UNFPA Supplies Annual Report 2015

Publication date: 2016

       Annual Report 2015                                                                                                                                                                                                               WHERE WE WORK Asia Pacific Lao People's Democratic Republic Myanmar Nepal Papua New Guinea Timor‐Leste Middle East Djibouti Sudan Yemen Latin America & Caribbean Bolivia Haiti Honduras East & Southern Africa Burundi Democratic Republic of the Congo Eritrea Ethiopia Kenya Lesotho Madagascar Malawi Mozambique Rwanda South Sudan Uganda United Republic of Tanzania Zambia Zimbabwe West & Central Africa Benin Burkina Faso Cameroon Central African Republic Chad Côte d'Ivoire Gambia Ghana Guinea Guinea‐Bissau Liberia Mali Mauritania Niger Nigeria Republic of Congo Sao Tome and Principe Senegal Sierra Leone Togo | UNFPA Supplies Annual Report 2015 CONTENTS  | UNFPA Supplies Annual Report 2015  Contents  FOREWORD . 1  MESSAGE FROM THE CHIEF, UNFPA COMMODITY SECURITY BRANCH . 1  MESSAGE FROM THE INCOMING CHIEF, UNFPA COMMODITY SECURITY BRANCH . 3  EXECUTIVE SUMMARY . 4  INTRODUCTION: DELIVERING REPRODUCTIVE HEALTH SOLUTIONS GLOBALLY . 14  GOAL: CONTRIBUTE TO UNIVERSAL ACCESS TO REPRODUCTIVE HEALTH . 20  OUTCOME LEVEL: INCREASED AVAILABILITY AND USE OF REPRODUCTIVE HEALTH SUPPLIES . 27  OUTPUT 1: IMPROVED ENABLING ENVIRONMENT FOR REPRODUCTIVE HEALTH COMMODITY SECURITY . 65  OUTPUT 2: INCREASED DEMAND FOR RH COMMODITIES BY POOR AND MARGINALIZED WOMEN AND GIRLS . 97  OUTPUT 3: IMPROVED EFFICIENCY FOR PROCUREMENT AND SUPPLY OF RH COMMODITIES . 114  OUTPUT 4: IMPROVED ACCESS TO QUALITY REPRODUCTIVE HEALTH AND FAMILY PLANNING SERVICES . 137  OUTPUT 5: STRENGTHENED CAPACITY AND SYSTEMS FOR SUPPLY CHAIN MANAGEMENT . 173  MANAGEMENT OUTPUT: IMPROVED PROGRAMME COORDINATION AND MANAGEMENT . 195  FINANCE AND RESOURCES . 229  Figures  Figure 1: Maternal mortality ratio (MMR) in UNFPA Supplies focus countries, 2015 . 22  Figure 2: Youth HIV prevalence rate (aged 15–24) by sex in programme countries, 2014 . 24  Figure 3: Programme countries with high adolescent birth rate (ABR>80), 2015 . 26  Figure 4: Percentage need for family planning services among currently married women, selected UNFPA Supplies  implementing countries . 29  Figure 5: mCPR in selected programme countries from latest demographic/health surveys . 30  Figure 6: mCPR progress between two demographic/health surveys in selected programme countries . 32  Figure 7: Number of additional users of modern contraception in 46 UNFPA Supplies implementing countries . 34  Figure 8: Total availability of seven life‐saving RH medicines, 2013–2015 . 37  Figure 9: Availability of seven life‐saving RH medicines by level of SDP, 2015 . 38  Figure 10: Availability of seven life‐saving RH medicines by urban/rural location, 2015 . 39  Figure 11: Availability of a full choice of modern contraceptives in at least 85 per cent of secondary and tertiary  SDPs, progress 2013–2015 . 40  Figure 12: Availability of five or more modern methods at secondary and tertiary SDPs in 2015, by SDP level . 42  CONTENTS    | UNFPA Supplies Annual Report 2015  Figure 13: Availability of five or more modern methods at secondary and tertiary SDPs in 2015, by urban/rural  location . 43  Figure 14: Availability of a full choice of modern contraceptives in at least 85 per cent of primary SDPs 2013‐2015 44  Figure 15: Availability of three or more modern methods at primary SDPs 2014‐2015 . 45  Figure 16: Availability of three or more modern methods at primary SDPs in 2015, by urban/rural location . 46  Figure 17: Percentage of SDPs with staff trained for insertion/removal of implants in 2015, by SDP level . 49  Figure 18: Percentage of SDPs with staff trained for insertion/removal of implants in 2015, by urban/rural location50  Figure 19: No stock‐outs of contraceptives in the last three/six months by type of SDP, 2015 . 53  Figure 20: No stock‐outs of contraceptives in the last three/six months by urban/rural location, 2015 . 54  Output 1  Figure 1.1: Existence of policies in place, plans and guidelines, 2013 to 2015 . 67  Figure 1.2: Trends in performance for key policy and strategy indicators, 2013 to 2015 . 67  Figure 1.3: National commitment and coordination . 69  Figure 1.4: Number of countries where the national Essential Medicines List (EML) contains all RH commodities  (modern contraceptives and life‐saving maternal/RH medicines) . 73  Figure 1.5: Total amount allocated and amount expended (in $) in national budgets of UNFPA Supplies  implementing countries for procurement of RH commodities, 2013 to 2015 . 74  Figure 1.6: Total amount allocated and amount expended (in $) in national budgets of UNFPA Supplies  implementing countries for procurement of CONTRACEPTIVES, 2013 to 2015 . 75  Figure 1.7: Total amount allocated and amount expended (in $) in national budgets of UNFPA Supplies  implementing countries for procurement of MH MEDICINES, 2013 to 2015 . 76  Figure 1.8: Number of countries achieving key environmental risk mitigation interventions . 77  Output 2  Figure 2.1 Number of countries with initiatives to reach key population groups . 98  Figure 2.2 Number of countries by type of demand generation interventions implemented, 2013 to 2015 . 101  Figure 2.3 Country implementation of key demand generation initiatives, 2013 to 2015 . 102  Figure 2.4 Country level partners involve in implementing specific initiatives to reach the poor and marginalized  women and girls, 2013 to 2015 . 103  Output 3  Figure 3.1: 170 organizations in 104 countries have partnered with UNFPA to procure supplies . 117  Figure 3.2: UNFPA Unit costs compared to average price of international procurers, 2013‐2015 . 117  Figure 3.3: Value for quantities of RH commodities dispatched from AccessRH, 2013‐2015 . 118  Figure 3.4: Total amount dispatched for third party procurement (AccessRH), 2013‐2015 . 119  Figure 3.5: Value of third party procurement (AccessRH) by contraceptive method, 2013‐2015 . 120      CONTENTS    | UNFPA Supplies Annual Report 2015  Figure 3.6: Savings made in US dollars by purchasing generic combined oral contraceptives in comparison to the  potential expenditure incurred if the innovator had been procured . 123  Figure 3.7: Total value of the orders placed (US$) with generic emergency contraceptives compared with the value  incurred if the innovator had been procured . 123  Figure 3.8: UNFPA Supplies expenditure by method, 2015 . 127  Figure 3.9: UNFPA Supplies ‐ CYPs per method 2013‐2015 . 127  Output 4  Figure 4.1: Number of countries supporting programmes to reach at least one marginalized group, 2013 to 2015 138  Figure 4.2: Number of countries supporting at least one aspect of integration for reaching marginalized groups,  2013 to 2015 . 140  Figure 4.3 Number of countries supporting integration of RH/FP service delivery with gender, HIV and maternal  health to reach specific poor and marginalized population groups . 111  Figure 4.4: Number of countries by at least one type support provided for training in FP, 2013, 2014 and 2015 . 142  Figure 4.5: Number of countries supporting at least one of the key focus areas of training, 2013 to 2015 . 143  Figure 4.6: Number of countries providing at least two forms of support for at least three focus areas of training in  FP, 2013 to 2015 . 144  Figure 4.7: Number of countries supporting non‐state actors to provide RHCS/FP services to reach poor and  marginalized groups . 145  Figure 4.8: Number of countries by type of marginalized groups for which non‐state actors implemented  programmes . 146  Figure 4.9: Number of countries where at least two non‐state actors were supported to reach at least three  category of marginalized group . 146  Figure 4.10: Total number persons trained to provided long term long term contraceptive methods to client, 2013 to  2015 . 147  Figure 4.11 Percentage of persons trained to provided long‐term contraceptive methods to clients, 2015 . 148  Figure 4.12: Percentage of kits supplied to implementing partners, 2014 and 2015 . 151  Figure 4.13: Percentage of women and/or girls, by broad age groups, reached in humanitarian settings with RH kits  and services . 151  Figure 4.14: Percentage of women and/or girls in humanitarian settings reached by different agencies with RH kits  and services . 152  Output 5  Figure 5.1: Government for demand forecasting for contraceptives, 2013 to 2015 . 175  Figure 5.2: Availability of trained national staff working in government institutions for demand forecasting, 2013 to  2015 . 175  Figure 5.3: Government leadership for procurement process for RH commodities, 2013 to 2015 . 176  Figure 5.4: Availability of trained national staff working in government institutions for procurement process for RH  commodities, 2013 to 2015 . 177  Figure 5.5: Level of functionality ‐ Forecasting aspects . 178  Figure 5.6: Level of functionality ‐ procurement aspects . 178  Figure 5.7 Number of participants using the procurement e‐learning platform to build knowledge, 2013 to 2015 . 181  Figure 5.8 Countries where LMIS can be used to generate data on distribution of MH medicines, 2013 to 2015 . 182  Figure 5.9 Countries where LMIS can be used to generate data on distribution of MH medicines, 2013 to 2015 . 182  Figure 5.10: Additional Information that can be generated from the LMIS . 183                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                CONTENTS Figure 5.11: Purpose/use of the health supply chain management information tool .184 Figure 5.12: Management of the health supply chain management information tool .185 Figure 5.13: Use of information generated from the health supply chain management information tool .185 Management Output Figure 6.1 Number of countries by types of partner institutions whose staff were trained in data generation, 2013-2015. 196 Figure 6.2 Total number of persons trained in data generation, 2013 to 2015.196 Finance Figure 6.3: Commodity vs. capacity building expenses, 2007 to 2015, in USD millions.231 Figure 6.4: Commodity vs. capacity expenses, 2007 to 2015, percentage.232 Figure 6.5: Breakdown by output, 2015 expense.233 Figure 6.6: UNFPA Supplies Budget and projections, 2007‐2020, $million .235 Annexes Annex A Maternal mortality ratio in UNFPA Supplies implementing countries between 1990 and 2015 .237 Annex H CPR, unmet need and demand satisfied for modern contraception in UNFPA Supplies implementing Annex I Percentage of secondary and tertiary SDPs offering at least five modern methods of contraception by type Annex M Amount allocated in national budgets of UNFPA Supplies implementing countries for procurement of Annex N Amount expended in national budgets of UNFPA Supplies implementing countries for procurement of Annex B Lifetime risk of maternal death in UNFPA Supplies implementing countries, 2015.238 Annex C Youth (15–24) HIV prevalence rate for UNFPA implementing countries .239 Annex D Adolescent birth rate per 1,000 women aged 15–19 in UNFPA Supplies implementing countries, 2015 .240 Annex E Maternal mortality ratio and lifetime risk of maternal death .241 Annex F HIV prevalence rate for adults (15–49) in UNFPA Supplies implementing countries .243 Annex G HIV prevalence rate for youth (15–24) in UNFPA Supplies implementing countries .244 countries, 2015 .245 of SDP, 2015 .247 Annex J Percentage of secondary and tertiary SDPs offering at least five modern methods of contraception, 2015 .248 Annex K Percentage of SDPs where seven life‐saving maternal health/RH medicines are available, all levels, 2015 .249 Annex L Percentage of SDPs with no stock‐outs of contraceptives in the last six months, 2013–2015 .250 RH commodities, 2013–2015.253 RH commodities, 2013–2015.255 Annex O Units approved, contraceptives and condoms, UNFPA Supplies approvals, 2015.257 Annex P CYP for contraceptives and condoms, UNFPA Supplies approvals, 2015 .259 Annex Q Expense (cost) of contraceptives and condoms, UNFPA Supplies approvals, 2015 .261 UNFPA Supplies Annual Report 2015                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        FOREWORD Message from the Chief, UNFPA Commodity Security Branch Since the mid‐nineties and over many years of promoting and pursuing reproductive health commodity security, I have seen tremendous progress. It is a continuum that thrives on trust won over many years and partnerships that endure. We have promised to deliver on sexual and reproductive health not where it is relatively easy to add new users of modern contraception but where we are called on to go the last mile. We have engaged with countries where global‐level support matters more, where there are few or no resources, where technical challenges are greater, and where health systems are not functional. We have made commitments for the long term, for sustainable impact, for investing the time required to create the conditions for the moment a woman realizes she can say, “I don’t have to have seven children and I can see my daughter go to school.” This UNFPA flagship programme with its rights‐based strategy and performance framework is the effective mechanism we envisioned in those earlier years in essential supplies, more systematically providing commodity procurement and capacity development. UNFPA Supplies operationalizes the UNFPA commitment to underserved women and girls in countries with high rates of maternal death and unmet need for family planning, including many in humanitarian crisis. Why and how are we so effective given our resources, which are limited in contrast to the need? We work in many countries with many partners; we influence governments with sound advice; and we contribute to goals we are all aspiring to achieve. At the heart of these goals remains the ICPD Programme of Action, which continues to guide and inspire after more than two decades. Reflecting on recent years, progress in three areas stand out. First, UNFPA Supplies invests in strengthening health systems and supply chains – often in countries with no functional health system at all. In some countries, we are one of few actors doing this kind of work, sometimes the only one. It works: we can see progress in increasing contraceptive prevalence rates and decreasing stock‐outs. Such work also contributes when disaster or conflict disrupt health systems. In the Ebola crisis, past support for health systems and supply chains helped in the humanitarian response; the same is happening within the Zika virus response. Even in complex conflict situations, as in Syria and Jordan, contraceptives and life‐saving maternal health medicines and technical training on supply chain management are making an impact. Our experience in demand creation and supply chain are helpful to many other operations. Such technical capacity development continues to be a priority in all of the 46 countries served by UNFPA Supplies. 1 | UNFPA SUPPLIES Annual Report 2015                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               FOREWORD Second, in 2007 we aimed for every programme country to have its own dedicated budget line for contraceptives; now nearly all have such a line in the national budget. This domestic financing is in the right direction. The experience is contributing to discussions around Universal Health Coverage, advocating for countries to include rights‐based family planning. The aim is to incorporate a choice of methods along with demand‐side activities for understanding and use, and technical activities for supply chains, forecasting, product quality – along with other dimensions of a comprehensive, integrated and sustainable approach. Third, we have invested in partnership and collaboration at the local, country and global levels. Today we are working together like a family – the UN family, donors, NGOs, civil society, the private sector and more – to see how we can support each other and contribute to FP2020 and the Sustainable Development Goals. To catalyse more progress, we are inviting countries to work with us to identify bottlenecks and barriers at the national and subnational levels, using data and experience. Though an STI or HIV or pregnancy at an early age have always been a matter of life and death to young people, there’s an added incentive for countries to improve access to adolescent sexual and reproductive health: the demographic dividend. If the dependent population is less, a country can invest more in its youth – health, education for girls, employment and empowerment. This is how countries harness the dividend and achieve economic development with equity and equality and social inclusion, but they need to act while window of opportunity is still open. With strong partners and the support of governments, progress in family planning is set to continue and succeed – provided there is adequate funding. For the past 20 years, the path has sometimes been difficult but today we have momentum. Over the years, resource levels have gone up and down but if we can keep up the momentum we have now, we can achieve goals that will save and improve lives. My hope as I retire from UNFPA is that we will take hold of our momentum, keep the partners working together, and move ahead deeply into the last mile. I would like to express my sincere appreciation to everyone who supported me throughout the years in a career that rarely took me to my home country of Nepal but forged lifelong links in many places, especially in Africa. I have valued the opportunity to connect with remarkable people in every part of the world. Jagdish Upadhyay, Chief Commodity Security Branch, Technical Division UNFPA New York 2 | UNFPA SUPPLIES Annual Report 2015                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    FOREWORD Message from the incoming Chief, UNFPA Commodity Security Branch This annual report presents the compelling results of a programme I have been engaged with since its inception in 2007, then the UNFPA Global Programme to Enhance Reproductive Health Commodity Security and now renamed UNFPA Supplies. I look forward to building on its many strengths in the years to come as the new Chief of the Commodity Security Branch. During 2015, the year covered by this report, I was in Yemen as Surge Emergency Coordinator from September to December. Amidst instability compounded by natural disaster, millions of adolescent girls and women were in urgent need of sexual and reproductive health services, and the supplies to sustain them. This experience was a recent reminder of why, as a medical doctor from Ghana, I have worked in reproductive health for most of my career, and why I firmly believe that we must ensure family planning is delivered right to the last mile so that a choice of quality, affordable contraceptives reach women, men and adolescent girls no matter where they live. The success of UNFPA Supplies to date lies in its catalytic role in fostering national leadership of programmes. The progress reported here clearly demonstrates government ownership of programmes and the commitment of the 46 UNFPA Supplies’ focus countries to building stronger health systems and widening access to a reliable supply of contraceptives for family planning and life‐saving medicines for maternal health. Also key to achieving these results and to effecting meaningful change is the power of the partnerships that UNFPA convenes – not just with governments of programme countries, but also with donors, United Nations agencies, civil society, non‐governmental organizations and private sector. These partners, particularly civil society, are always encouraging and inspiring us to do more. We need to build on our successes, and focus our efforts where they have the most impact. I look forward to leading UNFPA Supplies to build on what has already been achieved and to do even more to reach our shared aspirations of FP2020 and the Sustainable Development Goals. Dr. Gifty Addico, Chief Commodity Security Branch, Technical Division UNFPA New York 3 | UNFPA SUPPLIES Annual Report 2015 EXECUTIVE SUMMARY Executive Summary: UNFPA Supplies 2015 UNFPA Supplies provided catalytic support of $99 million in commodity procurement and $37.5 million in capacity development for 46 countries in 2015. DELIVERING REPRODUCTIVE HEALTH SOLUTIONS GLOBALLY UNFPA Supplies is the world’s largest provider of contraceptives, accounting for 42 per cent of all contraception procured by donors on behalf of developing countries. In 2015, UNFPA Supplies helped some 18 million women in more than 46 countries obtain modern contraceptives and reproductive health services. Contraceptives provided in 2015 had potential to avert an estimated: • 9 million unintended pregnancies • 26,000 maternal deaths • 170,000 child deaths • 3.2 million abortions, of which 2.8 million would be unsafe These contraceptives had potential to save families and countries $500 million in direct health-care costs (antenatal, delivery and postnatal care and post-abortion care). The number of countries with initiatives to reach displaced persons and refugees in humanitarian settings increased from 18 in 2014 to 34 in 2015; as part of the UNFPA humanitarian response, UNFPA Supplies provided family planning for 1.4 million women and girls in humanitarian situations. FINANCIAL SUMMARY UNFPA Supplies experienced a budget decrease of 20 per cent from 2014 to 2015, though the programme had seen year-to-year increases in the annual budget since 2012. The total available budget for the year was $226 million ($226,068,343). It was made up of the cash in hand at the beginning of the year and the income received during the year. Of this income, $23 million was received in December 2015 to be programmed in 2016, and $10 million was set-aside in a special reserve for procurement of implants as per the agreement with DFID. The available budget for programming in 2015 was $192,686,679. Expenses totalled $155 million ($155,481,286). Approximately $8 million came from a reduction in inventory purchased prior to 2015. Also, $20,129,721 was committed in firm and binding purchase orders for delivery in early 2016. Expenses and payments for 2015 totalled $147,608,861. This results in an implementation rate of 87 per cent which is very close to the implementation rate in 2014 which was 88 per cent. The unspent amount was carried forward to 2016 and used for placing 4 | UNFPA SUPPLIES Annual Report 2015 EXECUTIVE SUMMARY procurement orders early in 2016 and will ensure that the budget for 2016 will not differ drastically from 2015. Support for commodity procurement of $99 million accounted for 67 per cent of programme expenses. Support for capacity development of $37.5 million accounted for just over 25 per cent of programme expenses. Human resources accounted for 7 per cent of expenses. Key results for 2015 ❶ UNFPA SUPPLIES PROCURED AND DELIVERED $99M IN SUPPLIES IN 2015. Support for commodity procurement of $99 million accounted for 67 per cent of programme expenses. The majority of supplies are contraceptives, including condoms that afford dual protection from HIV and other sexually transmitted infections. Additional items include life-saving medicines for maternal health and emergency obstetric care as well as reproductive health kits supplied to humanitarian situations. ❷ UNFPA SUPPLIES INVESTED $37.5M IN CAPACITY DEVELOPMENT FOR HEALTH SYSTEMS AND SERVICE. In 2015, support for capacity development of $37.5 million accounted for 34 per cent of programme expenses. Supply chains are stronger, more countries are using computerized logistics management information systems (LMIS), and more health workers are promoting family planning and delivering quality services. ❸ USE OF MODERN FAMILY PLANNING CONTINUES TO INCREASE. Use of modern methods of family planning has continued its positive upward trend. The contraceptive prevalence rate for modern methods (mCPR) has increased by 13.1 percentage points in Ethiopia over three years; by 15.2 percentage points in Malawi, 9.2 in Zimbabwe and 8.2 in Senegal over four years; by 18.1 percentage points in Kenya, 10.2 in Togo, and 8.8 in Liberia over six years; and by 12.1 percentage points in Zambia over seven years (as measured between national surveys). Rates of progress have varied: increases in CPR range from between 0.2 percentage points per year in Central African Republic to 4.4 percentage points per year in Ethiopia. Demand for modern family planning is high in many programme countries, measured in unmet need for family planning and CPR. The percentage of demand satisfied is highest in Honduras (85.6 per cent) followed by Zimbabwe (79.7 per cent) and Kenya (75.2 per cent) and lowest in Guinea (16.3 per cent) followed by Benin (19.5 per cent) and Democratic Republic of Congo (22.0 per cent). 