Dashboard will be available in early 2009 online as part of the new RHCS pages of the UNFPA website [www.unfpa.org]. This tool goes beyond the country baseline to collect information on such areas as; country office capacity; national action plan for RHCS; logistics and supply management; policy and advocacy. Measuring progress against the baseline and looking at the RHCS Dashboard are designed to provide countries with critical information to improve planning and to encourage proactive corrective action and a focus on results. In Madagascar, it was found that simply creating a solid baseline has already helped ensure a more strategic orientation toward achieving measurable results with an increase in demand-creation efforts that aim to improve the contraceptive prevalence rate [CPR]. Managing national commodity supplies data: The UNFPA-developed Country Commodity Manager [CCM] is straightforward software currently used in 89 countries to help manage and report central warehouse commodity data. In addition, to address in-country needs from central warehouse to district level, UNFPA developed and is piloting CHANNEL, a computerised logistics management system, in five countries. The focus on ease of use has meant that these software tools are proving very valuable where the widespread use of existing more sophisticated software [which tends to require substantial training] is not feasible at the present time. UNFPA reorganisation: 2008 was a transitional year for UNFPA as the planned reorganisation process was implemented, with an increased focus on strong country teams. Regional offices have begun to move from headquarters in New York to the regions, with staff relocations and a new approach to the delivery of technical assistance adapted to the new organisational structure. Although the transition was smooth, it required changes in the implementation of country workplans and technical support modalities. In addition, International Public Sector Accounting Standards [IPSAS], a more rigorous system to be applied throughout the UN by 2010, was adopted. As IPSAS standards dictate that supplies must be received before funds are recorded as disbursed, the procurement process has had to begin much earlier. Internal adjustments are taking place in light of these new requirements and already many solutions have been found to resolve immediate obstacles caused by this new system. UNFPA continues to face challenges in providing procurement services to governments that request them and much attention has focused on strengthening this facility. UNFPA’s vision to build sustainable national systems and capacity for procurement, logistics and all elements of in-country supply management is beginning to take shape – with GPRHCS funds instrumental in helping this happen. GPRHCS 2008 Progress Report Page 6 Tackling human resource constraints: A lack of human resources in many countries has also proved to be a major challenge. Mozambique seems to have faced a severe lack of human resources in the Ministry of Health. Ethiopia recruited a new Chief Technical Advisor for RHCS to be placed in the Pharmaceutical Funds and Supply Agency to address the human resource challenge. In many countries, knowledge about logistics management is in particularly short supply. The situation is often compounded when, for a variety of reasons, there is high turnover of those trained. In response to this problem, UNFPA is in the process of identifying several regional and national institutions whose capacity will be developed to provide much needed capacity building on logistics to national counterparts on a continuous and sustainable basis. In addition, the Reproductive Health Supply Coalition, in which UNFPA plays a key role, is developing an initiative for the professionalisation of logisticians in order to raise the status of logisticians and to ensure logistics is defined as a specialised and crucially important profession. In Ethiopia, implementation of activities to expand reproductive health and family planning services and meet clients’ needs is boosted by strong government commitment. The expansion of services has been severely constrained, however, by the lack of adequately skilled health care providers. With GPRHCS funds and technical assistance, the MOH is now providing Training of Trainer courses on Comprehensive Family Planning [encompassing the intra-uterine contraceptive device (IUCD), Jadelle, Implanon and emergency contraception] to develop the human resource capacity of the regions. In 2008, 125 health care providers were trained; another 250 will be in the first six months of 2009. Building national capacity for better RHCS: Building capacity in country allows for sustainable progress and seeks to reduce reliance on outside technical assistance. In many cases, Global Programme funds were used to train health workers, government officials, local UNFPA staff, and partners in areas such as procurement, logistics management, forecasting RH commodity needs, the use of new or underutilised family planning methods and other critical areas. For example, Ethiopia trained 125 health care providers on Comprehensive Family Planning and 65 on long-term methods of family planning, who will go on to train others in a countrywide effort to expand coverage and variety of contraceptive options. The Asia-Pacific regional office in Bangkok conducted regional trainings on Logistics Management and Information Systems [LMIS] so that representatives from countries were able to return and train others. Afterwards, staff from UNFPA Mongolia organised two local trainings for national partners on use of the CHANNEL software which helps manage RH supplies from central to district level. Advocacy in support of RHCS including for budget lines for RH commodities: With RH commodities long funded by too few donations from external partners, a budget line for RH commodities is a powerful symbol that governments genuinely value the importance of RH commodities and want to move towards more sustainable financing. In 2008, much targeted advocacy work was carried out at regional and country level resulting in increased support for RHCS particularly by parliamentarians, senior government officials and the media and leading to increased government funding of budget lines for RH commodities. General support for RHCS increased significantly in Uganda, Kenya, Tanzania and Djibouti. In Burkina Faso, the national budget contribution for contraceptives rose from 13% to 32% in 2007 [donors 68%] and to 89% in 2008 [donors 11%]. In Nicaragua, government funds covered 1% of contraceptives used in 2006, about 10% in 2007 and about 36% in 2008. Mongolia’s government now purchases commodities to meet over 60% of the contraceptives supplied. Moreover, anecdotal evidence indicates that in countries receiving Global Programme support, RH commodity stockouts are down and the contraceptive use is up. In a number of humanitarian relief situations, Global Programme support has been crucial for the provision of sexual and reproductive health services. Demand generation: In the area of demand generation, several countries have begun to address the need for better information at the grassroots level, so that individuals can make more informed choices. Many areas still lack quality information about family planning and HIV hinder progress in reproductive health. Burkina Faso made extensive efforts in 2008 with a public outreach campaign using film, radio and theatre that reached 60% of the country’s population. In Laos, information campaigns and community outreach have helped to introduce the GPRHCS 2008 Progress Report Page 7 concept of family planning in areas where CPR does not keep pace with supply availability [CPR at only 35% while availability of contraceptives is as high as 96%], because many people are not familiar with modern methods. Niger has implemented an information campaign to reach currently underserved groups, targeting rural communities and the military. In addition to these efforts, in many countries RHCS efforts are combined with Comprehensive Condom Programming to prevent HIV and generate demand for male and female condoms. Developing synergies: As stated, the Global Programme is designed to help catalyse in-country action towards the prioritisation and mainstreaming of RHCS into national health policy. These additional funds are explicitly designed to complement the work of the UNFPA Country Programme and other in-country work to improve sexual and reproductive health in general. In addition, the Global Programme has increasingly strong operational links with the separate but very much complementary work financed by UNFPA's own Maternal Health Thematic Fund [MHTF]. In Madagascar, a GPRHCS Stream 1 country and a MHTF first wave country, the support provided is closely integrated. This approach of seeking and developing synergies is to be further developed from now on. Comprehensive Condom Programming: Another initiative that complements the Global Programme and may be seen as an integral part of it is the Global Condom Initiative to intensify comprehensive condom programming [CCP] for HIV prevention and dual protection. Much of the funding for this work comes from the UNAIDS Unified Budget and Workplan [UBW], combining in a Joint Programme the work of the ten UNAIDS cosponsors to maximise the coherence, coordination and impact of the UN’s response to AIDS. With a distinct management structure, though with full coordination with the Global Programme where in-country work overlaps, UNFPA’s work in CCP continues to make an important contribution globally. Based on UNFPA’s comparative advantage in the unified AIDS response, the ten-step process to scale-up comprehensive male and female condom programming for the prevention of HIV and unintended pregnancy is ongoing in 55 countries [23 in Africa, 23 in the Caribbean, 7 in Asia, 2 in Latin America]. For the third consecutive year, access to female condoms has dramatically increased and reached the record number of 33 million in 2008. Despite the difficult economic situation in Zimbabwe, as of 2008 the country has the largest female condom distribution programme per capita increasing distribution from 2.2 million [2006] to 3.5 million [2007] to 5.2 million [2008]. In the same period, a number of other countries have also doubled or tripled access to female condoms for women and girls. Partnership with a number of other partners is helping to maximise access to male and female condoms through public, civil society, social marketing and private sectors. Particular efforts were made to reach populations in remote and rural areas with targeted distribution programmes for vulnerable and marginalised populations including those most at-risk. Stronger Partnerships: In its work in the sphere of RHCS, UNFPA is developing increasingly strong partnerships at country, regional and global level, to develop new and better approaches to help countries achieve RHCS. All RHCS regional and global work is designed to facilitate better RHCS at national level. Regional Centres of Excellence: As mentioned before UNFPA is placing increased emphasis on building the capacity of regional institutions that can provide technical support to national RHCS efforts. This strategy takes inspiration from the example of Indonesia’s International Training Centre of the National Family Planning Coordination Board [BKKBN] which provides training courses on a wide range of RHCS components in the Asia Pacific region. Efforts are underway to build the capacity of a number of regional institutions in other parts of the developing world. In Africa, for example, strong and successful partnerships were further developed in 2008 with the following regional economic institutions: the East Africa Community [EAC]; the West Africa Health Organisation [WAHO]; the Inter-Governmental Authority on Development [IGAD]; and the Southern Africa Development Community [SADC]. Reproductive Health Supplies Coalition: At global level, UNFPA continues to play a key role in the Reproductive Health Supplies Coalition [RHSC], a global partnership of more than 70 multilateral and bilateral organisations, private foundations, national governments, civil society groups and private companies [see www.rhsupplies.org]. GPRHCS 2008 Progress Report Page 8 UNFPA has been particularly involved in: [1] development of two mechanisms that address key hurdles to RH commodity security – the Pledge Guarantee for Health helps developing countries to access supply finance when they need it, while AccessRH helps them secure favourable pricing and purchasing terms even when procuring low- or limited-volumes of supplies; [2] development of innovative approaches to address the increasingly acute budget constraints many countries are facing in the areas of SRH and RHCS – the Total Market Initiative aims to encourage better coordination and collaboration among RH/FP service providers from the public, private and NGO sectors to reduce overlaps and better target the delivery of services to those who need them, with particular focus on raising access and equity among the most marginalised communities; [3] definition of a Global Advocacy Strategy for RH supplies, building on a recently completed mapping exercise of the current situation; and [4] the prequalification of Condom and IUD factories to help country governments select quality supplies, encourage higher volume quality commodities purchases and help reduce costs. Global initiatives: At global level, UNFPA has also been instrumental in: [•] a collaboration with the World Health Organisation [WHO], launched in 2008, to review access to a core set of critical, life-saving maternal/RH medicines [Oxytocin, Ergometrine and Magnesium Sulphate], beginning in four selected countries; [•] development of a Unified Health Model [with UNICEF, WHO, World Bank, UNDP, UNAIDS] to support health economics and costing. GPRHCS 2008 Progress Report Page 9 Introduction This report sets out to provide an overview of how the funds allocated to the Global Programme were used in 2008. The report will cover the funds allocated under the Stream 1, Stream 2 and Stream 3 and also to a small amount of funding used to facilitate Reproductive Health Commodity Security at global level. Stream 1: In 2008, the five-year financial support facility provided by The Global Programme to enhance Reproductive Health Commodity Security [GPRHCS] was extended from the initial recipients of 2007 [Ethiopia, Burkina Faso, Mozambique, Nicaragua and Mongolia] to a further four countries [Haiti, Lao, Madagascar and Niger]. The core objective of this support is to facilitate the prioritisation of RH commodity security and ensure it is mainstreamed into national health policies, programmes, budgets and plans. In its adherence to the guiding principles of the Paris Declaration on Aid Effectiveness, at national level, the support provided by the Global Programme is decided by the government with the support and assistance, as required, of UNFPA and a range of the key in-country partners. For this reason, the focus of the support varies in each of the Stream 1 countries and progress varies, as a function of widely differing realities. On the one hand, Global Programme funds have been being used effectively since 2007 in Ethiopia to build on bigger on-going efforts to upgrade the logistics system with a complementary focus on neglected elements of RHCS. On the other hand, the opportunities provided by the Global Programme have yet to be used in Haiti which, in 2008, found itself on an emergency footing even more acute that usual. It should also be mentioned that in some cases, reporting also relates to the use of funds from other funding sources, where, as is often the case there is a strong element of complementarity in fund use. This is generally, though not exclusively in the case of UNFPA Country Programme funds. This is done in attempt to provide the reader with a more complete view of what is underway in Stream 1 countries in RHCS and related spheres. Stream 2: This funding can provide support to initiatives to strengthen several elements of RHCS in either one or more countries [providing the possibility of regional initiatives]. The formalisation of the selection of Stream 2 initiatives is well underway. Some 20 initiatives are currently being selected. The 2008 report will provide an overview of current work to facilitate, promote and support better RH commodity security, at regional level and in a selection of individual countries. Stream 3: This emergency fund continues to be indispensable in helping countries avoid RH commodity stockouts that would otherwise occur. Humanitarian crises caused by natural or man-made disasters continue to require this crucial source of support. UNFPA is monitoring the requests for Stream 3 support that derive from systemic failures related to poor planning, weak infrastructure and low in-country capacity. Anecdotal evidence suggests that such requests are beginning to fall. Indeed, UNFPA has been using the leverage provided by the fact that it now controls this more substantial, multi-year fund to help countries take sustainable action that will, in time, reduce non-humanitarian RH commodity stockouts. An overview of Stream 3 fund allocation in 2008 will be provided. At global level: UNFPA is involved in a number of initiatives that facilitate Reproductive Health Commodity Security. These include, UNFPA’s lead role in the Reproductive Health Supply Coalition; the Joint UNFPA-WHO collaboration to review access to a core set of critical, life-saving maternal/RH medicines; and the development by UNFPA of the RHCS Dashboard which monitors a range of core components and is used to monitor and track progress in programme countries. GPRHCS 2008 Progress Report Page 10 Stream 1 - Ethiopia A. Summary Global Programme funds are being used to complement to the sixth UNFPA Country Programme and the US$110 million five-year Ministry of Health [MOH] initiative, undertaken in partnership with the United Nations Children’s Fund [UNICEF] and the United States Agency for International Development [USAID], to implement a new Health Commodities Supply System [HCSS] “Masterplan” for the country. Over the past two years, Global Programme funds have helped finance a number of activities which complement the Masterplan with a sharper focus on RH commodity security, which was largely absent from the original HCSS. To facilitate the mainstreaming of RHCS, UNFPA placed one national technical adviser in the Federal Ministry of Health in 2007 and recruited an RHCS Chief Technical Advisor [CTA] in 2008. RHCS is being mainstreamed into national health policy and programmes thanks to the full costing and current implementation of the plan for national RH and Adolescent and Youth Reproductive Health [AYRH] strategies. Much emphasis has been placed on advocacy to strengthen policy, political support and leadership for greater commitment of national and regional political, religious and cultural leaders for RHCS and Family Planning as a priority issue. On health system strengthening, UNFPA is helping the government implement a better commodities supply system with skilled staff, appropriate infrastructure and a new governance structure which will transfer the burden of procurement, storage and distribution to a semi-private organisation. To help resolve acute human resources issues, GPRHCS funds are helping the government train a new cadre of middle level health officers to provide integrated emergency obstetric and surgical care in rehabilitated and newly established health centres. B. Accomplishments in 2008 1. Supply Chain Management 1.1 Support HMIS implementation: Service delivery and systems development strengthening efforts The implementation of a more extensive Health Management Information System [HMIS] is underway. HMIS tools [registers, forms, etc] have been distributed to all health facilities in the country. Focal persons for HMIS at health facilities have been designated. Mentors [with a second degree] hired by Tulane University have been trained on HMIS, deployed and their roles and responsibilities to support health offices at all levels defined. Providing support to strengthen the Health Management Information System [HMIS] contributes to better RH commodity security, as the goal of the HMIS is to strengthen the health services delivery system and help the flow of data and information for timely action at all levels of the health system. The most fruitful areas to establish linkages between the GPRHCS and the on-going HMIS work have been identified. The HMIS will capture service statistics and logistics data on family planning [comprising delivery of services and supplies]. To date the fact that this information was not collected and processed reduced national capacity to forecast RH/FP commodity needs. Such information will prove valuable in building national procurement capacity and ensuring the timely delivery of supplies and services. Supporting the scaling up of HMIS implementation has been and will continue to be a major area of work. Current efforts focus on establishing the improved system and, once fully functioning, will focus on the development of analytical reports using data generated and the use of this information to improve RH commodity forecasting activities. The piloting stage is now complete and all lessons learnt and challenges were documented and corrective measures taken. Full scale implementation of the HMIS is now underway. GPRHCS 2008 Progress Report Page 11 1.2 Procurement of FP commodities In 2008, GPRHCS and PBS II [Protection of Basic Services II] funds were used to finance the procurement of a significant quantity of contraceptives. A first tranche of 4 million Depo Provera arrived in Addis Ababa and was delivered to the Pharmaceutical Funds and Supply Agency [PFSA] warehouse. The remaining commodities, including 450,000 units of Implanon will be arriving by end February 2009. A national programme coordinator is currently being recruited to provide technical support for the distribution of commodities in all regions and health facilities. 2. Repositioning Family Planning Services A consultative meeting on the “Repositioning of Family Planning” took place in September 2008. Participants included experts in the field of Reproductive Health/Family Planning and Health Education and Communication from the Family Health Department [FHD], Health Education and Extension Centre [HEEC], Planning and Programming Department [PPD], UNFPA and other partners. The consultative meeting was initiated following the review of the 2008 progress report on RH/FP national programme implementation and the identified need to take extra measures to encourage and expedite implementation of RH services in the worse off regions. As a result Advocacy Workshops on RH/FP services in Somali and Afar regions took place in August 2008. The primary objective of the workshops was to initiate dialogue among decision makers at different levels in these regions and to build their commitment to facilitate and protect women’s ability to claim and exercise their rights to basic RH/FP services thereby contributing to the achievement of national and regional targets and the Millennium Development Goals [MDGs]. The objective of the meeting was to review and discuss the progress, trends and challenges of the Family Planning Programme and to develop a draft guideline for “Repositioning Family Planning in Ethiopia,” which will be used for family planning programming. A technical team, spearheaded by UNFPA and Chaired by the UNFPA-funded Chief Technical Adviser for RH/FP, was established and is currently developing this guideline. The consultative meeting was productive, allowing experts to review the literature and draw lessons from country experiences and identify issues to be considered in national programme and strategic documents. 