The West Africa Reproductive Health Commodity Security Sub-Regional Strategy: A Concept Paper

Publication date: 2005

i The West Africa Reproductive Health Commodity Security Sub-Regional Strategy: A Concept Paper The West Africa Reproductive Health Commodity Security Sub-Regional Strategy: A Concept Paper DELIVER DELIVER, a six-year worldwide technical assistance support contract, is funded by the U.S. Agency for International Development (USAID). Implemented by John Snow, Inc. (JSI), (contract no. HRN-C-00-00-00010-00) and subcontractors (Manoff Group, Program for Appropriate Technology in Health [PATH], and Social Sectors Development Strategies, Inc.), DELIVER strengthens the supply chains of health and family planning programs in developing countries to ensure the availability of critical health products for customers. DELIVER also provides technical management of USAID’s central contraceptive management information system. This document does not necessarily represent the views or opinions of USAID. It may be reproduced if credit is given to John Snow, Inc./DELIVER. Recommended Citation JSI/DELIVER. 2005. The West Africa Reproductive Health Commodity Security Sub-Regional Strategy: A Concept Paper. Arlington, Va.: John Snow, Inc./DELIVER, for the U.S. Agency for International Development. Contents Acknowledgements. v Acronyms. vii Executive Summary . ix 1. Introduction .1 1.1 Maternal and Infant Health Outcomes and Reproductive Health Commodity Security (RHCS) .1 1.2 A Sub-Regional RHCS Strategy .3 2. Why a Sub-Regional Approach?.5 2.1 Benefits of a Sub-Regional Strategy .5 2.2 Challenges of RHCS in the Sub-Region.5 2.2.1 Access to Quality Products and Services.5 2.2.2 Logistics Management .6 2.2.3 Financing .6 2.2.4 Coordination—Donor, Government, and Private Sector.8 2.2.5 Policy Support .8 2.3 Thematic Areas of a Sub-Regional Strategy .8 3. Framing a Sub-Regional Strategy: the Strategic Pathway to Reproductive Health Commodity Security (SPARHCS). 11 4. Sub-Regional Opportunities. 15 4.1 Illustrative Opportunities . 15 4.2 Sub-Regional Partners . 15 5. Strategy Development Process . 19 6. Outline For a Sub-Regional Strategy . 21 References . 23 Annex 1. Strategy Development Timetable . 27 Figures 1.0 CPR and Maternal Mortality in West Africa.1 1.1 Infant Mortality by Birth Interval: Selected West African Countries .2 2.0 Public Sector Service Delivery Point Stock Status: Ghana, Mali, Nigeria (2001–2002) .6 2.1 Donor Financing for Contraceptives (except condoms) Compared to Projected Need in West Africa .7 3.0 The SPARHCS Framework and Components . 12 Table 4.1. RHCS Country and Sub-Regional Opportunities. 16 v Acknowledgments The primary authors/editors of this concept paper were Raja Rao and Dana Aronovich from John Snow, Inc. (JSI)/DELIVER. The authors would like to thank the many people who contributed to the content of this paper. This includes Dr. Kabba Joiner of the West African Health Organisation; Alan Bornbusch of USAID/Washington; Felix Awantang, Kristin Cooney, and Jamie Browder of USAID/WARP; Antoine N’Diaye of the AWARE/RH project; and Aoua Diarra, Meba Kagone, and David Sarley of JSI/DELIVER. Additional members of the International Planning Committee and the RHCS Task Force also provided input for this paper, including staff from the UNFPA, the World Bank, the World Health Organization-Regional Office for Africa, the International Planned Parenthood Federation-Africa Regional Office, Japan International Cooperation Agency, KfW, Advance Africa, IPAS Africa Alliance, Population Services International, the Population Council, plus numerous country representatives from ECOWAS countries. We would especially like to thank USAID for their financial support of this paper. Finally, we would like to thank Pat Shawkey, Kathy Strauss, and Jose Padua of JSI/DELIVER for completing the publication of this paper. vii Acronyms ACAME Association Africaine des Centrales d’Achats de Médicaments Essentiels BCC/IEC behavior change communication/information, education, communication CERPOD Centre d’Etudes et de Recherche sur la Population pour le Développement CIB coordinated informed buying CMS Central Medical Store CPR contraceptive prevalence rate DHS Demographic and Health Survey ECOWAS Economic Community of West African States HIV/AIDS human immunodeficiency virus/acquired immunodeficiency syndrome IEC information, education, and communication IMR infant mortality rate IPC International Planning Committee IPPF International Planned Parenthood Federation KfW Kreditanstalt für Wiederaufbau LMIS Logistics Management Information System M&E monitoring and evaluation MDG Millennium Development Goal(s) MMR maternal mortality ratio MoH Ministry of Health NEPAD New Partnership for Africa’s Development NGO nongovernmental organization RH reproductive health RHCS Reproductive Health Commodity Security SDP service delivery point SPARHCS Strategic Pathway to Reproductive Health Commodity Security STI sexually transmitted infection UNFPA United Nations Population Fund USAID United States Agency for International Development WAHO West African Health Organisation WHO-AFRO World Health Organization—Regional Office for Africa ix ix Executive Summary Maternal and infant health indicators in the countries of the West African sub-region tend to remain weak, although they are comparable to other developing countries. The West African Health Organisation (WAHO) and its partners recognize the seriousness of the gaps in access to and the quality of maternal and perinatal health services in the sub-region. To address these challenges, they developed a Strategic Plan for the Reduction of Maternal and Perinatal Mortality in West Africa. This sub-regional strategy also supports the World Health Organization— Regional Office for Africa (AFRO)/African Union’s Road Map, and the New Partnership for Africa’s Development (NEPAD)/United Nations’ Millennium Development Goals (MDG). Both the Road Map and the MDGs include, among the indicators, improving maternal and infant health outcomes and reducing the spread of HIV/AIDS. All these indicators depend on reproduc- tive health commodity security (RHCS), and the consistent availability and use of reproductive health (RH) commodities (UNFPA 2004). RHCS exists when every person can reliably choose, obtain, and use quality, affordable essential reproductive health supplies whenever he or she needs them. There is a dem- onstrated relationship between health outcomes and RHCS. To address these reproductive health challenges and to advance its Strategic Plan for the Reduction of Maternal and Perinatal Mortality, WAHO has begun to identify and systematically address the interde- pendence between RHCS and these health outcomes. At the Fifth Annual Assembly in Accra in 2004, the Economic Community of West African States (ECOWAS) Health Ministers recommended that WAHO and its partners develop a sub-regional strategy for RHCS to support the maternal and perinatal strategic plan. By promoting increased access to and use of RH commodities, the additional RHCS strategy will also support the attainment of the MDGs and the Road Map goals—a significant reduction of maternal and infant deaths by 2015 (United Nations 2004). The benefits of implementing a sub-regional strategy for RHCS are many; they build upon and support country-level efforts to address RHCS (see section 2.1). Some of the challenges to RHCS are common to many countries across the sub-region. To take advantage of scale and to promote sub-regional coopera- tion, the challenges are often better addressed at the sub-regional level. A sub-regional approach to RHCS can— • Function as an excellent vehicle for advocacy at the sub-regional level and for working across coun- tries to compare, inform, and influence public health policies. • Bring key decision makers from different stakeholders together around a common conceptual frame- work, terminology, tools, and