5 | UNFPA SUPPLIES Annual Report 2015 EXECUTIVE SUMMARY ❹ UNFPA SUPPLIES CONTRIBUTES TO FP2020. All 46 of the UNFPA Supplies implementing countries are among the 69 focus countries of FP2020, the global partnership for expanding access to contraception to an additional 120 million women and girls in the poorest countries of the world by 2020. In the 46 UNFPA Supplies focus countries, where the programme is often the only or one of very few external sources of support for procurement of contraceptives, scaled up efforts by partners reached approximately 10 million additional users from 2012 to 2015 (4.4 million behind the benchmark need to reach the FP2020 goal in these countries). ❺ AVAILABILITY AND CHOICE ARE INCREASING WHERE SUPPORT IS SUBSTANTIAL AND SUSTAINED . At least five modern methods of contraception were available at more than 85 per cent of tertiary service delivery points (SDPs) in 23 countries, increasing from 11 in 2013 and 19 in 2014. Five methods were also available at more than 85 per cent of secondary SDPs in 14 countries, an increase from seven in 2013 and 13 in 2014. In 2015, three modern methods of contraception were available at more than 85 per cent of primary SDPs in 20 countries. ❻ STEADY ACCESS TO MATERNAL HEALTH SUPPLIES SAVES MOTHERS’ LIVES. In 2015, the availability of seven life-saving maternal medicines and reproductive health supplies increased in 12 of the 23 countries where comparison is available (surveys are not conducted every year in every country). UNFPA procures essential supplies that save lives in before, during and after pregnancy – notably contraceptives, magnesium sulfate, misoprostol and oxytocin. ❼ PROCUREMENT EFFICIENCY AND BETTER PRICING ARE BEING ACHIEVED. UNFPA saved over $750,000 in 2015 by increasing use of quality-assured generic contraceptives: with the same amount of money, more cycles of quality contraceptives will be accessible for women through procurement for ministries of health, NGOs and UNFPA Country Offices. UNFPA reduced prices for key contraceptives on 69 per cent of items in 2015 (compared with prior year prices). UNFPA also continued to be an active participant in a ‘volume guarantee’ agreement with manufacturers that has reduced the price of contraceptive implants by up to 50 per cent in recent years – effectively doubling the quantity of implants provided. 6 | UNFPA SUPPLIES Annual Report 2015 EXECUTIVE SUMMARY ❽ FORECASTING AND COMPUTERIZED LMIS ARE TRANSFORMING SUPPLY CHAIN MANAGEMENT. In-country skills in forecasting prevent dangerous shortfalls. In 2015, governments in all 46 UNFPA Supplies countries were participating in demand forecasting. Demand forecasting was led by the government with technical support from partners in 43 countries, up from 36 in 2013 and 40 in 2014. Governments of 43 countries had in place trained national staff to lead and coordinate demand forecasting, up from 29 in 2014. • 72 per cent (33 of 46) have functional national-level systems in place for both forecasting and procurement, an increase from 19 countries in 2014; • 87 per cent (40 of 46) of programme countries made no ad hoc request for contraceptives, compared with 65 per cent (30 of 46) in 2014, meaning that essential items were in stock when needed; • 93 per cent (43 of 46) countries used an information tool for monitoring supplies in 2015, up from 37 in 2013 and 39 in 2014. Computerized supply management is a cornerstone of improved supply availability. According to the 2014 and 2015 data on stock-outs available for 23 countries, the stock-out situation has improved in 11 countries in 2015 compared with the previous year. More specifically, in the 31 countries for which 2015 data are available, 10 countries achieved the benchmark of ‘no stock-out’ of any modern contraceptive in the past six months in at least 60 per cent of tertiary level SDPs; five countries at secondary level SDPs; and six countries at primary level SDPs (Burundi, Burkina Faso, Nepal, Nigeria, Niger and Senegal). ❾ TRAINING IS BUILDING CAPACITY FOR STRONGER HEALTH SYSTEMS. Training for health-care providers facilitates the increased availability of a full method mix of modern contraceptives. Given the increasing demand for long-acting reversible contraceptive methods (LARCs), especially implants, training of service providers increased in UNFPA Supplies implementing countries. In 2015, 18,589 health care service providers received training for insertion and removal of IUDs and/or contraceptive implants, up from 17,212 in 41 countries in 2014. In 2015, UNFPA Supplies supported 269 institutions in 36 of the 46 countries for the conduct of training for family planning service provision. ❿ SUPPORT IN HUMANITARIAN SETTINGS IS INCREASING. The support provided by UNFPA Supplies focuses on strengthening systems for delivery of RH commodities and services in humanitarian and fragile situations in various parts of the world. Displaced persons and refugees in humanitarian settings were supported in 29 countries in 2015, up from 26 countries in 2014. RH kits supplied to partners through the programme had the potential to reach 1.4 million women and girls, which is in addition to RH kits also provided by UNFPA through other funds. 7 | UNFPA SUPPLIES Annual Report 2015 EXECUTIVE SUMMARY UNFPA deployed 125 specialists in sexual and reproductive health through internal and external surge capacity rosters for humanitarian crisis response (100 UNFPA staff and 25 external). Five training workshops supported the expansion of the rosters. ⓫ COUNTRIES ARE INCREASING EFFORTS TO REACH UNDERSERVED POPULATIONS. • 94 per cent (43 of 46) of programme countries have national guidelines and protocols that include a rights-based approach to reproductive health commodity security and family planning, up from 39 in 2013 and 40 in 2014; • 76 per cent (35 of 46) had policies in place that that take into consideration both rights-based and total market approaches to family planning, up from 28 in 2014; • 89 per cent (41 of 46) had policies that take into consideration young people’s access to contraceptive services, up from 33 in 2013 and 37 in 2014; • 100 per cent (46 of 46) supported integrated interventions to reach young people, an increase from 33 countries in 2013 and 41 in 2014; • 94 per cent (43 of 46) implemented integrated interventions to reach the hard-to-reach in rural areas; up from 31 in 2013 and 38 in 2014; • 78 per cent (36 of 46) implemented integrated interventions to reach persons with disabilities, an increase of 10 countries since 2014 and 100 per cent since 2013. ⓬ DEMAND GENERATION IS REACHING NEW USERS OF FAMILY PLANNING. Efforts to increase awareness and acceptance of modern contraception took place in more countries in 2015 and, though activities were streamlined or reduced, partnership for demand creation increased. • 98 per cent (45 of 46) carried out resourced action plans to reach at least three underserved groups, up from 37 in 2013 and 42 in 2014; • 78 per cent (36 of 46) disseminated family planning messages through community health workers, a decrease from 44 countries in 2014; • 96 per cent (44 of 46) reported the government worked with at least three other agencies to implement specific initiatives to reach poor and marginalized women and girls, a significant increase from 23 countries in 2014 in efforts to increase demand for reproductive health commodities. 8 | UNFPA SUPPLIES Annual Report 2015 EXECUTIVE SUMMARY Summary of results by output area OUTPUT 1: ENABLING ENVIRONMENT The programme fosters the emergence of an ‘enabling environment’ for reproductive health commodity security (RHCS). The approach is to reduce barriers while increasing access through understanding and awareness of the benefits of rights-based family planning and RHCS. A programmatic priority is mainstreaming family planning and the elements of reproductive health commodity security in programmes, plans, budgets, institutional thinking and national policies. Evidence-based advocacy and information decision-making require good data: 38 countries finalized the RHCS situation and stakeholder mapping process, reported results and applied the finding to inform programming in 2015, an increase of 12 countries. The programme continued to promote rights-based and total market approaches to family planning. In 2015, an increasing number of countries had policies in place that that take into consideration both rights-based and total market approaches to family planning: 35 countries in 2015 compared with 28 in 2014. Compared with last year, five more countries also have policies that increase young people’s access to contraceptives, 12 more countries included all modern contraceptives in their national Essential Medicines Lists, and expenditures for reproductive health commodities from national budgets of UNFPA Supplies countries remained stable. Also more national institutions in more countries include RHCS/FP training, and 44 countries had an RHCS coordinating committee. Training programmes on RHCS and family planning reached 3,300 people, building capacity for procurement, quality assurance and other topics. Collaboration with NGOs and many other valued partners is critical to establishing an enabling environment. UNFPA continued to lead key areas of work as part of the Steering Committee of the RMNCH Trust Fund and with the UN Commission on Life-Saving Commodities for Women and Children, and to co-lead supply chain strengthening with USAID. Stock issues were addressed through Coordinated Supply Planning (CSP) with partners and Coordinated Assistance for Reproductive Health Supplies (CARhs) group. Through the Implant Access Programme, efforts continued to reduce prices and supply chain disruptions and improve service delivery quality. As core convenor of the FP2020 global partnership, in 2015 UNFPA contributed to the costed implementation plans and supported a strategic review to identify modes of country support and scale up strategies. These and many other collaborative efforts – HIV, youth-friendly services, the demographic dividend in Sahel countries, and with key partners in each region – supported a more positive environment for mainstreaming RHCS. OUTPUT 2: INCREASED DEMAND In Honduras, where 26 per cent of women give birth before age 18, more than 1,500 young people have received training to communicate sexual and reproductive health information among their peers. In 9 | UNFPA SUPPLIES Annual Report 2015 EXECUTIVE SUMMARY Zimbabwe, the CONDOMIZE! campaign distributed 110 million male condoms and 5 million female condoms. In Rwanda, a new teacher training programme on comprehensive sexuality education, which is part of the country’s new curriculum, was launched with a three-day training workshop that also sensitized deans from 1,508 secondary schools. In Lesotho, a life-skills training for young mothers in hard-to-reach areas links information with family planning services and supplies. Output 2 is about investing in demand generation interventions to reduce barriers and promote access to services for modern contraception. In 2015, initiatives in these areas were reduced following guidance from the UNFPA Supplies Steering Committee to focus resources on procurement and supply chain strengthening. At the same time, however, UNFPA supported more partnership efforts between governments and NGOs and other partners around activities to increase demand for family planning and other sexual and reproductive health services – 96 per cent of programme countries engaged with three or more partners in demand creation. UNFPA continued to support countries and partners to develop strategies and programmes to support community health workers, engage community leaders and religious leaders, and promote social and behavioural change communication. Activities utilized community radio, radio drama, television series, social media, SMS, websites, social marketing and voucher systems to improve demand for modern contraceptives. The trend towards more focused efforts to increase understanding and acceptance of family planning continued in 2015, reaching poor and marginalized adolescent girls and women, remote and hard-to-reach populations as well as persons with disabilities. In 2015, all 46 programme countries had initiatives in place (some in the draft or conception stage) to reach specific categories of underserved and marginalized populations, compared with 41 countries in 2013. OUTPUT 3: PROCUREMENT EFFICIENCY In 2015, UNFPA signed two new long-term agreements for contraceptive implant insertion and removal kits, increasing access to long-acting reversible contraceptives. UNFPA and The World Bank continued an agreement to that makes it easier for World Bank Group borrowers to obtain reproductive health supplies through UNFPA Procurement Services. A new initiative, “20 by 20”, launched in 2015 aims to increase the access, usage and availability of 20 billion condoms by 2020 in low- and middle-income countries. As a result of UNFPA Supplies supply procurement and capacity development, more people are able to choose quality contraceptives and receive quality maternal health medicines in the event that they need them. UNFPA and its many partner organizations benefit from more and better quality products – an overall effort that UNFPA continued to pursue in 2015. UNFPA Procurement Services (formerly AccessRH) is the UNFPA procurement and information service for reproductive health commodities. It offers convenient access to high-quality, affordable reproductive health products, as well as up-to-date information on various contraceptive orders and 10 | UNFPA SUPPLIES Annual Report 2015 EXECUTIVE SUMMARY several tools for planning and ordering purposes, to a range of government ministries, social marketing organizations, NGOs and other clients. UNFPA was able to reduce prices for key contraceptives on 69 per cent of item in 2015. In part, this is due to the increase in the number of generic reproductive health medicines complying with the internationally-recognized quality standards applied by UNFPA. UNFPA saved over $750,000 in 2015 by increasing use of quality-assured generic contraceptives. UNFPA’s quality/price proposition is consistently as good as or better than any other global player in the sector. Through UNFPA Supplies and key global partners, efforts continued in 2015 to promote the availability of quality, cost-effective reproductive health products and the emergence of viable markets for a variety of contraceptive methods and key maternal health medicines. UNFPA established more long-term agreements with 22 suppliers of prequalified and assessed hormonal products. Through UNFPA Procurement Services, shipments of reproductive health commodities went to a total of 55 countries, up from 52 in 2014. UNFPA works diligently to improve the quality and prices for the widening variety of products UNFPA provides. Through its market shaping efforts, improvements in forecasting and planning, and working with suppliers, UNFPA achieves better prices. UNFPA continues to advance global efforts to improve quality of products it provides, working with a range of manufacturers, testing facilities and government agencies to ensure the increased availability of quality goods and services. UNFPA is also working to reduce the environmental impact of the products it provides. OUTPUT 4: IMPROVED ACCESS In Bolivia, training for nurse midwives is offered in three public universities. In rural Djibouti, community health workers advocate family planning and work closely with community health centres. In Ghana, UNFPA supports training for young people living with disabilities and other efforts to reach the visually impaired with family planning services. In Haiti, six mobile teams bring sexual and reproductive health services to remote areas. In post-earthquake Nepal, RH kits helped pregnant women with safe delivery supplies in camps, health facilities and remote communities. In Rwanda, UNFPA provides supplies and services to protect the sexual and reproductive health of refugees fleeing the crisis in Burundi. In Yemen, emergency obstetric and neonatal care equipment for hospitals, health facilities and community midwifery clinics is a key part of the UNFPA humanitarian response. After flash floods in Zimbabwe, dignity kits and other supplies helped address sexual and reproductive health concerns. To improve access to quality family planning services, in 2015 UNFPA Supplies continued to support governments and national stakeholders to: (1) build capacity of health providers in family planning through pre- and in-service training programmes; (2) strengthen integration of family planning within other health services; (3) ensure that poor and marginalized women and adolescents are able to access and use services; and (4) strengthen provision of RH commodities and services in humanitarian settings. 11 | UNFPA SUPPLIES Annual Report 2015 EXECUTIVE SUMMARY There has been a dramatic increase in countries supporting integrated programming to reach persons with disabilities with services, with 36 countries offering targeted support in 2015 compared with none just two years ago. Integration of services also improves access. All 46 programme countries included a focus on young people within integrated family planning service provision, up from 33 in 2013 and 41 countries in 2014. Also, some 1.4 million women and girls were provided with RH commodities and services in humanitarian situations. The number of countries where RH/FP services are integrated with gender, HIV and maternal health to reach specific poor and marginalized population groups continued to increase, up from 12 in 2013 to 43 in 2015. As demand for and supply of contraceptive implants continues to grow, provider training will enable the scale up of family planning interventions. In 2015, UNFPA Supplies supported 269 institutions in 36 of the 46 countries for the conduct of training for FP service provision. The number of providers trained in long-acting reversible contraceptives (LARCs) increased. OUTPUT 5: SUPPLY CHAIN MANAGEMENT In Ghana, drone prototypes are quickly carrying essential reproductive health supplies when and where needed in a public–private partnership’s feasibility study. In Myanmar, where a new LMIS now functions, injectable contraceptives are the method of choice for women who once faced unpredictable shortages. In Zambia, accurate forecasting and quantification methods are saving lives after the government formed a forecasting team with UNFPA, USAID and other stakeholders. A steady, reliable supply of quality contraceptives empowers women to decide when and if to become pregnant. Supply chain management is a critical component of reproductive health commodity security. UNFPA Supplies works at all levels of the supply chain – from regulatory policies to forecasting, procurement, warehousing and inventory management as well as distribution of modern contraceptives and maternal health medicines to service providers, users and patients. In 2015, 43 countries used an information tool for monitoring supplies, up from 37 in 2013. Governments of 43 countries had in place trained national staff to lead and coordinate demand forecasting, up from 29 in 2014. Only six programme countries made unplanned or ad hoc requests (outside humanitarian emergencies) in 2015 compared with 15 in 2014 and 17 in 2015. Functional and resilient supply chains require collaboration with a wide range of valued global partners who provide health supplies in developing countries. In 2015, UNFPA reinforced partnerships with USAID and its different contractors, CHAI, JSI and private sector partners such as McKinsey. Countries are moving towards more unitary health supply systems and away from the vertical, fractured supply chains of the past. Key areas of action include collaboration, innovation and information communication technology (ICT). 12 | UNFPA SUPPLIES Annual Report 2015 EXECUTIVE SUMMARY MANAGEMENT OUTPUT Strategic guidance was provided through three Steering Committee meetings 2015; of which one was in person (November, The Hague). Items on the agenda included financial overviews, the evaluability study, updates on resource mobilization and the funding gap and discussion on the draft outcome of the study conducted by McKinsey on the strategic review of UNFPA Supplies. While substantial contributions were received, resource mobilization was prioritized as the programme faces a funding shortfall which could mean that UNFPA Supplies will be unable to meet the growing demand for contraceptives. In light of FP2020 commitments, analysis of UNFPA spending on family planning emphasized it cross-cutting nature and integral role across UNFPA area of work. In other aspects of programme management, implementation of a comprehensive communications plan for 2015 for UNFPA, in line with UNFPA’s One Voice Corporate Communications Strategy, secured coverage to increase awareness and support fundraising for the UNFPA Supplies programme. UNFPA delivered policy advice, guidance, training and support through its regional offices, including activities supported through UNFPA Supplies. Training for data generation has increased in recent years, with activities in 20 countries in 2013, 23 in 2014 and 38 in 2015. More than 70 per cent of the 3,698 trainees in 2015 were government staff. Countrywide facility-based RHCS surveys collected key data for monitoring stock-outs and availability of RH supplies in 32 countries, up from 27 in 2014. . 13 | UNFPA SUPPLIES Annual Report 2015 INTRODUCTION Introduction: Delivering reproductive health solutions globally Since its establishment in 2007, UNFPA Supplies has mobilized more than $1 billion for sexual and reproductive health services, including family planning, in the world’s poorest countries. Shortfalls in funding risk shortfalls in essential supplies. UNFPA Supplies ensures a secure, steady and reliable supply of quality reproductive health commodities – contraceptives and maternal health medicines – and improves access and use by strengthening national health systems and services. Launched in 2007 by UNFPA, the programme supports national action to reach poor and marginalized women and girls in countries with high unmet need for family planning and high rates of maternal death. In the developing world, 225 million women want to stop or delay childbearing but are not using modern contraceptive methods. UNFPA Supplies advances human rights, gender equality and empowerment by improving access to sexual and reproductive health, including family planning, which is a human right, applicable to everyone, everywhere. UNFPA Supplies is helping millions of people exercise that right in countries where the need is greatest. In 2015, contraceptives and condoms procured through UNFPA Supplies in 2015 provided nearly 31.5 million couple years of protection (CYP), an increase from 28.4 million CYPs in 2014. The programme is anchored in a rights-based approach to reproductive health that prioritizes equity over ease. Its 46 focus countries were selected because they represent the areas of greatest need. Within these challenging environments, a distinctive aspect of the programme is the commitment to reach the most vulnerable populations with reproductive health commodities: UNFPA goes the last mile to reach hard-to-reach populations, increasingly in situations of conflict and disaster. Progress is evident in programme countries: from 2014 to 2015, 10 more provided integrated programming to reach young people and 12 more did so for persons with disabilities. UNFPA Supplies is pivotal to the global development agenda. Achieving the Sustainable Development Goals and meeting the objectives of Family Planning 2020 and the International Conference on Population and Development depend on whether individuals have the means to prevent or delay a pregnancy. It is the world’s largest global programme for family planning, in 2015 accounting for 42 per cent of all contraceptives procured by donors on behalf of developing countries. All 46 countries supported by UNFPA Supplies are part of the FP2020 initiative: scaled up efforts by partners reached some 10 million additional users from 2012 to 2015. 