3. Access and Quality of Care 3.1 Capacity building of health facilities with IUCD Insertion and Removal Kits A major accomplishment to ensure access to RH services has been the effort made to identify capacity gaps at health facilities with regard to long-term family planning methods and services. Based on the conclusions and action points drawn from the 2008 review of the RH services performance, efforts are underway to scale-up IUCD services. Various studies also indicated poor uptake of other long-term family planning methods. A connected effort, which is gaining momentum, is the Training of Trainers [TOT] course on long-term family planning methods for health professionals that have been carried out on a massive scale. Using the GPRHCS and country programme resources, a considerable number of health workers received training on IUCD and Implanon methods. This initiative is to be scaled up in 2009 and beyond. It has been necessary to complement these training initiatives with the required equipment and contraceptive commodities to ensure that trained health workers can practice what they have learned and provide the required services. As a result, 1,050 Health Centres have been identified that are to be equipped with two IUCD Insertion and Removal Kits. The kits are currently awaiting customs clearance in Addis after which they will be delivered to FMOH and service delivery points to be used for the intended purpose. To date, 65 health care providers have been trained in Addis Ababa, Gambella and nationally, drawing health care providers from several regions. Trainees include health officers, clinical nurses and midwives. This initiative is to be scaled up in 2009 and beyond. GPRHCS 2008 Progress Report Page 12 3.2 Training of health care providers on Family Planning Methods In order to ensure access to sufficient contraceptive method choices, it is important to review services packages and keep service providers abreast of scientific and technological developments in the field. In Ethiopia, the method mix is dominated by injectibles [65-70%], with 33-35% for pills less than 2% for long-term methods. Government commitment is high and the implementation of activities to expand services and meet clients’ needs is moving forward briskly. However, the expansion of services has been severely constrained by a number of factors, in particular the prevalent lack of adequate skilled among health care providers. Thanks to GPRHCS funds and technical assistance, the Ministry of Health has now progressed from providing training only on single road implants to providing Comprehensive Family Planning Training encompassing IUCD, Jadelle, Implanon and emergency contraception. The objective of these Training of Trainer [TOT] courses is to develop the human resource capacity of the regions. Those trained will then turn trainer in a cascade effect providing training in their respective regions and helping to produce skilled health workers able to provide a range of contraceptive methods. 125 health care providers have now been trained on Comprehensive Family Planning. Trainees are medical doctors, health officers and midwives and clinical nurses. The plan is to train more than 250 in the next 6 months. 3.3 Mapping of Partners’ Operational areas The GPRHCS has provided technical assistance to support a mapping exercise of partners’ work in areas of RH/FP at district level [known as a woreda]. The aim was to: [1] reduce overlaps and ensure equitable access to FP services with special emphasis on the underserved and those in the remotest areas; [2] speed up implementation of the expansion and delivery of health services; and [3] maximise the effective use of limited resources. This Federal Ministry of Health process has been lengthy encompassing much consultation with the relevant NGOs [IPAS, Engender Health and Pathfinder International] to identify and get rid of overlaps. The process: [1] produced a new draft of woreda mapping, identifying woredas by region where the NGO mentioned will work; [2] clarified which organisation works where delivering what services; [3] concluded with a woreda mapping agreed upon by all partners, including a transitional plan to ensure continuity of services as providers refocus in some new areas. The woreda mapping exercise paves the way to strengthen the harmonisation and alignment of programmes at district level and to enhance planning and coordination. 4. Coordination with Public Private Partnership A major activity progressing well is the Public/Private Partnership focusing on enhancing coordination among key players in the field of RH/FP and in particular in areas of access and quality of family planning services. The partnership has gained momentum since April 2008 especially in the standardisation of family planning training programmes. The partnership has yielded synergy especially in mobilising resources and use of expertise skills. Accomplishments include: [•] standardised training on Comprehensive Family Planning Programs; [•] development and adoption of guidelines for use by health care providers and Health Extension Workers. UNFPA has provided technical and financial support through the GPRHCS in developing standardised FP guidelines for the health extension workers and in conduction trainings in collaboration with other partners. 5. Advocacy and Policy Advocacy work plays a key role in Ethiopia towards achieving RH commodity security and ensuring that clients can access and use quality FP commodities of their choice. On-going advocacy work includes a focus on soliciting commitment: [•] for resource allocation from Federal and Regional Government; [•] on the use of mass media for promotion of family planning services; [•] of religious and community leaders to use their daily religious teachings to encourage men’s involvement and support for their women when they seek family planning services. Following two earlier advocacy workshops in Mid 2007 and early 2008 [one at national level on using mass media; the other for Federal Parliamentarians on resource allocation] two additional advocacy workshops were held in GPRHCS 2008 Progress Report Page 13 July 2008 in regions where use of family planning services has dropped or stagnated [to below 2% in the Somali region and less than 20% in the Afar region. The reasons for this decline/stagnation are multiple and include: cultural taboos; poor health service delivery; poor access to health care facilities; providers’ bias; male dominance. The aim of the workshop was to initiate dialogue among decision makers at different levels in these regions and to build their commitment to facilitate and protect women’s ability to claim and exercise their rights to basic RH/FP services thereby contributing to the achievement of national and regional targets and the MDGs. Workshop discussions revealed that the concept of family planning as a means of birth control was discouraging clients from accessing FP services. Others issues like support and commitment of local government were examined and assessed and those present demanded more support. Participants included not only religious and community leaders but also decision-makers in local government, representatives of women’s affairs, social mobilisation groups and representatives of health offices and mass media. The outcomes of the advocacy workshops were encouraging with coordinating bodies for advocacy and social mobilisation established. The roles and responsibilities were defined of religious and community leaders and decision-makers in local government religious, health offices and the mass media. The concept of family planning was suggested as a means to improve the health of mothers and children and this has led to the process of repositioning family planning services in the country. C. Challenges and lessons learned Poor coordination and collaboration among partners; a challenge to establish coordination mechanisms. Though there is a strong coordination committee at central/federal level, much remains to be done at regional level, as communication and programme linkages are weak and the roles of donors is ill-defined. The plan is to support the establishment of technical committee is selected regions in 2009. Weak LMIS in terms of data collection, reporting, feedback, personnel levels and capacity. While these issues are being addressed they remain a particular challenge. The supply chain management system is weak at all levels of the health system and particularly with respect to forecasting, procurement, delivery and storage. Too often, allocation of contraceptives is arbitrary and not based on need, as there is no genuinely functioning system in place [be it pull or push]. Insufficient programme supervision and follow up. The plan is to address this by carrying out integrated supervision exercises on a regular basis starting 2009. Erratic supply of contraceptive commodities and lengthy procurement process. These related problems are being addressed but are particularly acute when the high level of unmet need [42%] is considered. UNFPA is working with partners to strengthen supply chain management by providing support to the Pharmaceutical Funds and Supply Agency to coordinate implementation of the new Masterplan. The advocacy workshops in the Afar and Somali regions showed that when opportunities are created, groups typically without a voice make themselves heard. One Woreda representative, Fatima Hassan, from Somali responded emotionally when the ‘Sheik’ religious leaders cited lack of supplies for “family planning services to be the major reason for poor utilisation of services in the region”. Fatima interrupted her speech to say that the reason given is not the problem. She said there are health facilities nearby that provide services with adequate supplies. She said, rather the reason for lack of use of the services is the lack of support from religious leaders, men and community leaders. Her speech was applauded by participants. Source: Feedback from workshop participants GPRHCS 2008 Progress Report Page 14 Distribution issues of overstocking at regional and zonal level while health facilities are often stocked out. While the Master plan is addressing these challenges, a lot remains to be done to alleviate them Poor counselling leading to skewed method preference and use of Family Planning commodities. The problem is being addressed by building the capacity of health care providers through cascade of training on long term FP methods with particular emphasis on methods of counselling and their advantages Unskilled health professionals for long term methods [insertion/ removal] leading to poor method choices. More than 125 health workers were trained through the GPRHCS fund on IUD and Implanon insertion and removal procedures. The plan is to reach the set target of 250 Health workers by the end of 2009. This is will be made possible with GPRHCS funds. D. Recommendations The following recommendations were identified during the implementation of 2008 activities. The core activities for 2009 will focus on and address the core problems of the logistic systems and advocacy issues. Intensify advocacy on RHCS to encourage all regions to finance essential RH commodities and to establish a budget line for contraceptives at state [regional] level Support health systems strengthening, specifically for procurement and the distribution system to build the capacity of the Pharmaceutical Funds and Supply Agency [this is part of the Master Plan] Provide additional funds to support the new focus of the Pharmaceutical Funds and Supply Agency [PFSA] programme and to streamline the technical assistance of the newly appointed UNFPA Chief Technical Adviser. The PFSA is in charge of the new Masterplan for the logistic systems, and UNFPA has placed a technical adviser within this agency. This will allow UNFPA to demonstrate its commitment to the implementation of the Master Plan [the five-year implementation plan is set to cost US$110 million] and to ensure the gaps relating to RHCS in the Master Plan are addressed with Global Programme support Support the health sector reform process: UNFPA Ethiopia is providing support and assistance to MOH’s reform efforts, which are intended to transform the Ministry into a results-oriented organisation. This includes the promotion of results-based management and results-based budgeting, including the adoption of the logical framework approach at the programme and projects levels. This aims to help the MOH focus on what it intends to accomplish, and to improve monitoring and reporting against key performance indicators. MOH’s results-based approach and guiding principles focus on achieving its objectives, while dealing with real constraints and the demands of clients and partners. The results-based approach demonstrates that the MOH is more concerned with the results that are achieved through various activities, rather than the activities themselves. E. GPRHCS baseline The baseline study carried out in Ethiopia in the fourth quarter of 2008 found that: 60% of Service Delivery Posts offer at least three methods of contraception. This figure will be measured during the Emergency Obstetric Care [EmOC] assessment 40% of Service Delivery Posts reported contraceptive stockouts during the last 6 months. This was marked progress though as there were essentially no stockouts at higher levels of health service provision The proportion of Service Delivery Posts offering at least five life-saving maternal health drugs will be measured during the forthcoming EmOC assessment. This is work in progress and the result will be made available by the end of the first quarter of 2009 GPRHCS 2008 Progress Report Page 15 There is a national line item budget for contraceptive procurement; in 2008, more than US$2 million of government funds was used to procure contraceptives An RHCS advocacy strategy has been developed; the implementation plan is to be developed in 2009 National capacity in forecasting and procurement [without any external technical assistance] is a key issue which GPRHCS funds will help to systematically and gradually address starting in 2009 National capacity to plan and implement a comprehensive approach to RHCS, including demand creation and resource mobilisation is being enhanced on an on-going basis; Coordination has been identified as a particular issue that UNFPA is working with the government and other partners to address. UNFPA is also working with partners to address the maternal health programme and RHCS. The Joint Finance Arrangement [JFA] is a working tool for resource mobilisation and commitment for the third phase of the Health Sector Development Plan [HSDIII] There is currently no systematic mechanism to document and disseminate RHCS lessons learned to inform future programme design and delivery; such a mechanism is being developed during 2009 Two new essential RH commodities [misopristol and mifepristol [Medabon]] were included in the national essential drug list in 2008. The following essential RH commodities were already on the national emergency drug list: male condom, oral pills, injectibles, IUD and implants. UNFPA is working to register the new female condom, “FC2”. F. Brief Commodity Report Commodities Total Quantity Received Total Value [in $] Implanon 340,000 pcs 7820000 Depo Provera 6,2 million vials 5,270,000 Pills 500,000 cycles 115,000 Emergency Contraception 400,000 100,000 IUCD 100,000 pcs 20,000 Total 13,325,000 GPRHCS 2008 Progress Report Page 16 Stream 1 – Burkina Faso A. Summary Global Programme funds have been used to finance previously unfunded areas of the 2006 defined National Plan for Contraceptive Security. Funds were also used to strengthen and broaden its scope into a National Action Plan for Reproductive Health Commodity Security. Advocacy work has targeted decision-makers, parliamentarians and opinion makers at central level and throughout the country to support the repositioning of Family Planning and for resource mobilisation to finance the national integrated plan for the reduction of maternal mortality. In 2005, 24% of funds for contraceptives in Burkina came from the national budget, with 76% from the principal donor contributors. In 2006, the national budget contribution fell to 13% [with donors contributing 87%]. The national budget contribution rose to 32% in 2007 [donors 68%] and to 89% in 2008 [donors 11%] – according to preliminary data already available. A public outreach campaign to reposition and increase the use and acceptability of Family Planning is estimated to have reached some 60% of the population. Moreover, to ensure increased availability of quality SRH services targeted efforts were made to increase capacity of service delivery point [SDP] staff on Family Planning and put in place better quality control mechanisms. The capacity of district health practitioners to forecast RH commodity needs and use of the logistics management information system was also increased. B. Accomplishments in 2008 1. Political commitment, sustainable financing of RH supplies During the year, advocacy work was carried out with decision-makers, parliamentarians and opinion makers at central level and throughout the country for the repositioning of Family Planning and for resource mobilisation to finance the national integrated plan for the reduction of maternal mortality. The advocacy activities at central level brought together senior government members [including the Prime Minister, the Minister of Health and the Minister of the Economy and Finance] and a range of key technical partners. It is worth noting, that during these advocacy events, these senior figures made clear public statements in support of Family Planning. In addition, advocacy activities were carried out in each of Burkina Faso’s 13 regions, involving over 300 leaders of the public administration, religious and traditional groups and professional associations. Moreover, awareness- raising activities targeted some fifty Muslim leaders [Islam is the majority religion in Burkina] who, as a result, came to adopt a positive stance to the promotion of Family Planning. Some of these Muslim leaders are now preaching in favour of Family Planning in their mosques. These different advocacy activities are contributing to a more favourable environment in the country for Family Planning and for resource mobilisation for the national budget, the common basket of the SWAp [Sector Wide Approach] and cost-recovery initiatives. With regard to the evolution of financing for contraceptives in Burkina in recent years, in 2005, 24% of funds came from the national budget, with 76% from the principal donor contributors [UNFPA and USAID]. In 2006, the national budget contribution fell to 13% [UNFPA and USAID – 87%]. The national budget contribution rose to 32% in 2007 [UNFPA and USAID – 68%] and to 89% in 2008 [UNFPA and USAID – 11%]. 2. Increased availability of quality SRH services To ensure increased availability of quality SRH services key actions were carried out: [•] to strengthen the capacity of service delivery point [SDP] staff on Family Planning with focused support from the central level; [•] to provide GPRHCS 2008 Progress Report Page 17 training materials in SDPs and training centres; and [•] to initiate better follow-up and supervision throughout the system. In total, in those areas where UNFPA is active [under the GPRHCS, where possible, UNFPA seeks to ensure full national coverage for any intervention], 150 health practitioners have been trained with a further 60 health practitioners trained in eastern and northern regions of the country. Elsewhere, training sessions have been conducted in 26 health districts. This activity, funded by the Global Programme, strengthened the capacity of over 1,000 health practitioners. To increase the participation and involvement of private sector stakeholders in the provision of quality Family Planning services, further training sessions were conducted in Ouagadougou and Bobo-Dioulasso [Burkina’s second city]. 66 senior health practitioners involved in the provision of delivery services, private SRH clinics and medical practices as well as private hospitals including those with a religious affiliation attended these training sessions. To improve the quality of on-the-job training, two sessions were conducted for those responsible for providing practical instruction to junior health practitioners on Family Planning and LMIS. These activities were complemented by additional training to inspire and train Family Planning service providers in centres under their jurisdiction by means of on-the-job training, supervision and periodic field visits. Finally, health centres have benefitted from the consistent availability of contraceptives, other Family Planning supplies and equipment, anatomical models, Jadelle and IUD insertion and removal kits. 3. Increased demand for Reproductive Health and Family Planning, Prevention of STIs, including HIV/AIDS 2008 was marked by an intensification of demand creation activities. Indeed, a multi-media campaign “A plan for life” involving mass-media [TV, radio, posters], group media [theatre plays, video screenings] and group communication [focus group discussions]was carried out throughout Burkina’s thirteen regions with particular focus on the Sahel, East and Centre-East regions. The campaign was carried out in French and the six most widespread local languages. Over 60,000 leaflets, 100,000 posters, TV items and a theatre play were used to transmit these messages with a particular focus on the rural population. The campaign reached a large proportion of the population with results which included: Airing of 230 films at 2,300 meetings, reaching 207,000 people 500 national radio broadcasts; TV; five public conferences Development of market for Family Planning services/commodities Some 60% of population reached by this public outreach effort 4. Logistics management information system strengthened A series of meeting were organised with district health practitioners to improve knowledge and use of the logistics management information system. These meetings were organised in each regions with a focus on improving the knowledge and understanding of those responsible on data management, indicators, data collection tools and the health system. These meeting increased the involvement of those responsible at district and regional level in monitoring the work of Family Planning practitioners and in data collection. In 2008, government capacity to develop six-monthly forecasts also increased [see details in the contraceptive procurement table]. Drawing up these contraceptive procurement tables with the regional health authorities meant that the central health authorities took ownership of this process and led to a better quantification of contraceptive commodity needs. This information was then used to advocate for increased funding from the Ministry of Health and other partners. According to the Ministry of Health, in recent years the contraceptive prevalence rate has evolved as follows: 12.6% [2001]; 14.5% [2002]; 15.9% [2003]; 16.4% [2004]; 21.9% [2005]; 24.3 [2006]; 25.7% [2007]. GPRHCS 2008 Progress Report Page 18 5. Coordination, monitoring and evaluation strengthened The Coordination Committee that has within its remit the issue of RHCS met twice [though four meetings were planned] while the RHCS Technical Committee met for one of the two planned meetings. These meetings provided the opportunity to review the progress of activities as per the national contraceptive security [CS] plan, to discuss and contribute to the development of the national reproductive health commodity security [RHCS] plan [an expansion of the CS plan supported by the Global Programme]. A draft national RHCS plan was finalised in the fourth quarter following an additional analysis of RH commodity needs and a Population Council analysis of the potential of the female condom. The national RHCS plan remains to be approved. 