The SPARHCS Process Guide - A Planning Resource to Improve Reproductive Health Commodity Security

Publication date: 2008

A Planning Resource to Improve Reproductive Health Commodity Security The SPARHCS Process Guide English, Spanish, and French language versions of this publication are available in print copy and on the World Wide Web at and http:// They are also included as editable electronic files on the accompanying CD-ROM. The recommended citation for this publication is: Rao, Raja; Olson, Nadia; Bornbusch, Alan (ed.); and Pilz, Kevin (ed.). 2008. The SPARHCS Process Guide: A Planning Resource to Improve Reproductive Health Commodity Security. Baltimore, MD: Information and Knowledge for Optimal Health (INFO) Project/Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health. © Information and Knowledge for Optimal Health (INFO) Project, Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health. All rights reserved. Organizations may reproduce or translate this publication, in whole or in part, for noncommercial purposes, provided the following notice appears with any such reproduction: “From The SPARHCS Process Guide: A Planning Resource to Improve Reproduc- tive Health Commodity Security. Copyright © 2008 INFO Project, Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health. Used by Permission.” The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The Johns Hopkins University and USAID do not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. This publication contains the collective inputs of an international group of experts and does not necessarily represent the decisions, the stated policy, or the views of The Johns Hopkins University or USAID. The SPARHCS Process Guide A Planning Resource to Improve Reproductive Health Commodity Security 2008 THE SPARHCS PROCESS GUIDE Preface The Strategic Pathway to Reproductive Health Commodity Security (SPARHCS): A Tool for Assessment, Planning, and Implementation has been applied in more than fifty countries to help improve the availability of reproductive health commodities. Used initially to assess the reproductive health commodity security (RHCS) status in countries, its use has evolved to support a broader process for advocacy, strategic planning, and implementation. Consequently, a need has arisen for guidance on how to use the SPARHCS Tool for this wider purpose. The SPARHCS Process Guide synthesizes the extensive field experience with the SPARHCS Tool to provide guidance to programs to customize RHCS assessments and planning. Program managers, technical assistance providers, and donors are encouraged to use the Guide as a companion to the SPARHCS Tool to develop a comprehensive policy and programmatic response to the RHCS challenge. ii A PlAnnInG RESOURCE fOR THE SPARHCS TOOl Contents Acronyms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. The SPARHCS Process and Framework. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Pre-Process Planning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1 Determine the Rationale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2 Product Focus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3 Setting Expectations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4 Identifying Available Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Awareness Raising. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. Joint Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1 The Major Steps of a Joint Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2 Adapting the SPARHCS Framework and Diagnostic Guide. . . . . . . . . . . . . . . . . . . . . . 5.3 Successful Approaches to the Joint Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.4 Tip Sheet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. Strategic Planning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1 Why is an RHCS Strategic Plan Important?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2 The Essential Elements of a Strategic Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. Implementation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.1 Political Will - The Leadership Factor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.2 Detailed Work Planning - Turning Strategy into Action. . . . . . . . . . . . . . . . . . . . . . . . . 7.3 Program Integration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. Three Model SPARHCS Processes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Model 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Model 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Model 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendices. Appendix A: Countries Where the SPARHCS Tool Has Been Applied. . . . . . . . . . . . . Appendix B: Sample Terms of Reference for an RHCS Coordinating Committee . . Appendix C: Sample RHCS Data from Desk-Based Research. . . . . . . . . . . . . . . . . . . . . . . . Appendix D: SPARHCS Assessment Tables and Graphs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix E: Select Actions from the Malawi RHCS Strategic Plan . . . . . . . . . . . . . . . . . . Appendix F: Sample RHCS Monitoring and Evaluation Plan. . . . . . . . . . . . . . . . . . . . . . . Appendix G: Work Plan Indicators from the Nigeria RHCS Strategy. . . . . . . . . . . . . . . . Appendix H: For Further Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii iv v vi 1 3 5 6 6 7 7 8 11 12 17 19 20 21 21 22 25 26 26 28 29 30 30 31 32 33 35 35 35 36 37 38 39 41 inside back cover THE SPARHCS PROCESS GUIDE Acronyms AIDS – Acquired Immunodeficiency Syndrome ACQUIRE - Access, Quality, and Use in Reproductive Health Project BKKBN – Badan Koordinasi Keluarga Berencana Nasional (Indonesian Population and Family Information Network) CA – USAID Cooperating Agency CPR – Contraceptive Prevalence Rate CPT – Contraceptive Procurement Table CSI – Contraceptive Security Index CYP – Couple Years of Protection DFID – Department for International Development DHS – Demographic and Health Survey ECOWAS – Economic Community of West African States EDL – Essential Drugs List EML – Essential Medicines List FGD – Focus Group Discussion FMIS – Financial Management Information System FP – Family Planning GFATM – Global Fund to fight AIDS, Tuberculosis, and Malaria HIV – Human Immunodeficiency Virus HPI – USAID | Health Policy Initiative IEC – Information, Education, and Communication IMR – Infant Mortality Rate INFO – Information and Knowledge for Optimal Health Project IPPF – International Planned Parenthood Federation IUD – Intrauterine Device IWG – Interim Working Group (now called the Reproductive Health Supplies Coalition) KfW – Kreditanstalt für Wiederaufbau (German Bank for Reconstruction) LAC – Latin America and the Caribbean LMIS – Logistics Management Information System LSAT – Logistics System Assessment Tool M&E – Monitoring and Evaluation MMR – Maternal Mortality Rate MOF – Ministry of Finance MOH – Ministry of Health MOHP – Ministry of Health and Population MSA – Market Segmentation Analysis iv A PlAnnInG RESOURCE fOR THE SPARHCS TOOl MSH – Management Sciences for Health NRHP – National Reproductive Health Policy NGO – Non-Governmental Organization PRSP – Poverty Reduction Strategy Paper RH – Reproductive Health RHCS – Reproductive Health Commodity Security RHCSAT – Reproductive Health Commodity Security Analysis Tool RHS – Reproductive Health Survey SDP – Service Delivery Point SPARHCS – Strategic Pathway to Reproductive Health Commodity Security SSI – Social Security Institute STI – Sexually Transmitted Infection SWAp – Sector Wide Approach TFR – Total Fertility Rate UNFPA – United Nations Population Fund USAID – U.S. Agency for International Development WAHO – West Africa Health Organization WHO – World Health Organization Acknowledgements Numerous organizations and individuals contributed to the development of this guide, with the U.S. Agency for International Development (USAID) providing both funding and tech- nical direction. The support that USAID, the United Nations Population Fund (UNFPA), and others have provided for RHCS activities over the past several years have made possible the wealth of experiences, data, and guidance presented in this publication. The USAID | DELIVER Project (John Snow, Inc. and partners) led the research and writing for this guide. Several organizations supported that effort by sharing a wealth of RHCS assessments, strategic plans, and analyses, and contributing thoughtful editorial comments and technical content. These groups include the Private Sector Partnerships-One Project (Abt Associates, Inc. and partners), Task Order 1 of the USAID | Health Policy Initiative (Constella Futures and partners), and the Access, Quality, and Use in Reproductive Health (ACQUIRE) Project (EngenderHealth and partners), and UNFPA. The principal authors of this publication are Raja Rao and Nadia Olson from the USAID | DELIVER Project. Alan Bornbusch and Kevin Pilz from USAID also helped draft early versions of the guide, and provided invaluable editorial and technical input throughout the process. The following individuals reviewed various drafts and contributed greatly to this publication: Graciela Avila, Paul Dowling, Parfait Edah, Marguerite Farrell, Jay Gribble, Colleen McLaughlin, Elaine Menotti, Barbara O’Hanlon, Leslie Patykewich, Caroline Quidaja, Tanvi Pandit-Rajani, Greg Roche, Tim Rosche, Suneeta Sharma, Gary Steele, Marie Tien, Jane Wickstrom, and Susan Wright. Staff of the INFO Project at the Johns Hopkins Bloomberg School of Public Health, Center for Communication Programs provided design, production, and dissemination services. v THE SPARHCS PROCESS GUIDE Executive Summary The Strategic Pathway to Reproductive Health Commodity Security: A Tool for Assessment, Planning, and Implementation (herein, the “SPARHCS Tool”) was published in 2004 to provide an adaptive strategic approach to assessing and strengthening reproductive health commodity security (RHCS). The SPARHCS Tool has inspired a number of distinct meth- odologies for assessing RHCS, determining priorities, and using findings from assessments to develop and implement strategic plans. However, there is limited documentation of how the SPARHCS Tool has been adapted to different country environments or how these differ- ent approaches were used to improve RHCS. The purpose of the SPARHCS Process Guide is to fill the information gap by describing how stakeholders can use the SPARHCS Tool as a framework for identifying and prioritizing key RHCS issues, use and adapt the Tool, and carry out a process to plan and implement RHCS strategic plans. The Guide provides real world examples and options on how to use the program planning cycle to guide the SPARHCS process – a set of activities from awareness raising and diagnosis, to monitoring the effectiveness of a funded and implemented strategic plan. This Guide is intended for use by program managers, consultants, and technical assistance providers to assist them in carrying out the SPARHCS process. This Guide should be used as a companion to the SPARHCS Tool. An examination of the tool together with a review of this Guide will help users understand the complex, overlapping systems and programs involved with RHCS and how to set in motion a process to improve it. The SPARHCS process uses the program cycle (planning-implementation-monitoring and evaluation) to improve RHCS planning and implementation. It emphasizes the processes and options for carrying out RHCS assessments and developing multi-partner strategic plans. It also includes guidance on improving awareness, prioritizing issues, and implementing and monitoring activities. The Guide shows how the SPARHCS process can be used to address one or all of the elements in the cycle, while emphasizing the need to carry out the process through the implementation stage. Before the process is started, stakeholders are advised to achieve consensus and resolve ques- tions on specific subjects such as defining the rationale for improving RHCS (e.g., is the country or region facing donor phase-out, unusually high unmet need, or system weakness- es?); the priority categories of RH products, short and long-term expected results, and the current and anticipated amount of available funding to plan and implement activities. Though several different adaptations to the SPARHCS process have achieved results, evidence from the use of the SPARHCS Tool and strategic planning exercises indicate that progress is more likely to be achieved when each element of the program cycle is addressed in the following order: 1. Awareness Raising – Awareness raising is usually the entry point for the SPARHCS process. Sensitizing stakeholders to the major gaps and potential solutions to RHCS challenges they face, and obtaining political and financial commitment to carry out a joint diagnosis and strategic planning exercise are important precursors to rolling out a funded implementation plan. Use of the vi A PlAnnInG RESOURCE fOR THE SPARHCS TOOl SPARHCS framework, inclusion of local issues, and demonstrating how existing programs and systems can be leveraged for RHCS are important awareness- raising tools. 2. Joint Diagnosis – The joint diagnosis (joint assessment) is carried out follow- ing awareness raising to help stakeholders understand and document the RHCS gaps and strengths. The diagnostic guide in the SPARHCS Tool presents a series of questions designed to assess each of the SPARHCS components (capital, coordination, client utilization, capacity, commitment, context, and commodities). An RHCS coordinating committee is formed to support and participate in the joint diagnosis and later serves to manage the development of the strategic plan. Options in the joint diagnosis include desk-based research, key informant interviews, and stakeholder workshops. The findings should be presented to the RHCS committee and support the strategic planning process. 3. Strategic Planning – A multi-sectoral strategic plan is the next step in the SPARHCS process following the joint diagnosis. The joint diagnosis identifies RHCS strengths and weaknesses. The planning process begins by defining a goal. It then defines priority issues and strategic objectives, activities, roles and responsibilities of partners; estimates budget requirements; and develops relevant output and outcome indicators. The RHCS committee should form a smaller technical working group to develop the strategy, which may take from 4 – 12 months, depending on how regularly they meet. 4. Implementation – Implementation is where many strategic plans fail. Over- coming this challenge requires political and financial commitments from the public and private sectors and development partners. Successful implementation also requires significant coordination between programs and a willingness of partners to develop joint work plans and commit to routine monitoring and evaluation of activities. There are numerous methodologies that can be employed to address each of the program cycle elements of the SPARHCS process. Available financing, technical resources, and the scale of the challenge must all be considered when determining which process makes the most sense. Users can review the models to gain ideas for how the SPARHCS process can be adapted and implemented for their situations. The Guide offers three model processes which represent different levels of investment in the approach. Model 1 can be used when there is limited financing for the process and established consensus on the main RHCS gaps in the country. Models 2 and 3 represent more intensive effort and require more resources, but will result in a more descriptive diagnosis and detailed strategic plan. The process to achieve RHCS is complex, resource intensive, and time consuming, and therefore requires deliberate planning and sustained commitment. The SPARHCS process is a well-tested and successful approach that helps manage this complexity, and allows stake- holders to take a strategic view of the RHCS challenges they confront. vii THE SPARHCS PROCESS GUIDE 1 Introduction The Strategic Pathway to Reproductive Health Commodity Security: A Tool for Assessment, Plan- ning, and Implementation (the SPARHCS Tool) has been used extensively to help improve Reproductive Health Commodity Security (RHCS). RHCS is defined as a situation in which women and men can choose, obtain, and use quality reproductive health (RH) commodities when and where they need them. The “SPARHCS process” attempts to measurably strength- en RHCS