14 | UNFPA SUPPLIES Annual Report 2015 INTRODUCTION UNFPA Supplies is catalytic in countries seeking reproductive health commodity security (RHCS). UNFPA Supplies maximizes the convening power, credibility, extensive partnership and global platform established by UNFPA by focusing on RHCS and reducing barriers to access to sexual and reproductive health supplies, information and services. The influence of this catalytic leadership with governments and partners can be seen in stronger and more inclusive policies, stronger and more sustainable national health systems and supply chains, and stronger more inclusive commitment to family planning programming for women and girls who are young, poor, marginalized, minority, disabled, displaced or otherwise disadvantaged. In 2015, domestic budget lines for contraceptives allocated $20 million more than last year; 17 countries spent at least 80 per cent of their allocated resources, up from 13 in 2014; and the number of non-state actors such as NGOs trained in RHCS and family planning more than tripled. UNFPA Supplies strengthens health systems and supply chains. Country-led action to improve demand forecasting and procurement, distribution and stock-level monitoring can transform weak systems into functional systems with a steady, secure supply. UNFPA-supported training in these areas build in- country capacity. Shortfalls put women at risk, and progress can be seen where stock-outs are reduced. Of the 23 countries with 2015 facility-based survey data, the stock-out situation improved this year in 11 countries – the same number added contraceptives and maternal health medicines to their Essential Medicines List. Only when supplies are available can services fully function, and method choice be assured: in 2015, more countries offered five or more moderns methods of contraception at both secondary and tertiary level. UNFPA Supplies provides procurement expertise and efficiencies. With UNFPA Procurement Services in Copenhagen, UNFPA Supplies collaborates directly with industry to secure volumes of high-quality reproductive health supplies and seeks favourable pricing arrangements. UNFPA saved over $750,000 in 2015 by increasing use of quality-assured generic contraceptives. Through UNFPA Supplies, countries decide which methods their populations prefer with the donor funds the programme makes available. Expertise in procurement and supply chain management for global market shaping activities and in- country capacity-building is a hallmark. In 2015, more countries had trained national in place for procurement process in government institutions. UNFPA Supplies responds in humanitarian crises. Rapid response to contraceptive and reproductive health supply needs that arise in emergency situations plays a critical role in protecting women and girls. UNFPA deploys hygiene supplies, obstetric and family planning supplies, trained personnel, and other support to vulnerable populations. The number of countries with initiatives to reach displaced persons and refugees in humanitarian settings increased from 13 in 2014 to 29 in 2015 – more than 60 per cent of countries in UNFPA Supplies. 15 | UNFPA SUPPLIES Annual Report 2015 INTRODUCTION SCALING UP FOR IMPACT Launched in 2007, from 2008 through 2012 the programme prioritized multi-year funding for 12 countries (Stream One) as well as other funding for 36 countries (Stream Two). Scaling up extended priority support to 46 countries. In 2013, the programme benefited from changes in governance, more robust monitoring, and a greater emphasis on partnership, youth and marginalized populations. This was the baseline year for data presented in this report, which can now be compared year to year. In 2014, the programme welcomed its highest-ever level of funding at $185 million, despite a gap of $74 million early in the year between available funds and budgeted need. The urgent need to bridge that gap was supported by research confirming that the programme delivers good value for money. Overall, progress in RHCS continued to build in 2014. In 2015, crisis-affected countries required heightened response, inclusiveness improved in policies and programmes for young people and the disabled, and many countries reported continued improvement in key aspects of reproductive health commodity security. By financial measures, the programme decreased by 20 per cent though family planning coverage increased compared with last year, delivering contraceptives worth 31.5 million couple years of protection. ABOUT THE PROGRAMME UNFPA procures essential supplies for counties and works in partnership to help them strengthen health systems and services to empower couples to plan and space births, reduce maternal deaths, and protect the reproductive rights of young people. UNFPA Supplies has two over-riding priorities: • Procurement: The programme seeks to ensure the consistent and reliable availability of quality supplies of the right products in the right quantities, condition, place and price. More supplies make more services and better health possible; and • Capacity-building: The programme seeks to ensure, over time, the sustainability of national RHCS efforts, with a focus on enhancing national health systems for supply chain management and the delivery of reproductive health services, including family planning services, for all with a particular attention to poor, underserved and marginalized populations. Technical and financial support provided through this programme make a significant contribution to achieving global and national goals related to family planning and RHCS, including contributions to the following: 16 | UNFPA SUPPLIES Annual Report 2015 INTRODUCTION • Millennium Development Goals, directly contributing to MDG 5A and B, improving maternal health and providing access to reproductive health; as well as furthering MDG 3 on gender equality, MDG4 on child survival, and MDG 6 to combat HIV; • Sustainable Development Goals, increasing access to voluntary family planning will positively influence and help advance the post-2015 development agenda; and • UNFPA Strategic Plan 2014–2017 and Choices Not Chance, the UNFPA Family Planning Strategy. The programme is anchored in human rights and is based on the guiding principles of the International Conference on Population and Development’s Programme of Action (Cairo 1994), the Millennium Development Goals, the Paris Declaration on Aid Effectiveness and the Accra Agenda for Action. It contributes to delivery of the UN Secretary-General’s Global Strategy on Women’s and Children’s Health, the UN Commission on Life-Saving Commodities for Women and Children, and the Campaign for Accelerated Reduction of Maternal Mortality in Africa (CARMMA). ABOUT THE REPORT This report presents more than 100 progress indicators and follows a Performance Monitoring Framework with a goal, outcome and five outputs. It is a response to donor requests for detailed programme results. The results come from an annual questionnaire submitted for 2015 by each of the 46 programme countries as well as a countrywide RHCS survey of stocks at service delivery points (SDPs) that has shifted from an annual to a biannual undertaking. The facility-based RHCS survey was conducted in 2015 by 29 countries, compared with 26 countries in 2014 and 20 in 2013. All data tables are posted online. The report is structured according to the three levels of reporting: GOAL: The goal level is also known as the ‘impact’ level. The indicators are maternal mortality ratio (MMR), adolescent birth rate (ABR) and the youth HIV prevalence rate. Data are sourced from national DHS reports, the UN Population Division and other sources. OUTCOME: Data come from several sources. The indicators include contraceptive prevalence rate and unmet need for family planning, using data from national DHS reports, the United Nations Population Division and other databases and technical publications by the UN and international development partners. Also, financial data from the UNFPA External Procurement Support Report and other Commodity Security Branch sources provides numbers on funding available to procure contraceptives. The most programme-specific outcome-level data come from facility-based RHCS surveys. These surveys of service delivery points (SDPs) are countrywide and supported by UNFPA, through UNFPA Supplies. Each country hires a consultant to conduct the survey under the leadership of the national government, with the support of country coordinating committees. Annual surveys placed a financial 17 | UNFPA SUPPLIES Annual Report 2015 INTRODUCTION burden on a resource-constrained programme and an administrative burden on UNFPA Country Offices; the recommendation is that each country conduct a survey at least once every 24 months. OUTPUT: The outputs or ‘results’ measured by the programme cover many indicators in five key output areas: (1) enabling environment, (2) demand, (3) procurement efficiency, (4) access and (5) capacity and systems for supply chain management. A management output is also reported. Output data come from annual country reporting questionnaires. Self-reporting on what was achieved for the year is carried out by various UNFPA offices. The questionnaires are completed by UNFPA Country Offices, Regional Offices and Headquarters and by other units such as the UNFPA Procurement Services Branch and Humanitarian Services Branch. In 2015, questionnaires were received from all 46 implementing countries. The questionnaires are based on the UNFPA Supplies Performance Monitoring Framework, available online, with indicators, baselines, milestones and targets. RHCS = REPRODUCTIVE HEALTH COMMODITY SECURITY Reproductive health commodity security is achieved when all individuals can obtain and use affordable, quality reproductive health supplies of their choice whenever they need them. RHCS benefits: • Reduction in unintended pregnancy and unplanned births • Reduction in the recourse to abortion, including unsafe abortion • Reduction in maternal deaths • Reduction in newborn and child deaths • Prevention of the transmission of HIV and other STIs • Helps adolescent girls stay in school, and young women develop careers • Helps countries harness a ‘demographic dividend’ • Yields economic benefits for families and societies, and for the development of low- and middle- income countries • Promotes women’s rights and gender empowerment • Makes a positive impact on linkage between reduced fertility and climate change effects • Contributes to an enabling environment to gain additional users of family planning 18 | UNFPA SUPPLIES Annual Report 2015 INTRODUCTION TOO OFTEN, EFFECTIVE AND INEXPENSIVE REPRODUCTIVE HEALTH SUPPLIES DO NOT REACH THE PEOPLE WHO NEED THEM. THESE SUPPLIES HAVE THE POWER TO CHANGE LIVES – AND TO SAVE THEM. UNFPA SUPPLIES CATALYSES ACTION IN FIVE STRATEGIC AREAS. 19 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME Goal: Contribute to universal access to reproductive health Providing universal access to reproductive health – including family planning – is one of the smartest investments the world can make to create a more equitable and prosperous future. It is a goal shared by UNFPA and partners worldwide. The country-driven actions supported by UNFPA Supplies are a contribution to this global effort to meet the sexual and reproductive health needs of millions of women and girls. Progress can be measured in many ways, and at the global level three indicators offer insight into the lives saved and opportunities gained for school, income and empowerment: • maternal mortality ratio; • youth HIV prevalence rate; and • adolescent birth rate. Progress is presented here at the global level, and for the 46 countries participating in UNFPA Supplies. The programme, however, does not claim responsibility or credit for the achievement; rather, it contributes to such progress through a broad range of interventions and networks from the global to the local level. MATERNAL MORTALITY Globally, maternal mortality has declined by nearly 44 per cent over the past 25 years, and the approximate global lifetime risk of a maternal death fell considerably from 1 in 73 to 1 in 1801. However, 303,000 women died for pregnancy related causes in 2015, almost all (99 per cent) in developing countries. This is about one woman every two minutes. For every woman who dies, many other encounter complications with serious and often long-lasting consequences. Most of these deaths and injuries are entirely preventable. If all women who wished to avoid pregnancy were able to use modern contraceptives, and if all pregnant women and newborns received appropriate care and essential medicines, maternal deaths would drop by an estimated 67 per cent, according to the most recent data.2 Unintended pregnancies would fall by about 70 per cent, and newborn deaths would drop by about 77 per cent. Making motherhood safer is a human rights imperative, and it is at the core of UNFPA’s mandate. UNFPA works around the world with governments, health experts and civil society to train health workers, 1 WHO, Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division, 2015. 2 Guttmacher Institute, UNFPA, Adding It Up 2014: The Costs and Benefits of Investing in Sexual and Reproductive Health, 2014. 20 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME improve the availability of essential medicines and reproductive health services, strengthen health systems, and promote international maternal health standards. • UNFPA Supplies focus countries account for approximately 65 per cent of the global maternal deaths in 2015; • At the country level, Nigeria and DRC together account for over one quarter of all maternal deaths globally in 2015. Sierra Leone is estimated to have the highest maternal mortality ratio (MMR) in the world, at 1,360; • Among the 46 programme countries, the MMR range is 129 maternal deaths per 100,000 live births in Honduras to 1360 maternal deaths in Sierra Leone; • 17 countries are estimated to have a very high MMR (between 999 and 500 deaths): Central African Republic (881), Chad (856), Nigeria (814), South Sudan (789), Liberia (725), Burundi (712), Gambia (706), Democratic Republic of the Congo (693), Guinea (679), Côte d’Ivoire (645), Malawi (634), Mauritania (602), Cameroon (596), Mali (587), Niger, (553), Guinea- Bissau (549) and Kenya (510). • 9 out of 46 countries have an MMR 239 or less, which is the average MMR for developing regions; • The most dangerous places to be a mother among programme countries, and in the world, are Sierra Leone and Chad, where the chance of dying from pregnancy related causes are 1 in 17 and 1 in 18 respectively. 28 programme countries (61 per cent) have an adult lifetime risk of maternal death worse than the average of 1 in 41 for low income countries. See the Annex for figures and tables. 21 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME Figure 1: Maternal mortality ratio (MMR) in UNFPA Supplies focus countries, 2015 0 50 100 150 200 250 300 350 400 450 500 550 600 650 700 750 800 850 900 950 1000 1050 1100 1150 1200 1250 1300 1350 1400 M M R VERY HIGH MMR (>500) HIGH MMR (300-500) AVERAGE MMR DEVCOs (239) HIV PREVALENCE Latest data suggest that HIV-related deaths are down 35 per cent from 2005 – but estimates suggest that deaths among adolescents are actually rising. Much more must be done to provide adolescents with comprehensive sexual and reproductive health information, services to help them prevent HIV transmission, and treatment for those who are infected. There are 35 million people living with HIV, up from 29.8 million in 2001, according to the UNAIDS GAP Report 2014. About 50 per cent of all adults living with HIV worldwide are women and it is one of the leading causes of death among women of reproductive age. In sub-Saharan Africa, young women are twice more likely to become infected with HIV than their male counterparts. It is estimated that 4 million young people age 15 to 24 are living with HIV of which 29 per cent of are adolescents aged 15 to 19. 22 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME The global HIV prevalence rate (the per cent of people aged 15 to 49 who are infected) has plateaued at 0.8 per cent. • Among the 46 programme countries, the highest HIV prevalence rates are found in Lesotho (9.3 per cent), Mozambique (7.9 per cent) and Zambia (6.5 per cent); • 20 of 46 countries have an HIV prevalence rate that is still below 1 per cent; • Seven times more young women (aged 15 to 24) have HIV than young men in Côte d’Ivoire; five times more in Cameroon and four times more in Burundi. HIV prevalence among young women is between three and four times higher than among young men in Congo, Haiti, Mali, Mozambique, Rwanda, Sao Tome and Principe, and Lesotho. In addition to their biological susceptibility to HIV, young women in these countries face gender inequalities, differential access to services, and sexual violence. UNFPA promotes integrating HIV responses with sexual and reproductive health care, part of an overarching strategy for universal access to HIV prevention, care and treatment services, including condoms. UNFPA supports the empowerment of key populations, women and girls, and young people to access the services they need, free from stigma and discrimination and all forms of gender-based violence. See the Annex for figures and tables. 23 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME Figure 2: Youth HIV prevalence rate (aged 15-24) by sex in programme countries, 2014 0 2 4 6 8 10 Benin Bolivia Burkina Faso Burundi Cameroon Central African Republic Chad Congo Côte d'Ivoire DR Congo Djibouti Eritrea Ethiopia Gambia Ghana Guinea Guinea-Bissau Haiti Honduras Kenya Lao PDR Lesotho Liberia Madagascar Malawi Mali Mauritania Mozambique Myanmar Nepal Niger Nigeria Papua New Guinea Rwanda Sao Tome and Principe Senegal Sierra Leone South Sudan Sudan Tanzania Togo Uganda Yemen Zambia Zimbabwe Youth HIV prevalence rate 24 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME ADOLESCENT BIRTH RATE Adolescent pregnancy is a global issue. Every day in developing countries, 20,000 girls below age 18 give birth. Worldwide, approximately 16 million girls between the ages of 15 and 19, and 2 million girls under age 15, become pregnant every year. When a girl becomes pregnant, her life can change radically. Her education may end and her job prospects diminish. She becomes more vulnerable to poverty and exclusion, and her health often suffers. Complications from pregnancy and childbirth are a leading cause of death among adolescent girls. Adolescent pregnancy is often not the result of a deliberate choice, but rather the absence of choices: It is a consequence of little or no access to school, information or health care. The problem is made worst by the fact that adolescent girls, in general, face greater barriers than adult women in accessing reproductive health services. The adolescent birth rate (ABR) refers to the annual number of births per 1,000 women aged 15 to 19 years. It is useful in assessing the impact of various interventions implemented at the country level. • 43 out of 46 countries (93 per cent) have a higher ABR than the global average of 51; • 33 programme countries (72 per cent) have high ABR (the designation set by UNDESA for rates greater than 80 births per 1,000 women aged 15–19);3 • In the 46 programme countries the ABR ranges from 17 in Myanmar to 229 in Central African Republic per 1,000 women aged 15-19. UNFPA works to address adolescent pregnancy by focusing on the protection and fulfilment of girls’ rights. This includes supporting comprehensive sexuality education and sexual and reproductive health care, including access to modern contraception, to help girls avoid pregnancy. UNFPA also advocates supporting girls who become pregnant so they can return to school and reach their full potential. 3 United Nations, Department of Economic and Social Affairs, Population Division (2013). Adolescent Fertility since the International Conference on Population and Development (ICPD) in Cairo (UN publication), page viii. 25 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME Figure 3: Programme countries with high adolescent birth rate (ABR>80), 2015 0 50 100 150 200 250 Benin Bolivia Burkina Faso Cameroon Central African Republic Chad Congo Côte d'Ivoire DR Congo Eritrea Gambia Guinea Guinea-Bissau Honduras Kenya Lao PDR Lesotho Liberia Madagascar Malawi Mali Mozambique Nepal Niger Nigeria Sao Tome and Principe Sierra Leone South Sudan Sudan Tanzania Uganda Zambia Zimbabwe Adolescent birth rate (ABR) 26 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME Outcome level: Increased availability and use of reproductive health supplies More than 225 million women in developing countries want to avoid pregnancy but are not using modern contraceptives. With partners in FP2020, UNFPA is committed to expanding contraceptive access to many of them: the aim is to reach 120 million more women and girls in the world’s poorest countries by 2020. Most of the commodities procured through UNFPA Supplies are contraceptives, destined for family planning programmes, as well as essential are life-saving maternal health medicines, condoms for HIV preventions, RH kits, dignity kits and medical equipment. More supplies mean more people can be served, and more efforts can be made to inform people about the benefits of family planning. UNFPA created UNFPA Supplies as a strategic, catalytic, rights- based programme to achieve this key outcome: Increased availability and utilization of reproductive health commodities in support of reproductive and sexual health services including family planning, especially for poor and marginalized women and girls. UNFPA supports family planning programmes to assist governments in their efforts to ensure that women have access to a broad range and choice of contraceptive methods to attain their reproductive intentions. The achievements shown in the following sections are not the work of any single organization but rather the success of concerted efforts made by all stakeholders, including governments. How the outcome-level results are measured Progress towards the programme outcome is measured through several indicators: • unmet need for family planning; • contraceptive prevalence rate; • demand for family planning satisfied; and • availability and stock-outs at service delivery points. 