UNFPA Supplies Annual Report 2019

Publication date: 2020

UNFPA SUPPLIES ANNUAL REPORT 2019 HIGHLIGHTS OF KEY PROGRESS WHERE WE WORK Humanitarian or fragile context country Map disclaimer: The designations employed and the presentation of the material on the map do not imply the expression of any opinion whatsoever on the part of UNFPA concerning the legal status of any country, territory, city or area or its authorities, or concerning the delimitation of its frontiers or boundaries. UNFPA Supplies also provides strategic support to other countries in response to humanitarian crises, to support Family Planning 2020 commitments, and to implement the UNFPA Family Strategy, including Pacific Island Countries and Territories. Asia & the Pacific Lao People’s Democratic Republic Myanmar* Nepal* Papua New Guinea* Timor-Leste* Arab States Djibouti Sudan* Yemen* Latin America & the 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* Congo* Côte d’Ivoire* Gambia Ghana Guinea Guinea-Bissau* Liberia Mali* Mauritania Niger* Nigeria* Sao Tome and Principe Senegal Sierra Leone Togo Acronyms and abbreviations 2 Acknowledgements 3 Report of 2019 progress 4 Foreword 5 Executive summary 6 CHAPTER ONE: Expanding method choice: meeting needs and affirming rights 10 Reliably choose, obtain and use quality contraceptives 11 Improving access to a choice of methods 12 Scaling up subcutaneous injectable contraception 14 Expanding access to contraceptive implants 15 IUDs and permanent methods 16 Reaching young people and marginalized groups 17 CHAPTER TWO: Supply chain strengthening for access and choice 20 Towards reliability and sustainability of national supply chains 21 Better logistics management information systems 22 Timely planning and response 23 Evidence-based practices to strengthen supply chains 23 Gaining programme visibility via last mile assessments 26 Enhancing data for decision-making 27 Partnerships are critical to steady, reliable, quality supplies 28 CONTENTS CHAPTER THREE: Expanding access to contraceptives in humanitarian settings 30 Supply chains in humanitarian settings 31 Reproductive health kits: essential supplies in crises 31 Family planning in humanitarian and fragile contexts 33 Country responses in humanitarian and fragile contexts 34 CHAPTER FOUR: Towards sustainable financing for family planning 36 Innovative approaches for sustainable finance: countries taking action 37 Making the case for investing in family planning 37 Expanding sources: mobilizing for more domestic funding resources 40 Ensuring efficient use of all resources 43 Total market approach 45 CHAPTER FIVE: Strengthening the programme 48 Contributions to the global movement for family planning 49 Strategic communications to raise awareness of impact 50 Programme management 51 Data collection, analysis and monitoring 52 Building on strengths to drive progress towards the 2030 Agenda 52 Financial snapshot 53 CARhs Coordinated Assistance for Reproductive Health Supplies CIFF Children’s Investment Fund Foundation CRT Commodity Requirement Tool CSP Coordinated Supply Planning Group CYP Couple-years of contraceptive protection DAC UNFPA Supplies Donor Accountability Council DFID United Kingdom Department for International Development DHS Demographic and Health Surveys DHIS District Health Information Software DMPA-SC Subcutaneous injectable depot- medroxyprogesterone acetate ECHO Evidence for Contraceptive Options and HIV Outcomes Trial FCDRR Facility Consumption Data Report and Request GFF Global Financing Facility HSS Humanitarian Supplies Strategy IMPACT Information Mobilized for Performance Analysis and Continuous Transformation KEMSA Kenya Medical Supplies Agency LARC Long-acting reversible contraceptive LMA Last mile assurance LMIS Logistics management information systems MISP Minimum Initial Service Package for Sexual and Reproductive Health during a Humanitarian Crisis NACP National AIDS Control Programme NIDI Netherlands Interdisciplinary Demographic Institute OPCU Ouagadougou Partnership Coordination Unit QPM Quarterly Programme Management RHCLS RH Commodity Logistics System RHSC Reproductive Health Supplies Coalition ROI Return on investment TMA Total market approach TPP Third party procurement UHC Universal health coverage UNSDCF United Nations Sustainable Development Cooperation Framework ACRONYMS AND ABBREVIATIONS UNFPA SUPPLIES ANNUAL REPORT 20192 ACKNOWLEDGEMENTS The results achieved in 2019 