The Hashemite Kingdom of Jordan Higher Population Council General Secretariat Contraceptive Security Strategy

Publication date: 2005

The Hashemite Kingdom of Jordan Higher Population Council General Secretariat Contraceptive Security Strategy DRAFT Amman, Jordan November 2005 ii List of Abbreviations and Acronyms DOP Department of the Budget HCY Higher Council for Youth HHC Higher Health Council HPC Higher Population Council FP Family Planning JAFPP Jordanian Association for Family Planning and Protection JCSS Jordan Contraceptive Security Strategy MOE Ministry of Education MOF Ministry of Finance MOH Ministry of Health MOHE Ministry of Higher Education MOP Ministry of Planning MSD Ministry of Social Development NGOs Non-Governmental Organization(s) NPC National Population Council NPS National Population Strategy PSHA Private Sector Health Association RHAP Reproductive Health Action Plan RH Reproductive Health RMS Royal Medical Services TFR Total Fertility Rate UNRWA United Nations Relief and Works Agency The Hashemite Kingdom of Jordan Contraceptive Security Strategy 1. Introduction The Reproductive Health Action Plan (RHAP) for 2003 – 2008 of the Hashemite Kingdom of Jordan defines the nation’s initial strategy for responding to our population’s need for increased quality of reproductive health and family planning services. Most activities under the Reproductive Health Action Plan are conceived as short-term, high impact interventions whose implementation will form the base for a longer-term (2008 – 2020) Strategic Plan for Reproductive Health in Jordan. The RHAP will therefore serve as an important testing ground for deriving best practices, coordinating strategies and high impact responses and as a bridge to the definition of a longer-term vision for the future. As a series of activities and sub activities defined in response to defined objectives, Jordan’s Contraceptive Security Strategy (JCSS) for 2005 – 2008 represents a key element of the RHAP’s first phase of implementation. Less than twenty years ago, Jordan’s annual rate of natural increase ranked among the world’s highest. Today, the rate of natural increase has declined to an estimated annual rate of 2.3 percent. If this rate remains constant, Jordan’s current population of 5.8 million will reach 8 million in 2020, the year on which the Reproductive Health Action Plan’s long-term vision is focused. As an element of the RHAP, the JCSS was developed in response to recognition by His Majesty King Abdullah II Ibn Al Hussein that the nation faced a critical need for a proactive approach for reducing the annual growth of its population. As such activities within both the RHAP and the JCSS were defined to support the emphasis of Jordan’s 2001 revised National Population Strategy (NPS) and its focus on ensuring the continued growth of the nation’s reproductive health program with a foundation based on gender equality and sustainable development. In common with the RHAP, the JCSS should be viewed as an expression of the Government of Jordan’s interest in and commitment to a dynamic and proactive response to the nation’s unmet demand for family planning services. The government will encourage all partners in this effort to view the JCSS as a framework for national and nation-wide coordination of a unified effort to rationalize Jordan’s population growth so that it is consistent with sustainable economic development. Toward that end, as specified in the National Population Strategy, it is anticipated that, by the Year 2020, Jordan will reduce its total fertility rate (TFR) to 2.1 children per married woman of reproductive age. Contraceptive Security is “…achieved when a program is able to forecast, finance, procure, and consistently deliver a sufficient supply and choice of well-made, dependable contraceptives to every person that needs them.”1 Accordingly, in the Jordanian context, the Goal of Jordan’s Contraceptive Security Strategy (JCSS) is to support the Hashemite Kingdom of Jordan’s National Population Strategy (NPS) for 2000-20020 through ensuring that, by 2020, all married men and women of reproductive age will have access to high quality contraceptives in response to their expressed needs. The JCSS is a product resulting from the technical guidance and direction provided by a multisectoral Steering Committee2 whose work was facilitated and closely coordinated by the Higher Population Council (HPC). Development of the JCSS began in April 2004 with an initial draft defined by the Steering Committee in November 2004. Thereafter, the JCSS/HPC Steering Committee provided technical facilitation to a series of retreats, workshops, surveys and discussions whose focus was upon ensuring that the strategy represented a unified consensus of key stakeholders with reference to a realistic approach to the attainment of the goal of contraceptive security in Jordan. As a partner in the HPC’s effort to define a contraceptive security strategy with a truly Jordanian context, the United States Agency for International Development, through its resident POLICY Project, has provided targeted technical assistance throughout all steps associated with the development of the JCSS. 1 Finkle, Clea, Ensuring Contraceptive Supply Security, Outlook, July 2003. 2 Current membership JCSS Steering Committee is drawn from the following agencies and organizations: the Ministry of Health, the Ministry of Finance, the Higher Population Council, the Ministry of Planning, , the Jordanian Association for Family Planning and Protection, The Ministry of Religious Affairs, the Royal Medical Services, the Ministry of Education, the Department of the Budget, and the Higher Council for Youth. 