6. Advocacy and Policy Much work was carried out in this area in 2008, particularly under the nationwide multi-media campaign “A plan for life”. C. Challenges and lessons learned Constraints and weaknesses Tardy disbursal of funds undermines implementation of plans Low capacity of health sector personnel slows execution and weakens monitoring of activities. Challenges Ensure disbursal of funds in the first quarter of the year for timely implementation of plans Organise an advocacy campaign to shore-up national commitment and mobilise resources for RHCS Evaluate the LMIS and improve the quality of reports to ensure sound forecasting and avoid stockouts; Strengthen UNFPA capacity to meet reasonable procurement delivery times Install CHANNEL at all levels to improve RH supply management Put in place a monitoring system for drugs and tracer products Strengthen training, supervision and monitoring capacity among national stakeholder counterparts Evaluate the impact of the Family Planning BCC campaigns carried out in 2008 Extend the BCC activities to district level in areas where UNFPA is not generally present Develop a study for total market segmentation to improve in-country use of resources Document the on-going work on commodity security to inform and improve work in this area Formalise the Coordination Committee that deals with RHCS and up-grade it to have real decision-making power Lessons learned Half the health districts in the country [26] have been able to build the capacity of their health practitioners – this can be expected to improve the quality of SRH services Earlier awareness-raising work on Family Planning [from the 1990s] constituted working capital which made last year’s Family Planning campaign easier Burkina’s religious leaders are favourable to Family Planning and can support its promotion Providing adequate follow-up and supervision of trained health practitioners in order to ensure new skills are mastered and properly used in the field is crucial Non-targeted national coverage [e.g. as part of the FP campaign] avoids the balkanisation of the country into uncoordinated and unequal regions; increasing access to FP services of the whole population improves inter-regional harmony Setting a baseline prior to a large campaign/intervention is crucial to be able to measure the impact of our targeted communication messages GPRHCS 2008 Progress Report Page 19 D. Recommendations Ensure disbursal of funds in the first quarter of the year for timely implementation of plans Improve the procurement and delivery system for RH commodities and contraceptives in particular Strengthen the LMIS at all levels Formalise the Coordination Committee that deals with RHCS and up-grade it to have real decision-making power to make it more effective Increase demand creation efforts to reach underserved rural populations E. GPRHCS baseline The baseline study carried out in Burkina Faso in Q4 2008 found that: 1. The most recent figure for the Contraceptive Prevalence Rate [CPR] is 25.74%. The percentage increase in CPR from 2007-08 has not yet been calculated as updated 2008 figures were not available. 2. 98% of Service Delivery Posts offer at least three methods of contraception, according to the fourth quarter 2008 survey to set the baseline on availability of and levels of access to reproductive health services in Burkina. 3. 5% of Service Delivery Posts reported contraceptive stockouts during the previous six months, according to the fourth quarter 2008 baseline survey. 4. The proportion of all SDPs providing Comprehensive EmOC that offer at least five life-saving maternal health drugs has not yet been but is currently being calculated. 5. There is a national line item budget for contraceptive procurement. 6. A funded RHCS advocacy strategy implemented in collaboration with partners exists 7. There is functioning national capacity in forecasting and procurement [without external technical assistance] for contraceptives. It is felt that the presence of the Global Programme is helping build this capacity. 8. There is national capacity to plan and implement a comprehensive approach to RHCS, including demand creation and resource mobilisation. It is felt that the presence of the Global Programme is helping to build this capacity. 9. Those who conducted the survey found evidence of documentation and dissemination of RHCS lessons to inform future programme design and delivery. This is something that requires and will receive further systematisation in the coming years. 10. The country office reported that all essential RH commodities [Please list them] are included in the national essential drug list with the exception of Mesoprostol F. Brief Commodity Report Commodities Total Quantity Received Total Value [in $] Jadelle & Trocars 700 186,861 Depo-Provera 190,40 347,480 St.Syr Soloshot 476,000 33,320 Male Condoms 1,780,000 45,464 Female Condoms 104,000 68,894 Oxytocin 4,842 62,946 Magnesium Sulphate 4,100 6,970 Delivery Kits 27,850 40,476 Total 792,413 GPRHCS 2008 Progress Report Page 20 Stream 1 – Mozambique A. Summary Mozambique is lauded as a success story in development cooperation and the policy frameworks in place emphasise Reproductive Health Commodity Security as vital for comprehensive access to Reproductive Health. The MoH places much importance on the guiding principles of Paris Declaration and has chastised partners that have tried to go faster than the national authorities are ready or willing to. In the sphere of RHCS, programmatic elements have been developed under—and integrated into—the National Sexual and Reproductive Health Programme. On the logistics side, RHCS is regarded as an integral part of the broader horizontal system that aims to supply the whole health system, not covering merely the RH components. In this context, the development of the five- to seven-year National Master Plan to Reinforce the Health Sector Logistics System has been an on-going process involving a number of MOH National Directorates and Departments. In the first half of 2009, the aim is to finalise the strategic plan for the implementation of the Master Plan that will: [•] increase the capacity and quality of the current system in the short- and medium-term; and [•] over the longer-term bring about the unification of the what are currently two distinct and separately managed vertical systems covering [a] medicines and medical supplies and [b] material and equipment. UNFPA is devoting much time to help the government address these issues though progress has been hampered by the severe shortage of personnel [in terms of numbers of staff and skills profiles] to manage programmes and systems, such as the two national logistics systems, as well as the shortage of Health Personnel at national level to provide the approved and established range of health services at an appropriate level of quality. Despite these constraints, Global Programme funds have been used to help draw up a comprehensive Essential Medicines Commodity Security Strategy, including an RHCS Sub-Strategy. To ensure the long-term sustainability of the planned nationwide Logistics System, UNFPA has stressed its willingness to provide senior-level technical assistance to ensure effective building of national capacity, besides other support that will be negotiated and agreed with the MOH, as of June 2009, in the context of UNFPA support to the National Master Plan to Reinforce the Health Sector Logistics System. B. Accomplishments in 2008 1. Much high level support and progress mainstreaming RHCS Mozambique is the only country in sub-Saharan Africa on track to achieve MDG5. Reproductive Health Commodity Security is stated as crucial to ensuring comprehensive access to Reproductive Health and reflected in the PRSP, the Health Sector Strategic Plan, the RH National Policy and the National Integrated Plan to Achieve MDGs 4 & 5. The Ministry of Health is purchasing reproductive health commodities [RHC] through its budget to meet over 60% of RHC needs [medicines, materials and equipment, reagents]. The mainstreaming of RHCS into national policy is well underway, building on the 2006 RHCS situation analysis [conducted with key in-country stakeholders] and the opportunities provided by the support of the Global Programme. Indeed, key RHCS components were included in the February 2008, Presidential Initiative to Promote, Mother, Neo-Natal and Child Health, which, in turn, led to the National Partnership for MNNCH. 2. Coordination Mechanisms In terms of national coordination in the sphere of RHCS, a number of bodies include a focus on the different elements that make up commodity security. The Technical Working Group for RH/Neo-natal and Child Health & Nutrition has an RH sub-group under co-leadership of the Ministry of Health RH Division and UNFPA. In addition, an RHCS Task Force has members from the RH Division of the Ministry of Health, USAID, UNFPA and a number of NGOs. The Task Force meets quarterly or more often when urgent RHCS related matters require attention. In 2008, the TORs of the Task Force were expanded to include a focus on: [•] mobilisation of resources to guarantee GPRHCS 2008 Progress Report Page 21 the consistent availability of SRH commodities; [•] establishment of government budget line for contraceptives; [•] Advocacy for better RHCS focused coordination at provincial level. It is worth mentioning that while the RHCS Task Force only deals with RHCS, most of the elements it covers are also part of the TORs of the Medicines and Medical Supplies SWAp Joint Working Group and an integral part of the Condom Programming Working Group, which is a key coordination mechanism of the National Aids Council strategy to accelerate the HIV prevention. 3. RHCS as an integral part of Health System Strengthening In Mozambique, RHCS, while raising major challenges for the country, is seen very much in the wider context of Health Sector Reform and Health System Strengthening. RHCS is rightly positioned as part of a broader thrust towards Health Sector Commodity Security which is strongly prioritised in the national policy documents cited in the first paragraph. These documents mention the importance of ensuring the access to and availability of medicines, medical supplies, equipment and materials as well as the strengthening of the management of the Health System Logistics System. In the sphere of RHCS, the programmatic elements developed under the National SRH Programme include training MCH personnel [MCH nurses, surgery technicians and doctors] and improving their knowledge and skills on: FP services [including needs forecasting, the requisition process, data collection and information analysis]; EmOC and rational use of medicines; assessment of RH commodities at facility level; and demand creation for RH/FP services. On the logistics side, the key focus is to create a unitary supply system for health commodities [comprising medicines, medical supplies, equipment and materials] by bringing together what are currently two parallel systems: one for medicines and medical supplies; the other for durable health materials and equipment. Of further particular relevance to UNFPA’s focus on ensuring RHCS is mainstreamed at national level, the Health Sector Strategic Plan, the National SRH Policy and the National Strategic Plan to Achieve MDGs 4 & 5, identify the need to: [•] include a number of vital RH medicines in the national essential drugs list [EDL]; [•] ensure an adequate budget for RH commodities—as well as for logistics management—at all levels in-country; [•] develop strong institutional capacity for commodities management at all levels of the health system; and [•] ensure the availability of commodities for quality EmOC and FP services at all levels of health service provision – and this is to include transport and communication costs for referrals. 4. Impediments to progress, possible ways forward Set against these commendable and ambitious objectives, a severe shortage of human resources in the Ministry of Health at all levels [centrally, in the regions and districts] has hampered progress. In seeking to move things forward in 2008 and as progress stalled, UNFPA advocated for the implementation of a national sub-strategy for RHCS to be viewed as a tracer initiative, the first step of a phased approach towards Health Sector Commodity Security. A fully developed proposal was approved by the Minister of Health in the fourth quarter of 2008 outlining the intended strategic direction. The Minister has made it clear that the logistics components of the strategy must be fully incorporated into the upcoming Logistics System Master Plan and the programmatic part must be strengthened and integrated into the National SRH Programme. 5. Logistics System Master Plan Given the acute and serious challenges that need to be urgently addressed and resolved regarding the strengthening of Mozambique’s logistics system, in line with the large-scale integrated approach that the government has been keen to adopt, the John Snow Incorporated [JSI] for profit subsidiary, Supply Chain Management System [SCMS], with PEPFAR funds is set to coordinate and oversee efforts to create a fully functioning, unitary and nationwide health system logistics system. To ensure the long-term sustainability of this work, UNFPA is to provide senior-level technical assistance to ensure the effective transfer of skills and knowledge from the international contractors and building of national capacity. The quantification, procurement, acquisition, inventory management, warehousing and distribution of medicines and medical supplies for the Mozambique’s health service are the responsibility of the CMAM [Medicines and Medical Supplies Centre]. However, CMAM ability to fulfil its mandate is compromised as it currently employs no GPRHCS 2008 Progress Report Page 22 logisticians. It urgently needs to recruit, train, support and retain staff in logistics as well as pharmacists to focus on quality management. In light of this situation, the Minister of Health requested a two Phase Master Plan to establish and sustain the logistics capacity of CMAM consisting of: [1] an emergency plan up to April 2009; and [2] the Logistics System Master Plan mentioned above. C. Challenges and lessons learned Constraints and weaknesses A severe shortage of human resources in the health sector at all levels [particularly in the central Ministry of Health but also in the regions and districts] Acute constraints within the logistics system: no real-time accurate stock information resulting in need to do continual physical assessment; forecasting based on supply records not demand [leading to over and under ordering]; LMIS outdated and not fit for purpose; lack of warehouse management functions; general weakness of CMAM in fulfilling its broad mandate, coupled with its lack of appropriately skilled staff [no logisticians and too little focus on quality management] Challenges Facilitating better linkages between SRH and HIV/AIDS; in-country efforts to tackle HIV/AIDS and improve SRH are largely separate – much could be learned and much effort saved by better coordination. Ensuring strong coordination among partners: the emergency plan [phase one] of the two phase Logistics System Master Plan mentioned above was drawn up by JSI, SCMS, with support of the USAID co-chair of the SWAp Medicines Working Group and without UNFPA’s involvement. UNFPA has often reiterated its total commitment to continue to be an active partner in supporting the reinforcement of the National Logistics System, stressing the importance of coordination among partners. With dominant US players and the acute needs outlined above, coordination and what might be seen as other procedural niceties might become marginalised to the potential detriment of the sustainability of the crucial work to be undertaken. Broaden the range of stakeholders [particularly donors] engaged in discussions of RHCS requires particular attention. The periodic, strategic involvement in RHCS/logistics discussions will be important in ensuring that the overhauled logistics system [following implementation of the Logistics System Master Plan] is coupled with a focus on sustainability that includes the enhancement of national capacity to run the upgraded system effectively. Lessons learned Putting the guiding principles of The Paris Declaration on Aid Effectiveness [harmonisation, alignment, etc.] into practice and discontinuing more easily controlled project approaches can substantially reduce the capacity of stakeholders to influence progress and lead to marked resource underspending; However, the focus on promoting the mainstreaming of an issue, while time-consuming and not without frustrations is much better geared to country-driven and country-owned solutions that sustain over time. D. Recommendations Continue to support the use of GPRHCS funds to ensure a strong developmental focus of on-going and emerging work in Mozambique to improve commodity security and, in particular, the wholesale rehabilitation of the national logistics system Work with a broad range of donors to ensure the provision of periodic strategic support to work to improve commodity security and the rehabilitation of the national logistics system to ensure its sustainability over time Continue to work to complement the work of US partners in the sphere of national logistics system rehabilitation with a strong focus on the development of national capacity to run the overhauled system GPRHCS 2008 Progress Report Page 23 Stream 1 – Nicaragua A. Summary The National Sexual and Reproductive Health Strategy [ENSSR], finalised in April 2007, consists of eight areas of intervention that constitute the institutional reference framework for all interventions in Sexual and Reproductive Health in Nicaragua. To promote the mainstreaming of RHCS, GPRHCS funds were used to incorporate a strong RHCS component in the MOH’s 2008-2010 ENSSR plan and budget. RHCS is now an integral part of the ENSSR. Global Programme funds have been used to help implement the ENSSR through provision of technical and financial support to national efforts to improve women and men’s timely and sustainable access to quality SRH services and to strengthen the MOH’s Information System for the Logistics Management of Medical Supplies [SIGLIM]. Government financial commitment to RHCS has increased significantly in recent years, from covering about 1% of contraceptives used in 2006, to about 10% in 2007 and 36% of contraceptives used in 2008; a decrease is expected in 2009 though due to US disengagement and the global economic downturn. In 2008, UNFPA helped strengthen the capacity of health managers to conduct costing analysis for implementation of the ENSSR. UNFPA is the only UN agency currently allocating funds to the SWAp common basket with annual contributions; this modest investment has helped ensure ICPD is on the national development agenda, B. Accomplishments in 2008 Political and financial commitment and country ownership: In December 2006, the Ministry of Health officially approved the National Sexual and Reproductive Health Strategy, which was revised in April 2007. Reproductive Health Commodity Security and a section exclusively on the sexual and reproductive health of adolescents were included in the 2008 second edition version of the National Strategy. RHCS is also in the UNFPA-Nicaragua Country Programme for 2008-2012. In 2008, a number of things marked the increasing prioritisation and mainstreaming of RHCS in Nicaragua, including: The marked progress in recent years in the government's financial commitment to RHCS. According to MOH figures, the national budget for the purchase of contraceptives, rose from US$9,000 in 2006 [about 1% of what was used] to a little over US$100,000 in 2007 [covering about 10% of what was used] to a current total of US$536,000 [about 36% of contraceptives used] The important shift, in 2008, when the MOH accepted the concept of RHCS in an expansion of what in Latin America is the influential USAID-initiated “DAIA 1 ” approach which, in the past, focused only on contraceptive security The development of a draft of the RHCS Plan for the 2009-2011 The active participation of the Nicaraguan Institute of Social Security in a plan to expand family planning coverage to vulnerable and disadvantaged populations The purchase by the MOH, for the first time, of: [1] a three-month injectible [medroxyprogesterone acetate] through a national process competitive bidding process; [2] a contraceptive [monthly injection: 174 mil Norigynom] using UNFPA as the service provider [3rd party procurement] The costing of the National Strategy on Sexual and Reproductive Health began, with 20 officers central MOH officers trained in costing. A group for coordination for the National Strategy was also established. 1 Disponsibilidad Asegurada de Insumos Anticonceptivos – Assured Availability of Contraceptive Supplies GPRHCS 2008 Progress Report Page 24 Capacity Development Capacity Development of health personnel of the Ministry of Health was carried on topics, including: [•] Obstetrics Emergencies; [•] Diagnosis of STIs and HIV; [•] Diagnosis of cervical cancer; [•] Prenatal Care; [•] Endo-uterine manual aspiration; [•] Counselling on STIs, HIV and AIDS; [•] Awareness in dealing with sexual diversity and HIV; [•] Rational Use of drugs and medical supplies [32 health personnel in SILAIS [health administration units at department level] were trained and all 17 SILAIS developed a draft plan for the Rational Use of Drugs and medical supplies; [•] Community Strategy for the Provision of Contraceptive Methods, with a specific strategy for targeting underserved populations to increase access; [•] Planning needs of medicines and medical supplies for reproductive health, for staff at the central level of the Ministry of Health; and [•] Information System for the Logistical Management of Medical Supplies. Market Segmentation Through the DAIA Group, [the equivalent of the national coordination committee in much of Latin America though, generally, with a focus on contraceptives], efforts are being coordinated to insure the participation of different actors [social security, NGOs, the private sector] in the provision of contraceptive products. A projection exercise for the provision of contraceptive products during the 2008-2015 period was carried out with participation of all market segments [see chart below]. One significant development in 2008 is the active participation of the Nicaraguan Institute of Social Security, a plan that allows growth of coverage in family planning in this population. Strengthening of Logistic Management System Increased number of SILAIS implementing the Logistics Management Information System. This system is used for all medical supplies, for all programmes at the primary care level. Currently, 17 of the nation’s SILAIS are trained, and the system is being implemented in 8 out of 17 SILAIS systems [47%]. The supply system has also been integrated at the second level of care [hospitals]; JSI/DELIVER conducted a diagnostic of its operations and a proposal for improving secondary level care is expected to be developed in 2009. 