27 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME UNMET NEED FOR FAMILY PLANNING Performance Monitoring Framework: To measure ‘use’ of supplies, the programme tracks the average unmet need for family planning for the 46 UNFPA Supplies countries. Women with unmet need for family planning are those who want to avoid a pregnancy but are currently using no method or a traditional contraceptive method. Unmet need for family planning is almost twice as high among women who want to postpone (or space) births as among those who want no more children – 36 per cent vs. 20 per cent. Unmet need points to the gap between women's reproductive intentions and their contraceptive behaviour – though unmet need for family planning is not the same as unmet demand for modern contraception. A woman may not want to become pregnant but may not want or be able to use modern contraception for a variety of reasons, such as fear of side effects, opposition from family members or lack of access to services. Meeting unmet need for modern contraception is about reaching couples with information and services, as a matter of rights and of health. Unmet need for family planning among married women in UNFPA Supplies implementing countries varies widely: • Burkina Faso has the highest unmet need of 35.7 per cent and South Sudan has the lowest unmet need of 4.0 per cent (like other countries with low unmet need, it also has very low contraceptive prevalence); • 15 of 46 countries have an unmet need of 25 per cent or more; that is a level of at least one out of four women. See Annex for figures and detailed tables. 28 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME Figure 4: Percentage need for family planning services among currently married women, selected UNFPA Supplies implementing countries Burkina Faso PMA 2014 Haiti; 2012 DHS Uganda; PMA 2014 Togo; 2013-14 DHS Benin; 2011-12 DHS Liberia; 2013 DHS Ghana 2014 DHS Yemen; 2013 DHS Mozambique; 2011 DHS Congo Democratic Republic; 2013-… Nepal; 2011 DHS Cote d'Ivoire; 2011-12 DHS Mali; 2012-13 DHS Senegal; 2014 DHS Sierra Leone; 2013 DHS Gambia DHS 2013 Ethiopia PMA 2014 Guinea; 2012 DHS Cameroon; 2011 DHS Bolivia; 2003 DHS Zambia; 2013-14 DHS Lao PDR 2011-2012 Congo (Brazzaville); 2011-12 DHS Kenya; 2014 DHS Nigeria; 2013 DHS Niger; 2012 DHS Zimbabwe; 2010-11 DHS Honduras; 2011-12 DHS South Sudan; HHS 2010 4.0 10.7 14.6 16.0 16.1 17.5 18.4 19.9 21.1 22.8 23.5 23.7 24.1 24.9 25.0 25.6 26.0 27.1 27.5 27.7 28.5 28.7 29.9 31.1 32.6 33.6 34.7 35.3 35.7 Co un tr y/ su er ve y ye ar 0 5 10 15 20 25 30 35 Percentage 29 | UNFPA SUPPLIES Annual Report 2015 40 GOAL & OUTCOME CONTRACEPTIVE PREVALENCE RATE MODERN METHODS Performance Monitoring Framework: To measure ‘use’ of supplies, the programme tracks contraceptive prevalence rate for modern methods (mCPR) (disaggregated by quintile, urban–rural, education). The contraceptive prevalence rate for modern methods is useful for tracking progress towards the target of achieving universal access to reproductive health. More broadly it could be considered an indicator of health, population, development and women’s empowerment. It is an important measure of the outcome of family planning interventions. mCPR is the percentage of women who are currently using, or whose partner is currently using, at least one modern method of contraception. Higher rates of modern contraceptive prevalence mean that more individuals are using modern methods of contraception, supporting their right to plan their families. mCPR provides a very good indication of the extent to which women and girls want to increase control over their fertility and decide for themselves whether, when and how often to bear children. As such, this indicator is a powerful means of tracking relative levels of empowerment of women and girls. Increases in mCPR reflect improvements in the provision of and access to family planning supplies and services, which brings many benefits to individuals, families and society – from better educated women and girls to opportunities to harness the demographic dividend. Figure 5: mCPR in selected programme countries from latest demographic/health surveys 7.8% 9.8% 11.7% 12.5% 14.4% 15.1% 15.6% 17.3% 18.5% 19.1% 20.3% 21.0% 22.2% 33.3% 37.4% 40.4% 44.8% 47.1% 53.2% 57.4% 66.5% 0% 10% 20% 30% 40% 50% 60% 70% DRC 2013-14 DHS Nigeria 2013 DHS Sudan 2014 MICS Benin 2014 MICS Guinea-Bissau 2014 MICS Mali 2015 MICS Sierra Leone 2013 DHS Togo 2013-14 DHS Congo 2014-15 MICS Liberia 2013 DHS Senegal 2014 DHS Cameroon 2014 MICS Ghana 2014 DHS Madagascar MDG 2012-13 Sao Tome and Principe 2014 MICS Ethiopia Mini DHS 2014 Zambia 2013-14 DHS Nepal 2014 MICS Kenya 2014 DHS Malawi 2014 MICS Zimbabwe 2014 MICS mCPR married women 30 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME As shown in the figure below, the positive upward trend in mCPR is evident in a number of countries where CPR has increased between two successive Demographic and Health Surveys. CPR increased by: • 13.1 percentage points in three years in Ethiopia (2011 to 2014) • 15.2 percentage points over four years in Malawi (2010 to 2014) • 13.8 percentage points in six years in Kenya (2008/9 to 2014) • 9.2 percentage points over four years in Zimbabwe (2010/11 to 2014) • 5.2 percentage points over two years in Mali (2012/13 to 2015) • 4.6 percentage points over two years in Benin (2011/12 to 2014) • 6.6 percentage points over three years in Cameroon (2011 to 2014) • 8.2 percentage points over four years in Senegal (2010/11 to 2014) • 12.1 percentage points in seven years in Zambia (2007 to 2014) • 8.8 percentage points over six years in Liberia (2007 to 2013) Use of modern contraceptives among married women has increased at different rates in the past years: • 13 of 46 countries have seen mCPR (modern methods) increase between 1.0 and 1.9 percentage points per year: Benin at 1.8; Guinea-Bissau, Haiti and Madagascar at 1.0; Honduras, Niger and Togo at 1.2; Liberia at 1.5; Nepal and Tanzania at 1.3; Sierra Leone and Zambia at 1.9; Uganda at 1.6; • 4 countries have seen an increase in mCPR between 2 and 2.5 percentage points per year: Burundi at 2.0; Senegal at 2.3; Mali at 2.1; and Cameroon at 2.4; • 4 countries have seen an increase in CPR over 2.5 percentage points per year: Zimbabwe at 2.6; Kenya at 2.8; Malawi at 3.8 and Ethiopia at 4.4; • In other countries, mCPR remains rather stagnated over the past years, with annual increases of less than 0.5 percentage points, such as in Burkina Faso, Central African Republic and Nigeria. Also, in four countries there has been a slight annual decrease in the mCPR over the past years: Congo, Guinea, Ghana, Gambia and Mozambique. 31 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME Figure 6: mCPR progress between two demographic/health surveys in selected programme countries 7.9% 12.5% 14.4% 21.0% 20.0% 18.5% 5.4% 7.8% 27.3% 40.4% 10.3% 14.4% 39.4% 53.2% 42.2% 57.4% 9.9% 15.1% 43.2% 47.1% 9.7% 9.8% 33.7% 37.4% 12.1% 20.3% 8.1% 11.7% 13.1% 17.3% 32.7% 44.8% 57.3% 66.5% 0% 10% 20% 30% 40% 50% 60% 70% 2011-12 DHS 2014 MICS 2011 DHS 2014 MICS 2011-12 DHS 2014-15 MICS 2010 MICS 2013-14 DHS 2011 DHS Mini DHS 2014 2010 MICS 2014 MICS 2008-09 DHS 2014 DHS 2010 DHS 2014 MICS 2012-13 DHS 2015 MICS 2011 DHS 2014 MICS 2008 DHS 2013 DHS 2008-09 DHS 2014 MICS 2010-11 DHS 2014 DHS 2010 MICS 2014 MICS 2010 MICS 2013-14 DHS 2007 DHS 2013-14 DHS 2010-11 DHS 2014 MICS Be ni n Ca m er oo n Co ng o D RC Et hi op ia G ui ne a- Bi ss au Ke ny a M al aw i M al i N ep al N ig er ia Sa o To m e an d Pr in ci pe Se ne ga l Su da n To go Za m bi a Zi m ba bw e mCPR married women 32 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME FAMILY PLANNING DEMAND SATISFIED Performance Monitoring Framework: To measure ‘use’ of supplies, the programme calculates the demand satisfied calculated from the above two estimated values as: % Demand satisfied = [CPR ÷ (CPR + Unmet need)] x 100 Total demand for family planning is a measure that combines both CPR and unmet need for family planning. Generally, contraceptive prevalence rate is taken as the total demand for family planning that is satisfied (met need) and the demand that is not satisfied constitutes the unmet need. • The highest percentage of demand satisfied is in Honduras (85.6 per cent), followed by Zimbabwe (79.7 per cent) and Kenya (75.2 per cent); • The lowest is in Guinea (16.3 per cent) followed by Benin (19.5 per cent) and DRC (22.0 per cent). Where use of modern methods of contraception is high (e.g. Honduras, Zimbabwe, Kenya, Zambia, Lao PDR and Nepal) there is high satisfaction for contraception by modern methods. Where use of modern methods of contraception is low (e.g. South Sudan, Guinea, Benin, DRC and Gambia) there is low satisfaction for contraception by modern methods. See the Annex for a table on unmet, CPR and demand satisfied. Disparities are evident. There is an improvement in demand satisfied as CPR increases, yet the percentage of total demand for contraception satisfied by modern contraceptive use among women in the poorest households are far lower than among women in the richest households. In countries such as Bolivia, Cameroon, Ethiopia and Nigeria, there are more than 40 percentage points between demand satisfaction among women in the poorest wealth quintile and the richest wealth quintile. Even with improvements in CPR there are disparities in contraceptive use among women based on education levels, household income and urban–rural location. CPR is disproportionately higher among married women in the highest wealth quintile than those in lower wealth quintiles. In Ghana, Haiti and Honduras, there is a close to equal percentage of demand satisfied among women in the poorest and richest wealth quintiles. Yet there are signs that gaps are closing in UNFPA Supplies countries that have received significant levels of multi-year support since 2008 (the Stream 1 countries). Recent surveys in nine countries show that, on average, disparity has been reduced. • The differential in the CPRs between urban and rural populations has decreased from 13.6 to 12.9; • The differential between the highest quintile of household wealth and the lowest has declined from 20.2 to 18.7; 33 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME • The differential between those with secondary or higher education and those with no education declined notably from 23.9 to 19.2. FAMILY PLANNING 2020 – ADDITIONAL USERS Performance Monitoring Framework: To measure ‘use’ of supplies, the programme calculates additional women with modern methods of contraception reported through FP2020. A global partnership was formally established at the London Summit on Family Planning in 2012, known as Family Planning 2020 (FP2020). Its goal is to reach an additional 120 million more women and girls with contraceptive services in 69 of the poorest countries in the world. Since 2012, an additional 24.4 million women and girls in the 69 FP2020 focus countries are now using modern contraception. This progress, however, is still 10 million fewer than the benchmark for 2015 projected at the time of the London Summit. In the 46 UNFPA Supplies focus countries, which are all FP2020 focus countries, scaled up efforts by partners reached approximately 10 million additional users from 2012 to 2015 (4.4 million behind the benchmark need to reach the FP2020 goal in these countries). UNFPA, jointly with partners, is working to identify key interventions to accelerate, rights-based growth in contraceptive prevalence, especially among marginalized populations. Figure 7: Number of additional users of modern contraception in 46 UNFPA Supplies implementing countries ­ 5 10 15 20 25 30 35 40 45 2012 2013 2014 2015 2016 2017 2018 2019 2020 M ill io ns Historical (from London Summit) Current (2015 Progress Report) Potential Source: Track20. Note: * Historical progress is an extrapolation showing the progress that would have been made without scaled-up support from UNFPA Supplies from 2012 onwards. 34 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME AVAILABILITY AND STOCK-OUT OF RH COMMODITIES In 2015, 32 out of 46 countries conducted facility-based RHCS surveys with support from UNFPA Supplies, up from 27 in 2014. Some countries conducted the survey of service delivery points for the first time in 2015, and a few countries that had conducted the survey in 2014 did not repeat the exercise in 2015. Therefore, annual tracking of progress and comparison with the previous year is possible for 24 countries. For a few of them tracking of progress is available from 2013. In 2015 in Nepal, the MoH conducted the Nepal Health Facility Survey (NHFS). Some key indicators on RHCS measured by UNFPA Supplies are an integral part of the NHFS, and are included in this report. Disaggregated results for selected indicators from UNFPA-supported facility-based RHCS surveys analysed in this report are included in the Annex. AVAILABILITY OF LIFE-SAVING MATERNAL/RH MEDICINES Performance Monitoring Framework: The programme tracks the number of countries with seven life­ saving maternal/RH medicines from the WHO list available in 100 per cent of facilities providing delivery services (this must include magnesium sulfate and either misoprostol or oxytocin or both) (disaggregated for urban–rural and type of SDPs). An estimated 303,000 women are dying every year due to pregnancy related causes, 99 per cent of maternal deaths occur in developing countries.4 Complications of pregnancy are the second most common cause of death in adolescent girls aged 15 to 19 globally5 and the leading cause of death for girls under 15 years old in developing countries.6 Nearly 60 per cent of maternal deaths are due to four preventable causes: severe bleeding, high blood- pressure, infection and unsafe abortion. Most deaths could be prevented with adequate natal and postnatal care and access to essential maternal health medicines7. • 14 countries had seven life-saving maternal and reproductive health medicines available at all tertiary SDPs: Zambia, Togo, Timor-Leste, Niger, Mozambique, Liberia, Lesotho, Kenya, 4 Trends in Maternal Mortality: 1990 to 2015. Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division, 2015. 5 World Health Organization (WHO), “Mortality, morbidity and disability in adolescence”, 2014. Available at: http://apps.who.int/adolescent/second-decade/section3/page2/mortality.html, accessed Dec 2015. 6 WHO, Maternal mortality fact sheet (n. 348), Nov 2015. Available at: http://www.who.int/mediacentre/factsheets/fs348/en/, accessed on Dec 2015. 7 See Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels JD, et al (2014), “Global Causes of Maternal Death: A WHO Systematic Analysis”. Lancet Global Health. 2014, available at: http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(14)70227-X/fulltext, and WHO Maternal mortality fact sheet (n. 348), Nov 2015. Available at: http://www.who.int/mediacentre/factsheets/fs348/en/, accessed on Dec 2015. 35 | UNFPA SUPPLIES Annual Report 2015 http://www.who.int/mediacentre/factsheets/fs348/en http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(14)70227-X/fulltext http://www.who.int/mediacentre/factsheets/fs348/en http://apps.who.int/adolescent/second-decade/section3/page2/mortality.html GOAL & OUTCOME Honduras, Côte d’Ivoire, Central African Republic, Burkina Faso, Bolivia and Benin. This is a decrease in 2 countries compared with 2015; • 5 countries had all seven WHO priority RH medicines available at 100 per cent of secondary SDPs in 2015 (Togo, Papua New Guinea, Lesotho, Honduras and Bolivia), the same number as in 2014. No country achieved in 2015 full availability of essential RH medicines at all primary SDPs. However, a few countries were able to maintain reasonable levels of availability in at least 70 per cent of primary SDPs: Honduras, Lesotho, Mozambique, Niger, Nigeria, Papua New Guinea and Togo. When assessing progress it should be noted, however, that 9 countries with data from 2014 survey did not conduct the survey in 2015, and 8 new countries conducted the survey in 2015. Where comparison is available, 12 out of 23 countries where comparison is available, experienced increases in the total availability of at least seven life-saving maternal/RH medicines in 2015 compared with the previous year. In Benin, Côte d’Ivoire, Niger, and Uganda, the level of availability of essential medicines remained rather constant, with a slight decrease of less than 5 percentage points. Decreases over 5 percentage points occurred in Congo, Ethiopia, Gambia, Lao PDR, Lesotho, Myanmar and Rwanda. Essential life-saving RH medicines are less likely to be available in rural areas, 16 countries still have less than half of rural SDPs with seven essential RH medicines available. Increasing availability or even maintaining constant levels in rural areas continues to be a challenge: Although availability increased in 11 countries compared with 2015, it decreased in 12 countries in the same period. The reasons most cited on why some SDPs did not offer all seven essential life-saving RH medicines were mainly related to supply chain issues, such as weak supply systems causing delays in delivery and replenishment of stocks, weak forecasting systems causing delays of SDPs in requesting resupply, or stock-outs at the supplier level. Some countries also cited low demand of certain medicines by the health facilities and lack of trained staff to provide the medicine. 36 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME Figure 8: Total availability of seven life-saving RH medicines, 2013-2015 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Benin Burkina Faso Central African Republic Chad Congo Côte d'Ivoire Ethiopia Gambia Haiti Honduras Lao PDR Lesotho Liberia Mauritania Mozambique Myanmar Nepal Niger Nigeria Rwanda Senegal Sierra Leone Sudan Togo Uganda Zambia % Service delivery points (SDPs) 2015 2014 2013 37 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME Figure 9: Availability of seven life-saving RH medicines by level of SDP, 2015 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Benin Bolivia Burkina Faso Burundi Central African Republic Chad Congo Côte d'Ivoire DR Congo Ethiopia Gambia Haiti Honduras Kenya Lao PDR Lesotho Liberia Mauritania Mozambique Myanmar Nepal Niger Nigeria Papua New Guinea Rwanda Senegal Sierra Leone Sudan Timor-Leste Togo Uganda Zambia % SDPs Tertiary Secondary Primary 38 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME Figure 10: Availability of seven life-saving RH medicines by urban/rural location, 2015 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Benin Bolivia Burkina Faso Burundi Central African Republic Chad Congo Côte d'Ivoire DR Congo Ethiopia Gambia Haiti Honduras Kenya Lao PDR Lesotho Liberia Mauritania Mozambique Myanmar Niger Nigeria Papua New Guinea Rwanda Senegal Sierra Leone Sudan Timor-Leste Togo Uganda Zambia % SDPs Rural Urban 39 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME AVAILABILITY OF CONTRACEPTIVES AT SECONDARY & TERTIARY LEVEL Performance Monitoring Framework: To measure ‘availability of RH commodities’, the programme tracks the number of countries with 85 per cent of tertiary and secondary level service delivery points (SDPs) offering at least five modern methods of contraception. In 2015, the indicator measuring availability of a full choice of modern contraceptives at tertiary and secondary level SDPs is disaggregated as follows: • 23 countries reported having 85 per cent of tertiary SDPs offering five or more modern methods in 2015, compared with 19 the previous year, and 14 countries achieved availability of five or more methods in 100 per cent tertiary SDPs in 2015. • 14 countries reported having 85 per cent of secondary SDPs offering five or more modern methods, compared with 11 in 2014, and 4 countries achieved availability in 100 per cent of secondary SDPs. Figure 11: Availability of a full choice of modern contraceptives in at least 85 per cent of secondary and tertiary SDPs, progress 2013–2015 13 19 23 9 11 16 0 5 10 15 20 25 2013 2014 2015 2013 2014 2015 Te rt ia ry Se co nd ar y Number of countries Increases in secondary and tertiary SDPs offering at least five modern methods of contraception were seen in 17 countries (out of 23 countries for which annual comparison is available). Significant increases in the percentage of SDPs offering five or more methods were seen in Benin, Burkina Faso, Chad, Côte d’Ivoire, Gambia, Honduras, Lao PDR, Nepal, Rwanda, Senegal, Uganda and Zambia. Slight increases were seen in Ethiopia, Myanmar, Nigeria and Timor-Leste. 40 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME Togo and Niger were able to maintain availability of at least five modern methods at 100 per cent of both secondary and tertiary SDPs in 2014 and 2015. Honduras and Papua New Guinea also reached 100 per cent availability of five or more modern methods at both tertiary and secondary SDPs in 2015. Availability of at least five modern methods at secondary and tertiary SDPs decreased in Congo and Haiti. Lesotho, Mozambique and Sudan experienced a slight decrease, and in Central African Republic the availability of modern contraceptives did not vary from the previous year, with around half of SDPs offering five or more modern methods both in 2014 and 2015. A full picture on the availability of five or more methods in tertiary and secondary SDPs across all UNFPA Supplies supported countries since 2013 can be found in the respective tables in the Annex. UNFPA Supplies also tracks the availability of a full choice of five or more modern contraceptive methods in secondary and tertiary level facilities by urban and rural location. This is important to measure one key element impacting the access to family planning and contraceptives by rural communities. In 2015, although only 6 countries reached the target of having 85 per cent of rural SDPs at secondary and tertiary level offering at least five modern contraceptive methods, availability increased in 13 countries, compared with previous year: Burundi, Côte d’Ivoire, Honduras, Lao PDR, Lesotho, Mozambique, Myanmar, Nigeria, Rwanda, Senegal, Timor-Leste, Uganda and Zambia. A few countries reached 100 per cent availability in rural areas: Lesotho, Papua New Guinea, Rwanda and Senegal. However, in some others, the big gap in the access to contraception in rural facilities is a cause of concern. Intense efforts should continue in order to close the urban/rural gap and increase the access to family planning and modern contraception in rural areas. 41 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME Figure 12: Availability of five or more modern methods at secondary and tertiary SDPs in 2015, by SDP level 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Benin Bolivia Burkina Faso Burundi Central African Republic Chad Congo Côte d'Ivoire DR Congo Ethiopia Gambia Haiti Honduras Kenya Lao PDR Lesotho Liberia Mauritania Mozambique Myanmar Nepal Niger Nigeria Papua New Guinea Rwanda Senegal Sierra Leone Sudan Timor-Leste Togo Uganda Zambia Zimbabwe Tertiary Secondary 42 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME Figure 13: Availability of five or more modern methods at secondary and tertiary SDPs in 2015, by urban/rural location 0% 20% 40% 60% 80% 100% Benin Bolivia Burkina Faso Burundi Central African Republic Chad Congo Côte d'Ivoire DR Congo Ethiopia Gambia Haiti Honduras Kenya Lao PDR Lesotho Liberia Mauritania Mozambique Myanmar Niger Nigeria Papua New Guinea Rwanda Senegal Sierra Leone Sudan Timor-Leste Togo Uganda Zambia % of SDPs Rural Urban 43 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME AVAILABILITY OF CONTRACEPTIVES AT PRIMARY LEVEL Performance Monitoring Framework: To measure ‘availability of RH commodities’ the programme tracks the number of countries with 85 per cent of primary level service delivery points offering at least three methods in 2013 and increasing to five modern methods in 2016 and beyond. The primary level includes clinics, health posts and community-based distribution through health workers. In 2015, 20 countries reported having at least 85 per cent of primary SDPs offering three or more methods, compared with 22 countries in 2014. It should be noted that 5 countries that reached the indicator in 2014 did not conduct the facility survey in 2015 (Yemen, Malawi, Mali, Madagascar and Guinea-Bissau). Figure 14: Availability of a full choice of modern contraceptives in at least 85 per cent of primary SDPs 2013-2015 7 22 20 0 5 10 15 20 25 2013 2014 2015 Pr im ar y Number of countries Also, 12 countries (48 per cent of the countries for which annual comparison is available) reported increased availability of three or more methods at primary level: Burkina Faso, Burundi, Chad, Côte d’Ivoire, Ethiopia, Haiti, Nepal, Nigeria, Senegal, Timor-Leste; and Benin and Central African Republic maintaining similar levels as in previous year. And 12 countries achieved almost universal availability of three or more methods at primary level in 2015, with over 95 per cent of primary SDPs offering at least three methods: Bolivia, Burkina Faso, Chad, Ethiopia, Haiti, Lesotho, Nepal, Niger, Sierra Leone, Togo and Zambia. In addition, the choice of modern contraceptives is increasing in some countries: primary SDPs were offering five or more methods in Togo (89.5 per cent of primary SDPs), Mozambique (90 per cent), and Gambia (37.5 per cent). In rural areas, 16 countries achieved the minimum choice indicator of 85 per cent of rural facilities offering three or more methods of modern contraceptives. Significant inequalities exist in access to contraceptives in rural areas, posing an important challenge in terms of equity. 