2 2. Situation Analysis of Contraceptive Security in Jordan 2.1 Current Status of Reproductive Health and Family Planning The Hashemite Kingdom of Jordan’s record on many reproductive health issues3 is indeed impressive when judged against other nations in the region: Infant mortality rate is currently estimated at 22.1 per 1,000 births4, more than 94 percent of Jordan’s children are fully immunized and 97 percent of Jordan’s citizens have access to health services. At the same time, Jordan’s reproductive health program emerges to be less positive when the nation’s maternal mortality rate, estimated at over 40 per 100,000 live births, is coupled with the fact that maternal morbidity is listed by Jordan’s Ministry of Health as the second cause for female admissions to hospitals.5 In addition, Jordan’s total fertility rate (TFR) of 3.7 children per woman of reproductive age, calculated as a sum of the age-specific fertility rates in a given year, remains higher than Egypt, Morocco or Tunisia. Moreover, unless decisive action is taken, the TFR will remain the same largely due to the fact the use of modern contraceptives appears to have leveled off at less than 42 percent. 2.3 Current Status of Contraceptive Security in Jordan As estimated by the Population Reference Bureau, less than 43 percent of all married women currently use modern contraceptive methods and 14 percent of all married women’s need for contraceptives is unmet.6 Of those clients using modern contraceptive methods, the 2002 Jordan Population and Family Health Survey estimated that 34 percent receive their contraceptives from the public sector, 28 percent from NGOs, and 38 from the commercial center.7 In terms of actual use of modern contraceptive methods, this same survey concluded that IUD utilization, at 57 percent of all modern method users, is followed by that of oral contraceptives (18 percent), condoms (8 percent), and injectables (2 percent). Utilization of modern methods for the remaining 14 percentage of clients is scattered among a variety of other methods including vaginal creams, tubectomies. Since 1997, the United States Agency for International Development, as the sole provider for the procurement of all contraceptives for Ministry of Health and Royal Medical Service facilities and, through the Ministry of Health, for a number of Non-Governmental Organizations (NGOs), has worked in close collaboration with the Ministry of Health’s Logistics Unit in responding to forecasted needs defined by the Logistic Unit’s Jordan Contraceptive Logistics System (JCLS). Management assessments of Jordan’s public sector logistics system have consistently confirmed the high quality of Jordan’s public sector logistics system in terms of its ability to accurately forecast needs as well as its ability to reliably prevent contraceptive supply shortages throughout its public sector service delivery points. In June 2005, as noted in the foreword to this document, the Government of Jordan, recognizing the importance of contraceptive security to the fulfillment of the National Population Strategy, undertook the challenge to assume total responsibility for contraceptive procurement as of 2008. Accordingly, as indicated in Table 1, starting with the procurement of injectable contraceptives in 2005 for delivery starting in 2006, the Government of Jordan will work with USAID on a phased approach to Jordan’s assumption of procurement responsibilities for all public sector contraceptives by the end of 2008. 3 Information on health care indicators included in this report is drawn from the Report of the Jordan Population and Family Health Survey, 2002, Government of Jordan Department of Statistics, Amman, Jordan, June 2002. 4 For the purposes of this document, infant mortality is defined as the mortality rate for children between the ages of 0-4 years. 5 37 percent of “ever married” women of reproductive age (15-49 years of age) have had a miscarriage, abortion, or experienced a still birth. 6 World Population Data Sheet, Population Reference Bureau, August 2005 7 Jordan Population and Family Health Survey, 2002. 3 Table 1: CONTRACEPTIVE PROCUREMENTS SCHEDULED FOR 2005 - 2008 GOVERNMENT OF JORDAN/USAID PROCUREMENT PHASEOVER PERIOD. Procurement Quantities Per Method Per Procurer PRODUCT: INJECTABLES CONDOMS IUDS ORAL CONTRACEPTIVES YEAR Jordan MOH USAID Jordan MOH USAID Jordan MOH USAID Jordan MOH USAID 2004 17,400 2,100,000 57,204 547,980 2005 31,000 10,000 4,806,000 73,000 449,500 2006 0 2,304,000 2,304,000 38,000 712,800 2007 22,000 4,704,000 46,000 42,000 760,200 2008 25,300 4,800,000 82,000 447,024 404,400 2.3 Impact of Contraceptive Security on Jordan Development In the Government of Jordan’s publication documenting the nation’s Reproductive Health Action Plan (RHAP)8, many of the anticipated benefits of an effective implementation of the RHAP apply equally to that of the RHAP’s Contraceptive Security Strategy. Accordingly, as with the RHAP, we can expect that successful and progressive implementation of the contraceptive security strategy will: • Support and extend Jordan’s progressive increase in life expectancy; • Decrease Jordan’s national and state health care costs associated with professional care, access to hospital beds, and drugs and medical supplies; • Reduce unsettling medical, emotional, and social costs associated with undesired pregnancies, infant mortality and maternal morbidity and mortality; • Support Jordan’s economic growth, with a special emphasis on the reduction of growing population pressure in the use of the nation’s limited national resources in terms of water and arable land; • Promote wider collaboration and understanding on national goals and aspirations among public and private sector entities; • Reduce the impact of population growth on the production of food and cash crops; • Ease the pressures on the educational system associated with population growth; • Increase the amount of individual and family discretionary funding for such items as education, health and improved living standards through a decrease in the dependency ratio; and • Increase the ability of reproductive age women to take advantage of educational and employment opportunities. 