11 of 17 SILAIS [64.7%] and 12 of 34 [35.2%] hospitals report their stocks levels through the Medical Supplies Monitoring System. The Contraceptive Logistical System has been integrated into Ministry of Health’s supply system since 2006; with respect to other RH products, these have always been integrated into MOH’s supply system. It is necessary to create a software to strengthen the monitoring system of medical supplies tin order to have a more efficient and effective national coverage. by sub-sectors, 2007 - 2015 67% 66% 64% 60% 57% 4% 8% 12% 18% 22% 4% 3% 3% 4% 4% 15% 15% 14% 12% 10% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2007 2008 2009 2010 2015 MOH INSS Profamilia Private Coverage of the population of women of childbearing age GPRHCS 2008 Progress Report Page 25 Within the framework of South-South cooperation, UNFPA Nicaragua provided technical assistance to the Ministry of Health and the UNFPA Office in Venezuela for the Diagnosis of SILOGIA [National System for Management of RHC] and a proposal for its improvement. Further issues UNFPA, in collaboration with the MOH prepared a proposal for a pilot study to assess the feasibility of introducing the female condom in the country. This was included in 2008 Annual Work Plan, however, the MOH latter requested the non-completion of this activity. Sessions were carried out to develop a proposal for the implementation of a software of SIGLIM, DELIVER [SASI] and UNFPA [CHANNEL] however this was not carried as the MOH decided to extend the SIGLIM [manually] throughout the country. The MOH has requested the software to be included in 2009 AWP. Advocacy and Policy With funding from the "Project VozJoven” [The “Young Voices” Project] activities for the promotion of reproductive rights, with emphasis on adolescents and youth, were carried out. This included: [•] an information, education and communication campaign of audiovisual and internet technologies to reach adolescents and young people to prevent violence and promote their reproductive rights; [•] a workshop with journalists addressing issues related to social change and sexual and reproductive rights; and [•] a workshop on gender with adolescents, young people and youth. A range of guidelines and policy documents were revised, covering issues including: [•] Family Planning [in print]; [•] Review of Standards and Protocols for Obstetric Emergencies; [•] Standards for the Care of cervical cancer [in print]; [•] Prenatal Care [in print]; [•] High risk obstetric care [in print]; [•] Rational Use of drugs and medical supplies [in process]; and [•] Guidelines nursing care during pregnancy, childbirth and postpartum low risk. Studies completed in 2008 included the following: [•] Non-obstetric factors associated with maternal mortality in adolescents; [•] Comparative study on the experiences of offering SRH services to adolescents in other Latin American countries, compared with the national experience; [•] Situation Analysis on Population of Adolescents and Young People. C. Challenges and lessons learned Challenges Definition of the best mechanism to implement the Global Programme. During 2007, the funds were challenged through FONSALUD [the Health SWAp financing mechanism] previous agreement that these funds were to be implemented of ENSSR [including RHCS]. National mechanism established to support national ENSSR committees [to include RHCS – expansion of the ‘DAIA’ coordination mechanism that previously focused only contraceptives]. Consolidation and ratification of the Multi-annual Plan for RHCS [3 years] Conclusion of the process of costing ENSSR. Strengthening the Logistic Management System at primary and secondary level of care [including automation of the SIGLIM software, RH national procurement and rational use of drugs and medical supplies] Addressing efforts so that the MOH and the Nicaraguan Social Security Institute [INSS] acquire contraceptives using their own budgets through the UNFPA [3 rd party procurement]. Ensuring a timely receipt of medicines, medical supplies and medical equipment purchased through UNFPA Strengthening the implementation of national RHCS plans, the provision of technical assistance and M&E by the local office [UNFPA] GPRHCS 2008 Progress Report Page 26 Inclusion of a humanitarian response and disaster preparedness focus in the RHCS Plan Ensuring budget lines for RHCS/FP: MOH’s budget has a budget line for drugs, medical supplies and laboratory that includes Reproductive Health products. In general since 2007, the trend has been modest increases [16% excluding the estimated annual depreciation by 14%] of the 2008 budget with respect to 2007. The budget is still insufficient; with the largest deficits for medical equipment. In the MOH’s draft 2009 budget, there is an 18% budget reduction for the purchase of drugs and medical supplies. It is necessary to provide technical and financial assistance to improve the supply of drugs, medical supplies and equipment in RH [including FP]. Value [U.S. $] for planning, budget and purchase of drugs and medical supplies to the MOH [2007-09] Years Planning Budget Variation budget % Budget/ Planning Total purchased 2007 653,940,961.00 335,965,571.00 11% 51% 527,896,772.70 2008 589,579,422.00 436,954,167.00 30% 74% 451,109,104.16 2009 774,938,615.00 359,786,184.00** -18% 46% Source: MOH [**Preliminary information] Lessons learned When funds are channelled through the Health SWAp [FONSALUD] as part of the Global Programme funds were in 2007, activities are included in the Annual workplan drawn up by the MOH ensuring the implementation of activities planned. [This relates to the crucial importance of promoting the mainstreaming of RHCS in national health policies, programmes, budgets and plans] Crucial need of coordination with a range of partners to ensure contraceptive security [DAIA] Preparation of annual workplans within the government’s Institutional Planning process guarantees the implementation and appropriation [by government partners] of the annual workplans. The crucial need for commitment at the highest political level to ensure the institutional implementation of the roadmaps on RHCS Compelling evidence that working in effective coordination with donors and other agencies has greater impact with governments and produces better results. D. Recommendations These recommendations are aimed to guarantee the adequate implementation of the ENSSR and to strengthen the Country Office local capacities in order to provide technical assistance to the MOH Include the financing of Global Programme in the Health Common Basket Fund - FONSALUD. This will ensure the implementation of ENSSR [including RHCS] and will allow budget to be included in the National Budget. Conclude the process of costing estimate of the ENSSR. Strengthen the implementation of the national RHCS plan, and provide technical assistance for the M & E by the local office UNFPA. The conformation of the National mechanism established to support the implementation of the ENSSR based on the experience of the DAIA committee. Consolidate and ratify the Multiannual Plan of RHCS [3 years]. This plan must be ratified at the highest institutional level and supported by a ministerial resolution. Strengthening the Logistic Management System in the first and second level of care [including automation of the SIGLIM software, RH national procurement and rational use of drugs and medical supplies]. Requires greater technical assistance to the local office in this process. GPRHCS 2008 Progress Report Page 27 The MOH acquire contraceptives from its fiscal budget through the 3rd party agreement with UNFPA, It is therefore essential to ensure timely receipt of drugs and medical supplies and equipment purchased through UNFPA. It is important to analyse an option to acquire the INSS contraceptives through UNFPA. Include HRU in the 2009 RHCS AWP. The late availability of financial resources from the Global Programme [until July 2008] limited the implementation of the agreed work plan. For a proper implementation of the Global Programme it is necessary to know the budget for the following year by October of the previous year in order for it to be included in the budget for next fiscal year E. GPRHCS baseline 3% increase in CPR based on official data from 2001 and 2006/07 18% of SILAIS and 50% of hospitals with stockouts of at least one contraceptive in the last six months 98.4% SILAIS and 94.4% of hospitals offer at least 5 life-saving maternal health drugs There is no RHCS advocacy strategy which is funded and implemented in collaboration with partners There is no functional national capacity in forecasting and procurement [without any external technical assistance] There is no national capacity to plan and implement a comprehensive approach to RHCS, including demand creation and resource mobilisation. However, a Committee on Insured Availability of Contraceptive Products is operating in the country, whose work plan finalised in December 2008. For the future plan, MOH has requested that it be expanded into the Reproductive Health Commodities Security [RHCS] Committee, so that the current committee would convert into the RHCS Committee. The development of the RHCS Plan for the 2009-2011 period is currently underway. There is no documented and disseminated RHCS lessons learned to inform future programme design and delivery All RH commodities are listed in the national essential drug list except female condom and implants.MOH utilises a monitoring system for stocks of drugs and medical supplies [including RH products] through established key products [total 107: 74 drugs and 33 medical supplies]. These products include: oxytocin, magnesium sulfate, hydralazine, diazepam, ceftriaxone, and penicillin. Doxycycline has not been included. Table 4 provides details about availability at the time of the monitoring report. Monitoring Report on Medicine Stocks Medicines Primary Care Second Level Care Oxytocin 11/11 [100%] SILAIS 12/12 [100%] hospitals Magnesium sulfate 11/11 [100%] SILAIS 12/12 [100%] hospitals Hydralazine 11/11 [100%] SILAIS 11/12 [91.6%] hospitals Diazepam 11/11 [100%] SILAIS 11/12 [91.6%] hospitals Ceftriaxone 10/11 [90.9%] SILAIS 10/12 [83.3%] hospitals Penicillin 11/11 [100%] SILAIS 12/12 [100%] hospitals Doxycycline NI NI Source: Key products Monitoring System, MOH NI: no information Note: The MOH include 17 SILAIS and 32 hospitals 100% [11/11 of SILAIS systems] have at least 3 contraceptive methods available. Of these, 2 out of 11 have three methods in stock [stock out of one contraceptive] and 9 out of 11 [81.8%] have four methods. 33.3% [4 out of 12 hospitals] have at least 3 contraceptive methods in stock, with the following overall availability: GPRHCS 2008 Progress Report Page 28 o 4/12 [33.3%] have fewer than 3 contraceptive methods in stock o 2/12 [16.6%] have 3 contraceptive methods in stock o 6/12 [50%] have 4 contraceptive methods in stock Nicaragua has set a common basket fund mechanism for support the Ministry of Health. Participating donors are 2 : Netherlands, Finland, Sweden, Austria, Spain, World Bank and UNFPA [UNFPA has provided US$100,000 per year since 2006]. The total contribution to the common basket in 2008 was US$23 million, i.e. 75% of overall external aid to MOH. The UNFPA 2008 contribution for drugs, medical supplies and equipment was US$2,740,253 [see table]. UNFPA contribution for drugs, medical supplies and equipment, 2008 Description NIC6R204 Global Programme Total Medical equipment [included clothing hospital] 1,332,905 294,000 1,626,905 Drugs and medical supplies [included family planning] 581,180 381,000* 962,180 Office equipment and support 151,169 151,169 Total 2,065,253 675,000 2,740,253 Source: UNFPA Note: A significant percentage of these products to arrive in country in 2009 *200,000 Depo-Provera; 100,000 Norigynom and 7 million male condoms. F. Brief Commodity Report Commodities Total Quantity Received Total Value [in $] Medical equipment [included clothing hospital] 1,443,281.55 Drugs and medical supplies [no included family planning] 392,513.08 Office equipment and others 85,290.26 Norigynom [include syringes] 176,406 177,278.46 Depo Provera [include syringes] 100,000 77,000.00 Lo Femenal 645,600 135,576.00 Total 2,310,939.35 2 The Inter-American Development Bank [BID] is not a signatory to the MOU but is aligned with the common fund. GPRHCS 2008 Progress Report Page 29 Stream 1 - Mongolia A. Summary Reproductive Health Commodity Security is one of the outputs of the UNFPA Fourth Country Programme and a priority area of the Mongolia’s third National Programme on Reproductive Health. It aims to improve national capacity and systems to ensure RHCS to achieve universal access to RH and HIV prevention. The main counterparts for implementation of planned activities for RHCS are Ministry of Health, the Division of Drug and Medical Devices Policy, Ministry of Finance, the multi-sectoral national RHCS coordination group and [the formerly state-owned and now essentially privatised] MONGOLEMIMPEX pharmaceutical company. Global Programme support has helped Mongolia accelerate efforts to enhance RHCS in a more comprehensive and systematic manner. Almost all planned GPRHCS activities were successfully implemented with a budget implementation rate of about 90%. In addition to those activities, a number of important activities directly and indirectly related to RHCS, part of the 2008 Country Programme annual workplan were also carried out, including: the Joint Health Sector Review; some training; demand creation activities; recruitment of a full-time national RHCS/LMIS advisor; and procurement of EmONC equipment and supplies for five western aimags and three maternity hospitals. Funds from the Global Fund for AIDS, TB and Malaria, for which UNFPA is a sub-recipient as well as a joint initiative implemented with GTZ, also contributed to complementary activities. B. Accomplishments in 2008 Strategy # 1: Development of effective policies and strategies for RHCS 1.1. Development of National Strategy/Action Plan for RHCS One of the major accomplishments of 2008 was the finalisation of the National Strategy/Action Plan for RHCS. The inter-sectoral RHCS Working Group took a lead role to ensure participation of and consultation with stakeholders in development of the strategy. Two short-term local consultants were hired with GPRHCS support to help the strategy development process. A series of consultative meetings were organised involving different stakeholders to discuss key strategies and actions to be taken to enhance RHCS efforts. A high-level advocacy meeting was held in November 2008 in Ulaanbaatar, attended by a senior official from UNFPA HQ. The aim of the meeting was to initiate dialogue among decision-makers on the importance of RHCS and the government’s role. The high level meeting was successful and the Ministers of Health and Finance made statements on enhancing the government role in RHCS in order to reach national MDG targets. Participants have reached consensus on the action points to be taken by concerned parties. The National Strategy/Action Plan for RHCS aims to support the achievement of MDGs 4, 5 and 6 and the goals of universal access to RH and HIV prevention methods by 2015. It includes ensuring access to contraceptives, essential RH drugs, medical equipments and other supplies for Emergency Obstetric and Newborn Care [EmONC] and HIV prevention. The three main outputs of the strategy/plan of action are: [1] Effective policies and strategies for RHCS developed and implemented on sustainable basis in line with the national development policies and strategies; [2] Strengthened national capacity to forecast, plan, finance and manage essential RH commodities; and [3] Improved sustainability of RH commodity supply, and accessibility and quality of SRH services with emphasis on EmONC and underserved populations. The approximate cost requirement for implementation of the national strategy/action plan was estimated US$12.0 million for the period of 5 years [2008-2012]. Now, the RHCS working group is working on detailed costing of the action plan and Ministry of Health will submit to the government cabinet for endorsement. GPRHCS 2008 Progress Report Page 30 1. 2. Support to incorporate RHCS into health sector development policies and strategies The Ministry of Health has attempted to harmonise ongoing efforts in different thematic areas and facilitate better linkage with the implementation of Health Sector Strategic Master Plan [HSSMP]. In this context, an important activity was the Joint Health Sector Review supported by collaborating partners including UNFPA. UNFPA in collaboration with other UN agencies has been supporting a MDG costing exercise. Ministry of Finance is the main counterpart for MDG monitoring. With this support, local training on the Integrated Health MDG Costing Model was conducted with technical assistance from UNFPA HQ. As a result the Country Office has a resource persons trained in the costing tool. An initial attempt to cost the RHCS action plan has been carried out but follow- up technical support is needed. A regional advocacy meeting on public health issues including RHCS was organised in the western region with GPRHCS support. Local policy makers, heath managers and RH coordinators of the western 5 aimags [provinces] attended this important meeting. It was good opportunity to increase understanding and commitment of local decision maker on importance of RHCS. The principal national stakeholder in national efforts to enhance RHCS is the Division on Drug and Medical Devices of the Ministry of Health. GPRHCS funds have helped ensure a modest improvement of the working conditions of the Division staff thanks to better computers and an internal network connection. Strategy # 2: Strengthening of Logistic Management System 2.1. Improving LMIS The introduction of CHANNEL software to improve quality of logistic data is progressing well. In 2002, UNFPA helped install a logistics management and information system [LMIS] for RH commodities was placed in Mongolia and a wide range of service providers and logisticians have been trained on LMIS. However, logistic data was recorded and processed manually and data quality needed improvement. In view of this, with GPRHCS support, the Ministry of Health is to use CHANNEL software at central and provincial levels. For this purpose, in addition to central and local warehouses of MONGOLEMIMPEX Concern [MEIC], RH coordinators from all 21 provinces and the 12 districts of Ulan Bator were provided with a computer and printer thanks to GPRHCS support. Following a CHANNEL training organised in Bangkok by UNFPA’s regional office in 2008, the trained team from Ministry of Health, UNFPA and MEIC organised two local trainings on CHANNEL. 56 RH coordinators and MEIC staff have now been trained to use CHANNEL. The CHANNEL manual and software has been translated into Mongolian by the UNFPA country office. Now, the Ministry of Health is revising the LMIS guidelines and reporting forms. Creating online access to CHANNEL reports is very useful to manage RH commodity stock; as a result, the UNFPA country office plans to develop complimentary software. Nationwide use by Mongolians of the computerised LMIS is helping collect and produce accurate logistic data: a very important step towards accurate forecasting and procurement of RH commodities. 2.2. Public Private Partnership to strengthen Logistic Management System Mongolia’s current logistic management system is privately owned by MEIC and the private sector plays a key role in Mongolia’s RH commodity management chain. Thus, a major on-going activity is a Public Private Partnership. The Ministry of Health and UNFPA have been working in partnership with MEIC in accordance with the tri-partite Partnership Agreement. The formerly state-run and now private company is dealing very smoothly and without charging user fees with all logistics related to customs clearance, physical receipt, storage, inventory control and distribution of contraceptives and RH drugs procured by UNFPA throughout the country. MEIC local staff were provided with computers, printers and software and trained in CHANNEL. GPRHCS 2008 Progress Report Page 31 Strategy #3: Access to and quality of FP and EmONC 3.1. Access to contraceptives and quality of FP services With GPRHCS assistance, UNFPA has procured male condoms, oral pills, IUD, essential RH drugs such as Oxytocin, Ergometrine and Iron Dextran and distributed them to service providers in all provinces. In 2008, no stockout of essential RH commodities and no expired commodities were reported in service delivery points. A key to the quality of family planning services is improving the counselling skills of service providers to help in making informed choices. UNFPA is working in partnership with WHO and Ministry of Health and jointly conducted training of trainer courses [TOT] and trained all Primary Health Care [PHC] providers on use of the Decision Making Tool: the Mongolian version of which has been disseminated widely. 