would not have been possible without the partnership and collaboration of national governments and our implementing partners as well as numerous international and national non-governmental organizations, United Nations agencies, civil society organizations and members of the private sector. We are grateful for the technical and financial support of donors to the UNFPA Supplies programme. Our 19 donors in 2019 are as follows: Australia Belgium Canada Denmark European Union Liechtenstein Luxembourg The Netherlands Norway Portugal Regione Lombardia (Italy) Slovenia Spain United Kingdom The Bill & Melinda Gates Foundation Children’s Investment Fund Foundation (through Crown Agents Limited) Friends of UNFPA Winslow Foundation Private contributions (including online) Anonymous donor Since the launch of the programme in 2007, it has also received support from: Finland, France, Ireland, Norway, Sweden, Spain-Cataluña, the RMNCH Trust Fund and Treehouse Investments. 3 UNFPA SUPPLIESANNUAL REPORT 2019 2019 REPORT OF 2019 PROGRESS UNFPA Supplies, the United Nations Population Fund thematic fund, is the only United Nations programme dedicated to family planning and it is the world’s largest provider of donated contraceptives. UNFPA Supplies supports countries with the greatest needs, helping them to strengthen their supply chains so that women and adolescent girls can access a choice of contraceptives no matter where they live. The programme has a particular focus on 46 countries, in addition to providing support for reproductive health services in humanitarian crises. This report of UNFPA Supplies’ progress in 2019 has two sections: Highlights of Key Progress in 2019 is a narrative overview of key highlights of UNFPA Supplies work in 2019. Select examples from countries illustrate the programme’s support. Reporting on the Performance Monitoring Framework is a detailed report of progress against the programme framework, including a scorecard for at-a-glance information and a detailed financial report. Part II of the report is available on the UNFPA website. An important data source for annual reporting is the facility-based survey. These large-scale national surveys are conducted in collaboration with governments in each programme country at least every two years and provide point-in-time stock measurements. Twenty-three (23) countries submitted survey results for 2019. However, not all 23 countries reported on all indicators. The number of countries with available data is specified as relevant, e.g. 19 of the 21 countries surveyed. The annual country reporting questionnaire is another key source of country-specific information. It is completed each year by UNFPA country offices in each of the 46 UNFPA Supplies programme countries. UNFPA SUPPLIES ANNUAL REPORT 20194 Reaching the last mile with contraceptive supplies and services requires an unwavering commitment to poor and marginalized women and adolescent girls. Yet, as supply chains are disrupted and health systems struggle under the burden of the COVID-19 pandemic, access to sexual and reproductive health services, including contraceptives, has been significantly constrained. UNFPA estimates show that 6 months of movement restrictions and major disruptions to health services could leave 47 million women in low- and middle- income countries unable to use modern contraceptives, resulting in 7 million additional unintended pregnancies. Our support for family planning has always extended to challenging contexts and humanitarian emergencies, and in many ways, these experiences have informed UNFPA’s response to COVID-19. As before, our work continues to be geared towards resilience and results. In 2019, modern contraceptives provided through UNFPA Supplies helped avert 24,000 maternal deaths and 152,000 child deaths around the world. Indeed, contraceptives save lives. As part of a coordinated effort to prevent stock-outs of life-saving contraceptives and maternal health medicines, UNFPA is leveraging established mechanisms to anticipate needs and respond to disruptions. With governments and other partners, UNFPA is working to prioritize supply requests, orders, shipments, production schedules and other operational aspects of procurement. Meanwhile, assessments and data collected by forecasting, monitoring and tracking help keep information current and inform decision-making. The progress made and issues raised in this 2019 report resonate