methods for assessing and addressing challenges. • Facilitate the sharing of experiences between countries. • Attract the attention and support of governments, multilateral organizations, bilateral donors, and other partners for RHCS. The partners, including WAHO, the United Nations Population Fund (UNFPA), the United States Agency for International Development (USAID), Kreditanstalt für Wiederaufbau (KfW), World Bank, and other agencies, recognized that there were many common challenges to RHCS that face countries in the sub- region, and that a sub-regional RHCS strategy could be an effective mechanism to address them. The challenges that cut across countries in the sub-region include (1) limited access to quality RH commodi- ties and services; (2) weak national logistics systems for managing RH commodities; (3) insufficient financing for RH commodities and services from all sources (household, community, national govern- ments, multilateral and bilateral donors, and funders); (4) a lack of coordination mechanisms between partners in the sub-region; (5) a multiplicity of poorly coordinated activities in countries, leading to un- xi xi The West Africa Reproductive Health Commodity Security Sub-Regional Strategy: A Concept Paper necessary redundancies and an inefficient use of the limited resources available for RH; and (6) national and operational policy barriers to RHCS. These challenges are described in section 2.2. Three key areas have been identified where a sub-regional strategy can add maximum value for support- ing and advancing RHCS. 1. A coordinated informed buying (CIB) network among ECOWAS countries would allow national pro- curement and supply managers to share information with their counterparts in the sub-region on supplier price, quality, and other relevant data. This information could enable them to make in- formed procurement decisions, and, by comparing prices obtained by other countries in the network, help ensure the procurement of low priced and high quality RH commodities. 2. Weaknesses in human resource development, institutional capacity building and technical assistance are common to countries in the sub-region. The capacity to deliver RH commodities to clients through effective supply chains, monitor and test the quality of commodities, and train personnel in the multitude of functions involving RHCS, varies by country. That capacity needs additional attention. 3. The sub-regional strategy is advocacy for a harmonized regulatory and policy framework. Sub-re- gional organizations can play a catalytic role in advocating for a strengthened policy and regulatory environment in support of RHCS. These areas are described in more detail in section 2.3. The proposed sub-regional strategy will seek to achieve RHCS by focusing on strengthening systems to increase access to RH commodities to current users and those expressing an unmet need for these com- modities (that is, a desire or a need to use, but who are not currently using). The Strategic Pathway to Reproductive Health Commodity Security (SPARHCS), described in detail in section 3, will be used as a conceptual guide for developing this sub-regional strategy to achieve RHCS. SPARHCS takes a strategic, long-term, multidisciplinary, and multi-stakeholder perspective on RHCS by identifying how elements, such as logistics policies, financing, service delivery, advocacy, and others, are both interdependent and vital to achieving RHCS. See table 4.1 for illustrative country and sub-regional opportunities, organized around the SPARHCS conceptual framework. These include, for example— • Strengthening sub-regional quality testing laboratories to improve quality of RH commodities. • Mobilizing donor commitments to RHCS. • Supporting national governments and RHCS coordination mechanisms. • Working with member states to introduce budget line items for RH commodities in their budgets. • Documenting and disseminating sub-regional technical materials and best practices (e.g., logistics and service delivery). • Facilitating sub-regional technical assistance exchanges. • Enhancing sub-regional coordination around policy implementation (tariffs, regulatory environment, procurement). • Harmonizing sub-regional drug registration, standard treatment guidelines, and essential medicines lists. This sub-regional RHCS strategy will depend on the participation and contributions of the many West African institutions working in reproductive health, as well as support from international and bilateral partners. WAHO, as the primary sub-regional health authority for ECOWAS, is positioned to take a leader- xii Executive Summary ship role in coordinating a sub-regional RHCS strategy and to advocate for material support of a sub- regional strategy directly with donors and member countries. In addition, there are other sub-regional actors, notably WHO-AFRO, the Association Africaine des Centrales d’Achats de Médicaments Essentiels (ACAME), the Centre d’Etudes et de Recherche sur la Population pour le Developpement (CERPOD), and others who, with WAHO, could also have roles in a sub-regional strategy and serve as advocates, brokers, and catalysts for its adoption and implementation. The next steps and timeline for the development of the sub-regional RHCS strategy are presented in section 5 and annex 1, including several additional meetings between WAHO and the other partners in the sub-region to define the content of the strategy and to develop an implementation plan. Section 6 presents a proposed outline for the strategy. This outline and the final strategy needs to be developed and debated during the coming year, with input from all partner organizations. The sub-regional RHCS strategy should be finalized by August 2006. xiii % M W RA u si ng m od er n co nt ra ce pt i o n M at er na l d ea th s pe r 10 0, 00 0 liv e bi rt h s Gu in ea Gu in ea -B iss au Ni ge r Si er ra Le on e Ma ur ita ni a Li be ria Ma li Be ni n Cô te d’ Iv oi re Ni ge ria Se ne ga l Bu rk in a Fa so Ga m bi a To go Gh an a Ca pe Ve rd e Ea st er n Af ric a We st er n Af ric a Eu ro pe As ia La tin Am er ic an & Ca rib be an 1. Introduction 1.1 Maternal and Infant Health Outcomes and Reproductive Health Commodity Security (RHCS) For every 100,000 live births in West Africa, there are 880 maternal deaths, and more than 100 infant deaths for every 1,000 live births (PRB 2005). The percentage of married women using modern meth- ods of contraception in the sub-region stands at 8 percent—marking it near the bottom worldwide for contraceptive use. Additionally, the percentage of adults in West Africa ages 15–49 with HIV/AIDS is 4.3 percent, and nearly 60 percent of those individuals are women (PRB 2005). These maternal, infant, and reproductive health statistics are unacceptable. The United Nations’ Millennium Development Goals (MDGs) include among its indicators improving maternal and infant health outcomes and reducing the spread of HIV/AIDS, all of which depend on the consistent availability and use of RH commodities (UNFPA 2004). Reproductive health commodity security (RHCS) exists when every person can reliably choose, obtain, and use quality, affordable, essential reproductive health supplies when he or she needs them. RHCS is critical for achieving these international goals. For example, figure 1.0 shows the relationship between high maternal mortality ratios (MMR) and low contraceptive prevalence rates (CPR). By helping women plan and space their children and eliminate undesired pregnancies, RHCS can play an important role in reducing maternal mortality and improving maternal health. Figure 1.0 CPR and Maternal Mortality in West Africa 70 2500 4 4 4 4 5 5 6 7 7 8 8 9 9 9 19 46 8 17 62 57 54 740 1,100 1,600 2,000 760 1,000 1,200 850 690 800 690 1,000 540 570 540 150 880 1,020 190 330 24 CPR Maternal deaths 60 50 2000 150040 30 20 10 0 1000 500 0 Sources: CPR and MMR: PRB 2005 Women of Our World Liberia