2.4 Contraceptive Security in Jordan: Programmatic Issues As stated in the RHAP, the Goal of the National Population Strategy (NPS) is to contribute to a sustainable base for economic development through a gradual decline in population growth and a progressive decrease in the total fertility rate for 3.7 children per woman of reproductive age in 2002 to 2.1 children in 2020. In stating his government’s commitment to the long-term procurement of modern contraceptives, H.E. has clearly recognized the role that the Government will continue to play in ensuring the availability of contraceptives supplies to the client’s utilizing public sector and NGO services. Accordingly, while attention to procurement and logistics issues constitutes a cornerstone of the contraceptive security strategy, program managers responsible for implementing and coordinating the strategy will also be addressing a variety of allied issues. Each of these issues has been identified by the strategy’s steering committee as being of critical importance to ensuring that the availability of contraceptives results in increased utilization and, thereby, a progressive decrease in the nation’s total fertility rate. Among those issues that will be addressed under the strategy are the following: 8 The Hashemite Kingdom of Jordan, Higher Population Council General Secretariat, National Population Strategy: Reproductive Health Action Plan (RHAP), Amman, Jordan, April 2003 4 • Continuing need for reliable data on contraceptive utilization; • Informed collaboration of health care providers in promoting and ensuring contraceptive security and access to methods of choice for all clients; • Lack of current and updated knowledge and information related to the role of the private sector in providing contraceptive services; • Need to ensure sustained government funding for the procurement of contraceptives; • The importance of ensuring that the private sector continues to play a role in ensuring that financial viability of Jordan contraceptive security strategy ; • The need to enhance the role of health insurance providers in promoting and support the nation’s contraceptive security strategy; • The need to ensure sustained nationwide support among providers and clients for Jordan’s contraceptive security strategy; • The need to respond to existing institutional, operational, and social barriers among service providers, program managers and key decision makers with reference to contraceptive security for all Jordanian citizens; • The need to ensure informed support for contraceptive security among Jordanian parliamentarians as a key element of Jordan’s national population strategy; • The need to promote and sustain the National Agenda Committee’s informed support for Jordan’s National Population Strategy and for contraceptive security as a key element of the nation’s response to existing economic, demographic, and environmental challenges; • The need to promote and sustain the Government of Jordan’s informed support for client access to all modern methods as key principle of contraceptive security; • The need to promote and sustain increased informed support for contraceptive security among the Ministry of Awqaf and Religious Affairs and among key religious leaders; • The need to maintain and support continued quality of Jordan’s contraceptive logistics system; • The need to address ways in ensure the quality of Jordan’s contraceptive supplies; and • The need to promote and sustain increased quality of providers’ contraceptive counseling. 5 3. Jordan’s Contraceptive Security: 2006 – 2020 3.1 Jordan’s Contraceptive Security Strategy: 2006 – 2020: Goal As a key element of the nation’s Reproductive Health Action Plan (RHAP) for 2004 – 2008 and of subsequent revisions of the RHAP, Jordan’s Contraceptive Security Strategy focuses on the following long-term (2006 – 2020) Goal: To support the Kingdom of Jordan’s National Population Strategy (NPS) for 2000 – 2020 through ensuring that, by 2020, all married men and women of reproductive age will have access to high quality contraceptive methods in response to their expressed needs. As such, the Contraceptive Security Strategy is closely linked to the RHAP’s goal to establish technical and operational support for the National Population Strategy (NPS) Goal for the Year 2020: To contribute to a sustainable base for economic development through a decrease in the nation’s total fertility rate to 2.1 children per married woman of reproductive age. 3.2 Jordan’s Contraceptive Security Strategy: 2006 – 2008: Components, Objectives, Activities, Key Actors, and Estimated Budget. Based on a review of issues affecting the nation’s ability to respond to its established 2020 goal for contraceptive security, HPC-coordinated steering committee identified objectives, activities and key actors with direct linkage to five of the RHAP’s technical components. At the same time, the steering