44 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME Figure 15: Availability of three or more modern methods at primary SDPs 2014-2015 0% 20% 40% 60% 80% 100% Benin Burkina Faso Burundi Central African Republic Chad Congo Côte d'Ivoire DR Congo Ethiopia Gambia* Haiti Honduras Lao PDR Lesotho Mozambique* Myanmar Nepal Niger Nigeria Rwanda Senegal Sudan Timor-Leste Togo Uganda Zambia % SDPs 2015 2014 45 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME Figure 16: Availability of three or more modern methods at primary SDPs in 2015, by urban/rural location 0% 20% 40% 60% 80% 100% Benin Bolivia Burkina Faso Burundi Central African Republic Chad Congo Côte d'Ivoire DR Congo Ethiopia Haiti Honduras Kenya Lao PDR Lesotho Liberia Mauritania Mozambique* Myanmar Niger Nigeria Papua New Guinea Rwanda Senegal Sierra Leone Sudan Timor-Leste Togo Uganda Zambia % SDPs Rural Urban 46 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME WHY DID SOME SDPS NOT OFFER A FULL BASKET OF MODERN CONTRACEPTIVES? Reasons why SDPs did not offer at least five modern methods of contraception (or three in case of primary facilities) at the time of the facility-based RHCS survey varied from country to country. In their surveys, 26 countries provided detailed information. The three most cited reasons for not offering a full choice of modern contraceptives in 2015 were, as in previous years, low client demand for certain methods, lack of trained staff to provide the method and problems in the supply chain causing delays in receiving the supplies from the warehouse. Low client demand • 22 countries out of 26 (79 per cent) reported that SDPs not offering certain methods because there was no demand of that method among the population. Among countries where disaggregation per method is provided, female condom appear as the method least offered by facilities because of low demand. However, in a significant number of countries low demand is also mentioned by a significant portion of SDPs as a reason for not offering other modern methods. Problems in the supply chain • 19 countries (68 per cent) reported that delays in receiving the supplies from the warehouse was the reason why certain methods were not regularly offered by facilities; • 9 countries also reported delays in the requisition of supplies by the facility. In some cases delays may affect the availability of a particular method, such as in Lao PDR, where some problems in the distribution of male condoms reduced their availability at facilities. Some facilities may be more impacted by the delays, such as in Ethiopia, where one third of primary facilities report being significantly affected by delays from the warehouse, versus less than 10 per cent of secondary and tertiary SDPs. Lack of trained staff • 20 countries (71 per cent) reported that some facilities were not offering implants and IUDs because there was no trained personnel available to provide these methods. In Central African Republic, Côte d’Ivoire, Kenya, and Uganda over one third of SDPs reported not offering implants due to lack of skilled staff. In Mozambique, Nigeria and Papua New Guinea around half of surveyed facilities did no provide implants due to lack of trained staff. Facility-based RHCS surveys supported by UNFPA Supplies also measure certain aspects of the service provision and the capacity gap that exist in countries to provide long-term methods, particularly contraceptive implants, in conditions of safety and security for clients and providers. 47 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME As will be further presented in the following section, in many countries, a significant part of SDPs reported that no trained provider was available for the insertion and removal of implants. The lack of trained staff for the provision of long-acting methods significantly hampers the efforts made to expand the basket of contraceptives available in countries and has a negative impact in increasing the access to family planning and the contraceptive uptake. In order to achieve and sustain an increase in the contraceptive use it is critical that efforts to ensure that clients have a full choice of contraceptives that can be safely provided are maintained and expanded. THE CAPACITY GAP AND ITS IMPACT IN THE AVAILABILITY OF MODERN CONTRACEPTION AND QUALITY OF CARE As already mentioned, lack of trained personnel available to provide these methods is often one of the major reasons cited in facility-based RHCS surveys to explain why certain methods, particularly long- acting contraceptives (implants and IUDs), were not offered. Surveys supported by UNFPA Supplies also measure certain aspects of the service provision and the capacity gap that exist in countries to provide long-term methods, particularly contraceptive implants, in conditions of safety and security for clients and providers. In 2015, surveys conducted in 32 countries provide information regarding the percentage of SDPs that have trained staff to insert and remove implants. The total aggregation shows that in 15 countries (52 per cent) at least one third of facilities do not have trained staff for implant insertion and removal. In 10 of them at least half of all facilities do not have a trained provider (Sudan, Sierra Leone, Papua New Guinea, Myanmar, Mauritania, Lao PDR, Honduras, Haiti, Ethiopia, and Congo). Primary level facilities are the most understaffed, with 13 countries reporting over half of primary facilities with no staff trained for implant provision. Rural facilities are also greatly impacted by the lack of trained personnel, aggravating the low access to modern contraceptive technology by rural populations. Some 11 countries reported that over half of rural facilities do not have any trained provider. In most countries, a significant proportion of SDPs reported that the most recent training occurred more than one year ago. 48 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME Figure 17: Percentage of SDPs with staff trained for insertion/removal of implants in 2015, by SDP level 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Benin Bolivia Burkina Faso Burundi Central African Republic Chad Congo Côte d'Ivoire DR Congo Ethiopia Gambia Haiti Honduras Kenya Lao PDR Lesotho Liberia Mauritania Myanmar Niger Nigeria Papua New Guinea Rwanda Senegal Sierra Leone Sudan Timor-Leste Togo Uganda Zambia % SDPs Tertiary SDPs Secondary SDPs Primary SDPs 49 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME Figure 18: Percentage of SDPs with staff trained for insertion/removal of implants in 2015, by urban/rural location 0% 20% 40% 60% 80% 100% Benin Burkina Faso Burundi Central African Republic Chad Congo Côte d'Ivoire DR Congo Ethiopia Gambia Honduras Kenya Lao PDR Lesotho Liberia Mauritania Myanmar Niger Nigeria Papua New Guinea Rwanda Senegal Sierra Leone Sudan Timor-Leste Togo Uganda % SDPs Rural Urban 50 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME In assessing the quality of care, aside from the technical aspects related to the capacity of the facilities to provide family planning services, it is also important to take into account other ethical issues regarding the informed consent of the client – and especially the information regarding the side effects of the method-, and the due respect for clients’ individual choices. UNFPA Supplies facility-based RHCS surveys include client exit interviews to measure clients’ satisfaction with the services received. Although it should be acknowledged that the information from the exit interviews is based on clients’ subjective perceptions; it can provide a valuable starting point to advance the discussion around particular aspects of the quality of care in family planning. • 29 countries included client exit interviews in the facility survey conducted in 2015. In 2 of them the information was incomplete; • In 12 countries (out of 29), over 20 per cent of clients interviewed reported not being informed about the common side effects of the contraceptive method received; • In 13 countries (out of 27), over 10 per cent of clients interviewed indicated being forced by the health service providers to accept a method, or the service provider insisted he/she should accept the FP method. A preliminary analysis indicates that, in some cases, there are significant differences in this percentage depending on the level of care and the location, whereas clients from primary level facilities and rural areas are more likely to report being forced or pushed to accept a FP method. Further analysis should be conducted. Evidence indicates that increased support in capacity-building of health providers is critical to scale up family planning programmes and provide adequate coverage and access to quality family planning services and commodities. In this regard, efforts should continue to ensure that capacity-building programmes of family planning providers include training in new contraceptive technologies, including insertion and removal of implants at all levels, where allowed by applicable regulations; and also modules on ethical codes of conduct to advance on the respect to the individual choices and autonomy of clients to make informed decisions about their reproductive health. 51 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME STOCK-OUT OF CONTRACEPTIVES Performance Monitoring Framework: The programme tracks the number of countries with 60 per cent of SDPs with no stock-out of contraceptives in the last six or three months (disaggregated for urban– rural and type of SDPs). Stock-outs are shortages or shortfalls in essential reproductive health supplies. Having ‘no stock-out’ is a sign that a country’s supply chain is functional. The impact of stock-outs of contraceptives are serious, and mean leaving current users of contraceptives and condoms at risk of unintended pregnancies and/or STI infection. Stock-outs of essential RH medicines can be deadly. At the programmatic level, stock-outs seriously hinder the scaling up of reproductive health interventions and their sustainability. In 2015, data for 31 countries are available through the RHCS facility survey supported by UNFPA Supplies. Results for the indicator measuring no stock-out of contraceptives in the last three or six months are disaggregated as follows: • 10 countries had no stock-out of any modern method in at least 60 per cent of tertiary SDPs in 2015: Côte d’Ivoire, Democratic Republic of Congo, Gambia, Honduras, Nepal, Niger, Nigeria, Senegal, Sierra Leone and Togo; • 5 countries had no stock-out of any modern contraceptive in at least 60 per cent of secondary SDPs in 2015: Burkina Faso, Burundi, Nepal, Niger and Senegal; • 6 countries had no stock-out of any modern method in at least 60 per cent of primary SDPs in 2015: Burundi, Burkina Faso, Nepal, Niger, Nigeria and Senegal. It should be noted that nine countries with data from 2014 survey did not conduct the survey in 2015 and eight new countries conducted the survey in 2015, both of note when assessing progress. The stock-out situation improved in 11 countries in 2015 compared with the previous year, according to the 2014 and 2015 data on stock-outs available for 23 countries: Benin, Central African Republic, Chad, Congo, Côte d’Ivoire Haiti, Honduras, Myanmar, Nepal, Senegal and Togo. Stock-out levels slightly decreased by less than 5 percentage points in Zambia, Rwanda, Mozambique and Lao PDR. Decreases over 5 percentage points were registered in Burkina Faso, Ethiopia, Gambia, Lesotho, Niger, Nigeria, Sudan and Uganda. In many countries stock-outs in rural areas are improving and achieving levels similar to urban facilities – such as in Burundi, Burkina Faso and Rwanda. They are even outperforming urban areas, such as in Nigeria, Senegal or Togo. In other countries the gap in rural areas is still very marked (Honduras, Gambia, Bolivia, Papua New Guinea, Mauritania). 52 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME Figure 19: No stock-outs of contraceptives in the last three/six months by type of SDP, 2015 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Benin Bolivia Burkina Faso Burundi Central African Republic Chad** Congo** Côte d'Ivoire** DR Congo Ethiopia** Gambia** Haiti** Honduras Lao PDR** Lesotho** Liberia Mauritania Mozambique** Myanmar Nepal Niger** Nigeria** Papua New Guinea Rwanda** Senegal Sierra Leone** Sudan Timor-Leste Togo Uganda** Zambia % SDPs Tertiary Secondary Primary 53 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME Figure 20: No stock-outs of contraceptives in the last three/six months by urban/rural location, 2015 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Benin Bolivia Burkina Faso Burundi Central African Republic Chad** Congo** Côte d'Ivoire** DR Congo Ethiopia** Gambia** Haiti** Honduras Kenya** Lao PDR** Lesotho** Liberia Mauritania Mozambique** Myanmar Niger** Nigeria** Papua New Guinea Rwanda** Senegal Sierra Leone** Sudan Timor-Leste Togo Uganda** Zambia % SDPs Rural Urban 54 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME WHY DID SOME FACILITIES EXPERIENCE STOCK-OUTS? As in the past, stock-outs of contraceptives occurred for various reasons that need to be addressed in a comprehensive way. Some factors are beyond the influence of UNFPA Supplies, of course, such as a flood destroying a roadway or the decision of a country to launch a major family planning campaigning that creates an unexpected jump in demand. Three main causes of stock-out cut across almost all programme countries: Delays in the supply chain system (for reordering or re-supplying) have caused stock-outs in many countries. In Kenya, for example, the majority of public facilities, which mainly get their supplies from the central medical stores, have to wait over one month before receiving their orders. In Sierra Leone, it was identified the need of building service providers capacity in quantification in order to avoid delays in reordering supplies and, at the same time, increase availability of ICT systems in facilities to enhance proper monitoring and reporting of stock levels and consumption. Low or no demand for certain family planning methods for various reasons has caused persistent stock- outs, because no orders are placed and no stocks are maintained. In many countries high stock-out rates for female condoms were registered due to low demand. In Rwanda, the female condom was missing in over 30 per cent of facilities mainly due to no client demand of this method. Analysis conducted excluding this method revealed that all other products were available in 82.4 per cent of health facilities three months prior to the survey, and in 85.9 per cent of health facilities on the day of the survey. Lack of skilled personnel, especially to deliver IUDs and implants, is another frequently cited cause. 55 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME Scorecard for Goal and Outcome, UNFPA Supplies 2015 Goal: Contribute to universal access to reproductive health Results and indicators 2013 baseline 2014 target 2014 actual 2015 target 2015 actual Scorecard 1 Maternal mortality ratio (per 100,000 live births) 491 469 New data 447 475 not available 2 HIV prevalence rate (including disaggregated data on youth HIV prevalence rate) 310 2.97 New data not available 2.85 3.08 3 Adolescent birth rate 113.9 110.9 New data 108 111.6 not available 56 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME Outcome: Increased availability and utilization of RH commodities in support of reproductive and sexual health services including family planning, especially for poor and marginalized women and girls. Use 1 Unmet need for family planning 24.6 24.3 23.6 24.6 2 Contraceptive prevalence rate (CPR) for modern methods (disaggregated by quintile, urban–rural, education) 20.2 21.7 23.2 26.6 3 Demand for modern contraception satisfied (disaggregated by quintile, urban–rural, education) 45.1 47.1 49.6 51.9 4 Method mix score (including disaggregated data for prevalence of long-term and short-term methods) 8.8 9.0 9.1 6.9 5 Additional women with modern methods of contraception reported through FP2020 Reference Group8 8.4 million (for 69 FP2020 countries) 3.2 million (for 46 UNFPA Supplies countries) 21.2 34.5 24.4 million (for 69 FP2020 countries) 10.1 million (for 46 UNFPA Supplies countries) Availability of reproductive health commodities 6.1 Number of countries with 85 per cent of tertiary and secondary level service delivery points (SDPs) offering at least five modern methods of contraception 11/46 17/46 11/46 19/46 16/46 8 From FP2020 Annual reports 57 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME 6.2 Number of countries with 85 per cent of primary level service delivery points offering at least three methods in 2013 and increasing to five modern methods in 2016 and beyond 7/46 15/46 22/46 19/46 20/46 6.3 Number of countries with seven life-saving maternal/RH medicines from the WHO list9 available in all facilities providing delivery services (this must include magnesium sulfate and either misoprostol or oxytocin or both) (disaggregated for urban–rural and type of SDPs) 0/46 8/46 0/46 10/46 0/46 7 Number of countries with 60 per cent of SDPs with no stock-out of contraceptives in the last six months (disaggregated for urban–rural and type of SDPs) 8/46 11/46 8/46 14/46 7/46 Country engagement within FP2020 partnership 8 Percentage of UNFPA Supplies supported countries that have met their FP2020 commitments 010 ― ― Not applicable Not applicable 9 According to the WHO Priority life-saving medicines, for women and children, 2012; the priority medicines are: i) Oxytocin, ii) Misoprostol, iii) Sodium chloride, iv) Sodium lactate compound solution, v) Magnesium sulphate, vi) Calcium gluconate, vii) Hydralazine, viii) Methyldopa, ix) Ampicillin, x) Gentamicin, xi) Metronidazole, xii) Mifepristone, xiii) Azithromycin, xiv) Cefixime, xv) Benzathine Benzylpenicillin, xvi) Nifedipine, xvii) Dexamethasone, xviii) Betamethasone, and ixx) Tetanus toxoid. For further information please see to the updated list at http://www.who.int/reproductivehealth/publications/general/emp_mar2012.1/en/index.html 10 UNFPA will continue to work with partners to establish consensus for the measurement of this indicator. It has been difficult to translate political commitment statements into measurable statements in most countries which makes this indicator difficult to measure 58 | UNFPA SUPPLIES Annual Report 2015 http://www.who.int/reproductivehealth/publications/general/emp_mar2012.1/en/index.html GOAL & OUTCOME About the scorecard Goal: Contribute to universal access to reproductive health Progressing well Results in 2015 shows that impact level results continued to improve. However, there is need to accelerate progress towards universal access to reproductive health as a central strategy for achieving the Sustainable Development Goals. UNFPA Supplies continued to be a major contributor to reaching the FP2020 goals. Africa (with 37 out of the 46 UNFPA Supplies implementing countries) has contributed about 40 per cent of the total additional users; even though the continent contains less than 30 per cent of the number of women of reproductive age. Results and indicators Summary methodology Comments 1 Maternal mortality ratio (per 100,000 live births) In 2014, global partners published new estimates for the maternal mortality ratio (see Trends in Maternal Mortality: 1990 to 2013 Report). Based on the 2013 estimates, average MMR for the 46 UNFPA Supplies implementing countries is estimated as 491 maternal deaths per 100,000 live births. Also, the average rate of change in these 46 countries for the period 1990 to 2013 was –3.4 per cent. A rate of change in MMR of –4.5 is assumed for the period 2013 to 2020. Thus MMR is assumed to decline from 491 in 2013 to 425 in 2016, 381 in 2018 and 336 in 2020. Progressing well towards target MMR is decreasing but at a slower pace than previous decade 2 HIV prevalence rate HIV prevalence rates obtained from The World Bank Progressing well towards target (including disaggregated data on youth HIV prevalence rate) (http://data.worldbank.org/indicator/SH.DYN.AIDS.ZS) give an estimated average of 3.1 per cent for the 46 UNFPA Supplies implementing countries, which has been used as the Total HIV prevalence is decreasing but at a slower pace than previous decade 2013 baseline. The average rate of change in these 46 countries for the period 2010 to 2013 was –2.02 per cent. A rate of change in the HIV prevalence rate of –4.04 per cent is assumed for the period 2013 to 2020. Thus the average HIV prevalence rate for the 46 countries is assumed to decline from 3.1 in 2013 to 2.8 per cent in 2015 and 2.2 per cent in 2020. 3 Adolescent birth rate Based on data from UNFPA State of World Population Report, the average ABR per 1,000 women aged 15 to 19 for the 46 countries is calculated as 113.9 per 1,000 women aged Progressing well towards target 59 | UNFPA SUPPLIES Annual Report 2015 http://apps.who.int/iris/bitstream/10665/112682/2/9789241507226_eng.pdf?ua=1 http://apps.who.int/iris/bitstream/10665/112682/2/9789241507226_eng.pdf?ua=1 http://data.worldbank.org/indicator/SH.DYN.AIDS.ZS GOAL & OUTCOME 15 to 19 in 2013 and 110.9 in 2014 (www.unfpa.org/sites/default/files/pub-pdf/EN-SWOP14­ Report_FINAL-web.pdf, pages 104 to 108 and www.unfpa.org/sites/default/files/pub-pdf/EN-SWOP2013­ final.pdf, pages 100 to 105). The observed percentage rate of ABR decline of 0.52% is assumed to hold from 2014 to 2020. Thus the average ABR for the 46 countries is assumed to decline from 113.9 per 1,000 women aged 15 to 19 in 2013 to 108 in 2015 and 94.6 in 2020. The adolescent birth rate is decreasing but at a slower pace than previous decade Outcome: Increased availability and utilization of RH commodities in support of reproductive and sexual health services including family planning, especially for poor and marginalized women and girls. Some progress is being made but challenges need to be addressed While much progress has been made to increase contraceptive use and expand on method mix, challenges still exist in making a range of methods available and averting stock-outs, especially at the level of primary service delivery points. Use 1 Unmet need for family planning Average unmet need for family planning for the 46 UNFPA Supplies countries based on World Contraceptive Use 2011 data is calculated as 25.1 per cent for 2011 (www.un.org/esa/population/publications/contraceptive2011/ contraceptive2011.htm). This is assumed to decrease at a rate of 1 per cent up to 2015; 2 per cent from 2016 to 2018; and 3 per cent for 2019 and beyond. Based on this, the unmet need for family planning is estimated to decrease from 20.6 per cent in 2013 to 23.6 per cent in 2015 and 18.0 per cent in 2020. Progressing well towards target On average, unmet need for family planning in the 46 countries has remained unchanged even as mCPR has increased during the same period. 