CPR: PRB 1998 World Population Data Sheet 1 1 In fa nt d ea th s pe r 1, 00 0 liv e bi rt h s The West Africa Reproductive Health Commodity Security Sub-Regional Strategy: A Concept Paper Additionally, RHCS has an impact on infant health. For example, when mothers space their births at least two years apart, infant mortality rates are reduced by as much as 50 percent (see figure 1.1). Figure 1.1 Infant Mortality by Birth Interval: Selected West African Countries Mali 2001 Nigeria 2003 Benin 2001 Burkina Faso 2003 Guinea 1999 Togo 1998 Ghana 2003 Senegal 1999 Source: Demographic and Health Surveys, MEASURE/DHS+, year of survey listed 120 50 177 154 143 142 142 121 160 104 87 104 105 66 53 111 0 20 40 60 80 100 120 140 160 180 200 less than 2 years at least 2 years Although the sub-region has made progress in increasing the use of family planning services during the past decade—CPR (for modern methods), for example, has doubled in a number of countries1—the use of family planning is still low and unmet need is high (approximately 30 percent on average for the sub- region).2 If these women were using contraception, maternal and infant health outcomes would improve. According to the Human Development Report 2003, “If the unmet need for contraception were filled and women had only the number of pregnancies at the intervals they wanted, maternal mortality would drop by 20–35%.” Unsafe abortions resulting from unwanted pregnancies cause about 13 percent of all maternal deaths every year (UNDP 2003). To cover this expressed need and improve maternal and infant health outcomes, access to reproductive health services and commodities in West Africa must increase substantially. Figures 1.0 and 1.1 indicate that there is a strong relationship between RHCS, specifically for family planning, and maternal and child health outcomes. In addition, the effect of the HIV/AIDS pandem- ic—which has already strained health delivery systems—will exacerbate the situation as demand for condoms to prevent HIV and other HIV/AIDS products continues to rise. Studies have demonstrated that it is reasonable to expect that a secure supply of condoms for the prevention of sexually transmitted infections (STI) and HIV/AIDS can help decrease the trend in the HIV/AIDS infection rate (CDC 1993). There are numerous other demonstrated links between reproductive health commodity security and im- proved maternal and infant health outcomes. For example, a document published by the POLICY Project, entitled, What Works: A Policy and Program Guide to the Evidence on Family Planning, Safe Motherhood, 1. CPR increased over the last decade in every ECOWAS country where data was available. However, CPR remains lower than in other regions of the world, at 8% compared to 14% overall in sub-Saharan Africa (Demographic and Health Surveys, 1990 through 2003). 2. Unmet need is defined as the percentage of all women of reproductive age who wish to delay or prevent their next birth but are not currently using family planning. 2 Introduction and STI/HIV/AIDS Interventions, cites many examples of this relationship among the proven safe moth- erhood interventions, including— • “Geographic access to and appropriate use of [emergency obstetric care (EOC)], trained responsive personnel, essential equipment, supplies, and drugs are correlated with improved maternal and infant health outcomes…” A prospective study of 19,545 women in West Africa through pregnancy and for 60 days postpartum found that [in] 69.1 percent of all maternal deaths . . . [the women] gave birth without access to EOC . . . (pg. 18) • Eclampsia is most effectively treated by magnesium sulphate… (pg. 29) • “Use of prophylactic antibiotics at the time of cesarean sections decreases the incidence of post- operative infectious morbidity.” For example, their use reduces the incidence of endometriosis by two-thirds to three-quarters and “substantially reduces episodes of fever, wound infection, urinary tract infections, and serious infections.” (pg. 33) • Immunizing pregnant women against tetanus is one of the simplest and most cost-effective means of reducing the neonatal mortality rate as well as reducing the incidence of maternal tetanus, which is responsible for at least 5 percent of maternal deaths in developing countries. (pg. 54) • Administering drugs locally effective for malaria to pregnant women may reduce the incidence of low birth weight and anemia among low parity women. (pg. 55) • Preventing, detecting, diagnosing, and treating TB can reduce the numbers of maternal deaths among pregnant women, including those with HIV. (pg. 58) • “Treating iron-deficiency anemia with iron during pregnancy has been shown to reduce … anemia and maternal morbidity … (pg. 79) Treating severe iron-deficiency during pregnancy may reduce the risk of maternal mortality. (pg. 78)” These examples underscore the importance of RHCS in improving maternal and infant health outcomes, because all these important interventions require uninterrupted supplies of quality RH commodities. 1.2 A Sub-Regional RHCS Strategy The West African Health Organisation (WAHO) and its partners have begun to identify and systematically address the interdependence between RHCS and the health outcomes noted in the previous section. In recent years, the ECOWAS Health Ministers have increasingly recognized the need for sub-regional coordination and cooperation as preconditions for sustainable development in West Africa (WAHO 2002). At the Fifth Annual Assembly in Accra in 2004, the ECOWAS Health Ministers recommended that WAHO and its partners develop a sub-regional strategy for RHCS in support of the WAHO Strategic Plan for the Reduction of Maternal and Perinatal Mortality in West Africa 2004–2008. By promoting increased access to and use of RH commodities, the strategy will also support the attainment of World Health Organization-AFRO/African Union’s Road Map, as well as the New Partnership for Africa’s Development (NEPAD) and Millennium Development Goals (MDG) targets for a significant reduction of maternal and infant deaths by 2015 (United Nations 2004). This concept paper is the first step in the development of the strategy by WAHO and its partners. The challenge in developing a sub-regional RHCS strategy and implementation plan is how to manage efforts at the sub-regional level that simultaneously supports country-level interventions. Because of its unique position as the leading sub-regional health organization, WAHO is positioned to take a leadership role in developing this strategy. However, to take advantage of their unique roles and capacities, both the development and implementation of the strategy will require the participation of other sub-regional partners. 3 2. Why a Sub-Regional Approach? 