through attention to each phase of the cycle of RHCS activities — from awareness raising to monitoring the effectiveness of a funded and implemented strategic plan for RHCS. Typically, the tool is used to frame activities at each phase and to guide strategic planning. In most instances, stakeholders have used the tool to carry out RHCS assessments of family planning or broader RH supply programs. An RHCS assessment (or joint diagnosis), which is a collaborative and multi-sectoral effort to assess the RHCS situation, has often served to catalyze a comprehensive approach to improve RHCS. The SPARHCS Tool has been used in more than fifty countries (Appendix A). This experi- ence demonstrates that the tool can be adapted for the objectives, resources, and constraints of any country or program. A number of different methods have been used to assess RHCS, determine priorities, and use findings from the assessment to develop and implement strategic plans. However, limited published documentation exists that examines how these different SPARHCS-based methodologies or processes were used to meet stakeholder objectives or how the SPARHCS Tool has been successfully adapted to a range of different country environments. This Guide aims to fill that information gap. It draws from experiences at the country and regional levels to show how the SPARHCS Tool and approach can be used to: • Establish, maintain, and increase RHCS awareness • Carry out regional, national, or local RHCS assessments (joint diagnoses) 1 A PlAnnInG RESOURCE fOR THE SPARHCS TOOl 2 • Establish consensus on RHCS priorities • Develop a multi-partner RHCS strategic plan • Support RHCS strategic plan implementation and related monitoring and evaluation Not all of the components in the SPARHCS process are addressed equally here. The Guide emphasizes RHCS assessment and strategic planning – the two components where guidance has been most requested, and where the field experience is most extensive. This Guide is intended for use by program managers, consultants, and technical assistance providers to assist them in carrying out the SPARHCS process. The Guide can also be used by donors and policy makers to plan the kinds of activities that they can support to strength- en RHCS. This Guide should be used as a companion to the SPARHCS Tool. An examina- tion of the tool and a careful review of this Guide will help users understand why RHCS is important and how to set in motion a process to improve it. Achieving RHCS is a complex and resource-intensive process requiring multi-sectoral col- laboration and coordination at many levels. This Guide reflects that complexity by providing extensive guidance and numerous practical examples. Audiences are encouraged to routinely consult the Guide as a reference when implementing the SPARHCS process. This Guide is organized into nine sections: • Section 2 describes implementation of the SPARHCS process throughout the Program Cycle and suggests that a comprehensive approach should be used to ensure funded implementation of an RHCS strategic plan. • Section 3 provides a pre-process checklist of essential considerations. It encour- ages users to identify the main obstacles in their program, achieve consensus on priority RH products, set expectations, and secure financing before beginning the process. • Section 4 describes important points to keep in mind for successful RHCS awareness raising, including options to build commitment and ways to integrate RHCS into existing programs. • Section 5 details the essential elements of an RHCS joint diagnosis, provides ideas for data collection, and shows how the SPARHCS Tool can be adapted to reach consensus on priorities. • Section 6 defines the multi-partner strategic planning process. It details why plan- ning is important and how to achieve consensus on priorities, and provides step by- step guidance on developing RHCS strategic plans. • Section 7 identifies success factors associated with funded implementation of a strategic plan – one of the most difficult challenges facing programs today. These factors include: political will, financial commitment, monitoring and evaluation, and integrating RHCS into existing health programming. • Section 8 describes three model SPARHCS processes. The models show how RH programs might tailor the SPARHCS process to available resources and objectives. • Conclusions are offered in Section 9. THE SPARHCS PROCESS GUIDE 2 The SPARHCS Process and Framework The SPARHCS process closely follows the typical program cycle (planning- implementation-monitoring and eval- uation). The figure shows the different elements of the process and how they relate to each other in the program cycle. The SPARHCS process can be used to address one or more of the elements. However, restricting efforts to a few elements without looking ahead to an implemented strategy has limited utility in strengthening RHCS. Evidence from previous applications of the SPARHCS process, which will be discussed throughout this document, suggests that addressing each element of the program cycle produces the most favorable results. The SPARHCS process includes awareness raising to highlight the SPARHCS and the Program Cycle A w ar en ess Joint Consensus on R ai sin g Diag nosis Priorities M onitoring & Funded M ult i-p ar tn er E valuation Implementation St rat eg y 3 A PlAnnInG RESOURCE fOR THE SPARHCS TOOl 4 importance, complexity, and relevance of RHCS to public health goals. The process includes a joint diagnosis to identify existing RHCS strengths and weaknesses. The SPARHCS Tool was developed to support this component in particular. The issues raised in the diagnosis can be used by stakeholders to create dialogue between the public and private sectors to establish consensus on priorities as part of an RHCS strategic plan. A fully costed, evidence-based strategy is more likely to attract support, both political and financial, for its implementation. Finally, a monitoring and evaluation plan will help ensure that implementation achieves measurable results for the priorities in the strategic plan. The SPARHCS process uses a conceptual framework made up of key components that help secure availability and access to RH supplies. The framework encompasses the policy, eco- nomic and social context that affects RHCS. It includes the commitment of policy makers, senior managers, and staff to advocate for and implement RHCS activities, including invest- ing the necessary financial capital to support commodities and systems. Coordination and collaboration of programs and activities, and developing the necessary capacities for RHCS must also be addressed. Finally, the framework highlights the public, private, and non- governmental organization (NGO) service delivery channels that are necessary to effectively serve the ultimate beneficiary, the client, with affordable, routinely available commodities. The framework is detailed in Hare, et al. (2004). The SPARHCS process can begin with different elements of the program cycle. In Jordan and in Bangladesh, national stakeholders developed consensus on the priority RHCS issues through workshops, discussions, and use of existing data, rather than embarking first on a comprehensive awareness-raising effort or formal joint diagnosis. This approach, though, has been more the exception than the rule. Experience from other countries suggests that a deliberate effort to raise awareness and methodically diagnose the issues leads to a more comprehensive strategy that is likely to attract and sustain support. Ukraine: Using the Program Cycle to Ensure Funded Implementation In Ukraine, the Ministry of Health (MOH) and the USAID-funded POlICY Project used the program cycle to achieve inclusion of contra- ceptive security strategies into the government’s national Reproductive Health Policy (nRHP) 2006 – 2015. In 2004, the MOH launched RHCS activities by conducting an assessment of the current RH situ- ation in Ukraine using the SPARHCS framework. Results from the assessment served to raise awareness among policy makers on the critical gaps in RHCS (e.g., inadequate logistics data and available financing for contraceptives). At a subsequent RHCS issues workshop the following year, preliminary findings were presented and stake- holders achieved consensus on seven priority issues by majority vote. Strategies to address those issues were developed and included in the MOH’s nRHP and workplan at the end of 2005 (POlICY, 2006). THE SPARHCS PROCESS GUIDE 3 Pre-Process Planning Before users begin to build support for the SPARHCS process they need to determine the rationale for its use. A small planning group, led by the MOH RH/FP (family planning) program, should meet to discuss the process parameters. Members of this group should meet with stakeholders to ensure that consensus is achieved on expectations for both the process and the results. Resources required, including time, money, and staff commitments for the process, must be weighed against expected results. Moreover, in a process typically led by the MOH and supported by program staff and technical assistance providers, stakeholders must outline and then agree to the financial investments they will commit to the process itself. A pre-process checklist of issues SPARHCS users should consider is included in the table below. Pre-Process Checklist Consideration Description 3 Rationale (or impetus) for SPARHCS 3 Product focus 3 Short and long-term expectations and results 3 Available resources Example rationales are: high unmet need, low CPR; design for new donor assistance, donor scale-back; perceived problems in service delivery or logistics Determine category of products for which stakeholders are seeking to strengthen RHCS Achieve consensus on what is expected in the next two and then ten years Estimate potential funding levels and human resources for the process 5 A PlAnnInG RESOURCE fOR THE SPARHCS TOOl 6 3.1 Determine the Rationale In order to set RHCS goals and objectives, stakeholders should first broadly understand the scope of the challenge in their country. Have there, for example, been reports of stockouts of RH commodities, or other shortcomings in supply chain and service delivery systems? A demographic and health survey (DHS) or other reports may indicate trends in contraceptive use, such as method shifts or high unmet need, that are potentially attributable to lack of supplies. Or, the country may be undergoing changes in donor assistance, such as phase out of commodity support or a shift to direct budget support. Using existing data and analyses, RHCS stakeholders should review and discuss the major RHCS gaps and challenges. This is not a replacement for the joint diagnosis, but a way to help frame and guide it. In 2002, the Jordanian MOH identified donor phase out of contraceptive financing as an immediate and long-term issue. As a result, Jordan stakeholders created adequate time to carefully develop a strategic plan focused on government funding of contraceptives and procurement capacity to procure contraceptives (POLICY, 2006). 3.2 Product Focus Stakeholders should define the products on which the SPARHCS process will focus. In many countries where assessments have been carried out, stakeholders have directed efforts at securing contraceptives, including condoms1. In some instances this was because it was not financially or programmatically feasible to attempt to secure the supply of dozens of essen- tial RH medicines. In other countries, a focus on contraceptives was purposefully used as a starting point, with the inclusion of RH commodities planned at a later date. Programs that have conducted assessments focusing on contraceptives include Ghana, Bangladesh, Malawi, Nepal, Nicaragua, Peru, Bolivia, Egypt, Guyana, Guatemala, and Jordan. In other countries, RHCS stakeholders agreed that distinguishing between essential RH products is inherently biased, and that there were serious supply shortages for the range of maternal, obstetric, antenatal, and FP commodities. In Mozambique, Senegal, Cameroon, Togo, and the West African Regional Initiative, the SPARHCS joint diagnoses and strategic plans included the broader range of RH commodities. The implications of securing the full range of essential RH medicines are substantially different than a focus on contraceptive commodities, and should be carefully considered by stakeholders with regard to available resources and political commitment. 1Condoms are singled out here for their dual role in family planning and HIV/STI prevention, but are henceforth included under “contraceptives.” THE SPARHCS PROCESS GUIDE 3.3 Setting Expectations Donors, the MOH, technical assistance agencies, local NGOs, private sector entities, and other groups need to achieve consensus on expectations for the SPARHCS process. These expectations must be consistent with MOH RHCS objectives in order to ensure that plans are approved. Further, expected outcomes, in addition to intermediate results, such as form- ing an RHCS coordinating committee or completing a strategic plan, should be agreed upon. It is unlikely that simply raising awareness of RHCS or even prioritizing the major gaps in RHCS will of themselves lead to substantive improvements in RH product availability. When expectations are aligned and major actors, notably the MOH, agree on the necessity to commit to a funded and implemented strategic plan, then collaboration in carrying out the SPARHCS process will be expedited and improved. Stakeholders need to decide which activities to carry out within each component of the SPARHCS process. How will, for example, awareness raising be accomplished? What type of investment, given funding constraints and available data, is needed for the joint diagnosis? Will activities necessary to develop and implement a strategic plan be centrally coordinated or delegated among the implementing organizations? The next sections examine these ques- tions in detail. Broad agreement on each stage early in the process will help to avoid confu- sion and strengthen the focus and efficiency of the process. 