2 Contraceptive prevalence rate (CPR) for modern methods (disaggregated by quintile, urban–rural, education) Average CPR for modern methods for the 46 UNFPA Supplies countries based on the World Contraceptive Use 2011 data is calculated as 17.2 per cent for 2011 (www.un.org/esa/population/publications/contraceptive2011/ contraceptive2011.htm).This is assumed to increase at a rate of 1.5 per cent per annum up to 2017 and at an accelerated rate of 2 percentage points per annum beyond 2017. Based Achieved The contraceptive prevalence rate has increased in the 46 countries UNFPA Supplies implementing countries. 60 | UNFPA SUPPLIES Annual Report 2015 http://www.un.org/esa/population/publications/contraceptive2011/contraceptive2011.htm http://www.un.org/esa/population/publications/contraceptive2011/contraceptive2011.htm GOAL & OUTCOME on this, CPR is estimated to increase from 20.2 per cent in 2013 to 23.2 per cent in 2015 and 31.7 per cent in 2020. 3 Demand for modern contraception satisfied (disaggregated by quintile, urban–rural, education) The demand satisfied calculated from the above two estimated values as: % Demand satisfied = [CPR ÷ (CPR + Unmet need)] × 100 Achieved Demand satisfied has increased more than 6 percentage points compared with the baseline. 4 Method mix score (including disaggregated data for prevalence of long-term and short-term methods) Method mix score for the 46 UNFPA Supplies countries based on the World Contraceptive Use 2011 data (www.un.org/esa/population/publications/contraceptive2011/ contraceptive2011.htm). This is estimated by computing the difference in prevalence between the most prevalent modern method in a implementing countries and the third-most prevalent method; and further dividing the result by the total CPR for modern methods (on a scale of 10 a higher value signifies high concentration on fewer methods) Achieved: Method mix is improving The three most used methods accounted for 76.8 per cent of mCPR in 2015, which was a decrease from 81.1 per cent of mCPR in 2013. Compared with 2013, the prevalence of sterilization (male and female) in 2015 decreased from 7.2 per cent to 2.6 per cent. Also, the prevalence of long-acting reversible methods (implants and IUDs) increased from1.9 per cent in 2013 to 3.4 per cent in 2015. The prevalence of implants increased from 0.8 per cent in 2013 to 2.1 per cent in 2015. 5 Additional women with modern methods of contraception reported through FP2020 Reference Group11 This refers to the number of additional users of modern methods of contraception reached during the year. It is derived from FP 2020 Annual Reports and calculated by subtracting the estimated number of women and girls using modern contraceptive methods in the previous year from the estimated number using modern contraceptive in the current year (see for example http://progress.familyplanning2020.org/family-planning­ progress-highlights-2013-2014, pages 101 to 108). Making limited progress Though progress is described as limited, the number of additional users of contraception is significantly higher than the historical trend would predict. UNFPA Supplies is a major contributor to reaching the FP2020 goals. For instance Africa (with 37 out of the 46 UNFPA Supplies implementing countries) contributes about 40 per cent of the total additional users yet the continent contains less than 30 per cent of the number of women of reproductive age. 11 From FP2020 Annual reports 61 | UNFPA SUPPLIES Annual Report 2015 http://progress.familyplanning2020.org/family-planning-progress-highlights-2013-2014 http://progress.familyplanning2020.org/family-planning-progress-highlights-2013-2014 GOAL & OUTCOME Availability of reproductive health commodities 6.1 Number of countries with Data for this indicator are derived from facility surveys Progressing well towards targets 85 per cent of tertiary and secondary level service delivery points (SDPs) offering at least five modern methods of supported by UNFPA Supplies in the programme implementing countries. There is significant progress in this indicator for most countries where data for several years is available: 19 out of 23 countries with data for 2014 and 2015 experienced increased availability of modern contraception. contraception High-performing countries that achieved this indicator in previous years, such as Djibouti, Guinea, Mali and Malawi, did not conduct the survey in 2015 and are therefore not included. If the survey would have been conducted in these countries in 2015, it could have influenced more positively the result for this indicator. Most cited reasons for not offering a full basket of contraceptives relate to low demand of certain methods (namely female condom and emergency contraception) and lack of trained staff for the provision of implants and IUDs. Issues with the supply chain such as delays from the main warehouse are also commonly mentioned for all methods 6.2 Number of countries with UNFPA Supplies country surveys of SDPs Achieved 85 per cent of primary level service delivery points offering at least three methods in 2013 and increasing to five modern methods in 2016 and beyond Availability is increasing in most programme countries with data available for several years: 14 out of 23 countries with data from previous years increased availability of modern methods at primary level SDPs. Countries such as Gambia, Mali, Mozambique, Senegal and Togo are already increasing the availability of at least 5 modern methods at primary SDPs in 2014 and/or 2015. High-performing countries that achieved this indicator in previous years, such as Gambia, Guinea-Bissau, Madagascar, Malawi, Mali, and Yemen did not conduct the survey in 2015. If the survey would have been conducted in these countries in 2015, it could have influenced more positively the result for this indicator. 62 | UNFPA SUPPLIES Annual Report 2015 GOAL & OUTCOME Most cited reasons for not offering a full basket of contraceptives relate to low demand of certain methods (namely female condom and emergency contraception) and lack of trained staff for the provision of implants and IUDs. Issues with the supply chain such as delays from the main warehouse are also commonly mentioned for all methods 6.3 Number of countries with UNFPA Supplies country surveys of SDPs Insufficient progress made seven life-saving maternal/RH medicines from the WHO list12 available in all facilities providing delivery services (this must include magnesium sulfate and either misoprostol or This indicator measures the availability of seven essential maternal/RH medicines. In order to achieve the indicator all essential medicines have to be available at 100% of SDPs at all levels. Since UNFPA Supplies started to measure this indicator, no country has been able to have all seven life-saving medicines (which must include magnesium sulfate and either misoprostol or oxytocin or both) in all SDPs. oxytocin or both) (disaggregated for urban– rural and type of SDPs) However, some countries did achieve full availability of essential maternal/RH medicines at certain levels: in 2015, 14 countries had the medicines available at 100% of tertiary SDPs, while only 5 had full availability at all secondary SDPs. It should be noted that 11 countries increased availability of essential maternal/RH medicines in 2015, compared with previous years. Most commonly cited reasons for not offering essential medicines relate to supply chain issues, such as delays from main warehouse and delayed requests from the SDPs. Lack of awareness on the use of the medicines and lack of trained staff to administer them are also cited in some countries. 12 According to the WHO Priority life-saving medicines, for women and children, 2012; the priority medicines are: i) Oxytocin, ii) Misoprostol, iii) Sodium chloride, iv) Sodium lactate compound solution, v) Magnesium sulphate, vi) Calcium gluconate, vii) Hydralazine, viii) Methyldopa, ix) Ampicillin, x) Gentamicin, xi) Metronidazole, xii) Mifepristone, xiii) Azithromycin, xiv) Cefixime, xv) Benzathine Benzylpenicillin, xvi) Nifedipine, xvii) Dexamethasone, xviii) Betamethasone, and ixx) Tetanus toxoid. For further information please see to the updated list at http://www.who.int/reproductivehealth/publications/general/emp_mar2012.1/en/index.html 63 | UNFPA SUPPLIES Annual Report 2015 http://www.who.int/reproductivehealth/publications/general/emp_mar2012.1/en/index.html GOAL & OUTCOME 7 Number of countries with UNFPA Supplies country surveys of SDPs Insufficient progress made 60 per cent of SDPs with no stock-out of contraceptives in the last Reducing stock-outs remains a significant challenge for most programme countries. six months (disaggregated for urban–rural and type of SDPs) Total aggregates at the national level shows that only 7 countries achieved the indicator. However, stock-outs went down in many programme countries in 2015 compared with previous years, namely in: Togo, Timor-Leste, Senegal, Nepal, Myanmar, Mauritania, Côte d’Ivoire, Central African Republic and Benin. Stock-outs in rural areas are improving, and the urban–rural gap is also being reduced in many programme countries, notably: Burkina Faso, Burundi, CAR, Côte d’Ivoire, Kenya, Myanmar, Niger, Nigeria, Rwanda and Senegal, among others. Among the main reasons given by SDPs for the stock-outs, the most cited relate to issues in the supply chain (90 per cent of SDPs providing information mentioned issues with the supply chain, and especially delays from main warehouses to deliver the products), followed by lack of demand from clients (70 per cent of SDPs). Lack of trained staff was also mentioned by 55 per cent of SDPs to explain stock-outs of LARCs. Country engagement within FP2020 partnership 8 Percentage of UNFPA Supplies supported countries that have met their FP2020 commitments FP2020 Reference Group and Country Engagement Working Group This indicator has not been measured over the years, because of the inherent difficulty of measuring the various types of commitments made by countries. 64 | UNFPA SUPPLIES Annual Report 2015 OUTPUT 1 | ENABLING ENVIRONMENT Output 1: Improved enabling environment for reproductive health commodity security With transformational benefits, voluntary family planning can accelerate achievement across the Sustainable Development Goals. UNFPA Supplies is helping countries meet the objectives of Family Planning 2020 and the International Conference on Population and Development, providing contraceptives and building capacity for services and policies that give individuals the ability to prevent or delay a pregnancy. UNFPA works with partners to ‘mainstream’ family planning and RHCS in development agendas. This strategic focus includes strengthening coordination mechanisms at all levels. At country level, creating a positive programming environment includes a range of activities: • updating policies, strategies and plans; • adapting guidelines, protocols and tools (including those related to rights-based and total market approaches and environmentally sound disposal of supplies); • engaging in advocacy for increased resource allocation especially by governments; and • strengthening processes for making quality products available at country level. 1.1 SUPPORT FOR POLICIES AND STRATEGIES Programme Monitoring Framework: Support for policies and strategies is measured by the programme through several indicators, all contributing to an enabled environment. Number of countries with policies in place that take into consideration rights- based and total market approaches to family planning A country is judged to have achieved the indicator if there is/are policy or policies that; a) contains both elements (right based approaches to family planning; and b) total market approaches); b) has/have been finalized; and, c) is/are being implemented. (All the three conditions must be satisfied). Milestones to build on baseline and reach a target of 46 countries in 2018 and maintain progress until 2020 65 | UNFPA SUPPLIES Annual Report 2015 OUTPUT 1 | ENABLING ENVIRONMENT Number of countries A country is judged to have achieved the indicator if it is reported a) to have a 3 to 5 where a 3-5 year medium- years medium-term costed plan for family planning; b) that the plan contains both term plan for family elements (right based approaches to family planning; and total market approaches); planning, with rights-based c) and that these plan has been finalized, approved and is being implemented. (All and total market the three conditions must be satisfied.) Milestones to build on baseline and reach a approaches, is being target of 46 countries in 2019 and maintain progress in 2020 implemented Number of countries with A country is judged to have achieved the indicator if it is reported a) to have policies family planning policies in in place that takes into consideration young people’s access to contraceptive place that take into services; and b) that these policies have been finalized, approved and is being consideration young implemented. (Both the conditions must be satisfied). Milestones to build on people’s access to baseline and reach a target of 46 countries in 2019 and maintain progress in 2020 contraceptive services Number of countries with A country is judged to have achieved the indicator if it is reported to have a) a 3 to 5 a 3-5 year medium-term years medium-term costed plan for FP; b) that takes into consideration young costed plan for family people’s access to contraceptive services; and, c) that action plan has been finalized, planning that takes into approved and is being implemented. (All the three conditions must be satisfied.) consideration young Milestones to build on baseline and reach a target of 46 countries in 2017 and people’s access to maintain progress until 2020 contraceptive services Number of countries with A country is judged to have achieved the indicator if it is reported to have available national SRH and RR national SRH and RR guidelines and protocols which include a) right based approach guidelines and protocols to RHCS and family planning issues; and, b) that the guidelines and protocols have which include a rights- been finalized, approved and are being implemented. (Both the three conditions based approach to RHCS must be satisfied). Milestone to build on baseline and reach a target of 46 countries and family planning issues in 2015 and maintain progress until 2020 UNFPA Supplies directed support to all 46 countries to strengthen the policy enabling environment and ensure the availability of tools and guidelines in support of rights-based and total market approaches to FP and with special focus on young people: • 35 countries had policies that that take into consideration rights-based and total market approaches to family planning, compared with 28 in 2014; • 33 countries had three- to five-year medium-term plans for family planning, with rights-based and total market approaches, being implemented in 2015, compared with 24 in 2014; • 41 countries had policies that take into consideration young people’s access to contraceptive services, compared with 36 in 2014; • 37 countries had a three- to five- year medium-term costed plan for FP that takes into consideration young people’s access to contraceptive services, an increase from 25 in 2014; • 43 countries had available national SRH and RR guidelines and protocols which include a rights-based approach to RHCS and family planning issues, up from 40 countries in 2014. 66 | UNFPA SUPPLIES Annual Report 2015 OUTPUT 1 | ENABLING ENVIRONMENT Figure 1.1: Existence of policies in place, plans and guidelines, 2013 to 2015 50 30 40 35 33 33 36 41 37 39 40 43 20 26 28 25 24 24 25 10 0 Existence of policies in place Existence of a 3 to 5 years Existence of policies in place Existence of a 3 to 5 years Availability of national SRH and that take into consideration medium term plan for FP, with that take into consideration medium term costed plan for RR guidelines and protocols rights-based and total market rights based and total market young people’s access to FP that takes into which include right based approaches to family planning approaches, which is being contraceptive services consideration young people’s approach to RHCS and family implemented access to contraceptive planning issues services 2013 2014 2015 Figure 1.2: Trends in performance for key policy and strategy indicators, 2013 to 2015 20 25 30 35 40 45 2013 2014 2015 Existence of policies in place that take into consideration rights-based and total market approaches to family planning Existence of a 3 to 5 years medium term plan for FP, with rights based and total market approaches, which is being implemented Existence of policies in place that take into consideration young people’s access to contraceptive services Existence of a 3 to 5 years medium term costed plan for FP that takes into consideration young people’s access to contraceptive services Availability of national SRH and RR guidelines and protocols which include right based approach to RHCS and family planning issues 1.2 COUNTRY-LEVEL COORDINATION AND PARTNERSHIPS Countries carry out a wide variety of activities to improve the enabling environment for reproductive health and family planning. Everywhere, advocacy adds up to impact. These are a few of many examples. A number of specific indicators are used to track ‘country-level coordination and partnerships’ as part of an enabled environment. 67 | UNFPA SUPPLIES Annual Report 2015 OUTPUT 1 | ENABLING ENVIRONMENT 1.2.1 COORDINATION MECHANISMS Performance Monitoring Framework: The programme tracks the number of countries with a functional national RHCS coordination mechanism (with inclusive membership including private sector, and terms of reference, minutes of meetings, follow-up action points). The number of countries where a) RHCS coordination mechanism exists, which; b) is under the leadership of government; c) has membership drawn from donor agencies, UN agencies, Civil Society Organizations, Private Sector, NGOs and other stakeholders; d) met at least two times during the year to address specific issues; e) has an annual action plan (workplan) which sets out what is to be done for each year; and, f) has report(s) including minutes of meetings available on its activities (All of conditions (b) to (f) must be present for the mechanism to be considered as functional). Milestones to build on baseline and reach a target of 46 countries in 2018 and maintain progress until 2020. Working with partners, UNFPA, through the UNFPA Supplies, assisted governments to scale up their commitments to reproductive health commodities and family planning. The interventions include making national coordination mechanism functional; promote the use of evidence from RHCS/FP situation analysis for programming; improving in-country processes to ensure RH commodities are available and most importantly allocating government resources for procurement of reproductive health commodities. In 2015, 44 countries reported the existence of an RHCS coordinating committee – the same number as in 2014. For a committee to be considered “functional”, they need to be under the leadership of government; to have memberships drawn from donor agencies, UN agencies, civil society organizations, private sector, NGOs and other stakeholders; to have least twice during the year; and to have had an annual action plan (workplan) that set out what was to be done during the year, with reports or minutes of meetings available. Of the 44 countries, 29 countries had committees that met all these criteria, with the remainder meeting some but not all (for example, only one meeting was held during the year). 1.2.2 SITUATION ANALYSIS Performance Monitoring Framework: The programme tracks the number of countries where RHCS situation analysis and stakeholder mapping is conducted and results used for planning and programming. The number of countries where a) studies on RHCS situation analysis and stakeholder mapping have a) been conducted; b) the report has been finalized; and c) the recommendations of the studies are being implemented in planning and programming. (All the three conditions must be satisfied). Milestones to build on baseline and reach a target of 46 countries in 2019 and maintain progress until 2020. 68 | UNFPA SUPPLIES Annual Report 2015 OUTPUT 1 | ENABLING ENVIRONMENT • 40 countries were engaged in RHCS situation analysis and stakeholder mapping in 2015, an increase of eight countries; • 38 countries finalized the situation and stakeholder mapping process, reported results and applied the finding to inform programming in 2015, an increase of 12 countries; • 16 countries spent at least 80 per cent of the resources allocated in national budgets for the procurement of reproductive health in 2015, up from 13 in 2014 – showing growing national commitment by UNFPA Supplies countries. Figure 1.3: National commitment and coordination 32 14 28 15 37 26 27 13 39 38 39 16 Existence of a functional national RHCS co-ordination mechanism (with inclusive membership - (including private sector, terms of reference, minutes of meetings, follow-up action points) Availability of report on RHCS situation analysis and stakeholder mapping and evidence of the results used for planning and programming Country Essential Medicines List contains all RH commodities (modern contraceptives and life-saving maternal/RH medicines) Amount (in $) allocated in the national budget for reproductive health commodities and amount expended (in $) during the year 2013 2014 2015 1.2.3 INTEGRATING RHCS IN INSTITUTIONS Performance Monitoring Framework: The programme tracks the number of national institutions supported to integrate RHCS issues in training curricular including for procurement. Methodology summary: The number of training institutions at national level, with which UNFPA Country Offices collaborate or support, a) that have RHCS and FP issues include in various course curricula; b) the curricula has been approved and is being used for training as part of the institutions approved course structure; and c) that people were trained using this curricula for the reporting year. (All the three conditions must be satisfied). Milestones to build on baseline (on the average 10 per year) and reach a target of 85 institutions in 2019 and maintain progress until 2020. 69 | UNFPA SUPPLIES Annual Report 2015 OUTPUT 1 | ENABLING ENVIRONMENT When training in RHCS and family planning is integrated into national institutions, it contributes to a more positive environment for sustainable progress. In 2015, UNFPA Supplies supported various elements of RHCS/FP training in 32 institutions in 24 countries compared with 27 institutions in 22 countries in 2014. 