2.1 Benefits of a Sub-Regional Strategy All countries in West Africa face the challenges of achieving RHCS (see section 2.2); some have already begun to address them strategically. National commodity security strategies have been put in place in Ghana, Mali, and Nigeria, and others are in development: for example, in Burkina Faso, Cameroon, Niger, and Togo. These strategies address challenges and barriers specific to each country. In addition to these country-level RHCS interventions, some challenges are common to many countries across the sub-re- A sub-regional approach to RHCS can— gion; to take advantage of scale • Serve as an excellent vehicle for advocacy at the sub-regional level and to promote sub-regional and for working across countries (and with multiple countries cooperation, these challenges simultaneously) to compare, inform, and influence public health can often be better addressed at policies. the sub-regional level. Donors • Bring key decision makers from different settings (countries, are also increasingly looking multilateral agencies, bilateral donors, etc.) together around a at ways to channel support for common conceptual framework, terminology, tools, and methods for assessing and addressing challenges. sub-regional activities to address some of the challenges noted in • Help countries share their experiences. the section below. • Stimulate countries and individuals to higher levels of performance. • Bring together individuals who should be talking to each other in 2.2 Challenges of individual countries (but are not necessarily doing so). This gives these individuals the time and space, outside their politically charged RHCS in the Sub- and busy environments, to share experiences and problem solve Region together. • Attract the attention of governments, along with multilateral As part of WAHO’s RHCS program, organizations, bilateral donors, and other partners. in-depth RHCS country assess- • Allow for the introduction and rapid testing of new approaches and ments have been completed in tools across countries, which can result in substantial savings for Ghana and Burkina Faso. Ad- organizations and projects. ditional assessments to design the coordinated informed buying system have also been carried out in Burkina Faso, Ghana, Mali, Nigeria, and Senegal. These assessments, and similar ones planned for the future, provide critical country-level data that will inform the RHCS sub-regional strategy. Field and desk work completed in previous RHCS efforts have also disclosed some of the key challenges facing the sub-region. Based on the desk research, country assessments, and deliberations with sub-regional organizations, a number of key issues have been identified; these include some of the major, cross-regional RHCS chal- lenges that reinforce the benefits of a sub-regional RHCS strategy. The issues constitute a set of com- mon challenges that must be overcome to achieve RHCS, while, at the same time, addressing maternal health outcomes and meeting the challenges posed by the MDGs. 2.2.1 Access to Quality Products and Services Access to RH commodities is limited in many areas of West Africa. Long physical distances to health fa- cilities, frequent stockouts that result in chronic unavailability, lack of reliable transportation, and poor 5 5 Pe r c en t P e r c en t The West Africa Reproductive Health Commodity Security Sub-Regional Strategy: A Concept Paper infrastructure characterize the situation in many parts of the sub-region. Affordability and inadequate or incorrect information on the use and benefits of RH products are also significant barriers to meeting client demand. In many cases, clients do not have access to a full range of commodities to meet their needs (e.g., there is a limited contraceptive method mix and limited access to new contraceptive tech- nologies) and service providers often do not have the capacity, skills, or the desire to offer a complete range. Further, social, cultural, and religious barriers exacerbate the limits on access. 2.2.2 Logistics Management Although most countries in the sub-region have public sector logistics systems in place, the effective- ness of these systems varies. Assessments have revealed weaknesses in human resources, procurement capacity, data management, warehousing, and transportation.3 Moreover, integration of product lines and decentralization are creating new complexities that sometimes hinder effective supply chain man- agement. Systems will be further strained as they respond to the HIV/AIDS pandemic. These weaknesses in the logistics systems lead to expired products, supply imbalances (overstock), and stockouts at ser- vice delivery points. Figure 2.0 shows the results of recent quantitative assessments of logistics indicators in three countries (Ghana, Mali, and Nigeria). The indicators assessed contraceptive stockouts at service delivery points on the day of visit and stockouts during the preceding six months. While there is some variation between countries, stockouts remain a common occurrence, depriving clients of needed supplies. Figure 2.0 Public Sector Service Delivery Point Stock Status: Ghana, Mali, Nigeria (2001–2002) Stockout on day of survey Stockout during past 6 months 5 22 7680 60 40 20 0 3 56 60 5 17 49 13 22 60 40 20 0 10 61 10 24 Pill Condom Injection Pill Condom Injection Ghana Mali Nigeria Ghana Mali 2.2.3 Financing The Abuja Declaration of 2001 stated that at least 15 percent of the national budgets should be com- mitted to improvements in the health sector (OAU 2001). No country in the sub-region has met this goal for government funding or allocating sufficient resources for RH. The increasing number of women and men of reproductive age, and the growing demand from this population for RH products, indicates that the existing financing gap for RH commodities will grow unless a sustainable investment from all levels is made to finance commodity costs—households, communities, third parties, governments, and international donors and partners. 3. JSI/DELIVER. Logistics System Assessment Survey Results: Select West African Countries (2001–2002). 6 US $ in m ill i o ns Why a Sub-Regional Approach? At the household or community level, there are limits to what the people of West Africa can afford to contribute to financing for RH commodities. “Currently, the true commercial sector, defined as non-sub- sidized products and services provided for profit through private sector sources, has a limited role in West African reproductive health markets. A benchmark income level of around U.S.$1,000 per capita is taken as the level at which low-end commercial contraceptives become affordable. In West Africa, a very small percentage of the population (around 10 percent or less in most countries) has this income level.” (Dowling 2004) Most cannot afford, even nominally, to finance RH commodities. Also, most governments in West Africa do not contribute adequately to financing the procurement of RH commodities to meet the needs of their populations. Many do not have a budget line item for these commodities. The commodities are often combined with other health commodities for procurement, often leading to insufficient quantities, as reproductive health competes for scarce resources, or govern- ments rely largely on donor contributions, which often fluctuate. From 1996–2002, at the donor level, financial support in the sub- Figure 2.1 region for contraceptives Donor Financing for Contraceptives (except condoms) has been erratic (see Compared to Projected Need in West Africa figure 2.1). Donor sup- port for contraceptives 24 in West Africa decreased sharply from $17 million in 2001 to under $11 20 million in 2002. The projected costs for con- 16 traceptives are expected to reach nearly $25 million by 2010. Further, 12 as indicated in figure 2.1, if donor financ- 8 ing from 2002 levels remain constant, there will be at least a $14 4 million funding gap for contraceptives in 20104, 0 excluding condoms. 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 When additional RH commodities for sexually Past donor financing transmitted infection Constant donor financing (based on financing 1999–2002) (STI) prevention, an- tenatal care, and other 3% annual increase in donor financing conditions are consid- Projected cost of contraceptives ered, the requirement 4. UNFPA provided the levels of current and past donor support for contraceptives. The projected financing needs for contraceptives were obtained from the ongoing West African Reproductive Health Commodity Security Study, and were estimated by factoring projected needs with unit cost. The software SPECTRUM, developed by the Futures Group, was used to estimate the projected quantity needed by applying demographic data from the most recent surveys (i.e., Demographic and Health Surveys conducted by ORC Macro International, the Multi-Indi- cator Cluster Surveys conducted by UNICEF, or the Reproductive Health Surveys conducted by CDC) to the UN estimated fertility goals for the region. The global average was used for the unit cost of contraceptives. 