3.4 Identifying Available Resources After stakeholders have reached consensus on the ”why” for a SPARHCS process, deter- mined the RH products to include in the process, and set expectations regarding how the process will be implemented, they should estimate the resources required and available for the process. Understanding the financial requirements of the process and what each partner is prepared to commit for its implementation will help ensure that the expectations of all concerned parties are aligned, and all understand their obligations and roles in supporting the process. Section 8 can help stakeholders estimate the financial requirements for different potential SPARHCS processes, while Section 6.2 discusses how to estimate the financing needed for one element of the process – implementing an RHCS strategic plan. UnfPA provides support for advocacy workshops to sensitize decision- makers to the importance of RHCS at national and local levels. UnfPA also supports RHCS assessments and activities to develop strategic plans. Expectations are agreed upon by all parties at the outset of each assessment, with stakeholders agreeing that the assessment findings will be used as the basis to develop a national strategic plan. 7 A PlAnnInG RESOURCE fOR THE SPARHCS TOOl 8 4 Awareness Raising RHCS – as a goal to strive for – has taken root in a number of countries and RH/FP programs. Awareness of the issue – beyond a small group of donors and technical agencies – grew significantly following the May 2001 Meeting the Challenge conference held in Istanbul (see Interim Working Group, 2001). From there, support for RHCS has grown through the efforts of UNFPA, the World Bank, and other multi-lateral organizations; bi-lateral donors; the Reproductive Health Supplies Coalition (RHSC); and a range of regional, country, and technical partners. Typically, awareness raising has been the entry point for the SPARHCS process (e.g., in Egypt, Ghana, and many Latin America/Caribbean countries). In some countries, including Ukraine, Bangladesh, and Nigeria, findings from the joint diagnosis served to raise awareness and build support for the process. Sometimes, awareness of RHCS may already be sufficient enough that awareness-raising activities are not necessary to build support for a joint diagnosis. Communicating to Stakeholders Information can be effectively used in awareness-raising efforts to support RHCS issues and solutions. Pre-existing information, such as data from a demographic and health survey, as well as new information gained from a joint diagnosis can shape the debate surrounding RHCS, create a more positive image for solutions to improve RHCS, and foster an accurate discussion among key stakeholders on RHCS issues. Sharing information with stakeholders is half the task. Effective advocates for RHCS can communicate information in ways that help their target audiences listen, understand, and act. Audience research plays an important role in identifying appropriate as well as clear and consistent messages that are tailored to different audiences. Each message captures (a) what the RHCS objective is, (b) why it is important, (c) how it can be achieved, and (d) what specific actions are needed from the audience. THE SPARHCS PROCESS GUIDE Usually target audiences for RHCS messages are high-level audiences who are not RHCS experts and must manage competing demands on their time. For them, a message and its presentation should be (a) clear and not too technical or complex; (b) brief, where an execu- tive summary, highlighted quotes, text boxes, or tables are used concisely to make a point; (c) attractive, utilizing an audience-friendly design that facilitates rapid comprehension of the material; and (d) accurate. This last point is especially important. The data used must be correct, and claims of benefits and costs that are used to justify the importance of an RHCS objective should be realistic and defensible. Credibility is paramount. In addition, the person who delivers a message may be as important, or more important, than the message itself. He or she must have access to the target audiences, be perceived as credible, and be someone to whom the audience responds. The messenger should be articu- late, know the issues thoroughly, and be able to present RHCS messages clearly. Use the RHCS Framework The SPARHCS framework (see Chapter 2 in Hare, et al., 2004) can be used in awareness raising to describe, define, and demonstrate the complexity and multi-sectoral requirements of RHCS. The framework allows stakeholders to understand and visualize the benefits of the multi-sectoral approach and, more importantly, demonstrates how seemingly unrelated components need to be addressed simultaneously to strengthen RHCS. For example, a discussion of client utilization can show how greater use of the private sector by higher in- come groups can allow the public sector to focus its limited capital on supporting FP provision for the poor. Promote Program Integration Awareness-raising efforts should emphasize that the SPARHCS process need not displace, but rather can complement or integrate with existing RH/FP programming and larger systems, strengthening efforts. In Ghana, Ministry of Health policy makers made a decision early on to ensure that efforts to improve HIV/AIDS commodity security were incorporated into the existing national HIV/AIDS strategy to avoid duplication and improve coordination (Ghana MOH, 2006). In Nicaragua, the RHCS strategic plan takes into consideration larger health sector reforms that aim to integrate the logistics systems for various essential medicines (including contraceptives). An important aspect of the Nicaragua plan focuses on securing the provision of contraceptives by working to improve the supply system for all medicines, thus necessitating collaboration with other programs (DELIVER, 2005). Raising Awareness in Indonesia Knowledge of RHCS in Indonesia was minimal in 2003. Awareness raising was the entry point into the SPARHCS process to build support for conducting a SPARHCS joint diagnosis at the district level. BKKBn, the national government’s coordinating agency for family planning, and partners formed a contraceptive security advocacy group that used the SPARHCS framework to inform and engage stakeholders at the district level about RHCS and its essential components. Sensitization workshops held in Central and East Java were successful in convincing local health officials to support a district level diagnosis. The presentations demonstrated how the SPARHCS process could be ap- plied to a decentralized health system with messages consistent with the policies of the national and district level governments. 9 A PlAnnInG RESOURCE fOR THE SPARHCS TOOl Include Local Issues Specific, local data will make presentations and other materials more relevant to local stake- holders and demonstrate to the audience that the presenters have researched issues important to country stakeholders. In several countries (including Georgia, Nigeria, and Bangladesh) country-specific contraceptive financing analyses focused stakeholder attention on immediate gaps and demonstrated how an RHCS strategic plan could help address them. In Guatemala, where equity is a major challenge and concern to local stakeholders, awareness-raising pre- sentations included data – such as unmet need, access to contraceptives, and Contraceptive Prevalence Rate (CPR) – about the underserved. Consider an Awareness-Raising Workshop An awareness-raising workshop can help convince stakeholders to invest political and finan- cial capital in the SPARHCS process. In Madagascar, the software program SPECTRUM was used to develop demographic projections of contraceptive demand. These projections raised questions about potential costs and policies needed to secure contraceptive supplies to meet rising demand. Policy makers were not aware of these issues until the projections were pre- sented in a workshop. The budgetary implications of the projections resulted in the president of the country asking key stakeholders to discuss how the government and partners would finance the country’s contraceptive requirements over time. Political support was generated for the SPARHCS process as a way to address the key issue of contraceptive financing. In Egypt, a workshop co-sponsored by the Ministry of Health and Population (MOHP) and titled, “Contraceptive Security in Egypt: Basic Issues,” was successful in raising awareness about RHCS issues and gaining support for an RHCS assessment. The workshop helped build consensus among stakeholders on priority issues and approaches for addressing them (POLICY, 2006). An important issue that was highlighted in the workshop was donor phase- out of contraceptive procurement. This was subsequently addressed in the national RHCS strategic plan, with the MOHP taking primary responsibility for contraceptive procurement in 2005. These and other examples show that successful awareness raising targets key stakeholders such as policy makers, senior technical managers, donor representatives, and those involved in other sectors that impact RHCS. Messages use country-specific data to “localize” compo- nents of the SPARHCS framework, familiarize stakeholders with the benefits of RHCS (for both clients and broader health, economic, and social objectives), highlight local challenges, and obtain stakeholder buy-in to the SPARHCS process to find solutions. SPARHCS and the Whole Market Approach A whole market approach to RHCS helps ensure that the entire market of clients – from those who require free supplies in the public sector to those who can and will pay for commercial products in the private sector – is covered in a coordinated way. It offers a comprehensive look at the supply of and demand for fP services and products in all sectors – public, commercial, and non-governmental. A whole market approach helps identify different market segments, target subsidies more effectively, address market inef- ficiencies, and engage private suppliers who may play a role in meeting public health goals. Emphasizing a whole market approach in awareness raising for RHCS reinforces the multi-sectoral nature of the SPARHCS process, and provides a compelling case for the involvement of stakeholders from both the public and private sectors in the process. 10 THE SPARHCS PROCESS GUIDE 5 Joint Diagnosis The purpose of the joint diagnosis is to understand and document the RHCS status nation- ally, locally, or within a region. The diagnostic guide in the SPARHCS Tool is a series of questions designed to assess each of the SPARHCS components (capital, coordination, client utilization, capacity, commitment, context, and commodities). These questions help define specific challenges to be addressed in subsequent strategic planning and implementation. They also help identify existing strengths that can be built upon to help eliminate the weaknesses. The diagnostic guide is flexible. The questions in it are meant to guide the assessment process, not necessarily to be asked in every assessment. This flexibility is intentional. RHCS challenges and solutions are often complex. Capabilities, resources, and issues vary widely from country to country. If stakeholders know, for example, that RHCS gaps are more con- centrated in supply chain and service delivery systems, then adapting the diagnostic guide to focus more specifically on capacity issues is appropriate. Adapting the framework and the diagnostic guide may also be useful when applying the SPARHCS process to a regional setting. The West Africa Health Organization, for example, acknowledged that the seven SPARHCS components accurately reflect the constituent parts of RHCS in West Africa. However, the task force assembled to carry out a regional RHCS assessment and develop a regional strategy agreed that their efforts might duplicate, and not complement, country SPARHCS approaches if regional institutions were focused on the same elements used in country strategies. National RHCS strategies in Ghana, Mali, Nigeria, Burkina Faso, Togo, and Cameroon address many of the SPARHCS components. As a result, the framework used in the regional diagnosis was modified to reflect regional activities that support country efforts (DELIVER, 2006). In the Latin America/Caribbean region, the SPARHCS components were consolidated to focus on demand and use, market segmenta- tion, logistics, and financing to ensure consistency across five RHCS assessments carried out in Bolivia, Honduras, Nicaragua, Paraguay, and Peru (Taylor, 2004). The following section describes the key steps used in a joint diagnosis; reviews how to or- ganize data collection efforts and what to look for; documents how the SPARHCS frame- work and diagnostic guide have been successfully adapted; provides examples of successful processes; and offers a “Tip Sheet” of important points for users to consider while carrying out an assessment. 11 A PlAnnInG RESOURCE fOR THE SPARHCS TOOl 12 5.1 The Major Steps of a Joint Diagnosis The methods used to assess RHCS have all been customized to address specific priorities and environments. There are five major steps that have been used in different combinations to ensure a joint diagnosis is carried out successfully. These are outlined in the table below. Ad- ditionally, there are other activities that will need to be carried out that are not detailed in this section – for example, writing a comprehensive report to document assessment find- ings. The emphasis and time allotted for each of the major steps will vary depending on priorities and resources, and all the steps may not need to be fully addressed. A key infor- mant workshop, for instance, may not be necessary if adequate data can be collected through individual interviews. Step Description Rationale Essential Steps in the Joint Diagnosis 1. RHCS coordinating committee formed Engage a multi-sectoral group of technical and policy-level stakehold- ers to support and participate in the assessment and strategic planning. If an RHCS coordinating committee does not exist in the country, one should be formed to participate in and help coordinate the process. Identifies a group that is an es- sential resource, facilitator, and advocate for assessment and strategic planning. Builds ownership among stake- holders of the assessment, its results, and of the subsequent strategic planning. 2. Desk-based research and data collection Collect and analyze existing RHCS data; review technical reports. Begins the diagnostic process early and ensures the SPARHCS assessment team is prepared to present preliminary data. 3. Presentation of methodology to stakeholders Present the objectives, expected out- puts, and methods to key stakehold- ers, and obtain their feedback. Allows stakeholders the opportu- nity to ask questions and provide guidance. Raises awareness and strengthens buy-in and local owner- ship of the process. 4. Key informant interviews and workshops Interviews provide in-depth feedback from individuals with policy and pro- gram experience. The workshop can be used in place of or in combination with interviews de- pending on time and availability of in- formants. This setting allows informants to compare and share experiences and identify cross-cutting issues that may be missed in individual interviews. The interviews promote more open discussion about existing issues. Data may also be easier to obtain in an interview setting. Different interpretations of the RHCS situation can be identified and clari- fied in a workshop setting. Partici- pants can also work in groups to identify preliminary approaches to the issues they identify. 5. Presentation of findings and building consensus for the strategic plan Validate findings with stakeholders. Obtain commitment from stakehold- ers, especially government, to take the next step in the SPARHCS process – a multi-sectoral strategic plan. Builds consensus and acceptability of the findings; presents a rationale for and builds commitment to develop a strategic plan to strengthen RHCS. THE SPARHCS PROCESS GUIDE13 1. RHCS Coordinating Committee Formed An active coordinating committee for RHCS is often a necessary condition for the devel- opment and implementation of an RHCS strategic plan. An appropriately constituted and proactive group of policy makers and senior technical staff from donors, ministries, techni- cal partners, NGOs, and other stakeholders may already exist in the country. To avoid the proliferation of committees with duplicate mandates, it may be preferable that this already existing body assume the coordinating role for RHCS. If no such committee exists, one should be organized by the local institution coordinating the SPARHCS process. Typically, the coordinating agency is from the Ministry of Health. The committee should be engaged in the SPARHCS process before beginning the RHCS assessment to promote early local owner- ship. By doing this, local stakeholders will be accurately informed to help define and drive subsequent steps – particularly the development of the RHCS strategic plan. Sample terms of reference for an RHCS coordinating committee are provided in Appendix B. The RHCS coordinating committee should include, though not necessarily be restricted to: • Representatives of the Ministries of Health and Finance; • Other governmental and private bodies responsible for women’s issues, social services and social insurance; • NGOs (including those focused on RH, FP, HIV/AIDS, women’s issues and gender sensitive approaches), technical agencies, private companies (particularly those involved in social marketing), and major service delivery providers; • Technical partners and donors (e.g., USAID, KfW, UNFPA, GFATM, World Bank); and • Private sector and trade associations (e.g., pharmacy, supplier, and manufacturer trade associations) that could contribute to RHCS efforts. An RHCS coordinating committee is essential to: • Ensure important stakeholders participate in and take ownership of the assessment and subsequent planning process in the early stages; • Facilitate and advocate for the implementation of the SPARHCS process through each component of the program cycle; • Serve as a technical working group for the development and implementation of a strategic plan; and • Provide oversight and monitoring during implementation of a strategic plan. The RHCS coordinating committee in Bolivia is composed of individuals from two divi- sions of the Ministry of Health and Sports (Health Services and Medicines), nGOs (in- cluding PROSAlUD and Center for Research, Education, and Services), UnfPA, USAID, and a technical agency that provides assistance for RHCS. The committee was formed after a 2003 latin America/Caribbean regional conference, and played a valuable role in planning and preparation for a SPARHCS assessment in Bolivia by identifying key players and providing technical information. After completing the assessment, the RHCS committee assisted the assessment team in reviewing the assessment’s findings, providing additional information, and formulating national RHCS recommendations. A PlAnnInG RESOURCE fOR THE SPARHCS TOOl 14 The RHCS committee should aim to achieve consensus on the RH products to include in the SPARHCS process. As noted in Section 3, the number of essential RH commodities is substantial. The committee can prioritize the commodities to focus on by evaluating the health impacts, costs, and the flexibility of financing for each product category. The commit- tee, for instance, may decide to focus efforts on the most widely used FP commodities and a select few other RH products whose availability has the greatest impact on the RH needs in the country. Though the case is often made that all RH products are a priority, stakeholders should weigh the feasibility of this approach with available resources. 