1.2.4 PERSONS TRAINED IN RHCS ISSUES Performance Monitoring Framework: The programme tracks the number of persons trained in RHCS issues by type of training topic. Methodology summary: This is an aggregate of the number of persons trained for the various training activities supported in all the countries for the year. Milestones to build on baseline and train an average of 10,000 per year in 2014 and maintain progress until 2020. Training programmes addressed various aspects of family planning and RHCS: • 3,300 persons received training in 2015; • In 2015, Niger, Nigeria and Zimbabwe had a particular focus on RHCS training. The areas of training included a broad range of RHCS topics, including contraceptive technology in the National Public Health Institute if Burundi; contraceptive technology and LMIS in the School of Nursing and Midwifery and State Enrolled Nurses in Gambia; and, procurement training in the University of Health Sciences in Lao PDR and the Myanmar University of Public Health where procurement will be added to the curriculum for the Master of Public Health course and the Master of Hospital Administration course. In Chad a competency-based training was conducted for four regional schools and the National School of Midwifery training which included essentials in contraceptive technology including product management. Procurement, Ethics and Quality Assurance training was carried out in collaboration with Autorité de Régulation des Marchés Publics (ARMP) and the University of Kinshasa, Faculty of Pharmaceutical Sciences in Democratic Republic of Congo and Institute of Advanced Management & Technology (IAMTECH) in Sierra Leone. A webinar sharing lessons learned in the development of logistics management information systems in the Latin America and Caribbean Region was conducted. This webinar was used by UNFPA in Guatemala to involve national authorities in understanding the needs and functions of LMIS. Four online courses were implemented in Spanish in the Latin America and Caribbean Region: (1) Introduction to Reproductive Health Commodity Security; (2) Forecasting for Commodity Supply in Reproductive Health; (3) Technical Specifications for Commodity Supply in RH; and (4) Procurement Modalities for Commodity Supply in RH. In addition, the UNFPA online course on Quality of Medicines 70 | UNFPA SUPPLIES Annual Report 2015 OUTPUT 1 | ENABLING ENVIRONMENT was revised and translated into Spanish. A total of 280 participants were registered into courses, 260 of them have used these material in their regular activities and 87 have been certified. Health Professionals from Colombia (25 participants trained), El Salvador (20 participants trained), Cuba (25 participants trained) and Paraguay (2 participants trained) received a 32-hour training for implementing quality of care protocols that meets UNFPA evidence-based standards for rights-based family planning services, information and outreach focused on adolescent contraception. This training was reinforced through three workshops on contraception replicated in Colombia, El Salvador and Cuba. Capacity-building activities were carried out with: • ARMP, CEFOREP and IAMTECH in West Africa; • PRISMA and Reprolatina in Latin America; • Indian Institute of Health Management and Research in South-East Asia. 1.2.5 COORDINATED ASSISTANCE FOR REPRODUCTIVE HEALTH SUPPLIES Performance Monitoring Framework: To measure ‘country-level coordination and partnership’, the framework monitors the number of countries supported by CARhs to resolve problems and avert stock-out or overstock situations. Methodology summary: The number of UNFPA Supplies implementing countries for which the Coordinated Assistance for Reproductive Health Supplies (CARhs) group of key global-level partners including UNFPA (who fund and procure of contraceptives and condoms) a) shared information, b) identified issues relating supply shortages; and, c) collaborated to avert stock-outs. (All the three conditions must be satisfied). Milestones to build on baseline and reach a target of 35 countries in 2015 and maintain progress until 2020. UNFPA, through UNFPA Supplies, continues to work with global and in-country partners within the Coordinated Assistance for Reproductive Health Supplies (CARhs) group to take proactive actions for averting stock-out of RH commodities. On a regular basis, the group share information on contraceptive stock levels and shipments for various countries. In 2015, the number of issues addressed by CARhs relating to the UNFPA Supplies implementing countries was 322 issues (for 15 countries). This was a reduction compared with 347 issues (for 20 countries) in 2014. Much of the CARhs work involves providing valuable information to the MoH and our partner agencies operating in the countries we support. This information typically includes expected arrival dates and quantities of RH commodities. Examples of tangible accomplishments made in 2015 include: • An emergency shipment to Ethiopia of implants was created; • A scheduled shipment of implants to Ghana was postponed to avoid over-stocking in the already crowded central warehouse; 71 | UNFPA SUPPLIES Annual Report 2015 OUTPUT 1 | ENABLING ENVIRONMENT • Emergency shipments to Liberia of condoms and injectables were created to respond to shortages of both items. The Procurement Planning and Monitoring Report (PPMR), operated by CARhs, continue to be a very useful platform for sharing information on stock status of contraceptive products. 1.3 PRODUCT AVAILABILITY Programme Monitoring Framework Number of countries with all RH commodities (modern contraceptives and life-saving maternal/RH medicines) in-country EML This is the number of countries where the Essential Medicines List (EML) contains a) All contraceptives and b) all maternal health medicines. (Both conditions must be satisfied). Milestones to build on baseline and reach target of 46 countries in 2018 and maintain progress until 2020 Percentage of countries where WHO­ prequalified/ERP approved RH commodities (modern contraceptives and life-saving maternal/RH medicines) are registered This is the percentage of UNFPA Supplies implementing countries assessed by PSB where action was taken to register any RH commodity. Milestones to build on baseline and reach target of 100 per cent 2019 and maintain progress until 2020 Another factor in measuring a country’s ‘enabling environment’ is the inclusion of RH commodities, especially modern contraceptives and life-saving maternal health medicines, on the national Essential Medicines List (EML). The Essential Medicines List in 39 countries contained all RH commodities (modern contraceptives and life-saving maternal/RH medicines), an increase of 12 countries compared with 2014. 72 | UNFPA SUPPLIES Annual Report 2015 OUTPUT 1 | ENABLING ENVIRONMENT Figure 1.4: Number of countries where the national Essential Medicines List (EML) contains all RH commodities (modern contraceptives and life-saving maternal/RH medicines) 0 5 10 15 20 25 30 35 40 2013 2014 2015 28 27 39 Prequalification also contributes to product availability. In 2015, through UNFPA’s collaborative work with the WHO prequalification team, hormonal contraceptives were registered in three countries namely Kenya (combined oral contraceptives), Malawi (emergency contraceptives) and Tanzania (combined oral contraceptives, and emergency contraceptives). The specific WHO-prequalified RH contraceptives registered were ethinylestradiol + levonorgestrel + ferrous fumarate tablets 30/150 µg + 75 mg tablet in Kenya and Tanzania; levonorgestrel tablets 0.75 mg in Malawi; and levonorgestrel tablets 1.5 mg and levonorgestrel tablets 750 µg in Tanzania 2015. 1.4 NATIONAL BUDGET ALLOCATION FOR RH SUPPLIES Programme Monitoring Framework Number of countries, sustaining over time, increased national budget allocation for reproductive health commodities and the resources expended as planned The number of UNFPA Supplies implementing countries that have a) allocated national budget for either contraceptives or maternal health medicines or both; and, b) the allocation is sustained (that is it has not decreased compared to previous years); c) and a minimum of 80 per cent of the amount allocated for the year has been expended. (Both conditions must be satisfied). Milestones to build on baseline and reach target of 46 countries in 2019 and maintain progress until 2020 73 | UNFPA SUPPLIES Annual Report 2015 OUTPUT 1 | ENABLING ENVIRONMENT Working with partners, UNFPA advocates to governments for the allocation and use of their resources for the procurement of RH commodities. Such allocations and expenditures are tracked as one of the key measures of government commitment to ensuring commodity security. • 35 countries made allocations for the procurement of RH commodities (contraceptives and maternal health medicines) in 2015 up from 30 in 2014; • of these 35 countries that made budget allocations for the procurement of RH commodities, 26 countries made allocations equal or greater than for the previous year; • 18 countries spent at least 80 per cent of the current year's allocations for the procurement of RH commodities; • With respect to contraceptives, 27 countries had budget lines with allocations for the procurement of contraceptives in 2015; • of these 27 countries, 15 countries made allocations equal or greater than the previous year; • 13 countries spent at least 80 per cent of the allocated amount in their budget lines for procurement of contraceptives as planned compared with 10 countries in 2014. Figure 1.5: Total amount allocated and amount expended (in $) in national budgets of UNFPA Supplies implementing countries for procurement of RH commodities, 2013 to 2015 0 10 20 30 40 50 60 70 80 90 100 2013 2014 2015 A m ou nt (i n U S$ ) U S $ M ill io n Year Total amount allocated Total amount expended A total of $92.8 million was allocated in national budgets in 2015 for the procurement of RH commodities (both contraceptives and maternal health medicines), up from $74.1 million in 2014. Total expenditures, however decreased slightly from $63.2 million in 2014 to 62.9 million in 2015. A major 74 | UNFPA SUPPLIES Annual Report 2015 OUTPUT 1 | ENABLING ENVIRONMENT drop in expenditure was a decrease of over $5.5 million in expenditure on contraceptive in 2015 by Uganda. In previous years, a World Bank project has been supporting domestic contraceptive financing, but this has now has ended. However, in 2016 the Government is expected to increase spending to $1.2 million from approximately $560,000 in 2015. Detailed historical data on national budget allocations and expenditure in RH commodities from 2013 to 2015 are available in the annex. Figure 1.6: Total amount allocated and amount expended (in $) in national budgets of UNFPA Supplies implementing countries for procurement of CONTRACEPTIVES, 2013 to 2015 0 5 10 15 20 25 30 35 40 45 50 2013 2014 2015 A m ou nt in U S$ M ill io ns Total allocations for Contraceptives Year total expended for contraceptives Total allocations for procurement of contraceptives remained stable at $44.4 million in 2015 (compared to $44.5 million in 2014). Expenditures decreased significantly from $32.0 million in 2014 to $24.4 million in 2015. Procurement of life-saving maternal health medicines Total allocations for maternal health medicines increased markedly from $28.7 million in 2014 to $48.4 million in 2015. At the same time, the amount expended also increased from $28.4 million in 2014 to $38.4 million in 2015. 75 | UNFPA SUPPLIES Annual Report 2015 OUTPUT 1 | ENABLING ENVIRONMENT Figure 1.7: Total amount allocated and amount expended (in $) in national budgets of UNFPA Supplies implementing countries for procurement of MH MEDICINES, 2013 to 2015 0 10 20 30 40 50 60 2013 2014 2015 A m ou nt (U S$ ) M ill io ns Year Total allocations for MH Medicines total expended for MH Mediciness 1.5 ENVIRONMENTAL RISK MITIGATION Programme Monitoring Framework: Another set of indicators measuring ‘enabling environment’ pertain to environmental risk mitigation. The programme tracks the number of countries where the action has been taken to through meetings and workshops to disseminate the UNFPA Guidance Note on Disposal of MH Medicines to partners including government. It also tracks the number of countries where a) an assessment/study has been conducted to assess the national guidelines and protocols in line with the Guidance Note; and, b) recommendations of the study are available. And, thirdly, the programme tracks the cumulative total number of countries where a) actions the national guidelines and protocols have been updated in line with the study’s findings and recommendations. As a leading international agency working on reproductive health, UNFPA considers the management of the products throughout their life cycles as very important. As a result the agency issued in 2013 a guideline document for the management of waste from contraceptives or unusable contraceptives. The purpose of the guideline document was to provide guidance on the safe disposal of unusable contraceptives at the institutional level. It is intended to build awareness and capacity in managing of 76 | UNFPA SUPPLIES Annual Report 2015 OUTPUT 1 | ENABLING ENVIRONMENT 3 2 0 3 4 1 10 11 9 0 1 2 3 4 5 6 7 8 9 10 11 N um be r of c ou nt ri es contraceptive waste; and, guide countries in developing or updating country specific waste disposal policies and guidelines that include disposal of contraceptive wastes.13 Figure 1.8: Number of countries achieving key environmental risk mitigation interventions 12 UNFPA Guidance Note on Disposal of MH Availability of report on the assessment of Evidence of guidelines and protocols on disposal medicines is available and disseminated to country guidelines and protocols on disposal of of MH medicines being updated in line with partners including government MH medicines for benchmarking and contents of UNFPA Guidance Note programming Environmental risk mitigation intervention areas 2013 2014 2015 With the publication of the guidelines, UNFPA Country Offices are expected to take steps to raise awareness on the contents, purpose and relevance of the guidelines to ensure their implementation. • 10 countries took full action to disseminate the guidelines document to government and partners, up from 3 countries in 2014; • 11 countries used the UNFPA guideline document to assess national guidelines and protocols for benchmarking of actions where necessary in 2015; • 9 countries initiated actions for update of country guidelines and protocols on disposal of RH commodities, up from 1 country in 2014. 13 www.unfpa.org/sites/default/files/resource-pdf/Final%20Version%20­ %20Safe%20Disposal%20and%20Management%20of%20Unused%20Unwanted%20Contraceptives.pdf 77 | UNFPA SUPPLIES Annual Report 2015 www.unfpa.org/sites/default/files/resource-pdf/Final%20Version%20 OUTPUT 1 | ENABLING ENVIRONMENT 1.6 SUPPORT TO GLOBAL PARTNERSHIPS Programme Monitoring Framework: To measure progress towards an ‘enabling environment’, UNFPA Supplies looks at collaboration with NGOs for the scaling up of RHCS and family planning (e.g. Marie Stopes International and IPPF). The programme tracks the number of organizations, at the global level a) with which UNFPA, through the UNFPA Supplies, works to improving on RHCS and FP programming; and b) with which specific interventions were carried out for the reporting year. (Both conditions must be satisfied). Milestones to build on baseline and reach a target of 20 global institutions in 2016 and maintain progress until 2020. As part of the Steering Committee of the RMNCH Trust Fund and working with the UN Commission on Life-Saving Commodities for Women and Children, UNFPA continued to lead the work in the areas of female condoms, contraceptive implants, emergency contraceptive pills and the three maternal health commodities identified by the Commission (oxytocin, magnesium sulfate and misoprostol). UNFPA also co-leads with USAID on strengthening supply chain, a technical resource team that has put together various tools, forecasting guidance, good practices and indicators. The eight ‘pathfinder’ countries for the Commission saw increases in the budgets from the Fund, with many investing in RH commodities and supply chain management. An additional 11 countries submitted (or are in the process of finalizing) proposals for funding. UNFPA also contributed to the Commission’s communication strategy on visual identity, messaging and website. An inter-agency vision statement on supply chain management was issued by the Inter-agency Supply Chain working group (ISG), part of the RMCH Strategic Coordination Team. UNFPA led ISG work on last- mile distribution, informed push models, end-to-end visibility on supply chains, including pilots with bar-coding of health commodities. UNFPA and USAID have identified coordinated supply planning (CSP) as a way to use data to improve allocation of commodities and to foresee and address potential stock imbalances before they become emergency issues, creating a CSP group to improve supply chain coordination for family planning commodities. Close cooperation among the members of the CSP resulted in an additional procurement of commodities by USAID to cover expected shortfalls in funding for global contraceptive procurement. In October 2014, CSP began to pilot a joint USAID-–UNFPA supply planning tool to compare current shipment plans with the expected needs of recipient countries in 2015. Additional procurements of a long-acting reversible contraceptive by USAID freed up funds for UNFPA to purchase other commodities requested by countries for 2015. Shipments will support Chad, Gambia, Guinea, Liberia, Malawi, Rwanda, Sierra Leone, Tanzania, Timor-Leste and Zambia. Oral contraceptives will be donated to Niger. 78 | UNFPA SUPPLIES Annual Report 2015 OUTPUT 1 | ENABLING ENVIRONMENT UNFPA and USAID took an end-to-end approach (from manufacturer to end user) and improved and standardized data-collection on consumption, stock levels and shipments of various contraceptives. This improved visibility along the supply chains and identified countries with under- and overstocks. UNFPA continued to participate in the Implant Access Programme, a group of public and private organizations to make contraceptive implants available to women in the world’s poorest countries at price reductions of approximately 50 per cent through 2018. Proper insertion—subcutaneously in the upper arm—and removal of contraceptive implants requires trained health-care providers, and the Implant Access Programme members are collaborating with other organizations to train health workers, reduce supply chain disruptions, increase service delivery quality and availability, and raise awareness about implants at the community level. In 2013, 7.3 million implants were distributed in the world’s poorest countries—a 50 per cent increase from 2012. UNFPA is one for the four core conveners of the FP2020 global partnership. At the London Summit on Family Planning, leaders from around the world committed to expanding contraceptive access to an additional 120 million women and girls in the world’s 69 poorest countries by the year 2020. Family Planning 2020 (FP2020) is the movement that carries this global effort forward. Together with DFID, the United Kingdom’s Department for International Development, USAID and the Bill & Melinda Gates Foundation, UNFPA provides political guidance and support for scaling up and fulfilling country commitments to FP2020. Thirty-nine countries out of 69 FP2020 focus countries made commitments to FP2020. Commitment-making countries are increasing mCPR more than double compared with non-commitments makers. UNFPA has worked closely with governments to ensure that the country commitments are supported by national policies and strategies and have adequate funding. UNFPA directly supported development of a costed implementation plan on family planning in most countries. As of today there are 22 countries out of 39 commitment makers that have CIPs in place. In 2015, UNFPA supported the FP2020 Secretariat to go through the strategic review exercise taking into consideration the outcomes of the global FP2020 focal points meeting conducted in Istanbul earlier in the year. The strategic review crystallized modes of country support and identified tailored strategies to scale up progress in family planning across all 69 countries. Netherlands Interdisciplinary Demographic Institute (NIDI) partnered with UNFPA for a survey to collect data related to financial resource flows for family planning. The result was an analysis of family planning expenditures made by national governments, NGOs and the private sector. UNFPA is partnering with The World Bank to address resiliency and vulnerability of most at at-risk populations through a regional project, the Sahel Women’s Empowerment and Demographic Dividend (SWEDD) project. A similar endeavour is The World Bank Horn of Africa resilience project, to achieve 79 | UNFPA SUPPLIES Annual Report 2015 OUTPUT 1 | ENABLING ENVIRONMENT reduced fertility, improved human capital, empowerment of girls and women, and resiliency of the populations given the multiple threats (food insecurity, climate change, conflicts, internal security, migrations, etc.) SWEDD project development is on course. A high-level meeting was held as a side- event to the Sixty-ninth United Nations General Assembly, bringing together three heads of State of project countries, and partners including UNFPA, The World Bank and the Bill & Melinda Gates Foundation. UNFPA actively participated in working groups of the Global Financing Facility (GFF), aiming to ensure that family planning is on the list of priorities of the new mechanism. Where countries identify that they would like to address RH supplies through GFF they will be encouraged to procure through UNFPA Supplies, thus availing of comparative price advantages, short lead times and assured quality of products. UNFPA continued to analyse, model and redesign supply chains in African countries such as Senegal and Togo through a joint initiative with the Bill & Melinda Gates Foundation, McKinsey & Company and other partners. The collaboration aims to provide better end-to-end visibility on procurement and supply chains of contraceptives, in line with efforts to provide Visibility Analytics Networks (VAN) for RMNCAH commodities. UNFPA is part of the Sayana Press Consortium of partners that have supported introduction of an existing hormonal contraceptive, DMPA, in a new format – as a subcutaneous injectable in a compact, pre-filled, auto-disable injection device (cPAD) – in addition to other family planning methods as a way of broadening the choice of modern contraceptive methods offered to women. The partnership includes the Bill & Melinda Gates Foundation, Children’s Investment Fund Foundation (CIFF), DIFD, Pfizer Inc., PATH, UNFPA and USAID. In 2014, the consortium announced a reduced price for the product through a volume guarantee for the 69 FP2020 countries. Pilot phase projects were launched in 2014 in Burkina Faso, Niger and Uganda; since then, more than 2,000 providers have been trained. More governments have expressed interest in integrating the method in their national family planning programmes to support commitments made during the FP2020 Summit. It will be introduced in five more countries (Cameroon, Côte d’Ivoire, Djibouti, Madagascar and Mozambique) in 2015. UNFPA in partnership with International Planned Parenthood Federation has accelerated efforts in 16 countries to improve access to youth-friendly services providing contraception, and initiated global research on legal barriers to sexual and reproductive health and family planning among adolescents and young people, and initiated research to prepare technical guidance on programming for adolescents in urban settings. In Africa, the two organizations continued working with regional economic institutions to harmonize service delivery protocols. Over $6 million was provided to IPPF member associations by UNFPA Country Offices to support the implementation of community-based initiatives to improve access to services particularly for adolescents, along with funds provided through IPPF London to 80 | UNFPA SUPPLIES Annual Report 2015 OUTPUT 1 | ENABLING ENVIRONMENT support social marketing and behavioural change communication (BCC) programmes. A joint proposal with IPPF has been developed with the aim of increasing access to contraception among adolescents in the Caribbean and Latin America. UNFPA is in addition providing technical assistance to IPPF (through secondment of a technical expert to their London office) to improve supply chain management (SCM) though addressing short-term supply management issues, and defining mid and long-term strategic plans for supplies management, procurement and distribution systems, including the establishment of strategic partnerships. The two organizations are jointly providing support to African Forum on Population and Development (FPA). UNFPA and Planned Parenthood Federation of America (PPFA) collaborated on a project called ‘Global Mobile’ to increase access to sexual and reproductive health information that is accurate, culturally sensitive, context specific, and appropriate. It uses mobile phone technology and links to high-quality services for youth in Ecuador and Nigeria. If the Global Mobile model works in two cultures, serving two distinct populations, in concert with different sets of partners, then this model as a proof of concept that could be introduced and scaled up in Africa and Latin America. Marie Stopes International (MSI) is an implementing partner in many countries, relied on to provide family planning service to young people and hard-to-reach populations. UNFPA continued to work with the Global Fund to Fight AIDS, Tuberculosis and Malaria to integrate maternal and child health, HIV and family planning services. To ensure that family planning services are provided in accordance with human rights principles and standards, UNFPA jointly with the World Health Organization developed an implementation guide on ensuring human rights in contraceptives information and services. The guide is based on the WHO policy recommendations on human rights in contraceptive services provision and was launched in April 2015, with a joint UNFPA–WHO country offices training session to promote its implementation. UNFPA with UNAIDS continued to support the Global Network of People Living with HIV (GNP+) and the International Community of Women Living with HIV (ICW) to advocate for rights-based programming to improve the quality of family planning services and their integration in the prevention of vertical transmission. 