7 The West Africa Reproductive Health Commodity Security Sub-Regional Strategy: A Concept Paper for the sub-region doubles to nearly $60 million. In addition to commodity costs, there are substantial financing requirements for the costs of routine operations, service delivery, capacity building, and infra- structure. Given low purchasing power, low prevalence, and lack of economic development, it is unreasonable to expect that situation to change dramatically in the near future. 2.2.4 Coordination—Donor, Government, and Private Sector The lack of coordination mechanisms between partners in the sub-region and the multiplicity of uncoordinated activities at the country level often lead to unnecessary redundancies and an inefficient use of the limited resources available for RH. Because resources are limited, a premium is placed on effective coordination between government, donors, lenders, and implementing agencies to minimize duplication and mobilize additional resources. WAHO is in a strong position to facilitate this effective coordination. Within the ECOWAS community, there are good examples of stakeholder coordination at the country level. Nevertheless, sub-regional and national efforts could be strengthened by engaging a broader range of stakeholders, including ministries other than health (finance, planning, education, etc.), private sector retailers and manufacturers, physician and nursing associations, and civil society organizations (religious institutions, nongovernmental organizations and community-based agricultural and micro-finance institutions). 2.2.5 Policy Support Many national and operational policy barriers to RHCS remain in place. Increased sub-regional and na- tional policy support is needed to address these challenges, which include the lack of national financing for RH commodities (e.g., budget line item) and uneven, inconsistent, and excessive taxes, tariffs, and duties. Additional cross-cutting challenges include advertising restrictions; restrictive operational poli- cies for service provision; and a lack of quality information, education, and awareness raising. 2.3 Thematic Areas of a Sub-Regional Strategy With these cross-cutting sub-regional challenges in mind, three thematic areas have been identified, where, because of scale, reach, and cost-effectiveness, sub-regional actors and activities can add value by advocating, brokering, and catalyzing RHCS activities across the sub-region. These areas address many of the challenges noted earlier and include— • Coordinated Informed Buying Network for RH Commodities In 2004, the WAHO Health Ministers mandated that work begin on designing and implementing a coordinated informed buying (CIB) network among ECOWAS countries. The CIB network would allow national procurement and supply managers to share information with their counterparts in the sub- region on supplier price, quality, and other relevant data. Using this information to compare prices obtained by other countries in the network can enable them to make informed procurement deci- sions and help ensure the procurement of low priced and high quality RH commodities. Other poten- tial benefits could include improved commodity quality and harmonization of standards, improved supply chain management, and reduced wastage and loss. • Institutional Capacity Building, including Human Resource Development and Technical Assistance The capacity to deliver RH commodities to clients through effective supply chains, monitor and test the quality of commodities, and train personnel in the multitude of functions involving RHCS varies by country. Yet it is evident that these and other capacity weaknesses are common to countries in 8 Why a Sub-Regional Approach? the sub-region. A sub-regional RHCS strategy can, therefore, address these issues through support, for example, for quality control testing laboratories and sub-regional training programs in supply chain management and procurement. Resources for such facilities and activities are not available in many countries. Sub-regional and country actors should also document and disseminate best prac- tices and be regularly informed about the others’ activities to avoid duplication of effort, and to identify where complementary roles can be played and where south-to-south technical exchanges can be beneficial. To support this type of information sharing, a sub-regional reference center could be useful. • Advocacy for a Harmonized Regulatory and Policy Framework Sub-regional organizations can play a catalytic role in advocating for a strengthened policy and regulatory environment for RHCS. These groups could, for example, serve as an informational focal point and advocate for common and specific RHCS policies at the country level. These could include government budget line items for RH commodities, support for RHCS coordinating groups, and the dissemination of IEC materials to enhance policy support for RHCS. As ECOWAS countries continue to converge around common economic policies could help reduce costs for RH commodities; for ex- ample, advocating for a common external tariff for RH supplies or duty-free status for commodities deemed of strategic importance for public health, and/or an internal free trade zone. Further, to achieve greater efficiency in access to RH commodities, sub-regional bodies, such as WAHO, could help advocate for standard drug registration procedures across the sub-region. Current- ly, registration is specific to a particular manufacturer and country. Harmonizing registration may help efforts to expand the private sector’s ability to contribute to better access to RH commodities. Respondents to assessment questionnaires in Burkina Faso and Ghana (DELIVER 2004) indicated that the lack of coordinated and standardized product selection (e.g., for essential drug lists and standard treament guidelines, etc.), harmonization of product registration, and standards in product labeling within the sub-region were a constraint in promoting access to commodities. Sub-regional institutions could help coordinate and catalyze efforts between country stakeholders to adopt com- mon drug registration requirements, essential drug lists, and standard treatment guidelines within the community of ECOWAS countries. All the potential areas discussed above may be better addressed at the sub-regional level, while simul- taneously supporting country efforts. In addition to these specific areas, any sub-regional strategy must also support country RHCS strategies through advocacy and identification of resources and technical as- sistance to support national-level RHCS activities. After all, the client level is where commodity security is ultimately realized. 9 3. Framing a Sub-Regional Strategy: the Strategic Pathway to Reproductive Health Commodity Security (SPARHCS) The overall goal of the sub-regional RHCS strategy is reproductive health commodity security—a condi- tion where every West African can reliably choose, obtain, and use quality, affordable essential reproduc- tive health supplies whenever he or she needs them. As this strategy covers a limited period into the future, and because even current needs are not yet being met in the sub-region, the approach to achiev- ing this goal will focus on implementing primarily supply-side interventions. The goal of these interven- tions will be to strengthen systems to increase access to RH commodities for current users and those expressing an unmet need for these commodities—a desire or a need to use—who are not currently us- ing. However, the focus of the sub-regional strategy may expand to demand-side interventions as further discussions take place in the sub-region. With the goal and the approach defined, the Strategic Pathway to Reproductive Health Commodity Security (SPARHCS) framework and analytical tools were selected to articulate the sub-regional strat- egy. Numerous international partners and West African countries