committee agreed upon an estimated budget for each of the component’s first year of operations. Based on developments during the strategy’s first year (2006) of implementation, the HPC steering committee will work with government and private sector stakeholders to define a budget for the strategy’s 2007 and 2008 interventions. During 2008, the HPC will coordinate a multisectoral review and revision of all six components of the RHAP to include those five components into which the Contraceptive Security Strategy is integrated. In January 2009, it is anticipated that the HPC will implement a revised RHAP for the Years 2009 – 2013. Appendix A of this document provides an overview of the JCSS while Appendix B provides a detailed presentation of each component of the Contraceptive Security Strategy for 2006-2008. The following paragraphs represent a summary of Appendix B. Component 1: Information Systems Development Strategic Objective: To provide for the availability of critical, accurate, and reliable information related to contraceptive technology and Jordan-specific contraceptive utilization in order to enable decision makers, program managers, health care providers and clients to make informed decisions focused in the attainment of contraceptive security within Jordan. Issues: As a priority component for Jordan’s Contraceptive Security Strategy, the Information systems Development Component will address the following issues: the need for reliable data on contraceptive utilization; the importance of ensuring that health system personnel have current technical information to enable them to effectively contribute to the goal of contraceptive security; and the need to establish an information system that will provide accurate data related to both the public and private sector’s contribution to contraceptive security. Activities: As presented in Appendix A, the Information Systems Development Component of the Contraceptive Security Strategy has one primary objective focused on ensuring access to and the appropriate use of information critical to effective implementation of the RHAP’s Contraceptive Security Strategy. The primary focus of the component’s five activities and thirteen sub activities is upon establishing an information base that will allow program managers and service providers from both the public and private sectors to take informed action in support of providing health service clients interests in a sustained and secure access to modern contraceptives. Key Actors: Coordinating responsibility for the Contraceptive Security Strategy’s Information Systems Development Component centers on the Higher Population Council (HPC). The Ministry of Health, joined by representatives of the private sector, is the key agency responsible for the activities’ implementation. Estimated Budget for Year 1 of Component 1: JD 20,686 6 Component 2: Financial Sustainability Strategic Objective: To ensure that current, accurate, and reliable financial data related to contraceptive security in Jordan is available and effectively utilized in order to provide for informed decision-making focused on the long-term financial sustainability of Jordan's contraceptive security program. Issues: As a priority component for Jordan’s Contraceptive Security Strategy, the Financial Sustainability Component will address: the need for sustained funding in support of all elements of the nation’s contraceptive security strategy; the importance of clarifying the financial role of the private sector in support of national contraceptive security; and mechanisms for increasing the role of private health insurance schemes in support of contraceptive security. Activities: In addressing the above issues, the RHAP’s Contraceptive Security Strategy primary objective is to ensure the availability of long-term financial support from both the public and private sectors for Jordan’s contraceptive security strategy. As presented in Appendix A, the Financial Sustainability Component’s three activities and eight sub activities center on ensuring long-term financial sustainability for the contraceptive security strategy through a collaborative approach of the public and private sectors in supporting the anticipated growth of demand for contraceptive. As envisioned by the strategy, it is expected that the nation’s health insurance schemes will play an important role in assisting clients in their need for contraceptive security. Key Actors: Coordinating responsibility for the Contraceptive Security Strategy’s Financial Sustainability Component centers on the Higher Population Council (HPC). The Ministry of Health, the Ministry of Finance, the Department of the Budget, the Ministry of Planning, and representatives of the health insurance industry will join the HPC as partners in implementing this component’s activities. Estimated Budget for Year 1 of Component 2: JD 12,169 Component 3: Advocacy/ Behavioral Change Strategic Objective: To increase awareness, sensitization, and knowledge on contraceptive security issues among decision makers, program managers and health providers and clients in order to promote increased support for ensuring that all clients have sustained access to quality contraceptives in response to their expressed needs. Issues: The RHAP’s Contraceptive Security Strategy, Component 3: Advocacy and Behavioral Change will address: The need to ensure sustained nationwide support for Jordan’s contraceptive security strategy; the need to address operational, institutional and social barriers as they impact on contraceptive security; and the need for on-going