81 | UNFPA SUPPLIES Annual Report 2015 OUTPUT 1 | ENABLING ENVIRONMENT 1.7 REGIONAL PARTNERSHIPS AND COLLABORATION Programme Monitoring Framework Evidence of commitment and The number of regional intergovernmental institutions with support to RHCS and family which UNFPA Regional Offices collaborate or support, that have planning among partners (e.g. a) explicit policies; b) institutional structure in place (division, AUC, IGAD, ECOWAS and EAC) unit, etc.) to works on RHCS and FP issues; and c) a dedicated budget line to support its RHCS and FP activities (All the three conditions must be satisfied). Milestones to build on baseline and reach a target of 15 intergovernmental bodies at the regional level in 2016 and maintain progress until 2020. Number of regional institutions The number of regional training institutions with which UNFPA supported to integrate RHCS Regional Offices collaborate or support, a) that have RHCS and issues in training curricular FP issues include in various course curricula; b) the curricula has been approved and is being used for training as part of the institutions approved course structure; and c) that people were trained using this curricula for the reporting year. (All the three conditions must be satisfied). Milestones to build on baseline and reach a target of 15 regional training institutions in 2015 and maintain progress until 2020. To foster an enabling environment for RHCS and FP at the regional level, UNFPA Supplies focuses on two strategic interventions. The first is to work with regional organizations, including economic commissions, for the integration of RHCS and FP issues into their policies and programmes. It is envisaged that the regional level provides a very strategic entry point to engage with groups of national entities that work on health and development issues. The second focus of the regional interventions is to collaborate with regional and national institutions for building capacity and providing technical assistance to countries in support of RHCS and family planning. Commitment and support to RHCS and family planning among regional partners UNFPA Asia Pacific Regional Office, Bangkok, Thailand has initiated a process in 2015 to establish an institutional arrangement with the Indian Institute for Health Management & Research (IIHMR), Jaipur, India to offer International Training Programmes (ITPs) on FP/RHCS to enhance the capacities of UNFPA staff, partners, and counterparts in the region and beyond. A memorandum of understanding (MoU) has since been signed between UNFPA and IIHMR and as per the terms of agreement UNFPA has agreed to organize a Training of Master Trainers to train a group of faculty members from IIHMR who will in turn act as facilitators in offering these 2-weeks’ training beginning in 2016. In East and Southern Africa, in collaboration with WHO, conducted the first ever UNFPA webinars on generic substitution. These were attended by national line ministries, regulatory authorities and UNFPA 82 | UNFPA SUPPLIES Annual Report 2015 OUTPUT 1 | ENABLING ENVIRONMENT Country Offices from all the countries in the Region, as well as other RHCS partners including USAID and PSI. These webinars will pave the way for the first ever UNFPA Generic Substitution Capacity-Building Workshop for all countries in the region to be held in Addis Ababa, Ethiopia in June 2016. Savings through use of generics will be measured at the end of 2016. The promotion of generic substitution in the Region aims to encourage procurement of cost-effective but equally efficacious and safe contraceptives and medicines. In November, under the “Africa Beyond Condom Donations” campaign a meeting was held in Namibia that intended to increase the role of the private sector in condom provision in Africa. At the meeting, condom manufacturers identified six countries where they would consider setting up condom factories for local manufacturing (Botswana, Kenya, Namibia, South Africa, Zambia and Zimbabwe). UNFPA facilitated initial discussions with national officials. Regional economic communities (COMESA, EAC and IGAD), other regional entities, such as PSI and the Southern African Regional Programme for Access to Medicines and Diagnostics (SARPAM), were also involved to facilitate standardization and harmonization of systems, frameworks and regulations necessary for local manufacturing. (See also Output 3 example, “20 by 20: building a new condom coalition”.) UNFPA’s Latin American and Caribbean Regional office worked with the World Health Organization in Honduras to prepare for implementation of Honduras Multiyear Master Plan for Assuring Pharmaceuticals (supported by UNFPA). Both organizations jointly proposed technical files for the national Essential Medicines List, and advocated for the incorporation of new contraceptives and reproductive health medicines into the List. In Guatemala, UNFPA Supplies also worked with PAHO, UNDP and UNICEF in the preparation of the Multiyear Master Plan for Assuring Pharmaceuticals that has been incorporated by the new Logistics Division of the Ministry of Health. In the Sahel Region of West and Central Africa, a comprehensive programme to reduce fertility, child and maternal mortality and gender inequality was launched- the Sahel Women Empowerment and Demographic Dividend (SWEDD) initiative. This ambitious US$200 programme, funded by The World Bank through a combination of grants and soft loans, will run for four years and allow UNFPA, WAHO, CERPOD, WHO and The World Bank to work closely together to tackle the extreme challenges the Region faces. The six focus countries are Burkina Faso, Chad, Côte d’Ivoire, Mali, Mauritania and Niger. Specifically the programme will focus on: demand generation through social behavioural change and women and girls’ empowerment; building regional capacity for availability of RMNCHN commodities and quality human resources for health; and political commitment and policymaking on the demographic dividend and project implementation. Also in West and Central Africa, UNFPA worked on developing an integrated plan with the African Union Commission, the UN Economic Commission for Africa and the International Planned Parenthood Federation, to help realize the aspirations contained in the International Conference on Population and 83 | UNFPA SUPPLIES Annual Report 2015 OUTPUT 1 | ENABLING ENVIRONMENT Development Beyond 2014, the 2030 Agenda for Sustainable Development and the African Union Agenda 2063. A joint planning and strategy meeting with these partners identified five priority areas for an action agenda for 2016 and beyond including: data; the demographic dividend; gender equality and women’s empowerment; ICPD and Addis Ababa Declaration on Population and Development beyond 2014; and sexual and reproductive health and rights. Through UNFPA’s role in the Ouagadougou Partnership, which covers nine francophone countries, in Benin, there has been a significant uptake of family planning users through the Partnership’s boat service (see cover image). The Partnership is also with faith-based leaders to overcome resistance and promote the availability and use of modern contraceptives and give young people and adolescents counselling. Use has already increased by more than 1 million since 2011 and the target is to get 2.2 million new users of modern contraceptives by 2020. UNFPA continues to have strong relationships with faith-based organizations in West Africa, such as as Association of Traditional Chiefs of Niger. Traditional chiefs and faith leaders can be pivotal in changing attitudes to the use of contraception. In October, UNFPA WCARO helped bring together more than 200 religious and traditional leaders, ministers and development institutions for a regional consultation in Dakar, facilitating a grassroots to government exchange on the best way to improve access to reproductive health services. This encouraging commitment from cultural leaders alongside government officials resulted in a Dakar Declaration in support of reproductive health, the SDGs and the Demographic Dividend. Participants also prepared country specific action plans to mobilize resources, strengthen partnerships, engage communities, promote interfaith dialogue and create multi-stakeholder alliances to act extensively – from grassroots to governments. UNFPA will continue to facilitate this joint effort to transform in- country dynamics and generate long-lasting changes. The UNFPA WCARO is also working with Sécurité Contraceptive en Afrique Francophone (SECONAF) a forum established by the Reproductive Health Supplies Coalition. The purpose of the forum is to facilitate and promote the successful application of the latest knowledge and to develop the understanding and capacity needed to accelerate reproductive health commodity security in francophone Africa. 84 | UNFPA SUPPLIES Annual Report 2015 OUTPUT 1 | ENABLING ENVIRONMENT Country examples RWANDA – Finding Common Ties: Engaging Religious and Community Leaders on Family Planning Religious and community leaders can play a significant role in a person’s behaviour and a community’s actions. Religious and societal values may deny women and adolescents their rights to access sexual and reproductive health (SRH) information and services, in particular family planning (FP). However, this does not have to be an absolute. Alignment and greater understanding of family planning and life­ saving services among religious and community leaders can produce positive changes in the health of women and children. In Rwanda, UNFPA led work with faith-based organizations (FBOs) to build acceptance of FP and expand its ICPD partnerships. Working with the Anglican Church in Rwanda, UNFPA held a conference on issues related to FP and the demographic dividend. More than 400 pastors and 11 bishops from the Province of the Anglican Church of Rwanda attended and discussed their role in the achievement of Sustainable Development Goals and how they could improve the well-being of Rwandan families, in particular through sensitization on family planning and gender equality. Together, an action plan was developed including activities related to FP demand generation and awareness on SRH among adolescents and youth members of the Anglican Church and surrounding churches. Conferences such as this give religions and communities increased access to life-saving FP services to women and adolescents. Photo: H6/A. Traylor-Smith 85 | UNFPA SUPPLIES Annual Report 2015 OUTPUT 1 | ENABLING ENVIRONMENT Scorecard for Output 1, UNFPA Supplies 2015 Programme Output 1: An enabled environment for RHCS, including family planning, at national, regional and global levels Policy and strategy Results and indicators 2013 baseline 2014 target 2014 actual 2015 target 2015 actual Scorecard 1.1.1 Number of countries with policies in place that take into consideration rights-based and total market approaches to family planning 26 33 28 35 35 1.1.2 Number of countries where a 3-5 year medium-term plan for family planning, with rights-based and total market approaches, is being implemented 25 28 25 32 33 1.2.1 Number of countries with family planning policies in place that take into consideration young people’s access to contraceptive services 33 34 37 36 41 1.2.2 Number of countries with a 3-5 year medium-term costed plan for family planning that takes into consideration young people’s access to contraceptive services 24 35 27 32 37 86 | UNFPA SUPPLIES Annual Report 2015 OUTPUT 1 | ENABLING ENVIRONMENT 1.3 Number of countries with national SRH and RR guidelines and protocols which include a rights- based approach to RHCS and family planning issues 39 42 40 46 43 Regional-level interventions 1.4 Evidence of commitment and support to RHCS and family planning among partners (e.g. AUC, IGAD, ECOWAS and EAC) 4 8 10 10 13 1.5 Number of regional institutions supported to integrate RHCS issues in training curricular 5 10 13 12 15 Global partnerships (support to global partners) 1.6. Evidence of support to and collaboration with NGOs for the scaling up of RHCS and family planning (e.g. Marie Stopes International and IPPF) 8 12 15 15 21 Country-level coordination and partnership 1.7.1 Number of countries with a functional national RHCS coordination mechanism (with inclusive membership including private sector, and terms of reference, minutes of meetings, follow-up action points) 32 38 37 42 39 1.7.2 Number of countries where RHCS situation analysis and stakeholder mapping is conducted and results used for planning and programming 14 18 26 24 38 1.8 Number of countries supported by CARhs to resolve problems and avert stock-out or overstock situations 25 30 20 35 15 countries for which 322 issues were attended to 1.9.1 Number of national institutions supported to integrate RHCS issues in training curricular including for procurement 17 25 27 35 32 institutions in 24 countries 1.9.2 Number of persons trained in RHCS issues by type of training topic 9,786 10,000 10,869 10,000 3,300 87 | UNFPA SUPPLIES Annual Report 2015 OUTPUT 1 | ENABLING ENVIRONMENT Product availability 1.10 Number of countries with all RH commodities (modern contraceptives and life-saving maternal/RH medicines) in country EML 28 32 27 36 39 1.11 Percentage of countries where WHO­ prequalified/ERP approved RH commodities (modern contraceptives and life-saving maternal/RH medicines) are registered 70% 75% An increase of 15 countries 80% Three countries (Kenya, Malawi and Tanzania) registered hormonal contraceptives through WHO Collaborative procedure of UNFPA partnership with WHO PQ National budget allocations for contraceptives 1.12 Number of countries, sustaining over time, increased national budget allocation for reproductive health commodities and the resources expended as planned 15 20 18 25 14 Environmental risk mitigation 1.13 Number of countries where the finalized UNFPA Guidance Note on Disposal of Maternal Health (MH) medicines is available and disseminated to partners including government 3 10 3 25 10 1.14.1 Availability of report on the assessment of country guidelines and protocols on disposal of MH medicines for benchmarking and programming 0 12 4 28 11 1.14.2 Number of countries where guidelines and protocols on disposal of MH medicines are update in line with contents of UNFPA Guidance Note 0 2 1 5 9 88 | UNFPA SUPPLIES Annual Report 2015 OUTPUT 1 | ENABLING ENVIRONMENT About the scorecard Programme Output 1: An enabled environment for RHCS, including family planning, at national, regional and global levels Progressing well towards targets Leveraging its extensive in-country presence, UNFPA continued to work with partners including governments to improve on the policy environment for a rights- based approach to family planning. More and more countries are engaged in long-term planning especially through costed implementation plans. While country- level coordination and partnerships became stronger in 2015, the challenge remains to ensure that governments allocate their own resources for the procurement of RH commodities, especially contraceptives. At the regional and global levels, UNFPA continued to work with various organizations including international NGOs, private sector entities and foundations to create strong partnerships in support of delivering on FP goals. The FP2020 partnership provide a very important platform for strengthening the enabling environment at country, regional and global levels. Policy and strategy Results and indicators Summary methodology Comments 1.1.1. Number of countries with policies in place that take into consideration rights-based and total market approaches to family planning A country is judged to have achieved the indicator if there is/are policy or policies that: a) contain both elements (rights-based approaches to family planning and total market approaches); b) has/have been finalized; and, c) is/are being implemented. (All three conditions must be satisfied.) Milestones to build on baseline and reach a target of 46 countries in 2018 and maintain progress to 2020 Achieved Over 70 per cent of the countries have policies in place that take into consideration both rights-based and total market approaches. This lays the foundation for improvement in the enabling environment for voluntary family planning and for ensuring the participation of a broad range of stakeholders. 1.1.2 Number of countries where a 3-5 year medium-term plan for family planning, with rights-based and total market approaches, is being implemented A country is judged to have achieved the indicator if it is reported a) to have a 3 to 5 years medium- term costed plan for Family Planning; b) that the plan contains both elements (right based approaches to family planning; and total market approaches); c) and that these plan has been finalized, approved and is being implemented. (All three conditions must be satisfied.) Achieved (milestones exceeded) An increasing number of countries have translated policies into plans – especially with the roll out FP costed implementation plans. 89 | UNFPA SUPPLIES Annual Report 2015 OUTPUT 1 | ENABLING ENVIRONMENT Milestones to build on baseline and reach a target of 46 countries in 2019 and maintain progress to 2020 1.2.1 Number of countries with family planning policies in place that take into consideration young people’s access to contraceptive services A country is judged to have achieved the indicator if it is reported a) to have policies in place that takes into consideration young people’s access to contraceptive services; and b) that these policies have been finalized, approved and are being implemented. (Both conditions must be satisfied.) Milestones to build on baseline and reach a target of 46 countries in 2019 and maintain progress to 2020 Achieved (milestones exceeded) Leveraging its extensive in-country presence and its long-standing relationships with governments, UNFPA Supplies has contributed to improving the policy environment for addressing young people’s access to contraception in nearly 90 per cent of the programme implementing countries. 1.2.2 Number of countries with a 3-5 year medium-term costed plan for family planning that takes into consideration young people’s access to contraceptive services A country is judged to have achieved the indicator if it is reported to have a) a 3 to 5 years medium- term costed plan for FP; b) that takes into consideration young people’s access to contraceptive services; and, c) that action plan has been finalized, approved and is being implemented. (All three conditions must be satisfied.) Milestones to build on baseline and reach a target of 46 countries in 2017 and maintain progress to 2020 Achieved (milestones exceeded) An increasing number of countries have translated policies aimed at addressing young people’s access to contraception into costed plans. This signifies an increasing commitment in programme countries to address unmet need among adolescents and youth and for improving their access to reproductive health services, including contraception. 1.3 Number of countries with national SRH and RR guidelines and protocols which include a rights- based approach to RHCS and family planning issues A country is judged to have achieved the indicator if it is reported to have available national SRH and RR guidelines and protocols which include a) rights-based approach to RHCS and family planning issues; and, b) that the guidelines and protocols have been finalized, approved and are being implemented. (Both conditions must be satisfied.) Progressing well towards targets More than 90 per cent of programme implementing countries have been supported in the development and rolling out of a broad range of tools, guidelines and protocols. 90 | UNFPA SUPPLIES Annual Report 2015 OUTPUT 1 | ENABLING ENVIRONMENT Milestone to build on baseline and reach a target of 46 countries in 2015 and maintain progress to 2020 Regional-level interventions 1.4 Evidence of commitment and support to RHCS and family planning among partners (e.g. AUC, IGAD, ECOWAS and EAC) The number of regional intergovernmental institutions with which UNFPA Regional Offices collaborate or support, that have a) explicit policies; b) institutional structure in place (division, unit, etc.) to works on RHCS and FP issues; and c) a dedicated budget line to support its RHCS and FP activities. (All three conditions must be satisfied.) Milestones to build on baseline and reach a target of 15 intergovernmental bodies at the regional level in 2016 and maintain progress to 2020 Achieved (milestones exceeded) At the regional level, UNFPA Supplies has strengthened partnerships with training institutions in Africa, Asia and Latin America to facilitate technical assistance and capacity-building for RHCS and FP. 1.5 Number of regional institutions The number of regional training institutions with Achieved (milestones exceeded) supported to integrate RHCS issues in training curricular which UNFPA Regional Offices collaborate or support: a) that have RHCS and FP issues included in various course curricula; b) the curricula has been approved and is being used for Regional Economic Commissions, especially in Africa, have provided valuable opportunities for reaching a core set of decision makers for advocacy and policy dialogue in support of FP. training as part of the institutions approved course structure; and c) that people were trained using this curricula for the reporting year. (All three conditions must be satisfied.) Milestones to build on baseline and reach a target of 15 regional training institutions in 2015 and maintain progress to 2020 Global partnerships (support to global partners) 1.6 Evidence of support to and collaboration with NGOs for the scaling up of RHCS and family The number of organizations at the global level a) with which UNFPA, through the UNFPA Supplies programme, works to improve RHCS and FP programming; and b) with which specific Achieved (milestones significantly exceeded) At the global level, UNFPA Supplies continues to work with various partners on technical and programmatic issues. As a Co-convener of the FP2020 partnership, UNFPA continues to build and strengthen 91 | UNFPA SUPPLIES Annual Report 2015 OUTPUT 1 | ENABLING ENVIRONMENT planning (e.g. Marie Stopes interventions were carried out for the reporting alliances in support of FP. Also, working with international NGOs, International and IPPF) year. (Both conditions must be satisfied.) Milestones to build on baseline and reach a target of 20 global institutions in 2016 and maintain progress to 2020 the private sector and foundati

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