contributed to the development of the SPARHCS approach; they have already committed to its use in the sub-region. Variations in the SPARHCS assessment tool and framework have already been used in Burkina Faso, Cameroon, The Gambia, Ghana, Nigeria, and Togo to assist in designing RHCS strategies. Its adoption by sub-regional–level organiza- tions in West Africa will strengthen its compatibility with country-level RHCS efforts. This section de- fines SPARHCS and discusses how it has, and can, be used to develop and implement RHCS strategies. It is an approach to help programs, countries, and regions conceptualize, frame, and assess how to achieve RHCS (SPARHCS 2004).5 An increasing number of country partners, donors, technical agencies, NGOs, and other organizations are taking a comprehensive approach to strengthen RHCS, using the multi-sectoral SPARHCS framework. The SPARHCS approach requires stakeholders to recognize that the issues and challenges affecting RHCS are interrelated, exist on multiple levels throughout the health sector, and require regular coordination and collaboration to be solved. SPARHCS takes a strategic, long-term, multidisciplinary, and multi-stake- holder perspective on RHCS by identifying how elements, such as logistics policies, financing, service delivery, advocacy, and others, are both interdependent and vital to achieving RHCS. It approaches reproductive health commodity security as a continuum that requires ongoing commitment and continu- ous progress. The SPARHCS strategic components are— • Client—access to a range of RH commodities • Commodities—ensuring the right method mix, quality, and price • Commitment—of governments, donors, and other key stakeholders • Capital—or financial resources required to procure and distribute RH commodities • Capacity—of human resources, and health and logistics systems 5. Portions of the text in section 3 were adopted from the SPARHCS: Strategic Pathway to Reproductive Health Commodity Security. A Tool for Assessment, Planning, and Implementation, © 2004 INFO Project, Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health. Used by permission. 11 11 The West Africa Reproductive Health Commodity Security Sub-Regional Strategy: A Concept Paper • Coordination—of key regional, country, donor, and public and private stakeholders • Context—economic and social issues that challenge or support opportunities to ensure a full supply of RH commodities. The SPARHCS conceptual framework (see figure 3.0) identifies key elements involved in securing client access to reproductive health supplies and related services, and that should be considered during assess- ment, planning, and implementation for RHCS. As illustrated in figure 3.0, the SPARHCS framework—with the client at the center—highlights the many elements involved in securing reproductive health supplies, and it provides the conceptual basis on which to build a RHCS strategy. At the outermost circle, there is a context that affects the prospects for RHCS—national policies and regulations that affect family planning/reproductive health, particularly on the availability of RH supplies, and broader factors like social and economic conditions, political and religious concerns, and competing priorities. Figure 3.0 The SPARHCS Framework and Components Reproductive Health Commodity Security Framework C O N T E X T Client Demand and Utilization Government Donor Third Party Household Forecasting Policy Procurement Distribution Service Delivery Monitoring & Evaluation Etc. Government Private Sector Donors C O O R D I N A T I O N C A P I T A LC O M M I T M E N T C A P A C I T Y Pub lic Sector N G O s C om m er ci al Se ct or Social Marketi ng 12 Framing a Sub-Regional Strategy: the Strategic Pathway to Reproductive Health Commodity Security (SPARHCS) Within this context, commitment, shown in part by supportive policies, government leadership, and focused advocacy, is a fundamental underpinning for RHCS. It is the basis from which stakeholders will invest the necessary capital (financing), coordinate for RHCS and develop the necessary capacities— the third circle in the figure.6 The boxes in the figure provide more details on each of these three compo- nents. Coordination involves government, donors, and the private sector to ensure more effective al- location of resources. Households, third parties (e.g., employers and insurers), governments, and donors are all sources of capital. Moreover, capacities must exist for a range of functions—policy, forecasting, procurement, and distribution, service delivery, and monitoring and evaluation. Moving closer to the client in figure 3, capital, coordination, and capacities form the basis for the public sector, NGOs, social marketing, and commercial sector to supply the commodity needs for the entire mar- ket of client demand, from those who need subsidized products to those who are able to pay for com- mercial products. Clients (women and men)—at the center of the figure—are the ultimate beneficiaries of RHCS (as product users) and, shown by the double-headed arrows, the drivers of the system (through their demand).7 Finally, SPARHCS can be used to better understand the interrelationship of RHCS issues at the sub-re- gional level and between the sub-regional and country levels. As the process is transitioned into a strat- egy, it can be a catalyst and advocacy tool to implement solutions. SPARHCS also includes a diagnostic guide based on the goal and framework, which helps stakeholders assess their present RHCS situation, define future expectations, and consider past trends. 6. Text adopted from SPARHCS 2004. 7. Text adopted from SPARHCS 2004. 13 4. Sub-Regional Opportunities Within the RHCS framework, focus must be given to what interventions can be most effectively done at a sub-regional and at a national level. The sub-regional strategy should focus on implementing those activities that it has a comparative advantage to undertake, providing support to member states. To take advantage of the opportunities afforded by a sub-regional approach, the interventions must be practical and feasible, while at the same time balancing expectations with a mixture of operational (near-term) and strategic (medium- to long-term) commitments, including expected resource levels. 4.1 Illustrative Opportunities The implementation of the RHCS strategy will need to occur at the sub-regional, national, and sub- national levels if it is to address the multiple, overlapping issues confronted by the sub-region. The funding for the implementation of the strategy cannot be supported by one single source due to its complexity and cost. It must come from a combination of national governments, donors, and lending institutions, with some resources leveraged from the private sector, if possible. A central coordinating body, perhaps WAHO, can inventory and monitor on-going RHCS efforts in order to avoid duplication of efforts. The sub-regional RHCS coordinating body, with the support of its partners, will then need to determine the cost and feasibility of implementing the activities in the strategy. Table 4.1 illustrates which opportunities are likely to be better suited for sub-regional and country implementation organized around the SPARHCS strategic components described in section 3. Establish- ing a coordinated informed buying network (CIB) and affecting change to the sub-regional regulatory environment for private sector trade are, for example, more efficiently managed at the sub-regional level. Conversely, local advocacy campaigns designed to increase youth access to RH services should be directed at the national or even community level. The overlapping and sometimes repetitive nature of table 4.1 illustrates the interrelationship between sub-regional and country interventions, and represents cross-cutting opportunities. These are opportuni- ties to strengthen what is implemented at the country level through complementary sub-regional inter- ventions and vice versa. Sub-regional institutions, such as WAHO and WHO-AFRO, can serve as brokers, coordinators, and catalysts for these country actions. Taking advantage of opportunities such as these will require the integration of sub-regional and country-level efforts. 