financial, legislative, and regulatory support for a sustained contraceptive security strategy. Activities: In addressing the above issues, the Contraceptive Security Strategy’s initial two years focuses attention on the need to advocate for support for the relatively new concept of contraceptive security. Accordingly, as presented in Appendix A, the Advocacy and Behavioral Change Component contains two objectives, one focused on working with health providers and clients and a second focused on parliamentarians and government leaders. As defined, the component’s two activities and twelve sub activities center on identifying target groups for advocacy initiatives and on defining and implementing activities appropriate to each of the identified target groups. The strategy’s design team anticipates that, by the Year 2008, action on this key component will result in increased knowledge and commitment to the Contraceptive Security Strategy by policy makers, program managers, health providers and by present and future clients of Jordan’s family planning programs. Key Actors: Coordinating responsibility for the strategy’s Advocacy and Behavioral Change Component centers on the Higher Population Council (HPC). The Ministry of Health, the Ministry of Education, the Jordan Association for Family Planning and Protection (JAFPP), the Royal Medical Services, the United Nations Relief and Works Agency, and representatives of Medical Syndicates will assist the HPC in implementing one or more of the component’s two activities. Estimated Budget for Year 1 of Component 3: JD 4,750 7 Component 4: Policy Development Strategic Objective: To reduce legal, human resource, financial, cultural, informational and operational barriers in order to increase client access to modern contraceptive methods in response to their expressed needs. Issues: The RHAP’s Contraceptive Security Strategy for Component 4: Policy Development will address: the need to promote the National Agenda Committee’s consideration and understanding of the Contraceptive Security Strategy as a mechanism for effectively reducing the nation’s total fertility rate; the need to promote parliamentary action related to contraceptive security; the lack of wide-spread government support for client access to all modern contraceptive methods; and the need for increased policy-level work with religious leaders focused on ensuring their support for contraceptive security. Activities: In addressing the above issues, the Contraceptive Security Strategy focuses, like the RHAP, on the progressive reduction of policy barriers that negatively affect the nation’s ability to succeed in meeting the National Population Strategy’s goal for 2020. As presented in Appendix A, the Policy Development Component for Contraceptive Security contains two objectives whose four activities are further broken down into twelve sub-activities. As defined, the component’s activities center on Jordan’s new National Agenda Committee’s recognition of the importance of contraceptive security to the nation’s development goals, on promoting Parliament’s formal recognition of contraceptive security as a national-level policy, on clarifying government policy so as to increase client access to all modern contraceptive methods, and on working on a program designed to promote an expanded role for religious leaders in supporting contraceptive security as a national priority. The strategy’s design team anticipates that, by the Year 2008, action on this component will result in a significant increase in the level of informed political support for the Contraceptive Security Strategy, in increased client access to modern contraceptive methods, and in an increase in contraceptive utilization linked to a reduction in current unmet need related to access and utilization of modern contraceptives. Key Actors: Coordinating responsibility for the Contraceptive Security Strategy’s Policy Development Component centers on the Higher Population Council (HPC). In its implementation, the HPC will be joined principally by the Ministry of Health, the Jordan Association for Family Planning and Protection (JAFPP), and by the Ministry of Awqaf and Religious Affairs. Estimated Budget for Year 1 of Component 4: JD 39,592 Component 5: Coordination Strategic Objective: To optimize the utilization and effective coordination of public and private sector resources in order to promote sustained contraceptive security for all health service clients. Issues: The RHAP’s Contraceptive Security Strategy, Component 5: Coordination will primarily address the need to define and monitor the application of public, private, and NGO sector roles and responsibilities in support of Jordan’s contraceptive security strategy. Activities: In addressing the above issue, Jordan’s Contraceptive Security Strategy focuses on the single objective of defining and implementing a mechanism to maintain public, private and NGO sector linkages essential to the support of Jordan’s long-term contraceptive security goal. As presented in Appendix A, the component’s single activity and four sub-activities are scheduled to be activated in 2007 following the initial implementation of the other five components’ activities in 2006. Key Actors: Coordinating responsibility for the Contraceptive Security Strategy’s Coordination Component centers on the Higher Population Council (HPC). It is anticipated that a broad-based coalition of public, private, and NGO sector stakeholders will work with the HPC in addressing this component’s activities starting in early 2007. Estimated Budget for Year 1 of Component 5: No budget is proposed for this activity in 2006. 