all the more strongly during the current pandemic. In June 2019, when more than 100 participants issued recommendations at the UNFPA Global Consultation on Ending Unmet Need for Family Planning, they focused on how to increase impact for everyone, everywhere. Likewise, the Nairobi Summit on ICPD25 reaffirmed the commitment to reach all those left behind, particularly youth and adolescents, people with disabilities, migrants and refugees, and people living in humanitarian settings. Evidence indicates that the health and socio-economic impacts of COVID-19 are being borne disproportionately by the most vulnerable populations. As we look to build a better future, UNFPA is committed to bringing down the barriers of inequality and poverty with life-saving sexual and reproductive health care, including family planning. Dr. Natalia Kanem Executive Director, UNFPA FOREWORD © UN Photo/Paulo Filgueiras 5 UNFPA SUPPLIESANNUAL REPORT 2019 The principles of “leaving no one behind” and “reaching the furthest behind” first permeate the UNFPA Strategic Plan 2018- 2021 and will continue to do so in strategic plans for years to come as UNFPA supports countries to achieve the Sustainable Development Goals by 2030. Among the many priorities and needed actions, UNFPA Supplies stretched to reach farther in our response, to reach the last mile, to ensure that all women and adolescent girls can realize their right to family planning. At the global level, UNFPA Supplies supported working groups and webinars leading up to the UNFPA Global Consultation on Ending Unmet Need for Family Planning in June and dialogues culminating in the Nairobi Summit on ICPD25 in November. At the national level, UNFPA Supplies worked closely with governments and many other valued partners in both development and humanitarian contexts to strengthen supply chains and procure quality contraceptives. Financial contributions to the programme increased in 2019 to nearly $220 million against a target of $252 million from 19 donors. Across the organization, UNFPA successfully met its Family Planning 2020 (FP2020) commitment to allocating more resources to family planning. Reaching the last mile was a programme priority demonstrated in efforts to deliver modern contraceptives into the hands of women and adolescent girls in remote areas and in poor and marginalized groups. In 2019, UNFPA Supplies conducted “last mile assessments” in 16 countries to identify aspects of supply chain systems that need to be strengthened, introduced a new Quarterly Commodity Review for each of the 46 programme countries, and welcomed the launch of the Global Family Planning Visibility and Analytics Network (Global FP VAN). UNFPA and partners worked to ensure that women and girls everywhere are able to choose from a range of contraceptive methods that suit their needs, expanding long-acting reversible contraceptives through the scale-up of subcutaneous injectables and a rapid survey on factors driving demand for implants. Some of the greatest challenges in reaching the last mile were in humanitarian settings, where millions of displaced women and girls need access to family planning services. In the UNFPA Supplies programme, almost two thirds of countries – 29 of 46 countries – were caught in situations of fragility, conflict, natural disaster and other emergencies in 2019. UNFPA Supplies supported development of the first UNFPA Humanitarian Supplies Strategy, and EXECUTIVE SUMMARY UNFPA SUPPLIES ANNUAL REPORT 20196 LASTMILE contributed to updating the forecasting tools and RH kits for emergencies. Reaching the last mile, sustaining gains, meeting needs – the resources required for sustainable family planning are significant, making the increase in donor funding to UNFPA Supplies welcome news for the fourth year in a row. In addition, the programme continued to promote sustainable financing for family planning, including through the use of domestic resources to procure contraceptives, and to support evidence-based advocacy to create an enabling environment for family planning. In 2019, UNFPA Supplies supported development of evidence-based business cases in Burkina Faso, Mali and Rwanda and fact sheets on investments in six countries in Latin America; facilitated dialogues and advocacy with parliamentarians in Burkina Faso, Ghana, Kenya, Madagascar, South Sudan and Zambia; and convened an ICPD25 Summit dialogue for policymakers. New domestic financing was