2. Desk-Based Research and Data Collection Prior to beginning the in-country assessment process, the assessment team should collect and analyze existing RHCS data. This is generally the first step in the data collection process for the joint diagnosis. Existing data may include DHSs and Reproductive Health Surveys (RHSs), economic and health-related statistics available from the World Bank, World Health Organization (WHO), and other international organizations, and in-country sources. A request should be made to in-country stakeholders for technical reports, policy papers, and related assessments. Appendix C provides sample data and suggestions of where these data can be obtained. Data collected from desk-based research allows the diagnostic process to begin early, takes ad- vantage of existing data to help lower assessment costs, and identifies issues and areas where further investigation will be necessary. The research provides the opportunity to synthesize existing data in new ways, using an RHCS “lens” to present data about client utilization pat- terns, financing, source of commodities, and stock status. Stakeholders will value the insight and analysis resulting from desk-based research because, although they may work on these issues regularly, they will not necessarily have had the time to compile or analyze data in a systematic manner. In addition, these data will help validate or clarify information collected and shared throughout the assessment process. Lastly, when external consultants are part of an assessment team, a desk-based analysis will provide them with the necessary background to function effectively as part of the team. Prior to an RHCS assessment in Nepal, desk-based research was used to form a preliminary analysis and provide quantitative data for an initial presentation to stakeholders (DElIVER, 2004). This allowed the assessment team to focus its limited time in-country on meeting with key informants. 3. Presentation of Methodology to Stakeholders The assessment team should propose the objectives, methodology, and expected outputs of the joint diagnosis to key stakeholders before beginning in-country data collection. The team should encourage feedback to determine if and how stakeholders want to tailor the assess- ment to local contexts and priorities, and solicit inputs on how stakeholders want to par- ticipate in the assessment. The team should make every effort to accommodate stakeholder recommendations. Section 5.2 expands on how to adapt the SPARHCS framework accord- ing to stakeholder inputs. This step provides stakeholders with the opportunity to ask questions and provide guidance. By emphasizing the adaptability of the SPARHCS Tool, and involving stakeholders in its adaptation, the team can build local ownership and raise awareness of the assessment, thereby facilitating data collection. THE SPARHCS PROCESS GUIDE15 4. Key Informant Interviews and Workshops Interviews with individuals that have information and insight into local RHCS issues are in many cases essential to addressing the questions in a SPARHCS assessment. The interviews and informant workshops, combined with the data collected from these sources is the second phase of data collection and should build upon information collected in the desk-based review. Interview appointments should be made before the assessment begins to ensure that key informants are available and engaged, and specific questions from the SPARHCS diag- nostic guide should be carefully tailored to the expertise of each interviewee. The assessment team should make every effort to include a range of stakeholders, from senior policy makers to clinicians, line managers, and clients. The assessment questions can be shared with inter- viewees prior to their interviews. The assessment process in Madagascar began with a national stakeholder meeting dur- ing which the SPARHCS framework was presented for review and discussed to determine if and how the framework should be adapted to reflect the concerns of the MOH and other service providers. The MOH decided to modify the assessment approach around five diagnostic components – demography, policy, demand, service delivery, and finance – to reflect priority RHCS gaps identified during the discussion (Moreland, 2003). Selecting Key Informants for Interviews and Workshops 3 When convening a key informant workshop, make sure to include experts from existing groups (such as logistics working groups and RH committees) as well as individuals who may be unfamiliar with RHCS or SPARHCS, but can contribute valuable insight and increase the multi-sectoral nature of the process. Many workshop participants may later form the basis for an RHCS technical working group. 3 Each participant, in either a key informant interview or workshop, should possess technical and/or policy expertise in the areas for which they are asked to provide information. 3 The assessment team should work with a range of stakeholders from the public and private sectors to identify and select appropriate participants/interviewees. for example, consider international donors and the Ministry of finance, and be sure to include someone with considerable policy expertise. Policy questions are typically a central concern on the SPARHCS process. likewise, consider nGOs, social marketing programs, the commercial sector, and associations of health care professionals. 3 The workshop should be carefully planned to ensure that all levels of technical experts and implementers are provided a chance to actively participate and provide their insights related to RHCS. A PlAnnInG RESOURCE fOR THE SPARHCS TOOl 16 A key informant workshop – typically two-to-three days in length – can be used in place of or in combination with interviews. An overview of the adapted framework and diagnostic guide used in the assessment should be provided at the workshop. Participants can then work in groups to identify RHCS issues. Lower level staff should be included in the interviews and workshop because they will often raise issues that higher level participants may be unaware of or unwilling to acknowledge. In the workshop setting, this requires skilled facilitation to ensure lower level informants partici- pate fully and are not intimidated in the presence of their superiors. Though key informant interviews do not allow for group discussions between people work- ing in different areas, they can promote more open and detailed discussion by individuals about existing issues and their causes. Interviews also provide an opportunity to validate data obtained through desk-based analysis, workshops, and other means. By meeting key infor- mants in their work place, in-depth data can often be collected at the time of the interview and data gaps or questions can be immediately filled or clarified. Reports, policies, budgets, and operational plans can be copied, collected, or shared. In addition, key informants can draw in other staff to help fill in data gaps, respond to other related requests, and name additional key informants from other organizations. By contrast, the workshop setting allows informants to compare and share experiences and identify cross-cutting issues that may be missed in individual interviews. If carefully facili- tated, institutional or individual differences in interpretations of the RHCS situation can be identified and clarified. Also, a consensus building process around RHCS issues can begin, creating a basis for later strategic planning activities. During an RHCS assessment in Kazakhstan, an assessment team visited different pharmaceutical companies and their distributors to determine the scope and range of their distribution networks. The information obtained from interviews with these private sector stakeholders would likely have not been obtained through a workshop – high- lighting the need to use different data collection methods (Abt, 2006). As part of an RHCS assessment in Burkina Faso, a one-day workshop brought together 28 participants from different RH program areas. The Director General of Health Services opened the workshop and provided political support for the assess- ment. Participants were divided into five working groups. The members of each group were selected based upon their knowledge of the particular diagnostic component that the group was asked to assess. A facilitator guided each group’s discussions and recorded their responses to the assessment questions. 5. Presentation of Findings and Building Consensus for the Strategic Plan The assessment team should validate their draft findings with stakeholders. Discussion and debate of the findings will help ensure accuracy and acceptance of the findings by program managers and policy makers. A half- or full-day workshop can be used to present the draft findings. Participants can review the findings, prioritize the issues raised, and begin to THE SPARHCS PROCESS GUIDE17 5.2 Adapting the SPARHCS Framework and Diagnostic Guide The SPARHCS framework and diagnostic guide are intended to be customized in ways that allow countries to make inquiries specific to their programs and are reflective of available resources. Customizing the approach promotes country ownership by better aligning the process with local priorities and needs. The SPARHCS Tool is not limited to assessing national programs. It has been adapted to di- agnose the RHCS situation at the district level in Indonesia and to develop a regional RHCS strategic plan in West Africa. In Latin America, the SPARHCS framework was used at the regional level as an awareness-raising and advocacy tool to help launch five in-depth country assessments and strategic planning processes. One major question that often arises when users adapt the SPARHCS framework is whether the tool is capturing the multi-sectoral requirements of RHCS. A diagnostic emphasis placed on one component over another can help programs narrow the range of RHCS inquiries to fit certain priorities. However, this can also constrain the flexibility of the SPARHCS Tool to address priorities that emerge during the process (e.g., in mid-course during an assessment). RHCS is an inherently complex subject, no matter where it is addressed. Adaptations of the SPARHCS framework for a joint diagnosis (and for strategic planning) should preferably include the range of financing and supply systems for RH products (public, NGO, social marketing, commercial), as well as the range of policies that affect RH product availability – policies that bear upon RH programs, the broader health sector, and actors outside the health sector (e.g., municipal governments, and finance and trade ministries). The following table compares how four countries have adapted the seven components of the original SPARHCS framework. The table does not show the underlying rationales for how each adaptation was made, but it does suggest that stakeholders have addressed each of the original SPARHCS components. In all four examples, stakeholders often elected to identify RHCS components using different criteria or to merge two or more components. Topics in the diagnostic guide that do not appear in the adapted frameworks by name are often ad- dressed under a new name. In some instances, the adapted components are cross-cutting to those in the original SPARHCS framework, and what is included in an adapted component can be broader than its name implies. Four examples follow. While drafting an RHCS assessment report in Guyana, the assessment team presented their draft findings to stakeholders from the public and private sectors. MOH and nGO partners validated and corrected the team’s findings and recommendations to ensure widespread support for the assessment and to more accurately inform the development of an RHCS strategic plan (DElIVER, 2006 ). develop strategies to address them. It is crucial before going into the strategic planning process that there is general agreement on the RHCS issues raised in the joint diagnosis. The workshop and a well-documented assessment report will help build consensus among decision makers that commitment to develop, fund, and implement a strategic plan will strengthen RHCS. A PlAnnInG RESOURCE fOR THE SPARHCS TOOl 18 • The RHCS coordinating committee in Ghana decided to base the joint diagnosis and strategic plan on a strategic framework already in use across the public health sector. They concluded that an approach to RHCS that used the MOH’s existing framework would have more acceptability within the health sector. This was particularly important, they reasoned, for integrating RHCS into the health sector’s work planning and budgeting process (Ghana MOH, 2004). • In Malawi, stakeholders compared the SPARHCS components with on-going RH/FP strategic efforts to avoid duplication. They discovered that a number of “Context” issues were being addressed through a broader RH service strategy. As a result, they deempha- Comparison of Adapted and SPARHCS Framework Components2 Country Components as Adapted Original SPARHCS Components C o n te x t C o m m it m en t C a p it a l C o o rd in a ti o n C a p a ci ty C lie n t U ti liz a ti o n C o m m o d it ie s Egypt finance Collaboration & Coordination Service Delivery logistics Advocacy Ghana Quality Efficiency Partnerships financing Monitoring & Evaluation Malawi Commitment Coordination Policies & Regulations Demand Creation Service Delivery logistics finance Nepal Coordination Capacities finance Client Utilization Policy Commitment 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 33 3 3 3 3 3 3 3 3 3 3 2The check marks indicate the original SPARHCS components that are addressed by each adapted component. 3 3 3 THE SPARHCS PROCESS GUIDE19 sized the focus on contextual issues and instead focused on logistics (Malawi, MOH, 2006). A “Policies and Regulations” component was developed that addressed issues that appear in the original framework under context, client utilization, and commodities. • In Nepal, the RHCS assessment team presented the SPARHCS framework components to existing RH and logistics working groups. Both groups concluded that each of the framework components should be addressed in the assessment. However, they stressed that because the components overlap, they decided to consolidate them into fewer, cross- cutting components. For example, the component “Policy Commitment” relates to com- modity financing, human resource capacity, and client utilization (DELIVER, 2004). 5.3 Successful Approaches to the Joint Diagnosis The preceding sections discussed the essential steps of a joint diagnosis and illustrated ways in which the SPARHCS framework and diagnostic guide have been adapted to address local situations. This section highlights a successful approach in Eritrea managed by UNFPA.3 The steps are detailed below.4 Adapting the Diagnostic Guide for the Supply Chain – The RHCSAT In order to focus more on logistics system components, UnfPA created the Repro- ductive Health Commodity Security Situational Analysis Tool (RHCSAT). The tool is a combination of the SPARHCS diagnostic guide and the logistics System Assessment Tool (lSAT). The tool supports stakeholders to conduct a joint RHCS diagnosis, with a detailed examination of a country’s supply chain (forecasting, distribution, storage, etc.). The tool responds to country-level requests to strengthen supply chains within the RHCS context. The RHCSAT has been used in Eritrea, fiji, Mozambique, Sen- egal, Somalia, and a number of other countries (UnfPA, 2005). 