8 Component 6: Service Access Strategic Objective: To provide for the availability of high quality modern contraceptive methods, care, and counseling in order to ensure that all clients have reliable and sustained access to contraceptives in response to their expressed needs. Issues: In the RHAP’s Contraceptive Security Strategy for 2006 – 2008, Component 6: Service Access will address: the need to strengthen, standardize, and maintain the contraceptive security logistics process including procurement, warehousing, distribution, and supply chain management; the need to ensure quality control related to modern contraceptives available to the Jordanian public; and the need to improve and maintain the quality of provider counseling on modern contraceptive methods. Activities: In addressing the above issues, the RHAP’s Contraceptive Security Strategy focuses both on the mechanics associated with contraceptive procurement and logistics and on the delivery of contraceptive services. As presented in Appendix A, the Service Access Component is comprised of one whose seven activities are further broken down into thirty-three sub-activities. As defined, the component’s activities center on addressing management needs associated with Jordan’s assumption of responsibility for contraceptive procurement and for contraceptive quality assurance. In addition, the service access component address the need to ensure that Jordan’s highly developed logistics system maintains its current high-quality standards and that health workers responsible for maintaining the logistics system are adequately trained and provided with periodic in-service logistics training opportunities. Finally, in the interest of increasing demand and on reducing contraceptive discontinuation rates, four of the service access component’s sub activities respond to the need to improve the quality of contraceptive counseling method currently available to health service clients. Key Actors: Coordinating responsibility for the RHAP’s Service Access Component centers largely on both the Higher Population Council and on the Ministry of Health. In the implementation of activities included under this component, the HPC and the MOH will share responsibility with the Jordan Food and Drug Agency (JFDA), the Jordan Association for Family Planning and Protection (JAFPP), the Royal Medical Services, the United Nations Relief and Works Agency, the Ministry of Higher Education, Jordan University, and representatives of Medical Syndicates and medical institutions. Estimated Budget for Year 1 of Component 6: The 2006 budget, largely for in-service logistics and contraceptive counseling training, is estimated at JD 83,195. Moreover, the budget for this component should be considered as a supplementary budget that does not include recurrent costs for system maintenance items associated with staffing and with contraceptive logistics. Finally, in estimating the cost for 2006, an additional amount of JD 63,000 will need to be budgeted for the procurement of condoms. A Appendix A. The Jordan Contraceptive Security Strategy (JCSS): Overview by Component, Component Strategic Objective, Major Issues Addressed, Estimated Budget for Year 1 Activities, Verifiable Indicators, and Principal Assumptions and Risks. Preface to Appendix A Table 1: Reproductive Health Action Plan (RHAP): Jordan Contraceptive Security Strategy: Phase 1 (JCSS): 2006 – 2008: Overview summarizes the more detailed Contraceptive Security Strategy provided in Appendix B. As such, the overview consolidates the JCSS’s information in a two page summary centered on providing the reader with a general understanding of the JCSS’s intended direction during its initial three year start-up phase. Developed from the perspective of the JCSS’s six components, the overview focuses on the following technical details: ƒ Each of the JCSS’s six components was designed to respond to specific strategic objectives which were, in turn, defined and developed with reference to existing program issues; ƒ Budgets for each component provide costs estimates for activities scheduled for completion within the JCSS’s first year of operations;; ƒ For each component, the JCSS summary lists verifiable indicators for use in measuring the program managers’ periodic progress toward expected JCSS results; and ƒ Finally -and again for each component - the JCSS lists assumptions and risks associated with the achievement of progress toward each specific strategic objective. Assumptions are those events or expectations that are essential to a component’s success but which are beyond the control of the strategy’s managers or service providers. Risks are those considerations which managers and service providers should take into consideration when working toward completing activities associated with each component. B Appendix B. Jordan’s Contraceptive Security Strategy (JCSS): Component Strategies by Objectives, Activities, Timing, Location, Estimated Funding Needs, Output Indicators, and Assumptions Preface to Appendix B As discussed in the body of this document, Jordan’s Contraceptive Security Strategy (JCSS), as part of the National Population Strategy (NPS) 2000 - 2020 : Reproductive Health Action Plan (RHAP) documents a multi-sectoral, participatory approach focused on ensuring that contraceptive security becomes a reality for all clients with the NPS’ twenty-year timeframe. With reference to the attached detailed strategy (Appendix B: Table 2), the following can be noted: ƒ Each of the JCSS’s six components was designed to respond to specific