met with a matching $4.46 million in the UNFPA Supplies Ouagadougou Partnership Commodity Matching Fund. Throughout the year discussions focused on strengthening the programme to deliver on future needs. Future-looking planning for the third phase of the programme was informed by 25 recommendations from the Global Consultation held in June in Antalya, Turkey, which was attended by 100 participants from 42 countries and organized as part of the consultative process leading up to the Nairobi Summit on ICPD25. Discussions regarding the next phase, 2021 to 2030, also addressed the governance structure and greater country engagement. The programme held four Donor Accountability Council meetings and three Steering Committee meetings in 2019, with all recommendations implemented. The UNFPA Supplies Quarterly Programme Management process was used by all programme countries. Contributing to the efficient and effective use of resources, 23 UNFPA Supplies countries carried out national facility-based surveys. 7 UNFPA SUPPLIESANNUAL REPORT 2019 With estimated savings of $497 million in health-care costs of unintended pregnancies and unsafe abortions. Improving access and availability • 41.9 million couple-years of contraceptive protection (CYP) were provided by contraceptives supplied through UNFPA Supplies. • 19 of 21 countries surveyed had trained staff for the provision of modern contraceptives at their primary-level service delivery points (SDPs). • 19 of 23 countries surveyed achieved national availability of three modern contraceptive methods. • Among 23 countries surveyed, 96 per cent of SDPs offered oral contraceptive pills, 93 per cent offered injectable methods and 92 per cent offered male condoms, across all SDP levels. • 37 UNFPA Supplies countries included the subcutaneous injectable contraceptive and 42 included implants as part of their range of methods offered in 2019, both marked increases. Strengthening supply chains • 40 countries have an eLMIS (electronic, automated and computerized logistics management system), up from 40 in 2018. • 43 countries have a system for forecasting and procurement, up from 40 in 2018. Contraceptives provided through UNFPA Supplies in 2019 had potential to avert: 8 million UNINTENDED PREGNANCIES 152,000 CHILD DEATHS 24,000 MATERNAL DEATHS 2.3 million UNSAFE ABORTIONS 2019 AT A GLANCE UNFPA SUPPLIES ANNUAL REPORT 20198 • 45 countries made no ad hoc requests to UNFPA Supplies for commodities (except in humanitarian contexts). • 31 countries have a functional logistics system meeting six criteria, up from 30 in 2018. • 34 countries have staff trained in LMIS in most service delivery points, up from 33 in 2018. Delivering humanitarian supplies • 18 countries received reproductive health kits provided through UNFPA Supplies. • 2.8 million women were reached by reproductive health services supported by these kits, up from 2.1 million in 2018. • 27 countries provided comprehensive training in 2019 on the Minimum Initial Service Package (MISP), and 40 offered basic MISP training. • Humanitarian response implementing partners in 32 of 37 countries supported by UNFPA reported no stock-out of reproductive health kits. Efforts towards sustainable financing • 28 countries allocated funds through national budget lines for contraceptives and 13 countries for maternal health medicines. • Countries allocated domestic funds of $43.8 million, up from $41.8 million in 2018, and spent $30.3 million of domestic funds for contraceptive procurement, up from $24.9 million in 2018, with higher allocations in eight countries. • UNFPA Supplies used its Bridge Funding Mechanism to expedite procurement of commodities worth $17.9 million that reduced shortages of 61 stock items in 21 countries at high risk of stock-outs. • UNFPA reduced prices for male condoms, oral contraceptives and injectable methods. • $3.4 million in price reductions were generated by negotiations with manufacturers and efforts to bring generic products to the market. © UNFPA/Pirilani Semu-Banda A community-based distribution agent demonstrates use of the female condom to a group of men, women and adolescents in Malawi. 