3 Pre-Assessment Literature Review - Available literature on demographics and reproductive health in Eritrea were reviewed prior to beginning the assessment. The review helped to determine information gaps. 3 Local Participation - A workshop was held with government partners and other stake- holders to build in-country capacity for conducting an RHCS assessment. The tools, techniques, and logistics for the assessment were discussed, and participants for the assess- ment were recruited. The standard RHCSAT (see box) was reviewed with partners and adapted to Eritrea’s needs. 3 Multiple Data Collection Techniques - A joint discussion group was assembled from stakeholders who included service providers, storekeepers, and program managers selected 3See Section 4.0 of Hare, et al. (2004) for other examples of how RHCS assessments have been conducted in Madagascar, Indonesia, nigeria, and in the latin America region. These illustrate how the SPARHCS Tool has been used at national or sub-national levels; in countries more or less experienced in working on reproductive health commodity security; in countries not yet ready to phase out donor support or in countries planning for self-reliance; and in countries at different stages of health sector reform. 4Text adapted from the Eritrea RHCS Situational Analysis. October, 2005. A PlAnnInG RESOURCE fOR THE SPARHCS TOOl 20 from central and zonal levels. Using the RHCSAT as a discussion guide, information on all aspects of RHCS and components of the logistics cycle was gathered from the partici- pants. Focus group discussions were conducted over a period of four days. Key informant interviews were held with the Director General, Regulatory Services, Ministry of Health, the Managing Director of PHARMECOR (the government parastatal responsible for drug procurement and distribution), and other key officers. Field visits were made to health facilities and warehouses at central and zonal levels. Interviews were held with service providers, issues were clarified and validated, and more in-depth knowledge of practices obtained. 3 Presentation of Findings – A stakeholder meeting was held immediately after the initial findings were developed. The meeting was used to share and validate the preliminary findings and recommendations, and agree on future steps. The diagnosis resulted in a report that was comprehensive, well informed, and well suited to serve as the basis for a national RHCS strategic plan. This was due in large part to the di- agnostic process that the assessment followed, which included a pre-assessment literature re- view, securing local participation, and using multiple data collection techniques. A diagnostic process such as this that produces well-defined issues and mobilizes stakeholders to act is an essential foundation for carrying out strategic planning, which is detailed in the next section. 5.4 Tip Sheet This tip sheet summarizes the key considerations that users should have in mind when plan- ning a joint diagnosis. The Joint Diagnosis Tip Sheet Pre-Assessment 3 Be prepared to adapt the SPARHCS framework to account for existing programs and strategies, available resources, and local priorities. 3 Consider sending briefing packets to stakehold- ers, including a short questionnaire asking them to identify RHCS issues. 3 Conduct a literature review to begin identifying key issues, and identify information gaps that the assessment should address. 3 Clarify objectives and expectations with key stakeholders before the assessment. This should include the timeline, budget, and special considerations. 3 Identify individuals and groups to contact in advance. Ensure assessment participants have both the time and required background to participate in the process. 3 Build in time and allocate budget for pre- and post- assessment stakeholder workshops to help reach consensus on methodological approach, prelimi- nary findings, and subsequent work planning. Assessment and Post-Assessment 3 Use multiple data collection techniques (interviews, workshops, site visits, docu- ments review). Appendix D lists data often gathered and presented for RHCS assessments. 3 Transfer capacity to local counterparts in joint diagnosis and strategy development. 3 Involve representatives from all levels and branches of the health system. This is essential in decentralized environments. 3 Involve representatives from outside the health sector and from both the public and private sectors to ensure that the inherent complexity of RHCS is addressed. 3 Share draft findings with key stakeholders before the assessment results are finalized. 3 Ensure that there is consensus on next steps after the assessment, including the identifica- tion of responsible parties and time frame for completion. THE SPARHCS PROCESS GUIDE 6 Strategic Planning A multi-sectoral strategic plan is the next step in the SPARHCS process following the joint diagnosis. The direction and focus of the strategic plan (or the “plan” or “strategy”) should be based on the findings of the joint diagnosis. While the joint diagnosis identifies RHCS strengths and weaknesses, the strategic plan is the opportunity to address the weaknesses, in part by leveraging the strengths and improving on-going programs. The term “opportunity” is pivotal. If the plan is not implemented, the chance to effect changes to improve RHCS in a comprehensive and strategic way will be missed. A strategic plan is a means to improve RHCS, and not an end in itself. 6.1 Why is an RHCS Strategic Plan Important? An RHCS strategic plan can unify stakeholders around a common set of objectives, and catalyze stakeholders to commit to and support the actions necessary to improve RHCS. An RHCS strategy can help stakeholders to prioritize the challenges to improving RHCS. Priori- ties should be first discussed during the joint diagnosis, and finalized by the RHCS coordi- nating committee and/or a smaller technical working group during the strategic planning process. A successful strategy identifies what the problems are, how they can be solved, who can implement the solutions, for how much, and how results can be measured. A strategic plan, grounded in empirical data (from the joint diagnosis) and prepared and vetted with stakeholder participation, provides the evidence base for decisions by senior policy makers (from government and donors in particular) that promote financial commitment to imple- ment the plan. The plan should demonstrate how the issues identified in the diagnosis and the specific activities and outputs described in the plan are linked to each other and how the interventions address broader public health concerns, thus providing donors and govern- ment policy makers with the information they need to advocate for RHCS within their organizations. In several countries, senior MOH officials have responded to the evidence- 21 A PlAnnInG RESOURCE fOR THE SPARHCS TOOl 22 based SPARHCS process by making direct requests to Ministries of Finance, donors, and the private sector for additional resources for RHCS – for example, to procure RH supplies. 6.2 The Essential Elements of a Strategic Plan The elements of a strategic plan for RHCS are not much different than those for other health sector goals, or more broadly for development. The essential elements of a comprehensive plan are illustrated in the figure below. The plan (as well as the process of strategic planning) begins by defining a goal. It then defines priority issues and strategic objectives, activities, roles and responsibilities of partners; estimates budget requirements; and develops relevant output and outcome indicators. Descriptions of these components follow. Public Sector Commitment: Benin In Benin, an RHCS financing gap analysis, conducted as part of a SPARHCS assess- ment, convinced senior political leadership that the country needed to both increase and diversify the funding base for contraceptives. As a result, in 2005, the Minister of Health provided, for the first time, budget support for three years for contracep- tive procurement. This has galvanized donors to increase their support for procure- ment. Donors and the Ministry of Health are providing funds for commodities and technical assistance to strengthen the supply chain to ensure that commodities are available to users through both public and private sector programs. The Strategic Planning Process for Reproductive Health Commodity Security GOAL (sample): Increased ability of people to choose, obtain, and use quality RH products when they need them P ri o ri ty I ss u es St ra te g ic O b je ct iv es A ct io n s Su b -a ct io n s C o o rd in a ti n g A g en cy Im p le m en ti n g A g en ci es Es ti m a te d B u d g et O u tp u t In d ic a to rs O u tc o m es Goal Stakeholders, working as a technical working group tasked with drafting the strategy, should think carefully about an RHCS goal. The goal is typically a broad, general statement of long- range purpose. It can be the attainment of RHCS, or something less ambitious, such as en- suring full supply for current users of RH products. In Ghana, Nigeria, and Malawi, the goal calls for RHCS to be achieved within the time period of the strategic plan (e.g., five years).5 5Many strategic plans consist of a five-year time period and are aligned with broader health sector strategies to help increase collaboration and resource mobilization. THE SPARHCS PROCESS GUIDE23 In the West Africa regional strategy, the goal was narrowed somewhat “to meet the demand of existing users and those expressing unmet need in the sub-region” (DELIVER, 2006). Priority Issues Prioritizing the issues identified in the joint diagnosis highlights the RHCS gaps that the strategic plan will focus on. The technical working group should determine (1) the issues that most crucially hinder RHCS, and (2) the feasibility (programmatic and financial) of address- ing those issues within a strategic plan. These considerations will inform the prioritization process. For example, issues related to the broad economic, political and social context that affect prospects for RHCS, such as religious or cultural factors that limit FP use, may not fall within the scope of a commodity-based strategy. They may be among the more intractable challenges to RHCS. Establishing reasonable expectations at this stage is crucial because the list of priorities will inform activities, have budget implications, and establish accountability among implementers for results. The technical working group must ensure that the plan is feasible by avoiding interventions that are beyond the scope of the stakeholders to imple- ment. The group should identify some “quick wins;” that is, near-term interventions where the likelihood of success is relatively high. Early successes can help maintain commitment to the plan’s implementation. Strategic Objectives Each component in the strategic planning framework (initially discussed for the joint diagno- sis – see Section 5.2) should have one or more clear and measurable objectives that address the priority issues. For example, under “Capital,” a strategic objective may be to “increase and diversify sustainable funding for RH commodities.” In Ghana, a strategic objective was developed for each of the four components in the Joint Diagnosis (Quality, Partnerships, Financing, and Efficiency). The strategic objective for “Partnerships,” for example, is to “strengthen public-private partnership in the supply and delivery of contraceptive products and services” (Ghana MOH, 2004). Actions and Sub-Actions There will be a number of major actions and specific steps (sub-actions) necessary to achieve each strategic objective. Under the “Capacity” component, for example, strategic planning groups have stated the improvement of supply chain and service delivery systems as a stra- tegic objective. Activities and sub-activities – such as training, infrastructure improvements, The Technical Working Group An RHCS technical working group can be immensely useful to complete the strategy and continue moving through the program cycle. This group, generally a cross-sec- tion of the broader RHCS committee, should include members who are prepared to carry out an often painstaking, detailed planning process and present drafts to the RHCS committee for review. The group’s diversity will help ensure that the strategy is evidence-based and feasible from a technical, political, and financial standpoint. Engaging senior decision makers will help to increase “buy-in” to the activities and facilitates the participation of potential implementing and funding agencies. An early investment in ensuring a proper, balanced membership in the working group will pay dividends in efforts to mobilize resources for implementation. A PlAnnInG RESOURCE fOR THE SPARHCS TOOl 24 and strengthening monitoring and supervision – were developed to achieve the objective, while being both measurable and financially realistic. Appendix E illustrates sample activities to support the “Commitment” component of the Malawi RHCS strategic plan. Coordinating and Implementing Agencies Stakeholders need to consider which groups will coordinate (or manage) and implement the activities outlined in a strategic plan. Discussions should naturally focus around which organizations are best suited to carry out specific activities, and the groups that have access to funding and political leverage. In Indonesia, district-level health officials are responsible for coordinating RHCS work and carrying out most of it as well. There are few other partners at the local level with the capacity, political will, and funding to share these responsibilities. Estimated Budget The budgeting exercise is perhaps the most difficult aspect of the strategic planning process. Stakeholders are encouraged to identify experts from the technical working group with a budgeting background or seek the help of experts from outside the group. Typically, the process, if it is to be comprehensive and accurate, will involve “bottom up” budgeting. This requires estimating costs for each sub-action (activity) in the plan and aggregating those figures to produce a summary by objective. Reports that detail the costs of each activity are useful, as is a summary that provides an overview of costs by objective. Donors and ministries are also often required to know when within the year disbursements will be requested because each source has their particular budget cycle governing when funds can be released. The sum- mary and detailed budgets should separate the estimated costs into existing allocations within organizations’ budgets and new funds that will be needed to carry out activities. Stakeholders can expect that the specific costs for activities and sub-activities may change when detailed work planning begins among the implementing partners. Annual costs to implement a strategic plan will likely represent estimates of expenditures. Initial costs for years one and two will often be substantially higher than for later years, and should be revised as more details become available. Monitoring and Evaluating for Success A key ingredient for successful implementation of a strategic plan is monitoring and evalua- tion (M&E), both for the implementation of actions and sub-actions, and for achievement of the strategic objectives. Routine M&E is an essential part of measuring and documenting the progress of implementation, as well as providing the needed information to make any necessary “mid-course corrections.” The direct results of the actions taken are the outputs, and indicators should be developed to measure the completion of each output. For example, an output indicator to measure the efficacy of activities to improve supply chain efficiency could be removal of a level in the supply chain pipeline for RH products. Outcomes are the programmatic benefits of the outputs, particularly as they affect clients. Using the same example, an expected outcome may be more rapid distribution of products through the supply chain. The outputs and outcomes can be used to develop broader indicators for each objective in the strategy; for example, a decrease in stockout rates of RH products. Appendix F shows illustrative indicators for monitoring RHCS objectives. This appendix also shows other essential elements of an M&E plan, including how the indicators are calculated, data sources, and the frequency of measurement. As part of the strategic planning process, the technical working group, with the assistance of M&E experts, should develop a comprehensive M&E plan that describes the output indica- tors, associated expected outcomes, as well as indicators to measure the achievement of each strategic objective. THE SPARHCS PROCESS GUIDE 7 Implementation It is possible to turn an RHCS strategic plan into actions that strengthen RHCS, but it is not easy! Members of RHCS coordinating committees report that a key obstacle to transition- ing from the planning process to implementation is the absence of leadership to obtain the necessary human resource and financial commitments. These difficulties are faced by many, if not all, of the countries who have developed an RHCS strategic plan. Despite this challenge, there have been substantial and measurable successes towards imple- menting RHCS strategic plans in countries and regions where the SPARHCS process has been used, and where stakeholders have worked diligently to bridge the gap between plan- ning and implementation. Measurable achievements include: • Increased capital and political commitment to RHCS, as evidenced by a rise in public funding for the purchase of contraceptives (Ecuador, Peru, Honduras, Dominican Republic, El Salvador, Ghana, and Benin), in some cases as a specific budget line item (Burkina Faso, Paraguay, Guatemala, and Nicaragua); • Expanded procurement capacity to obtain quality contraceptives at competitive prices (Peru, Dominican Republic, El Salvador, Nicaragua, Paraguay, Guatemala, Jordan, Egypt, Bangladesh, and Nepal); • Enhanced coordination between social security institutes and MOHs to increase the provision of FP commodities (Nicaragua, Guatemala, and Paraguay); and • Improved commodity availability at SDPs, as measured by lower stockout rates (Nigeria, Malawi, Mali, Guatemala, Paraguay, El Salvador, and Nicaragua). Three key elements that have been consistent throughout these successes are political will, detailed work planning, and program integration. 