objectives that were, in turn, defined and developed with reference to existing strategic issues.; ƒ As indicated in the Table 2, the strategy’s design team and other key stakeholders have designated a responsible authority to coordinate each activity. At the same time, the strategy identifies those ministries and other entities whose role will focus on implementing a sub- activity. While this designation of responsibility is a result of negotiations with representatives of the Government of Jordan’s ministries, it is understood that the large majority of the activities will call for mutisectoral contributions from both private and public sectors. Toward that end, the Higher Population Council will serve as a facilitator in providing administrative support focused on ensuring a coordinated approach to the action plan’s integrated implementation; ƒ While responsibility for managing and overseeing the JCSS’s implementation rests, by necessity, with central level authorities, responsibility for actually implementing many of the JCSS’s activities will eventually devolve on state or local authorities. In such instances, the RHAP/JCSS/HPC Steering Committee will work within the JCSS’s first year in integrating the role of Governorate officials into the JCSS; ƒ Budgets for the JCSS’s first year of operations are provided in Table 2. Coordinating and implementing agencies will develop budgets for subsequent years as information becomes available and as progress on activities is achieved; ƒ For the purpose of monitoring progress over the JCSS’s first three years (2006 – 2008) of implementation, the JCSS further suggests indicators of outcome and output for each activity: An Output is a measurement of largely short-term quantifiable results associated with the completion of each activity while an outcome is a measurement of the more important effect of an activity’s long-term impact upon an identified issue; and ƒ Finally, where appropriate, the JCSS lists observations and assumptions that are intended to provide guidance to those individuals responsible for implementing the strategy’s activities and sub activities. C Appendix C. The Reproductive Health Action Plan: Contraceptive Security Strategy for 2006 –2008 Preface to Appendix C As an integral part of the development of the Hashemite Kingdom of Jordan’s Reproductive Health Action Plan, the following analysis of illustrative quantitative indicators, developed by the RHAP Task Force, is intended to serve as a technical pathway to guide program managers as they monitor the RHAP’s progress toward established outputs and outcomes. While the summary of quantitative indicators is based on internationally accepted standards, it is important to note that the summary is based on data that is currently available or on data for which future information is expected to be available. Consequently, as the RHAP progresses in its implementation, program managers will need to adjust expectations on the indicators and the indicators themselves. Summary of RHAP Quantitative Indicators for 2003 - 2007 Narrative Illustration Monitoring and evaluation are usually integrated elements of any strategy. They are the tools for assessing the impact of the strategy and its progress towards achieving its goals. Qualitative and quantitative indicators are common instruments for monitoring and evaluation. Accordingly, it is imperative to carefully select these indicators as they will serve as the primary means to assess the program’s progress both during and at the completion of strategy’s implementation. In determining and selecting relevant indicators, program managers are guided by the consensus on key indicators among experts in the field and by the availability of current information focused on the time period within which the initiatives are expected to be completed. The RHAP includes qualitative and quantitative indicators that are linked to each of the 130 activities adopted in the plan. These indicators were defined to measure the outcomes and outputs of the RHAP activities that will be implemented according to a timely schedule. Moreover, the National Population Strategy (NPS) specifies quantitative indicators for the base year and for selected future target years within the RHAP’s own timeframe of 2003 – 2007. Therefore, the purpose of this brief annex is to show the technical linkages between the achievement of the NPS’ quantitative objectives and indicators and the implementation of the activities included in the first phase (2003 – 2007) of the RHAP. It is worth mentioning that the strategic goal of the NPS is to reduce the population growth rate to become compatible with Jordan’s resources and supportive to the achievement of its sustainable development that will meet the need of current generations without sacrificing the rights of future generations. Since fertility is the most important factor in determining Jordan future population growth, the RHAP quantitative indicators will focus on this component. As for the mortality component, it accepts one universal policy, i.e., the reduction in mortality level. On this measurement, it is important to note that, as mortality rates may increase due to the change in the age structure of the population brought about by a decline in fertility decline, a slightly accelerated decline in the rate of natural increase and consequently in the population’s growth rate will most likely also result. In the next section, we present the RHAP quantitative indicators and targets for the years 2003-2007. We are limiting ourselves to the indicators that are universally