3.2. Support to improve access and quality of EmONC A 2007 situation analysis showed that the majority of aimag [province] and soum [district] hospitals providing basic and comprehensive EmONC have a critical shortage of medical equipments and supplies for provision of quality care. Newborn care was particularly neglected and the majority of maternal and newborn deaths occurred because of poor quality emergency care. Thus, improving access to, and quality of, EmONC was identified as a priority area for UNFPA’s regular country programme to be complemented with GPRHCS support. A major accomplishment in ensuring access to, and quality of, EmONC, especially in rural areas, has been the supply of essential medical equipments and other commodities in five western aimags where UNFPA is particularly present. Based on the findings of rapid assessment, EmONC vans equipped with radio communication and medical equipments were procured and provided to the five aimag general hospitals and a selection of 11 of the most remote soum hospitals. In addition, a considerable number of doctors and midwives got skills building training to provide quality EmONC. These efforts led to a decrease of the maternal mortality ratio in the five most remote provinces to below the national average. This has greatly contributed to the reduction of MMR nationwide to under 60 per 100,000 live births in 2008 for the first time. The quality EmONC initiative is to be scaled up in 2009 and beyond. For this purpose, a nationwide comprehensive EmONC needs assessment to identify capacity gaps began in 2008 with GPRHCS assistance in partnership with UNICEF and WHO. The partnership has synergies especially in standardising EmONC, mobilising resources and the use of expertise and skills by implementing the Joint UN Programme on Maternal and Newborn Health. Strategy #4: Improved Multi-Sectoral Coordination Mechanism for RHCS The RHCS working group, strengthened and expanded in 2007, has members from government ministries, the private sector, NGOs, the media and international donors and aims to ensure effective coordination of multi- sector efforts towards RHCS. GPRHCS support has helped improve the leadership and coordination role of the RHCS working group. Four members of the RHCS working group including the Head of Drug Policy Division, the senior officer of Division of Economics and Planning of Ministry of Health, the Chief of the Pharmacology Department of the Health Science University of Mongolia, and the RHCS focal point of the UNFPA CO attended a study tour and training of trainers on RHCS hosted by BKK BN Indonesia. During a special 9-day programme, the participants gained very useful knowledge and skills in key areas of RHCS including the SPARHCS approach, forecasting tools, procurement, logistics, LMIS, policy and advocacy. Of particular interest was the opportunity to learn from the Indonesian experience in RHCS policy, planning, budgeting, and its public supply management chain at different levels. A full-time national RHCS/LMIS Advisor funded by UNFPA Country Programme has been working at Ministry of Health to provide day-to-day technical and logistic support to the ministry and RHCS group. For its part, the RHCS group meets regularly for coordination purposes and for knowledge exchange and information sharing. These efforts are greatly contributing to improving RHCS coordination and to increased pro-RHCS commitment and support from the main stakeholders. GPRHCS 2008 Progress Report Page 32 Advocacy and Policy Achievements: As the 2007 situation analysis showed that political and financial commitment for RHCS was not sufficient, advocacy has been a key strategy to build commitment and action for the establishment of a budget line for RH commodities including contraceptives. The Advocacy Group for RHCS, formed in March 2008, chaired by the State Secretary of Ministry of Health and with committed senior officials and members of parliament as members, developed a national RHCS Advocacy Strategy. Main advocacy target were parliamentarians and senior officials from the Ministries of Health and Finance. An experienced senior local consultant was hired to provide guidance to implement the advocacy plan; two targeted consultation meetings were organised in 2008 for senior officials of the Ministries of Health and Finance. The first meeting aimed to build better understanding on RHCS and general commitment to increase government resource for RHCS. Following that meeting, small working meetings between the Directors of Departments of both ministries were held and concrete action points were reached. Many individual advocacy meetings were conducted to create supportive environment for establishment of budget line for RH commodities. A small scale survey was also conducted to identify the needs of the poor following a Ministry of Finance suggestion. As result of all these advocacy efforts, a major accomplishments of 2008 was the explicit inclusion of RHCS in the “Medium Term Development Framework of Mongolia, 2009-2011” approved by the Parliament with the express aim to implement appropriate actions to secure the RH commodity needs of herders and the poor. In addition, for the first time, the Mongolian government has allocated 85 million Tug [about US$50,000] for the purchase of RH commodities including contraceptives in the 2009 state budget. C. Challenges and lessons learned Though government commitment is high, the main RHCS counterpart, the Ministry of Health’s its Division of Drug and Medical Devices has a limited number of staff; this leads to an overload of their regular work and challenges to dedicate enough time to RHCS efforts The implementation of activities to strengthen the logistics management system has been extremely constrained by a number of reasons including the absence of a public supply chain management system Limited experience in public private partnerships and unclear rules and regulations; poor coordination among private drug supply companies and the absence of a single procurement system Need to protect the RH commodities budget allocation in view of the threat to cut the state budget due to economic crisis Insufficient programme supervision and follow-up and poor availability of data for monitoring RHCS progress Need for technical support and guidance in utilisation of costing tools such as CHANNEL software Need for more experience sharing/networking among GPRHCS Stream 1 countries. D. Recommendations Stream 1 countries have different challenges and different needs with regards to RHCS, therefore, it is useful to take into account the specific needs of countries for GPRHCS support Regular meeting and experience sharing among GPRHCS Stream 1 countries would be useful Increased awareness and commitment of decision-makers with regard to RHCS is crucial. Thus, more regional and international advocacy meetings would be beneficial Adoption of a common approach to monitoring and evaluation, with more technical guidance in the application of different tools and best practices. GPRHCS 2008 Progress Report Page 33 E. GPRHCS baseline According to the HMIS and NCHD 2007, 95% of service delivery points offered at least three methods of contraception. None of them reported stockouts during the last six months National budget line with 85 million Tug [approximately US$50,000] allocated for RH commodities in 2009 state budget RHCS advocacy strategy which is funded and implemented in collaboration with partners Limited national capacity in forecasting and procurement [without any external technical assistance], though some training has been conducted Draft of the National Strategy/Action Plan for RHCS is finalised for endorsement Lessons learned have not yet been documented and disseminated 11 RH commodities are included in the essential drug list: Male condoms, IUD, Oral pill, Injectables, Oxytocin, Magnesium Sulphate, Iron Dextran, Folic acid, antibiotics, Metronidazole. F. Brief Commodity Report Commodities Total Quantity Received Total Value [in $] Male condoms 30,000 gross 87,000 Rigevidon 280,000 cycles 116,252 IUD 36,000 set 11,286 Oxytocin 400,000 amp 52,000 Ergometrine 40,000 amp 5,160 Iron Dextran 150,000 amp 4,500 Female condom 15,000 pcs 10,500 Diazepam 14,900 amp 1,639 Total 288,337 GPRHCS 2008 Progress Report Page 34 Stream 1 - Madagascar A. Summary Madagascar became a GPRHCS Stream 1 country in 2008, and despite delays in fund disbursement to the country office that meant that activities did not really start until May 2008, good progress can already be observed. RHCS enjoys a high level of political commitment [of President and Government] and is mentioned in strategic health sector policy documents such as the Madagascar Action Plan and the 2008-11 Health Sector and Social Protection Development Plan [PDSSPS]. Appropriate coordination mechanisms have been set up, RHCS institutionalisation will require much attention to renew political will. Efforts will also focus on expanding the stakeholders [particularly those engaged in the fight against HIV/AIDS and donors] engaged in RHCS discussions. Setting the baseline for GPRHCS work has helped ensure a strong strategic focus on results. While there is progress, more must be done to raise CPR from its current level of about 20%. Community mobilisation work to increase demand is producing encouraging results in inland regions with very low CPR. This has provided much knowledge and experience of how to raise awareness about RH and RH services which will be highly beneficial in extending and institutionalising this work in other parts of the country. GPRHCS support will also focus on the consistent availability of supplies to eradicate stockouts [more than one third of SDPs reported some stockouts] and meet rising use of services [thanks to mobilisation work to increase demand leading to increased use of RH services and supplies. The installation and use of CHANNEL at central level and in a few regions is already increasing in-country capacity to forecast RH needs, track consumption and manage stock. National capacity will be further boosted as CHANNEL is extended nationwide. B. Accomplishments in 2008 Focus on coordination and setting baseline: In this the first year of implementation of the Global Programme to enhance Reproductive Health Commodity Security activities have focused above all on putting in place appropriate structures and on the definition of the indicators against which the progress is to be monitored and measured. 2008 also saw the creation and institutionalisation of the national and regional reproductive health coordination mechanisms, the development of the Reproductive Health Commodity Security strategic plan, the carrying out of survey exercises to set the baseline indicators on availability of and levels of access to reproductive health services and an in depth analysis of the reproductive health commodity supply system. Increasing demand: The basis for collaboration and partnerships has been established among the different technical partners involved in community mobilisation to increase demand. In concrete terms, in collaboration with MSM [Marie Stopes International - Madagascar Branch], UNFPA targeted three inland regions with very low CPR [Melaky, Anosy and Androy] to carry out an intensive education and awareness-raising campaign on Reproductive Health [RH] and RH services with a focus on information about contraceptive methods and the referral of pregnant women to health centres]. The results have been very encouraging and as a result, over a four month period [September to December], 126 women have had tubal ligations; 584 have begun to receive Implanon, 17 have had IUDs inserted and one vasectomy has been carried out. Availability of RH supplies: The consistent availability of Reproductive Health products and supplies at the level of service delivery points [SDPs] has made an important contribution to reaching the goals set in the 2008 RHCS workplan as every individual has been able to access the Reproductive Health products and supplies that they have needed at the right moment. Nevertheless, some 37.5% of SDPs experienced some stockouts according to the supply system survey carried out in November 2008. These stockouts have affected the provision of the three priority services in Madagascar, namely, Family Planning, Maternal Health and the prevention, management and GPRHCS 2008 Progress Report Page 35 treatment of STIs, including HIV/AIDS. According to the November 2008 survey into availability of and access to SRH services, with regard to contraceptives, these stockouts have ranged from 6.9% to 13.8% respectively for oral contraceptives and injectibles in 2008. Installation of CHANNEL: It should also be noted that the contraceptive consumption and stock management software, CHANNEL, is now being used in Madagascar’s national health commodity purchasing centre and warehouse, SALAMA, and also in five of Madagascar’s 22 regions [in some thirty districts out of a total of 111]. Advocacy and Policy In the sphere of advocacy and policy, the UNFPA focus has been to seek to transform the current high-level of political commitment to issues of SRH and RHCS into an increase in the allocation of national budget resources for priority sexual and reproductive health services in Madagascar [Family Planning, Safe Motherhood, prevention, management and treatment of STI, including HIV/AIDS]. In addition, there has been a particular focus on building awareness about, and the supply of services for, reproductive health. Emphasis has been on seeking to ensure comprehensive access and availability of services for marginalised groups in particular. C. Challenges and lessons learned In this the first year of GPRHCS implementation in Madagascar, much progress has been made to put in place appropriate coordination structures. Now these mechanisms have been set up, the institutionalisation will be on-going and require much attention and the continual building and renewal of political will. Madagascar is able to benefit from the experience and insight of Stream 1 countries where work began earlier [GPRHCS Stream 1 2007 countries]. In particular, a key lesson centres on the need to broaden and deepen the range and alliance of stakeholders [particularly donors] engaged in discussions of RHCS is part of this challenge of will require particular attention. Ensuring that RHCS discussions are mainstreamed into the discussions of other coordination mechanisms—particularly those leading the fight against HIV/AIDS—will be of particular importance. The process of setting the baseline for RHCS work [supported by the Global Programme and other work] has been beneficial in ensuring there is a strong strategic focus to this work. The focus on important indicators of achievement, such as the proportion of SDPs offering at least three methods of contraception and five life- saving maternal health drugs, will ensure a very strong results focus. While progress is undoubtedly being made, much more has to be done to raised CPR from its current level around 20. The community mobilisation work to increase demand, carried out in collaboration with MSI Madagascar, has produced encouraging results in a four-month period in three inland regions with very low CPR. This has provided much knowledge and experience of how to raise awareness about RH and RH services which will be highly beneficial in extending and institutionalising this work in other parts of the country. The consistent availability of RH products and supplies in SDPs has been very important in ensuring people have access to the supplies they need when they need them. However, with more than one third of SDPs reporting some stockouts and with on-going community mobilisation work designed to increase demand [and so lead to a rise in CPR and more use of RH services and supplies] it will be important to continue to increase supply to eradicate stockouts and meet rising use of services [and supplies]. The use of CHANNEL at central level and in five of Madagascar’s 22 regions is already increasing in-country capacity to track contraceptive consumption and stock management software – also building national capacity to forecast RH commodity needs. This national capacity will continue to increase as CHANNEL is extended to other regions of the country. GPRHCS 2008 Progress Report Page 36 D. Recommendations Recruit a Chief Technical Adviser to support the strengthening of the current logistics system by supporting SALAMA, Madagascar’s national health commodity purchasing centre and warehouse Build and strengthen the capacity of all the stakeholders involved in RH commodities logistics at all levels – that is, Central, Regional, District and within SALAMA Extend the use of the contraceptive consumption and stock management software, CHANNEL to improve the monitoring and management of contraceptive supplies Strengthen coordination and collaboration between the Department of Laboratory Pharmacies and Traditional Medicine, in charge of purchasing health supplies in the Ministry of Health and Family Planning and the national purchasing centre, SALAMA E. GPRHCS baseline The baseline study carried out in Madagascar in Q4 2008 found that: 1. The percentage increase in the Contraceptive Prevalence Rate [CPR] from 2007-08 was approximately 23% – that is, from 16.7% in 2007 to 20.6% in 2008. The results of the most recent DHS will be available in May 2009. 2. 89.5% of Service Delivery Posts offer at least three methods of contraception, according to the November 2008 survey to set the baseline on availability of and levels of access to reproductive health services in Madagascar 3. 10.8% of Service Delivery Posts and 18% of District Hospitals reported contraceptive stockouts during the previous six months, according to the November 2008 baseline survey. 4. 43 hospitals providing Comprehensive Emergency Obstetric Care had appropriate supplies of essential life-saving maternal health drugs 5. There is a national line item budget for contraceptive procurement. However, the budget allocation has not increased despite the 2007 policy change guaranteeing free reproductive health services [for Family Planning and Caesarean sections] in public health centres. 6. A funded RHCS advocacy strategy implemented in collaboration with partners is under development; principal stakeholders also reached consensus in 2008 about the need for a resource mobilisation strategy to provide support to the government in order to achieve reproductive health commodity security 7. Functioning national capacity in forecasting and procurement [without any external technical assistance] exists for contraceptives. There is though limited capacity at central level and in certain districts to estimate needs [forecasting] and to purchase commodities for two key reproductive health areas, namely, for lesser risk motherhood [maternité à moindre risque [MSR]] and for the prevention, management and treatment of STI, including HIV/AIDS. A national strategy to build capacity for reproductive health commodity forecasting is part of the 2009 Annual Workplan for the GPRHCS in Madagascar. 8. National capacity to plan and implement a comprehensive approach to RHCS, including demand creation and resource mobilisation is growing; A national RHCS strategy exists and a corresponding plan of action has been developed for implementation in 2009; a resource mobilisation strategy to provide support to the government to achieve RHCS is under development [see point 6 above] 9. There is currently no systematic mechanism to document and disseminate RHCS lessons learned to inform future programme design and delivery; such a mechanism is being developed part of the 2009 Annual GPRHCS Workplan GPRHCS 2008 Progress Report Page 37 10. Five contraceptives are included in the national essential drug list [NEDL]; for lesser risk motherhood [MSR] some emergency supplies for emergency obstetric and neo-natal care are provided free but are not yet in the NEDL F. Brief Commodity Report Commodities Total Quantity Received Total Value [in $] Lo Femenol 1,156,300 358,453 Ovrette 57,000 17,760 Depo Provera 750,000 637,000 Implanon set [not yet received but approved by UNFPA HQ 31/10/2008] 35,250 891,120 Magnesium Sulphate, 500mg/ml 17,500 ampoules 50,000 Oxytocin, 1mg/ml 50,300 ampoules Adrenalin, 1mg/ml 36,000 ampoules Hydrocortisone 100mg 3,500 doses Atropine Sulphate 1mg/ml 36,000 ampoules Methylergometrine 0,2mg/ml 3,000 ampoules Vitamin K1 1mg/ml 16,000 ampoules Total 1,954,333 GPRHCS 2008 Progress Report Page 38 Stream 1 - Laos A. Summary Laos became a GPRHCS Stream 1 country in 2008, and despite delays in fund disbursement to the country office that meant that activities did not really start until the second quarter of 2008, the process of promoting the prioritisation and mainstreaming of RHCS is well underway. RHCS is being positioned as a key element of Laos’s Maternal Newborn and Child Health [MNCH] package and GPRHCS funds helped assess the vertical logistic systems that support the MNCH package. The strong maternal health focus on RHCS is also being emphasised, as shown by the WHO-UNFPA joint assessment in Laos on access and rational use of life-saving maternal drugs. Logistics sphere challenges include: slow development of a comprehensive Health Information System; lack of a systematic RH commodity transport and distribution plan; poor quality of data reporting of contraceptives in the LMIS and low level of use of the data for programme management, generally weak management capacity within the MOH; and insufficient numbers of primary health care workers at district level. B. Accomplishments in 2008 Two assessments, supported by GPRHCS, were undertaken this year to further RHCS goals and objectives in Lao PDR: [1] assessment of the vertical logistic systems in support of the Maternal, Newborn and Child Health [MNCH] package; [2] WHO-UNFPA joint assessment on Access and rational use of life-saving maternal drugs and other elements pertaining to how the MOH procures a range of drugs, medicines and accessories that are not centrally funded and procured but are vital, essential and necessary for providing better PHC services including RH. Based on the findings/recommendations from the “assessment of vertical logistic management systems in support of MNCH package”, a proposal to unify vertical logistic information systems was formulated and presented to the MNCH Technical Working Group [TWG]. The proposal will be further discussed on Jan 9 th 2009 and if agreed and implemented, it would strengthen one of the health system building blocks of “Medical products and technology” for the MNCH programme delivery by integrating other vertically managed commodities to contraceptive LMIS. The proposal was discussed in Jan 2009 and agreement was reached on its implementation, to strengthen one of the health system building blocks of “Medical products and technology” for MNCH programme delivery by integrating other vertically managed commodities into the contraceptive LMIS. Using MNCH TWG as a forum to discuss MNCH commodity/drug supply issues has been made and support has been expressed. This is a step toward using the Health Sector Working Group mechanism to consider RHCS issues. The MOH has made efforts to increase domestic fund allocation for contraceptive procurement from $5000 in 2006 [first fund allocation for contraceptives] to US$ 18,500 in 2008. C. Challenges and Lessons Learned LMIS has not consistently been used as management tool [inaccurate, incomplete and untimely information reporting]. Service providers have to cope with multiple reporting forms with some duplication. Need to: [•] streamline/unify the Contraceptive LMIS and other vertical logistic systems; [•] promote use of the MOH Food and Drug Dept. staff for transport and warehouse management to free MCH managers from logistic responsibility and allow time to focus more on the use of data; and [•] eliminate duplication of data between CLMIS and HIS to reduce reporting burden. Addressing these issues is hampered by the slow development of a comprehensive Health Information System including a Health Management GPRHCS 2008 Progress Report Page 39 Information sub-System, and the re-organisation of key functions of the MOH including its Food and Drug Department [FDD] and the Medical Products Supply Centre [MPSC] which recently has taken charge of health commodity management activities. The lack of a systematic transportation plan for MNCH commodities to the district level and sub-district service delivery points is a hindrance to RHCS objectives concerned with timely supply of appropriate commodities. Overall, a general lack of management capacity within the MOH at its different levels continues to hinder achievement of key MDG goals as does the dearth of service personnel at the PHC [sub-district] level. The generic RHCS products, OCs and IUDs, introduced to reduce costs had defects and may have cost more to the FP/RH programmes and clients [confidence to the FP/RH programme, time to deal with the problems, cost of destruction, etc.] National budget allocation for health sector is extremely low [0.4%]; as a result the government can provide only limited financial contribution for the supply of contraceptives. Bringing all stakeholders into the same logical framework is a vexing challenge, particularly as newer partners, such as the GFATM and GAVI, can shift the focus of key MOH officials on RH and MNCH priorities and this can actually work against attempts to integrate the vertical programmes that characterise prior health development efforts. That said, the GFATM Round 8 inclusion of Health System Strengthening proposals provides an opportunity to include the issues related to commodity security and to align these with MNCH and LMIS. D. Recommendations Use MNCH TWG as the forum to discuss RHCS issues and resource mobilisation from other development partners and the government. For government resource allocation, Finance and Planning TWG should be also used. Use other existing and functional mechanism such as National Committee for Mother and Child [NCMC] to raise support for RHCS. E. GPRHCS baseline The baseline study carried out in Burkina Faso in Q4 2008 found that: 1. The most recent figure for the Contraceptive Prevalence Rate [CPR] using modern methods is from the 2005 LHRS [35%]. The previous figure was 28.9% in the 2000 LRHS – representing a 6.1% point increase over that five year period. 