25 A PlAnnInG RESOURCE fOR THE SPARHCS TOOl 26 7.1 Political Will - The Leadership Factor Political will that concentrates on achieving sustained results and supporting stakeholders to fully participate in and commit to the implementation process is essential to the success of an RHCS strategic plan. Leaders, though, struggle to balance competing priorities with inad- equate budgets. In 2004, in a discussion on RHCS priorities, a senior MOH decision maker tellingly commented, “Children are dying. I have to buy vaccines!” RHCS champions understand the context in which they work and can relate RHCS to broader health and development goals. National leaders, for example, must emphasize the impact that RHCS improvements can have on reducing maternal and infant mortality rates (The Supply Initiative, 2005). RHSC leaders prioritize issues and employ simple, viable and attainable goals to motivate and support those charged to implement and coordinate RHCS activities. Members of an RHCS coordinating committee will look to their superiors for constant support to stay engaged with the implementation process. Guatemalan Congress Sets the Universal and Equitable Access to Family Planning Services Law in Motion Despite strong opposition, congresswomen as well as leaders of women’s groups in Guatemala began in the early 2000s to demand the provision of fP services and commodities to all men and women who need them. Through the sustained efforts of these committed leaders, the Universal and Equitable Access to Family Planning Services Law was presented to Congress in 2006. It went further than previous political actions regarding the provision of fP services by requiring the Government of Guatemala to finance the purchase of contraceptives. One of the law’s mandates was to form a Contraceptive Security Committee that would be responsible for addressing the key challenges to securing stable financing of contraceptives and fP services. The law was passed, and the MOH and the family Planning Program began to actively assume responsibility for leading the Contraceptive Security Com- mittee (Abramson, 2006). RHCS leaders, at a political level, support the engagement of players from the public and private arenas and from central and local levels. They work to ensure a coordinated and comprehensive approach to achieving RHCS. Among implementers, RHCS leaders – for example, the head of the RH program in the MOH, or director of a local NGO – actively oversee and monitor the planning and implementation of activities, and align their teams to achieve the ultimate objective of meeting client needs. In short, committed, sustained leadership is the common thread which runs through the entire SPARHCS process, and is especially critical to translate strategy into results. 7.2 Detailed Work Planning - Turning Strategy Into Action Detailed work planning links the major objectives of the strategy to program activities. A well-developed workplan will help ensure that the strategic plan is regularly referenced and THE SPARHCS PROCESS GUIDE27 modified through monitoring and evaluation of its implementation. This requires that action plans are embedded within the implementing institutions and are aligned with their core missions, and requires a mechanism for encouraging each of these institutions to fulfill its commitments. Several steps can be taken to ensure alignment and accountability while devel- oping and implementing an effective workplan: • Routinely communicate the purpose of an RHCS strategy to stakeholders to help ensure continuous focus on the guiding goals and objectives; • Develop detailed workplans that have M&E components built in; and • Consistently measure progress, realign workplans based on M&E, and provide feed- back about performance to stakeholders, including civil society. Every institution on the RHCS coordinating committee, as well as operational units within each institution, must understand the strategy, the actions for which they are responsible, and how they will coordinate their efforts to reach the objectives set out in the strategic plan. RHCS leaders can also help ensure that the “bigger picture” – the RHCS goal and objectives – is clear to implementers and that implementers have a sense of greater purpose for their RHCS work. Developing detailed workplans is an annual process whereby implementers identify how they will carry out the activities they have been tasked with in the strategy. This detailed work planning can be tedious, but is critical to make clear who is doing what, when, and how. It is important as well to define what success will look like and how it will be measured. As discussed in Section 6.2, clear output indicators and expected outcomes should be part of the strategy and workplans. Clear definitions of how the work will be monitored will help ensure that stakeholders have the information to make necessary adjustments while activities are be- ing implemented, and to ensure accountability throughout the implementation process.6 Beyond the identification of clear outputs and outcomes, mechanisms should be in place to ensure accountability on the part of implementers and to allow for adjustments in the strategy and workplans. One approach to help ensure accountability is to inform and engage civil society groups during the SPARHCS process. These organizations can serve a vital purpose to give the client a voice, and help monitor that the commitments made by funders Nicaragua’s M&E Strategy RHCS committee members have collaborated to detail broad strategic objectives and ac- companying activities to further RHCS over a ten-year period in nicaragua. Donor and government support has been secured for the plan and the various institutions respon- sible for implementation have begun to move forward to implement their components. A detailed M&E strategy has been developed with clear indicators of success that will be monitored on a quarterly basis. for example, two of the primary indicators are 1) percent of service delivery points offering a fully supply of basic contraceptives (orals, condoms, injectables, and IUDs) and 2) a protected government budget line for contra- ceptives by 2008. 6 Appendix G shows illustrative output and outcome measures for RHCS activities from nigeria’s RHCS strategy. A PlAnnInG RESOURCE fOR THE SPARHCS TOOl 28 and implementers are effectively carried out. Civil society organizations can help establish a network of specialized civic actors that monitor the performance of each institution that has committed to implement the RHCS strategic plan. For example, women’s groups and com- munity leaders in Guatemala help to regularly supervise local level health clinics and ensure commodity availability by triggering “fire alarms” when stockouts occur. When sufficiently involved, civil society members, implementing agencies, and other stakeholders can identify areas of workplans that are not adequately addressing the most im- mediate RHCS concerns. This requires not only a certain visibility into the implementation process, but also ways to review and revise activities and objectives when stakeholders identify barriers to success. Regular reviews by the RHCS coordinating committee, utilizing monitor- ing data as well as stakeholder inputs, are one mechanism. For example, monitoring data that illustrates increased stockouts can trigger an evaluation of efforts for strengthening the supply chain. In addition, the data and analyses used during the joint diagnosis should be routinely shared with and among technical experts to help inform the implementation process. Finally, results that can be attributed to the RHCS committee and/or local institutions should be carefully monitored and shared widely in order to capitalize on lessons learned and highlight the strengthened technical capacity within the RH/FP program that is gained through the RHCS implementation process. 7.3 Program Integration The energy and enthusiasm generated during the strategic planning process can easily be dis- placed by the weight of day-to-day priorities, particularly where programs are overwhelmed by multiple and competing health priorities. One way to ensure that RHCS activities remain a priority is to advocate for the integration of RHCS objectives in national policy and operational documents, such as poverty reduction strategy papers, sector-wide workplans, medium-term expenditure frameworks, and MOH workplans. Inclusion of RHCS in these frameworks will ensure that activities in the strategic plan are prioritized at the highest levels. If RHCS plans complement and further already defined organizational and sector objectives, country program directors and national leaders will be able to better justify their investment of time and resources in RHCS. Program integration can also help program directors more efficiently manage their health portfolios. And, once RHCS is inserted into policy frame- works, there is more chance that RHCS activities will be sustained and supported in future years, in spite of staff turnover and changes in the political environment. THE SPARHCS PROCESS GUIDE29 8 Three Model SPARHCS Processes There are countless ways to work through the SPARHCS process. This section offers three illustrative models. The models can help users to match the requirements detailed in the preceding sections with their local circumstances, including the potential resources and time available for the SPARHCS process. Users can review the models to gain ideas for how the SPARHCS process can be adapted and implemented for their situations. Regardless of the approach taken, it is important that stakeholders address all of the components of the pro- gram cycle. Experience shows that any one component – a joint diagnosis, for example – is not likely to by itself substantially improve RHCS. Of greater value is a more comprehensive process that leads to a funded and implemented strategic plan. • The three models represent different levels of investment in the SPARHCS process. Model 1 requires the smallest level of effort, while Model 3 represents the most intensive effort and hence requires the most resources. Model 2 is intermediate in its resource requirements. The models differ, for example, in the amount of required technical assistance, whether from in-country consultants, external experts, in-kind contributions by stakeholders (e.g., MOH staff time), and other sources. • The specific costs of the SPARHCS process used in a country should be developed as part of the pre-process budgeting and strategic planning exercises (see Sections 3 and 6.2). • The time required to move from awareness raising to implementation of an RHCS strategic plan will vary, and is dependent on factors that include the availability of funding, available staff time (particularly in-country program managers and policy makers), and the commitment of senior-level decision makers to drive the process. In general, Models 2 and 3 would require from 9 to 18 months, while Model 1 can be accomplished in 3 to 6 months. A PlAnnInG RESOURCE fOR THE SPARHCS TOOl 30 MODEL 1 Key Elements M&EAwareness Raising Joint Diagnosis Consensus on Priorities Multi-Partner Strategy Funded Implementation Develop awareness- raising materials using existing data Increase awareness by holding one-on- one meetings and/or an awareness-raising brie�ng for senior program managers, policy makers, and donors Adaptable for programs with limited �nancing E�ective when there is widely available RH/FP program data Focuses on strengthening RHCS within existing programs Useful when there are widely accepted priorities Example of a joint diagnosis: Malawi: Contraceptive Security Desk Assessment (Dowling, 2005) Prepare a strategic priorities document that uses joint diagnosis data to validate/clarify priorities Use a stakeholder meeting (1-2 days) to obtain consensus on priorities Carry out desk- based analysis, using available data and supplemented with information from in- country stakeholders collected through key stakeholder interviews Focus data collection on detailing previously identi�ed priorities Focus on integrating RHCS strategic objectives and activities within existing programs and partner work- plans Limited stand alone RHCS strategy Develop and implement work- plans that are integrated into existing programs RHCS coordinating committee meets quarterly for updates on status of activities and to monitor RHCS improvements Develop indicators for monitoring RHCS improvements as part of M&E plans of existing RH/FP programs PROGRAM CYCLE COMPONENTS MODEL 2 Key Elements M&EAwareness Raising Joint Diagnosis Consensus on Priorities Multi-Partner Strategy Funded Implementation PROGRAM CYCLE COMPONENTS More resource intensive; involves e�orts that are directed toward increasing awareness of RHCS prior to beginning the joint diagnosis Detailed joint diagnosis based on desk analysis and in-country data collection A strategic plan is developed, though it is balanced with need to limit expenditures on strategic planning activities. Example of a joint diagnosis: Madagas- car: Joint RHCS Evaluation (Moreland et al, 2003) Example of a strategic planning process: Meeting the Commodity Challenge: The Ghana National Contraceptive Strategy (MOH, 2004) Develop awareness-raising materials using existing data Increase awareness by holding one-on-one meetings and/or an awareness-raising brie�ng for senior program managers, policy makers, and donors Adapt SPARHCS framework by carrying out planning meetings with local stakeholders Conduct initial desk-based review Present assessment methodology and initial data to stakeholders, and re�ne methods/�ndings based on their inputs Carry out key informant interviews and/or workshop Encourage regional and district participation in the assessment Begin consensus building during the joint diagnosis Complete consensus building early in the strategic planning process Encourage assembly of a technical working group for strategy development, which can form the basis for an RHCS coordinating committee Hold a strategy development workshop to reach �nal consensus on priorities and strategic objectives; develop draft actions; identify implementing and coordinating partners; and identify RHCS committee members and develop terms of reference for the committee Use desk work following the workshop to document and draft workshop results; develop draft indicators; and develop a draft budget MOH and the RHCS coordinating committee �nalize and disseminate the strategy Hold a policy and media event to launch strategy and advocate for support RHCS committee focuses on obtaining resources and monitoring implementation Advocate to link