4.2 Sub-Regional Partners No one should underestimate the comparative advantage, influence, and scale sub-regional institutions inherently possess. The West African Health Organisation, as the primary sub-regional health authority for ECOWAS, is in a position to take a leadership role in coordinating a sub-regional RHCS strategy and to advocate directly with donors and member countries for material support of a sub-regional strategy. This advantage can be further leveraged with Ministries of Health (at the policy level) and WAHO liaison officers (at the operational level) to coordinate sub-regional and country interventions. There are other sub-regional actors as well, who, with WAHO, can also have roles under a sub-regional strategy and serve as advocates, brokers, and catalysts for the strategy. The World Health Organization’s Regional Office for Africa (WHO-AFRO) can also have a technical role in both developing and implementing the sub-regional strategy. The coordinating role it plays through its programs in family and reproductive health, and the direct technical support it provides to member states, can strengthen the technical capacity to implement the sub-regional strategy. 15 15 The West Africa Reproductive Health Commodity Security Sub-Regional Strategy: A Concept Paper Table 4.1. RHCS Country and Sub-Regional Opportunities SPARHCS Components Country Level Opportunities Sub-Regional Opportunities Client • Promote a favorable environment for multiple service outlets for clients (e.g., public, commercial, NGO, social marketing sites). • Improve BCC/IEC to all clients, including youth, men, and underserved populations. • Expand community-based distribution. Commodities • Expand method mix. • Ensure quality of RH commodities. • Develop pricing policies that maximize access/ reach to various sub-populations. • Strengthen sub-regional quality testing laboratories (Accra, Niamey) to improve quality of RH commodities. • Encourage countries to create pricing policies that consider sub-regional context. Commitment • Form/reinforce national RHCS coordination mechanisms and integrate into health policy and planning process. • Identify national and sub-national champions or supporters of RHCS. • Establish or increase government budget line items for RH commodities. • Mobilize donor commitments to RHCS. • Support national governments and RHCS coordination mechanisms. • Work with member states to introduce budget line items for RH commodities in their budgets. Capital • Broaden base of funding sources. • Conduct ability and willingness to pay studies. • Examine feasibility of implementing social security/national health insurance plans, community health funds, health savings and loan programs, client fee options, and revolving drugs funds; establish these programs, as appropriate. • Conduct sub-regional forecasts and coordinate sub-regional resource mobilization. Capacity • Strengthen national logistics management systems. • Strengthen national RH service delivery systems. • Improve national RHCS capacities in advocacy, policy, and planning. • Document, disseminate, and replicate best practices. • Document and disseminate sub-regional materials and best practices (e.g., logistics and service delivery). • Promote human resource development and institutional capacity building in the sub-region. • Facilitate sub-regional technical assistance exchanges. Coordination • Increase public-private sector coordination. • Improve donor coordination within national programs with both bilateral and multilateral agencies. • Enhance national coordination around policy implementation (tariffs, regulatory environment, procurement). • Enhance/improve coordination and integration with global, national, and other sub-regional programs. • Enhance sub-regional coordination around policy implementation (tariffs, regulatory environment, procurement). • Develop coordinated informed buying network for RH commodities. Context • Review/revise drug registration, standard treatment guidelines, and essential medicines lists to conform with sub-regional guidelines. • Review/revise national regulatory and policy frameworks to conform with sub-regional guidelines. • Harmonize sub-regional drug registration, standard treatment guidelines, and essential medicines list. • Develop and advocate for common sub-regional regulatory and policy frameworks that affect RHCS. • Conduct sub-regional analysis of unmet need. 16 Sub-Regional Opportunities The Association Africaine des Centrales d’Achats des Médicaments Essentiels (ACAME) was established to promote the concept of Central Medical Stores (CMS) and the exchange of information on essential medicines between a group of mostly Francophone countries. In the past, the association has conducted joint-bulk purchases of medicines for member countries. While the capacity and the feasibility to contin- ue this remains a question, WAHO and WHO-AFRO could support the sub-regional structure it represents to bolster its function as a technical resource for sub-regional procurement issues. The research capacity of the Centre d’Etudes et de Recherche sur la Population pour le Developpement (CERPOD) can provide sub-regional research and analysis in support of the strategy. It has already par- ticipated in a number of sub-regional technical training workshops to promote using research data for advocacy and policy change, and has specifically been involved in using its capacity to promote HIV/ AIDS sub-regional policy dialogue. These organizations and others possess varying degrees of capacity and resources. They do, however, have complementary strengths (coordination, policy support, technical capacity, etc.) to provide sup- port and leadership to the sub-regional RHCS strategy. Their roles can and should be enhanced through country and donor support of the sub-regional initiative. Bilateral and multilateral donors and lending institutions can support the sub-regional initiative through existing and potentially new sub-regional programs. 17 5. Strategy Development Process The development of the West Africa RHCS sub-regional strategy and implementation plan will require the commitment, leadership, and direction of ECOWAS member governments; WAHO; and other sub-regional partners, technical agencies, and donors. The strategy development timetable in annex 1 illustrates how the process could work. An International Planning Committee (IPC) chaired by WAHO will serve as the technical lead in developing the strategic concept, framework, and implementation plan. The IPC will work with the RHCS Task Force, made up of RH experts from the West Africa sub-region, which will help to further define objectives and the implementation timetable. This group will also work with country- level stakeholders who are developing and implementing national RHCS strategies to ensure that the strategies focus on complimentary roles and do not duplicate effort. IPC and Task Force members should strongly consider developing an advocacy plan. This plan would be aimed at member governments and donors to help ensure that there is a commitment to support the strategy development process and its implementation. Work on securing political and financial support for the strategy must begin soon. See annex 1 for additional details on this process. 