2. It is estimated that 96% of Service Delivery Posts offer at least three methods of contraception, according to the fourth quarter 2008 RH programme report setting the baseline on availability of and levels of access to reproductive health services in Laos. Though all PHC outlets are authorised to provide condoms, oral pills and injectibles the survey found human resource constraints. 3. With regard to the percentage of Service Delivery Posts reported contraceptive stockouts during the previous six months, it should be noted that the current reporting system does not report stock outs at health facility level. The emphasis is on maintaining min-max levels of contraceptives at PHC SDPs, district and provincial levels. 4. Gauging the proportion of SDPs [considered district hospital level in Laos] offering at least five life-saving maternal health drugs has not been possible. Current MOH policies do not authorise the use of five life- saving drugs at the health centre level; however at least one of the five is available at some SDPs. 5. There is no separate line item in the health budget for contraceptives. There is a general line item for medicines, drugs, etc. Regular budget earmarking for contraceptives is not yet the practice. GPRHCS 2008 Progress Report Page 40 6. Currently there is no specific RHCS advocacy strategy. As part of the integrated MNCH package advocacy costing of the package is planned for, and possible advocacy including RHCS will be included. At this time there is no plan to prepare separate RHCS advocacy strategy. 7. There is some capacity to forecast but external technical assistance is required to provide guidance and advice. Procurement of drugs and medicines, particularly life-saving maternal drugs, [but not of contraceptives] takes place at provincial and district levels. 8. With regard to national capacity to plan and implement a comprehensive approach to RHCS, including demand creation and resource mobilisation, there is a general lack of capacity in this area. Both demand creation and resource mobilisation tend to be externally driven. That said, the UNFPA Country Programme supports activities in this area, including working with local communities and promoting access to youth friendly services, currently with a higher focus on youth living in urban areas. 10. All registered contraceptives and life-saving drugs/medicines are included in the 2007 national essential drugs list: 5 contraceptives and 3 maternal life-saving drugs. However, there are regulations/policies concerning the levels of care at which they are available. F. Brief Commodity Report Commodities Total Quantity Received Total Value [in $] Male condoms 2,541,600 pieces 59,115 Combined Pills 1,587,840 cycles 199,184 Mini pills 734,077 cycles Total 258,299 GPRHCS 2008 Progress Report Page 41 Stream 1 - Niger A. Summary Niger became a GPRHCS Stream 1 country in 2008, and despite delays in fund disbursement to the country office that meant that activities did not really start until the second quarter of 2008, advances can already be observed. Building on the Reproductive Health Law of 2006 and the free services for Family Planning, Caesarean, Genital Cancers and Fistula, the government used the national budget line to procure RH commodities costing some CFA7.8 billion in 2008. Over US$1 million was also raised from in-country partners [IFAD, WB, EC] for commodities – procured by UNFPA. Mindful of the need to build broad and deep support to prioritise and mainstream RHCS, there are two National Coordination Mechanisms dealing with RHCS. The National Committee on RHCS, chaired by the MOH General Secretary, and discusses key, strategic RHCS related issues. The RHCS Technical Committee is a logistics and supply chain focused grouping that addresses more technical issues. As part of the 2008 RHCS Action Plan, a strategic partnership was formed with an NGO to carry out an RH IEC campaign directed towards marginalised and underserved populations including the military and rural communities to increase demand and use of reproductive health services. B. Accomplishments in 2008 Political and financial commitment and country ownership In 2008, the Government of Niger has demonstrated an increased level of political and financial commitment and country ownership: A range of reproductive health services are free [such as ante- and post-natal care, caesarean section, contraception, etc] In 2008, almost 50% of the contraceptives needed for the country [at a cost of more than US$ 1 million] were procured by the government [using common basket fund resources] with assistance from UNFPA’s procurement service Two meetings on contraceptive forecasting took place in Niamey in June and November 2008, under the leadership of the government and with the participation of a range of regional actors To raise awareness and knowledge about SRH issues country, accessible versions of national laws relating to Reproductive Health and HIV/AIDS were developed and are being endorsing by the government. National Coordination Mechanism in place and functional There are two National Coordination Mechanisms that deal with all elements of RHCS. The National Committee on RHCS met twice in 2008, is chaired by the MOH General Secretary, and discusses key, strategic RHCS related issues. It is at the highest policy-making level to ensure that the issues are effectively mainstreamed into national health policy, programmes, plans and budgets. It is composed of MOH bodies [Reproductive Health Office, Drug office, Planning Office, Care office, Information service, quality insurance service], Other ministries representatives [Ministers in charge of Social Affairs, Population, Women, Finance], NGOs and donors representatives [UN : WHO, UNICEF, UNFPA and others : African Development Bank, KFW, USAID, etc]. The RHCS Technical Committee, which met six times in 2008, is a logistics and supply chain focused grouping that addresses more technical issues. That body has as Secretary, a National Technical Committee which is chaired by the Office in charge of Reproductive Health and includes Technical representatives of the National Committee on RHCS Issues. In 2008, the National Committee on RHCS Issues makes two meetings which permit among others to adopt 2008 Action Plan, the Study on Market segmentation. GPRHCS 2008 Progress Report Page 42 The National Technical Committee makes more than 8 meetings which permit [i] to design 2008 and 2009 RHCS Work plans; [ii] to design and adopt TORs for three studies related to RHCS issues [Market segmentation Study, Community Based Distribution of Contraceptives Assessment and Study on RHCS indicators]. These studies permit to complete the situation analysis made in 2006 and recommend informed actions to enhance RHCS issues. Demand and access increased In 2008, as part of the RHCS Action Plan, a strategic partnership was formed with ANIMAS-SUTURA [an NGO working on SRH issues], under MOH leadership. In October 2008, the partnership launched an RH/IEC Campaign [called “The adventures of Fula”] in the Military Training Service near Niamey. The campaign is training: [] 25 new young military students in RH during their training [who will then be able to train their peers]; [] more than 1,150 new young military students on Reproductive Health and HIV/AIDS issues including RH and HIV/AIDS services around the military camps. To date, the partnership has carried out: A market segmentation study to develop a strategy to ensure RHCS within public and private sectors; An assessment of the community based distribution [CBD] of contraceptives to better use that approach to improve access of the population to contraceptive services and products; Activities to increase demand and use of reproductive health services among marginalised populations, including the military. This partnership will be further developed in 2009 to improve demand and use of Contraceptives in the military and in rural communities [with CBD and the promotion of oral contraceptive through social marketing]. Policy and Advocacy A traditional leader in Magaria District talked to UNFPA Representative about UNFPA Technical Assistance to District of Gouré “If UNFPA decide to move out this person, we will walk by foot towards Niamey in order to protest, because since its presence with us, no woman dead by giving life” Another Traditional Leader talking about Technical Assistance [midwife supporting Matameye District in Zinder] “If every Health Professional are like that woman most of health difficulties will end in our region”. C. Challenges and lessons learned The government bodies at national and regional levels don’t use adequate tools to deal with stock out which are report from the field in spite of the stock at regional and national levels. There are some lack of equipments and training on LMIS The presence of some donors at National Coordination meetings is not regular There is a lack of capacity [human and material-vehicle, computers] within some important offices in charge of RHCS: Office in charge of Reproductive Health D. Recommendations Reinforce national capacities in order to reduce stock outs and increase RHC demand within Reinforcing partnership with RH NGOs and private sector in order to increase demand and access to RH services and products Training of services providers at all levels in LMIS and provide computers for monitoring RHCS data; Technical Assistance for services in charge of RHCS [DSME and DPHL/MT] for a better forecasting and procurement at all levels Provide a vehicle for RHCS activities monitoring GPRHCS 2008 Progress Report Page 43 E. Brief Commodity Report Commodities Total Quantity Received Total Value [in $] Lo Femenal 1 945 000 550 630 Ovrette 687 000 161 580 Depo Provera 321 000 272 390 Implants 14 000 307 628 DIU 2 000 Female Condoms 3 000 3 467 Transportation 128 317 Total 1,424 012 GPRHCS 2008 Progress Report Page 44 Stream 1 - Haiti A. Summary Haiti became a GPRHCS Stream 1 country in 2008, but spent much of the year on an emergency footing due to unprecedented adverse weather conditions. This hampered planning efforts as a result of which GPRHCS funds were not used to help enhance national RHCS capacity and systems. In addition, the US reduced its financial support due to leaks in the distribution network and Ministry of Health reporting failures, creating RH commodity stockouts and other problems in the country. The adverse weather, coupled with the US decision to reduce its support to the MOH, did encourage officials to seek to reduce Haiti’s dependence on international aid in areas such as RH commodities. As a result, the MOH is seeking parliament’s approval for a RH commodity budget line and has resolved to build a solid national RH commodities distribution system. On-going advocacy work by UNFPA helped to ensure the adoption of male condom distribution norms as part of the MOH programme to prevent STIs, including HIV/AIDS. This will improve national capacity to forecast needs and report condoms use. In 2007, the MOH set up a Committee for the National Distribution System [including the Pan-American Health Organisation (PAHO) and UNFPA] to draft a national commodities security strategy and plan of action which, among other things, would: [1] address commodity distribution and report failures; and [2] improved the information system on stock levels and finance. A draft plan to improve the information system on stock levels and finance and to redesign the distribution network was submitted to health sector donors by the MOH in mid-2008. B. Accomplishments in 2008 Access and Quality of Care Following USAID’s decision to reduce its budget to support the Ministry of Health contraceptive programme, the UNFPA decided to compensate for this gap in contraceptive commodities and mitigate strategic stockouts at the central level, procuring Magnesium Sulphate and Oxytocin to ensure a strategic stock. Capacity Development UNFPA provided technical and financial support to the Ministry of Health, in the organisation of a training workshop on forecasting contraceptive needs based on population data. A presentation of the CHANNEL logistics management software was also made for the MOH at central level and PAHO/Central warehouse staff. Political and financial commitment and country ownership The Ministry of Health and UNFPA signed a Memorandum of Understanding on the GPRHCS in November 2008. The following month, the Ministry of Health created a Reproductive Health Commodities budget line in its budget proposal, to be submitted for deliberation and approval by the national parliament. Strengthening of Logistics Management Successful advocacy was carried out to adopt male condom distribution norms to tackle STIs, including HIV/AIDS as part of the MOH prevention programme. Distribution norms were approved by the MOH, its partners and donors [including USAID]. This will improve government ability to forecast needs and report condoms use. In 2007, the Ministry of Health set up a Committee for the National Distribution System [including PAHO and UNFPA] to draft a document to design a national commodities security strategy and plan of action which, among other things, would: [1] address commodity distribution and report failures; and [2] improved the information system on stock levels and finance. A draft plan to improve the information system on stock levels and finance and to redesign the distribution network was submitted to health sector donors by the MOH in mid-2008. GPRHCS 2008 Progress Report Page 45 C. Challenges and lessons learned USAID’s decision to reduce its support to the procurement of contraceptives because of monitoring failures complicated matters in 2008. Despite UNFPA efforts to mitigate the emergency RH commodity gap, stockouts occurred in the first half of 2008. However, the US decision certainly alerted Ministry of Health officials to the problems of high dependence on international aid in key areas, such as reproductive health commodities. The Ministry of Health became determined to improve the performance of its national distribution system for commodities and to create a RH commodity budget line in its budget proposal to the parliament. Faced with a crisis, a tough decision was made where years of advocacy had failed. It also brought UNFPA and USAID together to help manage the situation, creating for example a consolidated distribution plan for contraceptives and condoms coordinated by the Ministry of Health. The challenge now is to build a solid national distribution system for commodities. The Ministry of Health and its partners still have to find a consensus on the: Future national and provincial warehouses status Influence of the private sector within the national distribution system Logistics management software to be selected to monitor national RH commodities distribution Distribution/share of support among donors D. Recommendations To support the Ministry of Health in designing a new National Distribution System, the UNFPA country office needs strong technical support in French. The RHCS Global Programme could support hiring of an international francophone technical expert [as done in Madagascar] CHANNEL is well adapted to the Haitian situation but it will be challenged by other donor software. To improve CHANNEL capacity to be adopted by francophone Haiti, GPRHCS should develop a demo disc [in French, for easy use in Haiti]. E. GPRHCS baseline 1. Haiti showed an 18% increase in Contraceptive Prevalence Rate [CPR] in a DHS survey in 2005. 2. Ministry of Health 2008 surveys showed that 60.3% of service delivery points offer at least three methods of contraception. 3. The 2008 survey revealed that 74% of service delivery points reported contraceptive stockouts in the last six months. This high level of stock outs is explained by USAID decision [December 2007] to cut contraceptive budget [see above] 4. There is a survey underway but no information on the proportion of service delivery points offering maternal health drugs. 5. There is a budget line for contraceptives, but it still needs to be approved by parliament. 6. There is no RHCS advocacy strategy. 7. There is not strong national capacity in forecasting or procurement. Forecasting is improving owing to UNFPA and USAID trainings and workshops. Procurement is still carried out by donors. 8. There is no capacity to develop a comprehensive RHCS approach including demand creation and resource mobilisation. 9. There are documented lessons learned from an ACP-JSI 2007 international mission 10. Seven out of ten essential RH commodities are included in the national essential drug list [Please detail]. GPRHCS 2008 Progress Report Page 46 F. Brief Commodity Report Commodities Total Quantity Received Total Value [in $] Condoms 52,143,984 1,222,000 Lo femenal 586 000 690 000 Ovrette 175 680 IUD 300 Jadelle 5 000 Depo provera 414 000 Lubricant 90 000 13 900 Tubal ligation kits 3000 To be calculated by ACO/EU coordinator Mg Sulphate 148 000 50 770 Oxytocin 341 600 45 020 UNFPA Kit # 11 3 22 500 UNFPA kit # 6 12 14 340 UNFPA kit # 2 3 4 750 UNFPA kit # 10 10 2 500 Total 2,065,780 GPRHCS 2008 Progress Report Page 47 Stream 2 The 2008 Stream 2 report will focus on the extensive work to facilitate, promote and support better RH commodity security at regional level with periodic reference to on-going work in a number of individual countries. What follows is presented by region and represents merely a selection of the work underway. This section covers: Eastern and Southern Africa; West Africa; Asia and the Pacific; and Latin America and the Caribbean. Global Programme funds financed some though by no means all of what is reported. In 2008, no Global Programme funds were allocated to the Eastern Europe and Central Asia region nor to the Arab States region. RHCS is an issue though that does require significant attention in a number of countries across those regions. In 2009, with new regional offices becoming operational, a number of Stream 2 initiatives are expected in the Eastern Europe and Central Asia region and the Arab States region which, if funded, will be reported on in the 2009 GPRHCS report. Stream 2 – In Eastern and Southern Africa A. Summary Implementation of RHCS activities has been made easier in most countries in the region thanks to the existing in- country commitment to ICPD at various levels, and by the successful collaboration with regional economic institutions. This collaboration has focused on increasing the knowledge and commitment of high level policy makers in the sub-region and mobilising their support to help improve RHCS in their various countries. Sub- regional workshops to build capacity in advocacy were organised for these high level policy makers in 2008 in collaboration with both the EAC and IGAD. Outlined below is a brief overview of the regional work carried out. Much additional work took place in the countries in the region. B. Accomplishments in 2008 Capacity Development and Country Commitment Parliamentarians in several countries in the sub-region [Djibouti, Kenya, Uganda, Tanzania, Burundi, Rwanda, Sudan and Somalia] developed detailed country advocacy workplans to address priority RHCS issues in their countries. Many of these workplans are now being implemented by these parliamentary groups. In close collaboration with the Partners in Population and Development [PPD], several advocacy workshops were also carried out for parliamentarians and policy makers from countries in Africa and Asia in the spirit of supporting effective south-south collaboration. Strong commitments and declarations have been issued in support of RHCS by these various parliamentary groups. The regional RHCS technical advisor was trained in January 2008 to serve as a resource and co-facilitator for UNDAF Design Workshops and Strategic Planning Retreats with country teams and partners [Government, Civil Society Organisations, Donors, etc.]