relevant strategy components to existing programs Ensure implementing partners have the capacities and resources to carry out their implementation roles Develop M&E plan as part of the strategic planning process Ensure each implementing partner has the capacity and resources to carry out M&E THE SPARHCS PROCESS GUIDE MODEL 3 Key Elements M&EAwareness Raising Joint Diagnosis Consensus on Priorities Multi-Partner Strategy Funded Implementation Activities are included to increase awareness of RHCS and to form or engage an RHCS coordinating committee prior to the joint diagnosis. The committee will facilitate a more in-depth assessment Detailed joint diagnosis based on desk analysis and multiple forms of data collection Increased resources for joint diagnosis and strategic planning to help ensure that a comprehensive, detailed process leads to funded implementation Focus on the RHCS committee, technical working group, and local organizations actively participating and leading the process High visibility launch of RHCS strategic plan Example of an awareness-raising exercise: The Use of the SPARHCS in Ukraine (POLICY, 2006) Example of a joint diagnosis: Eritrean RHCS Situation Assessment (UNFPA, 2005) Example of a strategic planning process: Jordan Contraceptive Security Strategic Plan (POLICY, 2006) Example of RHCS M&E Indicators: West Africa Regional RHCS Strategic Plan (WAHO, 2006) Hold formal awareness- raising workshop prior to conducting the joint diagnosis to secure broad political commitment for the process leading to a funded strategic plan Use the workshop as a mechanism to form or engage an RHCS coordinating committee prior to the joint diagnosis Adapt SPARHCS framework to consider country priorities by carrying out planning meetings with stakeholders Carry out initial desk-based review, including analysis of major gaps Present assessment methodology and initial data to stakeholders, and re�ne methods/�ndings based on their inputs Conduct key informant interviews, with RHCS committee members included as interviewees Conduct a key informant workshop Encourage regional and district participation in the assessment Begin consensus building during awareness-raising workshop Continue to develop priority issues during the assessment process, and complete the consensus building early in the strategic planning Assemble a technical working group for strategy develop- ment Hold a strategy development workshop to achieve �nal consensus on priorities, develop strategic objectives, and develop draft actions Use a second workshop to �nalize actions and sub-actions; identify implementing and coordinating partners; develop draft indicators and outcomes; and develop draft budget Using the workshop results, technical working group drafts the strategic plan for review, possibly with assistance from consultants MOH and RHCS coordinating committee �nalize and disseminate strategy Hold a policy and media event to launch strategy and advocate for support Advocate to link relevant strategy components to existing programs Convene a high-level stakeholders meeting to secure commit- ment for funded implementation RHCS committee focuses on sustaining commitment and monitoring implementation Ensure implementing partners have the capacities and resources to carry out their implementation roles Develop M&E plan as part of the strategic planning process Ensure each implement- ing partner has the capacity and resources to carry out M&E PROGRAM CYCLE COMPONENTS 31 A PlAnnInG RESOURCE fOR THE SPARHCS TOOl 32 9 Conclusions The ultimate measure of success for any process to strengthen RHCS will be sustained im- provements in the availability of RH supplies to clients. The solutions, as with most develop- ment challenges, are not limited to increased funding. Greater awareness, political commit- ment, effective prioritization and coordination, strengthened human capacity, strengthened supply chains, and the many other variables that have been identified through experience in more than fifty countries all factor into the equation. There is no shortcut to achieve RHCS. The SPARHCS process is deliberately complex, resource intensive, and time consuming. It requires dedicated planning and sustained commitment to ensure that the range of variables that affect the prospects for RHCS are addressed. Understanding and implementing the SPARHCS process – the sum total of RHCS activities from awareness raising to monitoring the effectiveness of implemented solutions – will address this complexity and acknowledge the long- term nature of solutions. Complex as the process is, countries have made progress to improve RHCS. Countries and their development partners have shown their commitment to success in strengthening RHCS. As a critical first step, more than fifty country-level and two region-level SPARHCS assessments have been carried out. Over half of those countries have completed or are in the process of completing RHCS strategic plans, signaling a commitment to broad-based, comprehensive solutions. The development of the SPARHCS Tool was at the behest of countries and donors seeking a common approach to RHCS. Its widespread use to support awareness raising, assessment, and strategic planning has led to an experienced cadre of RHCS professionals in donor organizations, technical assistance agencies, ministries of health, and elsewhere. Appendix H provides contact information for three organizations – the Reproductive Health Supplies Coalition, USAID, and UNFPA – that can provide guidance on how the RHCS community can assist programs in implementing the SPARHCS process. 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Ghana Health Service and NACP. Accra. Ghana Ministry of Health, et al. 2004. Meeting the Commodity Challenge: Securing Contraceptives and Condoms for Ghana. Arlington, Virginia: DELIVER Project/John Snow, Inc. 45AD165E9AD85797E040007F01006357 [Report from the 2002 workshop held to raise stakeholder awareness of Ghana’s contraceptive security and to begin developing a national strategy.] Ghana Ministry of Health. 2004. Meeting the Commodity Challenge: The Ghana National Contraceptive Strategy 2005 – 2010. Ghana Health Service. Accra. Hare, L., Hart, C., Scribner, S., Shepherd, C., Pandit, T. (ed.), and Bornbusch, A. (ed.). 2004. SPARHCS: Strategic Pathway to Reproductive Health Commodity Security. A Tool for Assessment, Planning, and Implementation. Baltimore, MD.: Information and Knowledge for Optimal Health (INFO) Project/Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health. Interim Working Group on Reproductive Health Commodity Security (John Snow, Inc. [JSI]; Population Action International [PAI]; the Program for Appropriate Technology in Health [PATH]; and the Wallace Global Fund). 2001. The Report on Meeting the Challenge. Overview: Securing Reproductive Health Supplies. PAI. John Snow, Inc./DELIVER. 2004. SPARHCS Brief. Arlington, Va.: John Snow, Inc./DELIVER, for the U. S. Agency for International Development. John Snow, Inc./DELIVER. 2005. Promoting Contraceptive Security Through Innovative Health System Interventions Arlington, Va.: John Snow, Inc./DELIVER, for the U.S. Agency for International Development. portal/459E38FB586BB2C1E040007F010068D7 John Snow, Inc./DELIVER. November 2001. A Consequence of Success: The Issue of Contraceptive Security in Bangladesh. A Discussion Paper. Arlington, Va.: John Snow, Inc./DELIVER, for the U. S. Agency for International Development. 33 A PlAnnInG RESOURCE fOR THE SPARHCS TOOl 34 Kagone, Meba, Eric Takang, Antoine Ndiaye, Olga Sankara, and Ernest Ouédraogo. 2005. West Africa Reproductive Health Commodity Security. “Country Assessment Report: Burkina Faso.” Arlington, Va.: John Snow, Inc./DELIVER, for the U.S. Agency for International Development. Ministry of Health, Malawi. 2006. Addendum: Reproductive Health Commodity Security Strategy (2006 – 2010). Republic of Malawi. Lilongwe. Moreland, S., S. Alkenbrack, K. Smith, H. Abdallah, J. Durgavich, and N. DeMetz. 2003. SPARHCS Madagascar Field Test Evaluation Report. Washington, DC: Futures Group/POLICY Project. countryreports/SPARHCS%20Madagascar%20Reposition%20FP%20Final%20report.pdf Paul Dowling. Bunde, Elizabeth. Chirwa, Veronica. 2005. Malawi: Contraceptive Security Desk Assessment. Arlington, Va.: DELIVER, for the U.S. Agency for International Development. POLICY Project, DELIVER Project, and Commercial Market Strategies. 2002. Developing a Common Understanding of Contraceptive Security: Contraceptive Security Workshop Report, November 3-4, 2002, Amman, Jordan. Washington, D.C.: POLICY Project/Futures Group International. POLICY Project. Documenting the Use of the SPARHCS in Bolivia. 2006. Washington, DC: Futures Group/POLICY Project. POLICY Project. Documenting the Use of the SPARHCS in Egypt. 2006. Washington, DC: Futures Group/POLICY Project. POLICY Project. Documenting the Use of the SPARHCS in Jordan. 2006. Washington, DC: Futures Group/POLICY Project. POLICY Project. Documenting the Use of the SPARHCS in Paraguay. 2006. Washington, DC: Futures Group/POLICY Project. POLICY Project. Documenting the Use of the SPARHCS in Ukraine. 2006. Washington, DC: Futures Group/POLICY Project. Sanderson, Jeff and Nadia Olson. 2006. Contraceptive Security in Guyana: Arlington, VA: DELIVER, for the U.S. Agency for International Development. Taylor, Patricia A., Nora Quesada, Wendy Abramson, Varuni Dayaratna, and Leslie Patykewich. 2004. Regional Report: Contraceptive Security in Latin America and the Caribbean. Results and Recommendations. Arlington, VA: John Snow, Inc./DELIVER, and Washington, DC: Futures Group/POLICY II, for the U.S. Agency for International Development. The Supply Initiative. 2005. Why reproductive health supplies are crucial to achieving the Millennium Development Goals (MDGs). Belgium: The Supply Initiative. Thompson, H. Daniel. Shifting The Contraceptive Security Paradigm Towards A Model For Decentralized Environments: Lessons from Indonesia. 2005. Jakarta and Washington, DC. STARH Project for the U.S. Agency for International Development. UNFPA. Eritrea Reproductive Health Commodity Security Situational Analysis. 2005. UNFPA. Reproductive Health Commodity Security Situation Analysis Tool (RHCSAT): A Tool for Country RHCS Situation Analysis, Planning, and Implementation. 2005. Adapted from SPARHCS and LSAT By UNFPA Africa CSTs’ RH Logistic Advisers and Team of Africa RHCS Experts. Harare, Zimbabwe, 15th – 25th August 2005. New York, NY. UNFPA. 2006. Global Programme to Enhance RHCS 2007 – 2011. Commodity Management Branch (CST). New York, NY. UNFPA. 2006. Reproductive Health Commodity Security Assessment: Mozambique. New York, NY. USAID | DELIVER and USAID | HPI. Draft Guide: Addressing Operational Policy Barriers To Contraceptive Financing And Procurement. 2007. USAID | Health Policy Initiative. Contraceptive Security Strategic Plan for Egypt: 2006–2010. Washington, DC and Cairo for the United States Agency for International Development. West Africa Health Organization (WAHO) and DELIVER. 2006. Reproductive Health Commodity Security Strategy for the West Africa Sub region. Arlington, Virginia: DELIVER, for the United States Agency for International Development. English:, French: page/portal/45A9968C1995E980E040007F01003F1A THE SPARHCS PROCESS GUIDE Appendices Appendix A: Countries Where the SPARHCS Tool Has Been Applied • Africa Angola (2005, 2007), Benin (2006), Botswana (2006), Burkina Faso (2004), Burundi (2007), Cameroon (2005), Central African Republic (2007), Cote d’Ivoire (2007), Democratic Republic of Congo (2007), Egypt (2004), Eritrea (2005), Gabon (2006), Ghana (2002, 2004), Guinea Conakry (2007), Guinea Bissau (2007), Lesotho (2007), Liberia (2007), Madagascar (2003), Malawi (2006), Mozambique (2006), Nigeria (2002, 2008), Republic of Congo (2007), Rwanda (2005, 2006), Sao Tome and Principe (2007), Senegal (2006), Sierra Leone (2006), Somalia (2006), Southern Sudan (2007), Sudan (2007), Swaziland (2007), Tanzania (2007), Togo (2006), West Africa Region (2006) • Asia/Pacific Bangladesh (2004), Cambodia (2006), Fiji (2005), Indonesia (2003), Jordan (2002), Nepal (2003, 2006) • Latin America/Caribbean Bolivia (2003), Dominican Republic (2005), Ecuador (2005), Guatemala (2006), Guyana (2006), Haiti (2007), Honduras (2004), Nicaragua (2004), Paraguay (2004), Peru (2003), LAC Region (2004) • Eurasia Azerbaijan (2006), Georgia (2004), Kazakhstan (2006), Ukraine (2004) Appendix B: Sample Terms of Reference for an RHCS Coordinating Committee Terms of Reference for Reproductive Health Commodity Security (RHCS) Coordination Committee (Mozambique)7 Purpose To provide a platform for coordinating reproductive health commodity security activities to Mozambique; as well as, serve as a major coordinating structure for Sexual Reproductive Health / Maternal Mortality Reduction programmatic issues and commodities. To improve the reproductive health of the Mozambique population through a holistic and integrated approach to reproductive health com- modity security management. To maintain advocacy and lobby to ensure that earmarked funds in dedi- cated budget lines for FP contraceptives and supplies are actually used for procurement. Objectives Identify and address gaps and challenges in the provision of reproductive health commodity security. Exchange information on reproductive health commodity security. Identify need for and conduct joint planning, monitoring and assess- ments/evaluation of reproductive health commodity security. Serve as an integral part of the SWAp forum to mainstream the SRH/ MMR concerns and needs into the SWAp agenda and Common funding mechanisms support. Collaborate with the MOH to develop a National RHCS Strategy and Strategic Action Plan for RHCS system strengthening and implementa- tion activities. Duties and Responsibilities Urgently develop a national RHCS strategy, and strategic action plan for system strengthening and implementation of RHCS activities, including sustainability mechanisms. Identify and regularly review areas of common interest regarding repro- ductive health commodity security. Promote and conduct joint needs and mid-term assessments within reproductive health commodity security. Assist in mobilizing resources to implement the national strategic RHCS plan. Assist and recommend necessary actions towards facilitating administra- tive procedures towards distribution and custom clearance. Identify advocacy needs and recommend actions to enhance capacity in targeted groups (religious, socio-cultural, ethnic, parliamentarians and politicians). Identify common areas of monitoring and evaluation and develop joint implementation in order to optimize the use of resources and avoid dupli- cation of activities. Facilitate the establishment of similar coordinating mechanisms at provincial and district levels and provide necessary technical support for their functioning. Functioning of the RHCS Coordination Committee Meetings will be held quarterly. The committee may hold extraordinary meetings to address urgent RHCS issues, The Director of Community Health Department or the Designate, shall chair meetings of the committee, UNFPA will provide secretariat support including organizing meetings and taking and distributing minutes (upon receipt of a request from the MOH). Membership Director of Community Health Department, MOH. Director of Finance Department, MOH. Director of Pharmaceutical Services Department, MOH. Centre for Medicines and Medical Supplies, MOH. MEDIMOC Headquarter. DAG, MOH. Directors of Provincial Departments of Health. National STD/HIV/AIDS Coordinator, MOH. National MCS (Safe motherhood) Coordinator, MOH. National Head of Reproductive Health, MOH. National Head of Family Planning, MOH. RHCS Focal Person, RH Unit, CHD, MOH. Representative of Ministry of Finance. Representative of Ministry of Youth Affairs. Representative of Ministry of Women Affairs. UNFPA. WHO. USAID. UNAIDS. UNDP. UNIFEM. UNICEF. IPPF Affiliate. CDC. GFATM. Medicus Mundi. CUAMM. Health Alliance International. Forte Saude. Civil Society Organizations. NGOs. Faith Based Organizations. Representative of Disenfranchised. Commercial private sector. 