19 6. Outline for a Sub-Regional Strategy To ensure the success of this important yet complex strategy, a number of fundamental management components must be considered. As noted in section 3, the SPARHCS approach, including the conceptual framework and components, has been proposed to address and organize the sub-regional RHCS strategy with a comprehensive implementation plan. The overarching vision of the RHCS strategy is to ensure that every West African can reliably choose, obtain, and use quality, affordable, essential reproductive health supplies when they need them. In conjunction with the WAHO Strategic Plan for the Reduction of Maternal and Perinatal Mortality in West Africa, the mission is to ultimately reduce maternal and perinatal mortality. Finally, the goal of the RHCS strategy is to meet the demand of existing users and those expressing an unmet need for RH services in the sub-region. The initial outline for the sub-regional RHCS strategy includes— 1. Thematic areas (from section 2.3) • Coordinated informed buying network for RH commodities • Institutional capacity building, including regional human resources development and technical assistance • Advocacy for harmonized regulatory and policy frameworks. 2. Specific objectives for each thematic area—Each thematic area will require specific objectives that will guide the remaining components of the strategy (activities, responsible parties, timeline, bud- get, etc.). 3. Activities for each objective (examples in table 4.1)—Stakeholders should ensure that the activities listed in the strategy contribute to the strategic objectives, outputs, and outcomes. Activities must also be defined as managed by sub-regional and/or country-level implementing agencies. 4. Responsible agency—For each activity, a responsible agency or agencies should be identified to man- age and to ultimately be responsible for ensuring that each activity is completed in a timely and high-quality manner, within budget limits. 5. Implementing/collaborating partners—It is expected that the sub-regional organizations discussed in section 4.2 will participate as strategy coordinators and implementers. The participation of numer- ous national government organizations (within MOHs, for example), technical agencies, and local and international NGOs at the operational level, will also be required. 6. Timeline—The establishment of a timetable, with periodic revision as needed, will help ensure that the activities are completed in time to meet the defined objectives. 7. Budget—Identifying the necessary resources to implement the strategy will be an essential part of the strategy development. Planners must understand and, therefore, construct reality-based assump- tions about the strategy’s feasibility to attract potential financing sources. Part of this process will involve regular advocacy with donors, national governments, and other potential funding sources. 8. Critical assumptions—Because of the complexity and the number of stakeholders involved in the RHCS strategy, critical assumptions about achieving the objectives should be specified and periodi- cally revisited. 9. M&E plan—A comprehensive monitoring and evaluation plan is critical for monitoring progress to- ward RHCS goals and objectives, and for reporting results to stakeholders. 21 The West Africa Reproductive Health Commodity Security Sub-Regional Strategy: A Concept Paper 10. Output/outcome indicators—The development of specific, measurable, achievable, time-bound, and impact-oriented indicators will be critical for monitoring the success of strategy implementation. These indicators should also be used to identify any gaps or weaknesses in the strategy so that changes can be made, if necessary, to keep the overall strategy on track. During the coming year, this outline and strategy will need to be developed and debated, with input from all partner organizations. 22 References Center for Disease Control and Prevention (CDC). 1993. “Update: Barrier Protection Against HIV Infection and Other Sexually Transmitted Diseases.” Morbidity and Mortality Weekly Report 08/06/1993. 42(30); 589-591, 597. Diarra, Aoua. 2004. West Africa RHCS: Logistics System Capacity (DRAFT Report). Arlington, Va: John Snow, Inc.,/DELIVER, for USAID. Dowling, Paul. 2004. West Africa RHCS: Local Manufacturing of RH Commodities. Arlington, Va.: John Snow, Inc./DELIVER, for USAID. Gay, Jill, et. al. 2003. What Works: A Policy and Program Guide to the Evidence on Family Planning, Safe Motherhood, and STI/HIV/AIDS Interventions—Module 1: Safe Motherhood. Washington, D.C.: POLICY Project, for USAID. 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. John Snow, Inc./DELIVER. 2001–2002. Logistics System Assessment Survey Results: Mali, Nigeria, Ghana. Arlington, Va.: John Snow, Inc./DELIVER, for USAID. John Snow, Inc./DELIVER. 2003. No Product? No Program!: Reproductive Health Commodity Security for Improved Maternal and Child Health. Arlington, Va.: John Snow, Inc./DELIVER, for USAID. ORC Macro International Inc. Demographic and Health Surveys (multiple countries and years). Calverton, Md.: ORC Macro International Inc. Organisation of African Unity (OAU). 26-27 April 2001. The Abuja Declaration on HIV/AIDS, Tuberculosis and Other Related Infectious Diseases. Abuja, Nigeria: OAU. Population Reference Bureau (PRB). 2005. Women of Our World: 2005. Published with the support of the U.S. Agency for International Development (USAID). Washington, D.C. United Nations Development Programme (UNDP). 2003. Human Development Report 2003, Millennium Development Goals: A compact among nations to end human poverty. UNDP: New York: UNDP. United Nations Population Fund (UNFPA). 2003. Donor Support for Contraceptives and Condoms: 2002. New York: UNFPA. United Nations Population Fund (UNFPA). 2004. The Millennium Development Goals. New York: UNFPA. WAHO, USAID, UNFPA, and World Bank. 2002. “West Africa Regional Initiative for Reproductive Health Commodity Security.” A concept paper developed based on discussions between WAHO, USAID, UNFPA, and the World Bank. N.P.: n.p. World Health Organization Regional Office for Africa, African Union. 2004. “Road Map for Accelerating the Attainment of the MDGs Related to Maternal and Newborn Health in Africa.” Geneva: World Health Organization. 23 Annex 1 Strategy Development Timetable 25 Annex 1: Strategy Development Timetable Concept paper outline circulated to International Planning Committee members 1st Meeting of the International Planning Committee to review the initial concept paper April 25–27, 2005 During the meeting, partners provided written comments, defined potential participant Done organizations and the series of steps which need to take place to complete a final strategy. 1st RHCS Task Force Meeting (West African Expert Committee) to review the 2nd draft of June 27–29, 2005 the RHCS concept paper and prepare the third draft of the RHCS concept paper. Done DELIVER and AWARE finalize Concept Paper prior to the WAHO Ministers meeting Presentation of the final RHCS Concept Paper to the Annual WAHO meeting of Health Ministers 2nd Task Force Meeting to use the final concept paper to produce a 1st draft of a RHCS sub-regional strategy WAHO chairs meeting of program managers, WAHO liaison officers and donors to review 1st draft of Strategy, incorporate feedback, produce a 2nd draft and seek support for implementation The 2nd draft of the Strategy is circulated to a wide range of partners, individuals and organizations for their comments 2nd International Planning Committee meeting to review the 2nd draft and produce a 3rd draft Meeting of Health Experts from the 15 member countries to revise the 3rd draft and produce a 4th draft of the RHCS Sub-regional Strategy. Presentation of the 4th draft of the RHCS Sub-regional Strategy to the WAHO Assembly of Health Ministers 3rd meeting of the International Planning Committee incorporates Health Ministers’ recommendations and produces a final West Africa RHCS Sub-regional Strategy and Implementation Plan Date April 11, 2005 Done July/August 2005 November 2005 November 2005 November 2005 December 2005 January 2006 June 2006 June 2006 August 2006 Annex 1 27

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