. The adviser can now effectively address RHCS during national country programming processes which involve counterparts and all implementing partners. COs have demonstrated impressive progress in their commitment to RHCS activities over the past 3-4 years. RHCS technical assistance requests to the regional RHCS advisor were practically nonexistent in 2004/05, compared to approximately 28-36% of the sub-region’s demands for RHCS technical assistance in 2006-2008. Countries’ increased contribution to the RHCS Strategic Action Plan also shows the impact of the RHCS Situation Analysis process and how involving national counterparts can yield positive impact. All 2008 RHCS Strategic Action plans have received support from Country Office funds. GPRHCS 2008 Progress Report Page 48 Review of Comprehensive Condom Programming [CCP] in seven countries A comprehensive review [from February to December 2008] of condom programming issues in selected countries of the South African Development Community [SADC] region was commissioned by UNFPA, Population Services International [PSI] and the International Labour Organisation [ILO] in 2008, to build on and complement the existing data and information. Seven countries were surveyed: Botswana, Madagascar, Mozambique, Namibia, Swaziland, Zambia, and Zimbabwe. The three partners contributed particular expertise and information: UNFPA regarding condom programming in the public sector; ILO on condom programming in the private sector and in relation to employers, labour organisations and government; and PSI with respect to social marketing. The partners will also be in a position to apply the results for improved condom programming both directly and through sharing the findings widely with key stakeholders both nationally and regionally. A regional stakeholders’ workshop was held in December 2008 to present the CCP review findings to stakeholders. Government Support and Policy Formulation of RHCS multi-year action plans in Swaziland and Lesotho Follow-up to the 2007 RHCS Parliamentarian Advocacy workshop held in Gaborone, May 2008 with UNFPA Africa region staff. As a result, SADC has indicated an interest in continuing to promote the GPRHCS in the region as it fits with the priorities of SADC’s own Parliamentarian Forum [SADC/PF]. C. Challenges and lessons learned Although the business continuity plan for UNFPA was smooth, the roll-out of 2008 programmes in Southern Africa was affected by staff movement, notably in the implementation of the SADC/PF recommendations and in the timing of provision of technical support. Development of national RHCS Strategic Plans across the region has accentuated the challenge of working in conditions where: [•] Warehouses are often in inappropriate conditions; [•] LMIS is often not computer based; [•] there is typically a high turnover of government staff – making it difficult to retain trained staff. Investments in mobilising Parliamentary Groups yield significant in-country results as demonstrated by the numerous country examples of these high level policy makers increasingly taking their government to task about inadequate funding of commodities. This has also resulted in the establishment of budget lines for RH commodities and also in increased funding for RH commodities in many countries. In Uganda, the Ministers of Health and Finance were requested by advocates within the parliament to review their budgets and increase funding for RH and RHCS. D. Recommendations Provide additional technical and financial support to the advocacy workplans developed and being implemented by parliamentary advocacy groups within many countries in the sub-region Work with trained institutions and develop capacity of other institutions presenting potential to further enhance RHCS regionally or sub-regionally Make effective use of Regional and sub-regional strategies [such as Maputo Plan of Action, Africa Health Strategy 2007-2015, SADC sub-regional Strategy] to promote sustainability of RHCS Emphasise collaboration with SADC as a Legislative Body Work with Parliamentarians/Policy makers/Decision makers to sustain political influence to better advance RH/RHCS Use UNFPA’s comparative advantage as part of the overall RHCS advocacy programme: UNFPA is the largest international public sector supplier of contraceptives, condoms and other reproductive health supplies procuring nearly US$80 to US$100 million in goods and services each year. GPRHCS 2008 Progress Report Page 49 Enhance the pool of current RHCS Consultants [in number and variety of RHCS-related specialised thematic areas] to ensure stronger and better targeted technical assistance Work with other UNFPA Thematic Funds as well as external initiatives including the Global Fund and PEPFAR. Madagascar’s example of successful integration of GPRHCS with Maternal Health TF to be replicated/adapted in other countries; Partake in the development and implementation of external funding mechanisms, by contributing to proposal development, participating actively in negotiation fora. E. GPRHCS baseline Mainland southern Africa continues to have the highest HIV prevalence and AIDS-related morbidity and mortality in the world, although recent data show some decline in incidence and prevalence in Zimbabwe. It is essential to learn the lessons from Zimbabwe on the contributing factors for the decline so that such improvements can be sustained and so that, where possible, they can be replicated elsewhere. Women continue to be more affected by HIV and AIDS than men, and are infected younger. Average fertility rate is of 3-4 in Botswana, Namibia, Zimbabwe, Swaziland and Lesotho; only Mauritius is under 2 [and perhaps Seychelles for which data could not be found]. The contraceptive prevalence rate is: 40% in Botswana; 30% in Lesotho; 49% in Mauritius; and 54% in Zimbabwe. Progress towards the MDGs [as highlighted in the ICPD+10 review] is apparent but limited in extent. Few countries are on track to meet the goals in the planned timeframes. Likewise, no countries have met the Abuja agreement of 15% budget allocation for health. GPRHCS 2008 Progress Report Page 50 Stream 2 – In West Africa A. Summary Implementation of RHCS activities has been made easier in most countries in the region 3 thanks to the existing in- country commitment to ICPD at various levels, and by the readiness and desire to address RHCS at national level. Outlined below is a brief overview of the regional work carried out. Much additional work took place in the countries in the region. B. Accomplishments in 2008 Analytical Review: An analytical review of the political, legal, demographic and health context has been carried out in nine countries. In addition: data was collected and analysed on the availability of RH services; the strengths and principal weaknesses of the logistics system were analysed and practical recommendations to improve them drawn up; in the sphere of RH products, current financing, sources and use of funds and potential gaps were identified; the institutional framework and national level RHCS coordination mechanisms were evaluated. Situation analysis and development of five-year national RHCS Strategic Plan: Technical support missions were conducted in Benin, Central African Republic, Chad, Congo, Côte d’Ivoire, Guinea Bissau, Mauritania, Liberia, Senegal and Togo. The analyses focused on four keys components of RH: family planning, obstetrics and neonatal care, STI/HIV/AIDS and condom programming. These were followed by sensitisation workshops which culminated in the validation of results and recommendations for development of the five-year strategic plan. The proposed RHCS Strategic plan defines the objectives, strategy and activities required to progress towards RHCS in a planned and coordinated manner. During this process all RH commodities needs were forecast for a five-year period. In Benin and Mauritania the comprehensive condom programming component was integrated into the RHCS situation analysis and strategic plan. Separate assessments were carried out in Burkina Faso and Chad. Of further note: [•] unmet need for RHC, geographical barriers to access, socio-cultural and financial barriers, and other barriers to use of RH services were identified in ten countries; [•] in order to agree on the modalities to support the implementation of a RHCS strategy in the sub-region, a consultative meeting between the West African Health Organisation [WAHO] and UNFPA took place in Burkina Faso in March. C. Main challenges and lessons learned Facilitating factors The political will of governments to promote RHCS efforts – coupled with a supportive social and public environment receptive to RHCS issues. The active involvement of UNFPA country offices in sustaining RHCS efforts undertaken at country level. Broad commitment to the goals of GPRHCS, in government, at community and health facility levels. This has facilitated ownership and involvement of all stakeholders in implementation of work in-country. The willing collaboration of the existing in-country coordinating mechanisms that facilitate the implementation of the regular UNFPA-supported Country Programmes in countries. These coordination mechanisms facilitate: integration, management and monitoring of GPRHCS funded activities; joint follow-up with other development partners; and use of the UNFPA-developed dedicated RHCS software [CCM, CHANNEL] within the Ministry of Health. 3 The countries of the region are: Benin, Burkina Faso, Cameroon, Cape Verde, Chad, Central African Republic, Congo, Côte d’Ivoire, Equatorial Guinea, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Liberia, Mali Mauritania, Niger, Nigeria, Sao Tome and Principe, Senegal and Sierra Leone GPRHCS 2008 Progress Report Page 51 In-country partnerships [NGO, civil society, UN partners, public and private sectors] continue to be forged that are pooling resources for RH, with the express aim of attaining greater impact and reach. Constraining factors The lack of effective human resource management policies and the shortage of qualified professional staff, aggravated by the brain drain, are major constraints in the target countries, especially in Central African Republic and Chad. These factors are compounded by high-government staff turnover and the need for close technical and managerial backstopping at decentralised levels. The demotivation of government health staff carries important implications for the sustainability of these efforts in the future. Ministry of Health technical staff shortages pose difficulties in terms of RHCS coordination, institutionalisation and consultation processes [including decision-making related to RHCS activities]. While improving, the level of knowledge about the strategic importance of RHCS remains generally low. Further factors that constrain work to improve RHCS: contextual issues relating to conflict and post- conflict countries [accessibility issues where conflict is on-going, political instability, uncertainties undermining planning and training efforts, etc.]; reductions in health sector budget and staffing – as is the case in the Central African Republic and Chad. Challenges Low in-country capacity and competency of local consultants in some countries Lack of competency at country level in the area of forecasting Most RHCS strategic plans developed in the region face resource mobilisation problems undermining implementation Lack of human resources within WAHO to carry out planned regional activities Need to strengthen LMIS at national level Need to develop effective ways to maintain and increase the pool of trained RHCS consultants Lessons learned Strategic partnerships and networking at all levels can improve the quality of the projected results Advocacy is critical in highlighting the strategic role RHCS plays in the overall achievement of the ICDP Programme of Action and the MDGs Fostering ownership and participation of stakeholders and continued involvement of UNFPA country office are key if sustainable RHCS is to be achieved Consultations with programme partners and coordination of activities are essential for ensuring synergies with other RH related initiatives The situation analysis and strategic plan process is a very strong advocacy tool for RHCS and CCP at country level, as it provides opportunities to inform the staff of UNFPA country offices, national partners at Ministries of Health, as well as Technical and Financial Partners and NGOs at country level of the importance of RHCS in the successful and sustainable implementation of RH national programmes The involvement and support of the UNFPA country office is key to sustaining in-country RHCS efforts Investing in the training of country office staff to impart RHCS-related skills is a good strategy to support south-south collaboration while ensuring availability of in-house skills GPRHCS 2008 Progress Report Page 52 Stream 2 – In Asia and the Pacific A. Summary The principal focus of RHCS work in the Asia Pacific region has been on strengthening Universal Access to Reproductive Health Commodities. Much additional work took place in the countries in the region. B. Accomplishments in 2008 National Capacity Building Conducted capacity building workshops in The Maldives on: [•] newly adapted LMIS forms for 29 health workers, one each from Atoll, one each from health care facilities of central and five from Department of Public Health; [•] on operations of the electronic version of LMIS emphasising regular data entry and submission of monthly report from Atoll to central office via email; and [•] fundamentals of LMIS to enhance capacity to analyse and utilise data/information generated by the LMIS system now in place. Additional TA was provided to The Maldives to forecast contraceptive requirement for next 15 years and for the immediate period [2009] with national counterparts. An international consultant from Lao PDR also helped estimate current stocks and wastage of contraceptives providing accurate forecast figures of future requirements. Conducted capacity building workshops in Timor Leste on: [1] inventory records [for 20 districts and national level counterparts]; [2] the introduction/operation of the LMIS software; [3] selected features of LMIS software; and [4] forecasting to UNFPA programme staff [focal point of RHCS]. The LMIS system is now in place. Conducted capacity building regional workshop for participants from nine countries [Afghanistan, Bangladesh, Bhutan, Fiji, Indonesia, Mongolia, Philippines, PNG and Sri Lanka] on CHANNEL and CCM software. Participants gained useful knowledge and skills with many participants returning to their countries determined to pilot and/or improve the logistics system. As a result of these and subsequent efforts, Mongolia now has a tailor-made version of CHANNEL in the Mongolian language. Conducted capacity building through national workshops in Cook Islands, Kiribati, Nauru, Niue and Vanuatu in RHCS, LMIS and forecasting for RH providers and national and provincial pharmacists’ assistants. The International Training Centre of National Family Planning Coordination Board [BKKBN] conducted a Training of Trainers course on a wide range of RHCS components for participants from ten countries [Afghanistan, Bhutan, Fiji, India, Indonesia, Iran, Mongolia, Myanmar, Pakistan and PNG]. UNFPA Jakarta office collaborated with BKKBN to conduct this training. Strengthening Supply Chain systems RHCS Reviews/Situation Analyses were conducted in 13 Pacific Island Countries [PICs] in 2008 with support from UNFPA staff and four consultants. These situation analyses used the SPARHCS methodology and enabled countries to focus on the need for improved supply chain systems, better coordination in- country and increased resource allocation. RHCS reviews were published and presented at the Ministers of Health meeting as the basis for discussion on strategies on the way forward. For three of the countries [Nauru, Niue, Palau], it was the first ever mission for the UNFPA Sub-Regional Office. Prior to 2008, the four small island countries [the three mentioned and Tokelau] only received contraceptives. Developed/revised inventory records [1. requisition and issue, 2. stock registered book; and 3. daily activity register] for implementation and Adapted Logistics Management Information System [LMIS] software to newly adapted inventory records [Maldives] Developed/tested LMIS software and prepared user manual. [Timor Leste] GPRHCS 2008 Progress Report Page 53 Assessment of access to medicines for MNCH and RH, not routinely monitored, critical life-saving medicines for maternal/RH [Oxytocin, Ergometrine and Magnesium Sulphate injection] conducted by a joint mission of WHO and UNFPA. [Lao PDR and Nepal]. Findings of the assessment [and the deficiencies identified] have proved highly revealing to policy makers and programme managers and are being used currently to inform programming choices. Support from national and international consultants was mobilised to support country-initiated activities [e.g. assessment of vertical logistic management systems in support of MNCH package in Lao PDR; system strengthening/building national capacity in Maldives and Timor Leste] and globally-initiated activities [e.g. WHO-UNFPA joint assessment on Access and rational use of RH critical drugs in Lao PDR and Nepal]. Policy and Advocacy In the Pacific in 2008, RHCS Strategic Action Plans were developed for Tonga, Tuvalu, Nauru, Kiribati, Solomon Islands and Cook Islands. In the first two countries these were endorsed at the national level and have been adopted for inclusion in their National RH policies and RH strategies and the latter four are currently undergoing revision for inclusion in their respective policy documents. Four PICs developed National RH Policies and Strategies of which RHCS components were key thematic areas. Ministers of Health Meeting on Universal Access to RH services and commodities for fifteen Pacific Island Countries resulted in increased political advocacy and the endorsement of the Pacific Reproductive Health Policy Framework for Achieving Universal Access to RH commodities and services. Discussions on RHCS were within the context of: [•] strengthening health systems; [•] an integrated approach to RH services and commodities; and [•] ensuring universal access, especially for vulnerable groups. DVDs on Repositioning Family Planning and RHCS were developed and provided substantial opportunities for highlighting issues of importance for ministerial debate and discussion. A set of ten Advocacy Briefs on RHCS was developed, printed and disseminated to country offices of APRO, SROs, other regional offices [RHCS focal persons] and CSB/TD. [APRO Bangkok]. These Briefs, designed to serve as a proto-type for UNFPA Country Offices, were developed with the participation of parliamentarians, senior policy makers and media professionals of selected countries of East and South East Asia. Developing on above Advocacy Briefs, several countries of APRO adapted, translated and disseminated in the country of their own. For example, Mongolia’s advocacy brief was used in the High Level Advocacy Meeting and in the Philippines during an Advocacy Meeting. The Philippines meeting was attended by legislators and advocacy experts [from national and local offices] to equip them with effective advocacy strategies on RH and population management, in support of an RH bill which is opposed by religious groups. In the Pacific, the advocacy briefs were adapted with local data using local examples and were used at the Ministers of Health Meeting in the Pacific. The Advocacy Briefs were adapted using the country data with participation of leading national experts, media champions and parliamentarians. The 2008 Population Data was prepared to establish baseline and monitor RHCS progress in the Asia and the Pacific region. C. Challenges and lessons learned Lessons Learned Crucial need for ownership of proposed activities by government counterpart[s] and continued commitment by country offices. Security breaches and threats impede the implementation of planned activities: in 2008 such reasons caused the postponement of some activities. Given the right opportunities and support, there are talented national professionals whose capacity can be enhanced and used to provide technical assistance at country and regional level GPRHCS 2008 Progress Report Page 54 For commitment from highest level policy makers, a ministerial meeting obtaining signatures for a policy framework resulted in more countries raising the issue in parliament [Solomon Islands and Vanuatu] for a separate budget line for RH commodities. Similarly, the ministerial meeting led to increased awareness within Ministries of Health for Repositioning Family Planning as evidenced by the substantial increase in technical assistance requests for national advocacy and capacity building in Family Planning and RHCS in 2009. A follow-up meeting to the Ministers of Health meeting is needed to develop consolidated National Action Plans to achieve universal access to RH services and commodities and should involve both RH directors and Chief Pharmacists so that an integrated approach can be developed and implemented. Challenges Three areas: national capacity, systems improvement and advocacy Sustaining what has been implemented; continuous monitoring of progress and the provision of supportive supervision Collection of valid and reliable quality data for the baseline Engagement of national professionals and increasing number of Institution for Institute-based training and TA Quality of TA and training provided by consultants and Institutions For small island countries in the Pacific, the poor economies of scale and relative isolation due to infrequent transportation to widely dispersed small populations continues to pose challenges to supply chain management High staff turnover and inability to retain skilled professionals continues to be a major challenge resulting in the need for continual retraining on supply chain management GPRHCS 2008 Progress Report Page 55 Stream 2 – In Latin America and the Caribbean A. Summary The LAC region is well advanced in promoting reproductive health commodity security. If somewhat a victim of its own success [external funding is relatively scarce] examples in the region continue to indicate how others might come to address the diverse challenges of prioritising and mainstreaming RHCS into national health policies, programmes, budgets and plans. The LAC region has enjoyed much support from USAID in recent years and as that begins to fall as the US refocuses and disengages somewhat, UNFPA is helping countries in the region adopt an increasingly strategic approach to RH commodity security – with a particular focus on increased national capacity and durable commodity supply chains and logistics systems. The challenges of working with fractured procurement and in-country supply chains following the decentralisation that often accompanies health sector reform, has led UNFPA to advocate for the strengthening of central mechanisms rather than decentralisation. The LAC region is also beginning to develop approaches to tackle key challenges also seen elsewhere, namely in: [•]countries with persistently low CPR and large unmet needs [Guatemala, Haiti, Peru, many countries in sub-Saharan Africa]; and [•] countries with relatively better socio-economic indicator but alarming gaps between different socio-economic quintiles [Dominican Republic, Nicaragua, United States]. The better targeted policies under development may well come to be of wider application. B. Accomplishments in 2008 1. Providing additional funding and other resources UNFPA provides support to countries to implement information systems that help monitor the national overall stock of RH commodities. When countries have not developed these systems, UNFPA is able to provide technical assistance and tools [Country Commodity Manager – CCM & CHANNEL] to prevent shortfalls in the distribution chain at national level. In 2008, CCM was implemented in El Salvador, Haiti, Nicaragua, Panama, Peru, Dominican Republic and Paraguay. As a result of CCM implementation, Haiti, Nicaragua, Panama and Peru were able to access additional resources as an emergency response to tackle in-country stockouts. During the course of the year, conditions were prepared to implement CHANNEL in Anguilla, Antigua, Barbados, Belize, Bermuda, British Virgin Islands, Dominica, Grenada, Guyana, Jamaica, St. Lucia/OECS, St. Vincent and the Grenadines, Suriname, Trinidad, Ecuador and Nicaragua. 