7Taken from United Nations Population Fund. 2006. Reproductive Health Commodity Security Assessment: Mozambique. UNFPA. New York, NY. 35 36A PlAnning ResouRce foR the sPARhcs tool SPARHCS Component Context Coordination Source of Contraceptive Supply DHS, RHS Capacity Infant Mortality Rate, Maternal Mortality Rate Total Population, Population Growth Rate, Percent of Population Urban/Rural, Life Expectancy at Birth, Adult Literacy Rate, Gross Enrollment Rate HIV Prevalence International Poverty Line Finance, utilization, access, and other RHCS indicators Demographic Health Surveys (DHS) - Reproductive Health Surveys (RHS) Data Online for Population, Health and Nutrition (DOLPHN) - Report on the Global Aids Epidemic - World Development Indicators (WDI) - Contraceptive Security Index - Capital Family Planning E�ort (FPE) Scores Logistics System Assessment Tool (LSAT) and Logistics Indicators Assessment Tool (LIAT) Scores Supply chain strength Gross National Income, Per Capita Income Donor Expenditures for RH Products Quantity and Value of Contraceptives Shipped by USAID, UNFPA, and IPPF Projected Costs of Required Contraceptives Commitment Commodities Client Health Expenditure as % of Gross Domestic Product, Per Capita Health Expenditure National Policies related to RHCS WDI National Policy Documents Projected Quantities of Commodities Needed Availability of RH Supplies at Facilities Contraceptive Prevalence Rate, Unmet Need for Family Planning , Method Mix DHS, RHS RHCS Data Data Source WDI United Nations Population Fund -�le/590_�lename_dsr2004.pdf Reproductive Health Interchange (RHI) – , USAID | DELIVER Project “My Commodities” Database (USAID shipments only) – Pro�les for Family Planning and Reproductive Health Programs�les116FP2ed.pdf, USAID Contraceptive Product Catalog -, Estimates of required �nancing for contraceptives can also be obtained by using the SPECTRUM software Pro�les for Family Planning and Reproductive Health Programs, CPTs, SPECTRUM software, national inventories of supplies Facility surveys (e.g., LIAT) MEASURE Evaluation - USAID | DELIVER PROJECT – Contraceptive Security Index Appendix C: Sample RHCS Data from Desk-Based Research THE SPARHCS PROCESS GUIDE Appendix D: SPARHCS Assessment Tables and Graphs The following figures and tables illustrate the data that are often included in a SPARHCS assessment. For specific examples, please view the actual reports, listed in the References section of this guide. Sample Tables Figure 1 - SPARHCS Framework Figure 2 - Historic Population Figure 3 - Projected Populations (Women of Reproductive Age & Married Women of Reproductive Age) (2000-2020) Figure 4 - Comparison of Contraceptive Prevalence Rates in Region (present) Figure 5 - Total Fertility Rate (1990s – present) Figure 6 - Contraceptive Prevalence Rate and Unmet Need (1990s – present) Figure 7 - Contraceptive Prevalence Rate by Geographic Region (1990s – present) Figure 8 - Contraceptive Prevalence Rate by Age Group (1990s – present) Figure 9 - Contraceptive Prevalence Rate by Level of Education (1990s – present) Figure 10 - Contraceptive Prevalence Rate by Ethnicity (1990s – present) Figure 11 - Contraceptive Prevalence Rates by Selected Characteristics (1990s – present) Figure 12 – Maternal Mortality Ratio and Contraceptive Prevalence Rate across years (1990s – present) Figure 13 – Infant Mortality Rate and Contraceptive Prevalence Rate across years (1990s – present) Figure 14 – Contraceptive Prevalence Rate and Unmet Need by Wealth Quintile (present) Figure 15 - National Method Mix (present or over time) Figure 16 - National and Public Sector Method Mix (present) Figure 17 – Method Mix by Wealth Quintile (present) Figure 18 – Method Mix by Ethnicity (present) Figure 19 – Source of Supply (present) Figure 20 – Source of Supply by Method (present) Figure 21 – Source of Supply by Wealth Quintile (present) Figure 22 - Total Couple Years of Protection in Public and Private Sectors (1990s – present) Figure 23 – Diagram of Contraceptive Logistics System (flow of information and commodities) Figure 24 – Percent of Health Establishments Stocked Out on Day of Visit and Last Six Months by Method Figure 25 – Percent of Service Delivery Points Stocked Out of One or More Method on Day of Visit and Last Six Months by Method Figure 26 – Percent of Health Establishments that Received a Supervisory Visit in Last Six Months Figure 27 - Health Sector Expenditure by Major Sources (most recent) Figure 28 - Public Health Sector Expenditure (most recent) Figure 29 – Total Amount of Donations Received (1990s – present) Figure 30 – MOH Financial Requirement for Procurement of Modern Methods by Local and UNFPA Prices (US$) Sample Tables Table 1 - Development and Health Indicators Table 2 – Family Planning Reproductive Health Technical Program Objectives Table 3 - Health Care Facilities by Region Table 4 – Family Planning Service Statistics for NGO sector Table 6 – Key Partners and Actors in the MOH Supply Chain for Contraceptives Table 7 – Family Planning Reporting Rates, by Region and Type of Facility Table 8 – Maximum and Minimum Level by Level and Type of Facility Table 9 – Stock Status (%) at the Time of Visit by Method (Between Max./Min., Below Min., Above Max., and Stocked Out) Table 10 – Number of Proper Warehousing Conditions Met at the Time of Visit Table 11 - Health Sector Expenditure by Major Sources (most recent) Table 12 - Public Health Sector Expenditure (most recent) Table 13 - Household Proportion of Total Health Expenditure (most recent) Table 14 - National Estimated Total Modern Method Users (most recent) Table 15 - MOH, Estimated Total Modern Method Users (most recent) Table 16 – National Contraceptive Requirements (2000 -2010) Table 17 – MOH Contraceptive Requirements (2000 – 2010) Table 18 - Unit Price for Contraceptives by Source (US$) Table 19 – Ministry of Health Contraceptive Requirements and Estimated Cost at UNFPA Prices (2000 – 2010) 37 38A PlAnning ResouRce foR the sPARhcs tool 8 Ministry of Health, 2006. Addendum: Reproductive Health Commodity Security Strategy (2006–2010). Republic of Malawi. Lilongwe. Strategy/Activities Responsible Unit Partners Notes Increase knowledge of key decision makers about logistics issues • Technical Working Group conducts targeted advocacy and education for policy makers at MOH, MOF, and District Medical Stores, on the need for coordination on forecasting, quanti�ca- tion and procurement, and on the need for �exible supply chains that can respond quickly to impending stockouts with supportive policies and systems HIV/AIDS Treatment Satisfaction Survey Central Medical Stores Reproductive Health Unit Perception that top policy makers are a) not aware of current problems, b) do not understand how supply chain elements must work together seamlessly. For example, quanti�cation and procurement must follow forecasting in a timely manner or else forecast must be redone Increase advocacy for RHCS and FP at all political levels. Targets include: • District Assemblies and District Health Manage- ment Teams (to include traditional leaders) • Parliamentarians (through Parliamentary Committee on Health and Population and Reproductive Health Subcommittee) • The President and the First Lady • Minister of Health and Permanent Secretary HIV/AIDS Treatment Satisfaction Survey Increase advocacy at civil society level • Strengthen relationships with media for RHCS and FP • Prepare press brie�ngs on RH and FP Reproductive Health Unit HIV/AIDS Treatment Satisfaction Survey Very little exposure of RH, FP or RHCS in media Appendix E: Select Actions from the Malawi RHCS Strategic Plan8 Strategic Objective: That decision makers at all levels of government and society continue to support fully RHCS. 39 THE SPARHCS PROCESS GUIDE Indicator Data Source FrequencyIndicator Calculation Notes Finance Document discrepancy between �nancial need, based on forecasting, and actual funding received for contraceptive procurement Amount of �nancing provided by MOH, proportional to the amount of �nancial need forecasted in the same period Disbursement of funds (vs. schedule) [Allocated Budget / Financial Need Forecasted based on consumption] * 100 Ministry of Health, Ministry of Finance Annually Emphasis made on using annual forecast based on consumption data and cross- referenced with other sources (e.g., demographic and health service statistics) to inform �nancing needs. Procurement Ensure e�cient procurement Procurement plan exists Tracking mechanism exists to monitor status of products during procurement process Contraceptive costs as a percent of international benchmarks Contraceptive costs versus lowest local provider Procurement plan exists?: Yes/No Tracking mechanism exists?: Yes/No [Price paid for contraceptives / Int’l reference price] * 100 [Price paid for contraceptives / Lowest price paid for contraceptives from local provider] * 100 Program records UNFPA, Ministry of Health Previous tenders, current quotes Accounting system, procurement agents bid or cost Annually Monitoring plan will di�er depending on whether procurement is centralized or decentralized and whether commodities are procured directly or through a procurement agent Link to logistics indicators Logistics Maintain product availability at facility level Frequency, duration, and location of stockouts over time Number and duration of stockouts at the facility level Facility registers, spot checks, Logistics Management Information System (LMIS) At least quarterly In some countries physical inventories could be another source for this data Determine an estimate of the number of FP users per sector Number and percent Couple Years of Protection (CYP) by sector over time Calculated from consumption data with a conversion factor per method Ministry of Health Social Security, NGOs (based on consumption data) In lieu of DHS dataAnnually Improve forecasting accuracy Percent discrepancy between forecast and actual use [(Estimated Need – Actual Use) / (Estimated Need)] * 100 LMIS, Ministry of Health Social Security (based on consumption data) Annually Strive to have an automated LMIS calculate this automatically 9A template developed by the DELIVER Project in 2006 to promote the implementation, monitoring, and evaluation of RHCS strategic plans in the Latin America/Caribbean region. Subobjective/Result Appendix F: Sample RHCS Monitoring and Evaluation Plan9 A PlAnning ResouRce foR the sPARhcs tool 40 Subojective/Result Indicator Data Source FrequencyIndicator Calculation Notes Advocacy and Policy Integrating RHCS priorities into larger national level development plans Integration of RHCS into national development frameworks/plans (PRSPs, development plans, RH strategies, etc.) Review of o�cial documents National-level documents with mention of RHCS and RHCS priorities Annually, or whenever an o�cial paper is published Members of the RHCS coordinating committee should be involved in developing national strategic policy and planning papers and workplans (e.g., poverty reduction strategy papers and health sector strategies). They should seek inclusion on non-health committees developing policy documents to help ensure RHCS and FP are linked to other sectors, thereby included as a as priority for social development Ensure the appropriate range of methods are procured to meet country needs Basic package of methods included on essential drug list (Essential Drugs List (EDL); equipment for long acting and permanent methods, IUDs, condoms, pills, and injectables) Basic package products included on o�cially published EDL?: Yes/No Social Security Institute (SSI) and Ministry of Health EDL Once Programs should o�er at least one brand/ formulation of each method type to ensure availability of minimum method mix Strengthen legal/regulatory framework and policy environment in favor of RHCS Funded national budget line item for FP/contraceptives (earmarked funding) Is there a funded national budget line item?: Yes/No Ministry of Health budget papers and Ministry of Finance records Yes answer to this indicator will be based on review of written budget papers of MOH. This measures reduction of donor dependence Annually Market Segmentation Expand SSI �nancing of FP/ contraceptives for bene�ciaries and a�liates Number and percent of FP users who obtain FP methods through the SSI over time [# of FP users in the SSI (bene�ciaries)] / [Total # of married women of reproductive age who are bene�ciaries within the SSI] SSI program reports and # of female bene�ciaries 15-49 years old Specify by method Increase access to contraceptives among underserved groups Percent unmet need by socioeconomic quintile, geographic area, and ethnicity Source of contraceptives for users CPR Reported in DHS Secondary analysis of DHS; service statistics from facilities Every �ve years Assumes that countries will perform regular DHS surveys Annually Appendix F: Sample RHCS Monitoring and Evaluation Plan (continued) THE SPARHCS PROCESS GUIDE Appendix G: Work Plan Indicators from the Nigeria RHCS Strategy10 Component: 1.0 Finance Objective: 1.1 To ensure that key decision makers and financial managers at national, state, and local levels are provided with current and reliable data related to contraceptive security financial requirements. Issues Addressed: • Validity, reliability and comprehensiveness of financial data; • To ensure that key policy/decision makers make use of the financial data in planning; • Evidence-based planning and decision making. Coordinating Agency: • FMOH/DCDPA Assumptions: • Favorable political environment • Continued donor support • Positive response from the key policy makers • Collaboration between various levels of government and NGOs/private sector • Financial management 41 Appendix G: Work Plan Indicators from the Nigeria RHCS Strategy10 Component: 1.0 Finance Objective: 1.1 To ensure that key decision makers and �nancial managers at national, state, and local levels are provided with current and reliable data related to contraceptive security �nancial requirements. Issues Addressed: • Validity, reliability and comprehensiveness of �nancial data; • To ensure that key policy/decision makers make use of the �nancial data in planning; • Evidence-based planning and decision making. Coordinating Agency: • FMOH/DCDPA Assumptions: • Favorable political environment • Continued donor support • Positive response from the key policy makers • Collaboration between various levels of government and NGOs/private sector • Financial management Activities and Subactivities Implementing Agencies Estimated Budget (Naira) Timing Output Indicators Outcome Indicators 1.1.1 Develop financial management information system (FMIS) for effective planning, monitoring and evaluation of RHCS Total: 28.3m • % of states and LGAS e�ectively using FMIS • Structures developed and maintained at State and National levels • Financial data used to secure funding from government and donors FMOH, DCDPA, HPR Set up a committee to determine needs of RHCS �nancial information system. “ 1.2m 4th quarter 2004 a) Develop RHCS �nancial information system in response to identi�ed needs. 12m 4th quarter 2004 b) Provision of forms and stationery for FMIS 2.0m • Forms and stationery supplied • % of States and LGAs with adequate forms and stationery Develop FMIS training curriculum DCDPA, HPR, LGAs, SMOH 0.5m 1st quarter 2005 Train �nancial managers on FMIS DCDPA, HPR, LGAs, SMOH 9.6m 1st quarter 2005 • No. of �nancial managers trained in the use of FMIS • % of States and LGAs with manager trained in FMIS Generate quarterly and annual reports on the �nancial status of commodities DCDPA, HPR, SMOH, LGAs, NGOs 1.0m 2005 quarterly • No. of �nancial managers who make quarterly reports using the FMIS • % of states and LGAs which have a functioning e�ective FMIS Review the FMIS periodically DCDPA, HPR, SMOH, LGAs, NGOs 2.0m 2006 yearly Activity Subactivities “ 10 Taken from the Nigeria RHCS Strategic Plan. See Nigeria, 2003 in References section for full citation. • FMIS training curriculum developed • FMIS developed • Needs for FMIS identi�ed A PlAnnInG RESOURCE fOR THE SPARHCS TOOl Appendix H: For Further Information • Commodities Security and Logistics Division, U.S. Agency for International Development (USAID) Commodities Security and Logistics Division Office of Population and Reproductive Health Global Health Bureau USAID Washington, D.C., 20004 Email: • Commodity Management Unit, United Nations Population Fund (UNFPA) Commodity Management Unit Technical Support Division 220 East 42nd Street New York, N.Y. 10017 Email: • Reproductive Health Supplies Coalition (RHSC) Secretariat RHSC Rue Marie-Thérèse, 21 1000 Brussels Belgium Email: Designed and produced by: The INFO Project at the Johns Hopkins Bloomberg School of Public Health, Center for Communication Programs

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