accepted and for which future information will be available. The base year (2002) was selected because it coincides with the Jordan 2002 DHS, which is the main and most recent source of information. It is expected that another DHS will take place in 2007, the final year of the RHAP’s first phase. This will provide the necessary information for evaluating the overall impact of the NPS on Jordan population trends. Some of the indicators listed below are linked to end and strategic goals, while others are linked to intermediate objectives whose achievement will help realize the strategic goals. For example, raising the contraceptive prevalence rate is an intermediate objective and not an objective by itself. It is a means for achieving a strategic objective by reaching a lower fertility rate in the future and consequently a lower rate of natural increase. The reason we are presenting the RHAP quantitative indicators in an annex is that, in contrast to qualitative indicators, it is not easy to link quantitative indicators to a specific activity or component in the RHAP. That is, the D anticipated changes in these indicators over the RHAP years are in fact the overall result of the totality of all activities included in the RHAP and not necessary the result of an activity or set of activities within a specific component. Accordingly, the following listing of linkages are intended to convey the concept that action within a specific component may influence but will not be wholly responsible for changes in specific rates or ratios: • Component 1: Information Systems Development: Increased Contraceptive Prevalence Rate; Reduced Maternal Mortality Ratio • Component 2: Financial Sustainability: Increased Contraceptive Prevalence Rate; Reduced Infant Mortality Rate and Maternal Mortality Ratio • Component 3: Advocacy/ Behavioral Change: Reduced Total Fertility Rate, Rate of Population Natural Increase, and Shortly Spaced Births • Component 4: Policy Development: Reduced Total Fertility Rate, Rate of Population Natural Increase, Maternal Mortality Ratio, and Unmet Need for Family Planning • Component 5: Coordination: Reduced Total Fertility Rate, Rate of Population Natural Increase, and Infant Mortality Rate • Component 6: Service Access: Increased Contraceptive Prevalence Rate; Reduced Total Fertility Rate, Infant Mortality Rate and Maternal Mortality Ratio; Increased Life Expectancy at Birth. Similarly, as indicated in Table D1, we can expect that, based on current progress on reproductive health issues with the Hashemite Kingdom of Jordan, we can expect that implementation of the RHAP will contribute to the achievement of quantitative targets incorporated into the nation’s National Population Strategy. Table of Major Quantitative RHAP Indicators for 2003-2007 Objective-Based Indicator Base Year 2002 2003 2004 2005 2006 Target Year 2007 Strategic Total Fertility Rate (births per woman) 3.7 3.6 3.5 3.4 3.3 3.2 Rate of Population Natural Increase (%) 2.44 2.38 2.32 2.27 2.21 2.15 Life Expectancy at Birth (years) 69.9 70.2 70.6 70.9 71.2 71.6 Infant Mortality Rate (per 1,000 births) 27.0 26.5 25.9 25.4 24.8 24.3 Maternal Mortality Ratio (per 100,000 births) 41.0 40.2 39.3 38.5 37.6 36.8 Intermediate Contraceptive Prevalence Rate (%) 55.8 57.0 58.2 59.3 60.5 61.7 Unmet Need for Family Planning (%) 13.9 13.1 12.3 11.5 10.7 9.9 Unplanned Births (%) 33.1 32.3 31.5 30.8 30.0 29.2 Shortly Spaced Births (%) 62.6 60.5 58.4 56.4 54.3 52.2 Notes: Except for maternal mortality ratio figure, which was taken from the latest MoH Annual Statistical Report, all base year figures were taken from the Jordan 2002 DHS. Total Fertility Rate for the years 2003-2007 are taken from Jordan FamPlan Model for 2002-2020 (file jscs.pjn) where fertility rates are set according to the NPS fertility goals. Rate of Natural Increase for the base year (2.44) = Crude Birth Rate (29 as in 2002 DHS) – Crude Death Rate (4.6 taken from Jordan DemProj Model for 2002-2020. The rate for the years 2003-2007 was interpolated according to Jordan DemProj Model results for 2002-2020 Life Expectancy at Birth for 2003-2007 is taken from Jordan DemProj Model for 2002-2020 Infant Mortality Rate for the years 2003-2007 is projected according to the relevant NPS goal. Maternal Mortality Ratio for the years 2003-2007 is projected according to the relevant NPS goal. Contraceptive Prevalence Rate (CPR) for the years 2003-2007 is projected by Jordan FamPlan Model for 2002- 2020. The Model projects CPR needed to achieve the NPS fertility goals for the corresponding years taking into account other proximate determinants of fertility. Unmet Need for Family Planning, Unplanned Births, and Shortly Spaced Births for the years 2003-2007 are projected based on the inter-DHS 1997-2002 trends. List of Abbreviations and Acronyms 1. Introduction 2. Situation Analysis of Contraceptive Security in Jordan 3. Jordan’s Contraceptive Security: 2006 – 2020 Component 1: Information Systems Development Estimated Budget for Year 1 of Component 1: JD 20,686 Appendix A. The Jordan Contraceptive Security Strategy (JCSS): Overview by Component, Component Strategic Objective, Major Issues Addressed, Estimated Budget for Year 1 Activities, Verifiable Indicators, and Principal Assumptions and Risks. Appendix B. Jordan’s Contraceptive Security Strategy (JCSS): Component Strategies by Objectives, Activities, Timing, Location, Estimated Funding Needs, Output Indicators, and Assumptions Appendix C. The Reproductive Health Action Plan: Contraceptive Security Strategy for 2006 –2008

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