2. Strengthening technical and management capacities In 2008, UNFPA provided technical assistance to build capacity in many Latin American and Caribbean countries. In Venezuela, 22 professionals of Health Ministry were trained on Supply Management and Information Systems, as part of an RH service package initiative designed to reduce family planning unmet needs and maternal death. In Ecuador, in the context of the Maternal and Child Health Care Law, decision-makers, health programme managers from different levels of the Ministry of Health, members of the UNAIDS thematic group and PAHO representatives attended a national training on CHANNEL. Participants explored the advantages of using the tool for monitoring and managing the supply distribution chain. In addition, 10 health professionals participated in a Training of Trainers [TOT] workshop testifying to the MOH authorities about CHANNEL’s capacity and flexibility as a logistics management tool. The Ministries of Health in Bolivia, Nicaragua and 16 Caribbean countries undertook national training with UNFPA support to increase health service capacity to provide and secure RH commodities. The Caribbean focused on data generation about commodity distribution, stock and other logistic-related. Nicaragua made progress in training health personnel to facilitate implementation of an integrated logistics management system and update national GPRHCS 2008 Progress Report Page 56 regulations about Rational Use of Drugs and Medical Supplies. Bolivia strengthened health personnel capacity at local level on logistics after analysing the results of a national assessment. In 2008, UNFPA made an RH costing tool available which has been used for planning and budgeting commodities in Haiti. In Venezuela and Nicaragua the tool was used to help determine financial needs to implement RH services to reduce maternal death. In addition, UNFPA shared a set of instruments that have been used in Bolivia, Venezuela, Nicaragua and Haiti to assess the supply distribution chain. UNFPA also made available a check list on third party procurement. 3. Assisting countries to adopt a strategic approach UNFPA is helping LAC countries [Mexico, Guatemala, Honduras, Nicaragua, El Salvador, Dominican Republic, Venezuela, Ecuador, Peru, Paraguay, Uruguay], develop national strategies on Contraceptive Assurance Availability which aim to increase political commitment and public funding to secure RH commodities. In Ecuador, the MOH has become the largest contraceptive supplier since 2004 reaching a marketshare of about 31% compared to around 24% in 1994. This growth has helped narrowing the contraceptive prevalence rate gap between rural and urban populations. Inequities still prevail though as a high percentage of users from the richest and poorest quintiles access their commodities through public services while 27% population from both quintiles buy their contraceptives at private pharmacies. Since 2005, the Maternal and Child Care Law has suffered from a deficit that reached some US$8 million in 2007. Meanwhile, the MOH procures contraceptives locally at ten times the UNFPA prices. In this context, UNFPA and the MOH signed an agreement to develop a centralised procurement mechanism within the decentralised health system, taking advantage of UNFPA procurement services. This also served to provide technical assistance to introduce new arrangements to improve logistics and management processes, internal control measures, and sanitary registration of new commodities. These improvements are increasing people’s options to select the high quality commodities of their choice. Strategic Approaches: In LAC, countries such as Venezuela, Peru, Uruguay and Bolivia have achieved significant political commitments in support of access to RH services and increasing public investments to this end. Moreover, health authorities in these countries were keen to adopt a more strategic approach to improve the effectiveness and quality of care of the health services provided. UNFPA helped these countries assess their RH programmes with a particular emphasis on the performance and management of the supply distribution chain. The results of Venezuela’s assessment showed the opportunities of improving logistics procedures in support of the implementation of RH service package. In Bolivia, the recommendations highlighted the need to put in place a nationwide computerised tool to help the MOH make better decisions by providing up-to-date information on essential logistic data [stock, consumption]. In Peru, health sector reform is promoting the simplification of supply chain processes and improvement to the information system, warehousing and commodities distribution [which was outsourced until 2005]. In Uruguay, the assessment will be used to design a proposal to tackle the problems affecting the supply chain including the need to strengthen regulations and programme standards. National SRH Strategies: UNFPA is collaborating with the government of El Salvador and Nicaragua in the development of National Sexual and Reproductive Health Strategies [NSRHS] that are then set, in each country, to become the national framework in which RHCS is well-defined as a cross cutting issue. The National SRH Strategy constitutes a regulatory and guidance tool that promotes health equity, proposes reducing RH gaps particularly among the most social excluded populations and provides a wide-range of options to improve people’s quality of life. In short, the NSRHS is a national reference that set up priorities and channels resources to improve the sexual and reproductive health of all citizens. Better targeting: In 2008, UNFPA carried out a mid-term evaluation in seven LAC countries to analyse the current RHCS situation, compare progress and challenges against previous studies and identify where UNFPA may collaborate with countries by improving its strategic positioning and technical assistance. GPRHCS 2008 Progress Report Page 57 Preliminary results highlighted significant progress in CPR and a decline in fertility. These facts notwithstanding, two clear sets of alarming characteristics can be observed: [1] countries with low contraceptive prevalence rates and large unmet needs [Guatemala, Haiti, Peru]; and [2] countries where gaps between different socio-economic groups persist [Dominican Republic and Nicaragua]. In addition, the results highlighted the need to target three groups: adolescents; rural and poorly educated women; and indigenous populations. In order to contribute to addressing the effects of these findings, UNFPA will seek to: [1] ensure relevant and appropriate population groups are involved in the development of poverty reduction strategies, maternal mortality reduction and other health improvement plans; [2] address health services barriers that deter demand, particularly of the poor; [3] incorporate an unmet need indicator into the monitoring framework of family planning programmes; [4] take preventive measures in light of the economic crisis on social programmes; [5] facilitate the development of pooled procurement mechanisms; [6] shape social protection programmes to incorporate RH; [7] have a positive effect on sub-regional integration; and [8] contribute to increasing the marketshare and participation of NGOs and civil society. 4. Promoting innovation and experimentation as learning opportunities In the context of RHCS, UNFPA is tailoring its procurement policies and procedures to increase public investment from LAC countries, particularly considering the phased withdrawal of US support and the constraints countries face when procuring in having to provide 100% upfront payments with supplied many months later 4 . To tackle this situation, UNFPA created a Bridge Fund in LAC which is a revolving fund through which countries pay 50% of a purchase order with the remainder temporarily funded by the fund. Sixty days after receiving the goods countries reimburse the balance. The ceiling has been initially set at US$ 2million. In 2008, the LAC Regional Office launched the female condom [FC] initiative as part of the comprehensive condom programming [CCP] strategy of the UNFPA response to the HIV epidemic. The Female Condom remains the only female-controlled technology that empowers women to protect themselves against either pregnancy or STIs, including HIV. During 2008, in the vast majority of the Caribbean countries, Peru, and Ecuador UNFPA worked with governments and other counterparts to mainstream CCP into reproductive health services. In market segmentation, UNFPA is working with Social Security Institutions in Mexico and Costa Rica. The aim is to ensure social security providers provide the health service package and RH commodities they commit to. The RHCS regional evaluation showed that when services are incomplete users shift to public services further straining the public purse. Moreover, as those insured have demonstrated a willingness and ability to pay, it makes public services less equitable and can impose additional barriers for the poor. An RHCS strategy covering this issues is to be developed in 2009. 5. Contributing to system development RHCS only makes sense when it promotes an integrated programmatic approach between supply and demand improving people’s quality of life and ensuring that every pregnancy is wanted, every birth is safe, every young person is free of HIV/AIDS, and every girl and woman is treated with dignity and respect. With the above mentioned approach in mind, UNFPA has been working closely with RH and HIV national programmes in Ecuador, Peru and Paraguay to promote integrated strategies and programmatic inter-linkages. In Ecuador, UNFPA supported the HIV national programme to design a plan that is divided into three phases: [1] strengthening the supply management chain including CHANNEL implementation, forecasting and procurement; [2] Training on counselling and other RH-related activities; and [3] demand creation. The plan proposes to target six different population groups: youth; people living with HIV and AIDS; men who have sex with men; pregnant women; sex workers; and women of reproductive age with an active sexual life. 4 On this issue, see also the final section on Global initiatives to facilitate RHCS, the section on the Reproductive Health Supply Coalition and particularly the information about the innovative supplies mechanisms: Access RH and the Pledge Guarantee for Health GPRHCS 2008 Progress Report Page 58 In Peru, the focus is on improving women’s access to modern methods and strengthening the capacity of health authorities and civil society organisations to advocate for and up-scale STI/HIV and unwanted pregnancies prevention for women and young female, particularly the most vulnerable. C. Challenges and lessons learned Adolescent fertility is decreasing but still high in many countries and for specific socio-economic groups. These groups have the highest unmet needs for Family Planning. In countries such as Dominican Republic, an inadequate balance of RH providers is affecting the ability of adolescent to get the services they want and need. A market segmentation strategy might help better target this group. NGOs are supplying fewer contraceptives due to lack of funding though they might be effective in targeting specific groups. Market segmentation strategies that put in place incentives to increase NGO and private sector involvement could help tackle inequalities in health. The public sector has a high market share in RH/FP service provision. With financial resources under particular strain [economic downturn, US disengagement], the longer-term sustainability of services requires attention. Stronger and better coordinated alliances and partnerships with non-public providers will need to be scoped out and considered. It is important to explore new procurement arrangements to support market segmentation strategies through Social Security and NGOs. The burden of healthcare falls on public services though the funding is flowing away from MOH budget. Family Planning programmes in LAC are victims of their own success: despite tremendous progress there is reduced political and financial support. The National DAIA Committees have been key in achieving this progress but their future will depend upon their being part of national development frameworks. There is a general need to set standardised procedures and a regulatory framework for RH services. On-going procurement problems are undermining RHCS initiatives in LAC and undermining trust of UNFPA staff and governments. It is important to continue to monitor and map limitations as well as to jointly develop action plans. UNFPA must ensure that it treats procurement services as a client-oriented business where the client entrusts UNFPA with responsibility to supply public goods on their behalf and where they can expect value for money. When problems have occurred contracts mostly cover UNFPA financial liabilities while countries are left with unsolved stock outs. D. Recommendations Increase linkages and programme integration between RHCS and others RH by adopting joint missions, and common programming, management and monitoring arrangements in countries where different UNFPA RH programmes co-exists [MHTF, RHCS, Spain Fund] [Peru, Guyana, Haiti] There is a marked trend in LAC of using the legal arena to deliberate about the legitimacy and legal aspects of SRH topics. This has affected the map of actors and their levels of influence in the decision- making process. Since academic institutions are called to present evidence-based arguments, it is key to form strategic alliances with these institutions. Incorporate RHCS into [1] sub-regional integration mechanisms and [2] cash transference strategies and social protection programmes and monitor potential effects of adverse selection Strengthen regional and sub-regional institutions and networks from 2009 onward Ensure knowledge transfer of UNFPA tools and mandate to academic institutions GPRHCS 2008 Progress Report Page 59 Stream 3 This emergency fund continues to be indispensable in helping countries avoid RH commodity stockouts that would otherwise occur. Humanitarian crises caused by natural or man-made disasters continue to require this crucial source of support. UNFPA is monitoring the requests for Stream 3 support that derive from systemic failures related to poor planning, weak infrastructure and low in-country capacity. Anecdotal evidence suggests that such requests are beginning to fall. Indeed, UNFPA has been using the leverage provided by the fact that it now controls a more substantial, multi- year fund to help countries enhance RHCS to encourage durable action that will, in time, reduce non-humanitarian RH commodity stockouts. In line with the 1985 Memorandum of Understanding between UNFPA and UNHCR and in support of UNHCR’s HIV prevention programmes, UNFPA continues to play an active role to ensure that sufficient supplies of condoms are available to UNHCR programmes in Africa, Asia, the Middle East and Latin America. This collaboration, renewed in 2006, aims to: [•] ensure that refugee and internally displaced populations are included in the UNFPA country needs assessments for condoms; and [•] move towards the sustainable and cost- effective management of condoms at country level, ensuring that displaced populations have equal access to male and female condoms. Condoms are made available in different outlets, such as health centres, clinic for sexually transmitted infections, family planning units, voluntary counselling and testing centres, community services centres, women’s centres, markets, youth centres. In the major repatriation operations [e.g. in Burundi, DRC, Liberia and Southern Sudan] returnees receive condoms as part of the repatriation HIV awareness package. UNHCR continues to be actively involved in the promotion of female condoms in all countries. In 2008, UNFPA provided: 182 million male condoms and 5.25 million female condoms have been distributed to 59 countries under regular commodity support. Nearly 7 million male condoms and 440,000 female condoms provided to UNHCR to distribute to 26 conflict and post-conflict countries. This initiative, which began in 2006, has protected the health of men, women, and children in reaching refugees and internally displaced people. GPRHCS 2008 Progress Report Page 60 Global initiatives to facilitate RHCS Reproductive Health Supplies Coalition: UNFPA continues to play a lead role in the Reproductive Health Supplies Coalition [RHSC]. The increasingly relevant coalition, with over 70 members, is a global partnership made up of multilateral and bilateral organisations, private foundations, national governments, civil society groups and private companies. UNFPA is particularly active in the three working groups through which the Coalition operates, chairing the Market Development Approaches Working Group [since 2005], the Systems Strengthening Working Group [since 2008] and leading one of the three workstreams of the Resource Mobilisation and Awareness Working Group. UNFPA has three of the 12 places on the Coalition’s Executive Committee [UNFPA mandated members and two Working Group leaders] – more than any other Coalition member. In November 2008, UNFPA hosted the annual meeting of the Coalition’s Executive Committee in New York. For more information on the RHSC, please see www.rhsupplies.org. Of particular further interest are: AccessRH, a global procurement mechanism that helps countries and other buyers get the lowest possible price for supplies by allowing them to buy through a master framework agreement with suppliers. The Pledge Guarantee for Health, a global financing mechanism that will allow recipients of international donor assistance to obtain short-term commercial credit by essentially using their pending donor pledges as collateral. Recipients then use that credit to purchase RH supplies when they are needed – rather than wait for donor disbursements to materialise. When disbursements come through, the loan amount and associated costs are then simply deducted at source, with the donor, in effect, paying off the loan. For more information about Access RH and the Pledge Guarantee for Health go to: http://www.rhsupplies.org/working_groups/systems_strengthening/global_financing_and_procurement. html Total Market Initiative, to be piloted in two countries starting shortly, is designed to facilitate and increase the effective delivery of RH supplies. This is to be done by means of a market segmentation exercise involving the in-country stakeholders from the public and non-public sectors involved in the provision of RH/FP services. The aim is to ensure the better use and targeting of resources, in particular to increase access and equity for currently underserved and otherwise marginalised population groups. The overall aim is to ensure that all individuals within the selected country are able to obtain and use the RH commodities of their choice when they need them. The total market initiative will include the segmentation of the total national market in order to reach agreement among service providers as to which population groups they will target with their RH/FP services. For more information about the Total Market Initiative go to: http://www.rhsupplies.org/working_groups/market_development_approaches.html Joint UNFPA-WHO collaboration: This initiative, launched in 2008, is reviewing access to a core set of critical, life- saving maternal/RH medicines [Oxytocin, Ergometrine and Magnesium Sulphate]. In selected countries [Lao, Ethiopia, Nepal and Burkina Faso] joint UNFPA-WHO-MOH fact-finding missions are being carried out. The Lao and Nepal exercises are complete; Ethiopia is carrying out a nationwide EmOC study and in Burkina Faso the activities at the planning stage. RHCS Dashboard: This innovative tool generates information on a range of priority components of RHCS and is, increasingly, being used to monitor and track progress towards commodity security in programme countries. GPRHCS 2008 Progress Report Page 61 Using weighted questions for each of the priority components, UNFPA has developed an overall ‘Reproductive Health Commodity Security Country Status’ score to measure a country’s current overall progress. This web-based tool is to be displayed on a colour-coded map on the UNFPA website, scoring countries based on their level of reproductive health commodity security. Components coloured red require further attention, amber signifies some progress, while green acknowledges the positive current situation. The priority components into which RHCS is divided under the Dashboard are: country office capacity; national coordination; situation analysis and action plan development; policy and government commitment; logistics and supply chains; and access, equity and demand. Advocacy and Communication: At global level, UNFPA initiated a process, in collaboration with a range of partners in the RH Supplies Coalition, to begin work on the development of a consensually defined Global Advocacy Strategy in the sphere of Reproductive Health Supplies. To date, an initial mapping exercise of the current situation [including an analysis of gaps] has been carried out. This foundation is to be used to develop a joint Global Advocacy Strategy which, at the level of individual organisation, will be used, it is hoped to redefine or revisit existing advocacy approaches. This initiative, which UNFPA continues to lead, is now a workstream of the Resource Mobilisation and Awareness Working Group of the RH Supplies Coalition. For more information go to: http://www.rhsupplies.org/working_groups/resource_mobilization_and_awareness/global_advocacy_project.ht ml Within UNFPA, the RHCS section of the UNFPA website underwent a total redesign. Launch of the overhauled website is scheduled for Q1 2009. Country Commodity Manager [CCM]: This simple, easy to use software help to manage and report central warehouse commodity data and, to date, has been installed in 89 countries. In addition, to address in-country needs from central warehouse to district level, UNFPA has developed and is piloting CHANNEL, an easy-to-use computerised logistics management system, in 5 countries: Ethiopia, Tajikistan, St. Vincent/Caribbean, Nicaragua, and Afghanistan. Web-based versions of both CCM and CHANNEL are currently in development. Prequalification of Condom and IUD factories: UNFPA and a number of RH Supplies Coalition partners have been working to promote the prequalification of condom and IUD factories to facilitate the selection of commodities suppliers by country governments, encourage higher volume quality commodities purchases and help reduce costs. To date: 51 Condom factories applied for prequalified status under the WHO/UNFPA scheme; 22 Condom factories have been prequalified, of which ten have a re-inspection pending; there are 9 IUD factories in the WHO/UNFPA pre-qualification scheme; 8 IUD factories have been prequalified of which two have a re-inspection pending. Health Economics and Costing: UNFPA is leading the development of a Unified Health Model involving UNICEF, WHO, World Bank, UNDP, UNAIDS. Formal training sessions were organised for participants from UNFPA, other UN agencies, MOH and MOF in Nicaragua and Mongolia. Direct or supervised support was also provided for: Zambia, Benin, Chad, Ethiopia, Mozambique, Namibia, Rwanda, Zimbabwe, Venezuela, Laos. UNFPA’s costing work has also led to the development of: [•] updated global estimates for fistula prevalence; [•] humanitarian response cost estimates based on regional populations including adjustments for climate change related population migration; and [•] global estimates associated with the screening and treatment of reproductive organ cancers in developing countries. Comprehensive Condom Programming: An initiative that complements the Global Programme and may be seen as an integral part of it is the Global Condom Initiative to intensify comprehensive condom programming [CCP] for HIV prevention and dual protection. Much of the funding for this work comes from the UNAIDS Unified Budget and Workplan [UBW], combining in a Jo

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