9 UNFPA SUPPLIESANNUAL REPORT 2019 01 CHAPTER ONEExpanding method choice: Meeting needs and affirming rights © UNFPA Nepal Local volunteers show Nepali families the benefits of voluntary family planning. Delivering to the last mile means that family planning supplies reach all the way to the point of distribution, where they can be accessed by clients supported by trained health care providers. Many steps go into ensuring these supplies are available when and where they are needed, starting with a secure supply of quality-assured reproductive health commodities. In 2019, in support of a rights-based approach to family planning, UNFPA Supplies continued to make concerted efforts to expand the range of contraceptive methods available to women, men, adolescents and youth. The programme also worked to ensure availability of lifesaving maternal health medicines used for treatment of the conditions that are the main causes of maternal death. RELIABLY CHOOSE, OBTAIN AND USE QUALITY CONTRACEPTIVES In 2019, UNFPA Supplies continued to ensure reliable stocks of quality-assured contraceptives. A reliable stock of contraceptives supports voluntary choice, which is an important element in user satisfaction and method continuation. Expanding the choice of contraceptives promotes the increased and sustained use of contraceptives, enabling more women and couples to realize their reproductive rights and their ambitions for themselves and their families and helping countries achieve their development goals. • Contraceptives supplied through UNFPA Supplies in 2019 provided 41.9 million couple-years of contraceptive protection (CYP). • Trained staff for the provision of modern contraceptives were in place at service delivery points in 19 of 21 countries surveyed. On the day of the facility-based survey visit, service delivery points count family planning supplies on their shelves, looking for three methods at primary level. Twenty- three countries provided survey data on this indicator in 2019, attaining broadly similar results as in the 2018 surveys, which covered a different set of countries. • 19 of 23 countries offered at least three modern contraceptive methods at 85 per cent or more primary-level service delivery points in 2019. • In urban areas, 19 countries met this indicator for availability of methods at SDPs. • In rural areas, 17 countries met this indicator, with SDPs unable to offer certain methods (particularly IUDs and implants) due to a lack of trained providers. • Availability of three modern methods remained at a satisfactory level of coverage at 92 per cent in 2019, on average among the 23 countries surveyed. By method, SDPs in 22 of 23 countries offered oral 92% coverage Three modern methods available in 23 countries surveyed 41.9m CYP Couple-years of contraceptive protection provided in 2019 11 UNFPA SUPPLIESANNUAL REPORT 2019 12 to 37 UNFPA Supplies countries ordering DMPA-SC injectables increased 2017 to 2019 contraceptive pills and injectable methods and 21 of 23 countries offered male condoms, making them the most-offered methods in 2019. More countries ordered long-acting reversible contraceptive methods through UNFPA Supplies following an expansion of training for health service providers in several countries. Orders for both implants and injectables increased in 2019 among countries in the UNFPA Supplies programme. • Countries ordering subcutaneous injectables (DMPA-SC) increased from 12 in 2017 to 37 in 2019. • Countries ordering contraceptive implants also increased, notably 2-rod levonorgestrel implants from 4 in 2017 to 12 in 2019. Also in 2019, consideration was given to adding products to the list of maternal health medicines offered by the programme (e.g. carbetocin and tranexamic acid) and medical abortion supplies, where the legal framework supports the use of these products. IMPROVING ACCESS TO A CHOICE OF METHODS The UNFPA Global Consultation on Ending Unmet Need for Family Planning in June 2019 produced a set of recommended actions to accelerate progress, include three aimed at improving access to a choice of methods: • Explore options to add to the basket of contraceptive choices for women. Add new types of contraceptives and new technologies to expand method choice and advocate for their introduction and inclusion in the range of methods available. • Increase options for procurement, expand the number of suppliers for each method of contraception, and negotiate with all suppliers for increased volumes and production capacities. • Overcome bottlenecks in registration to increase procurement options for countries of both innovator (the original brand-name) and generic products. Identify accelerators for in-country product registration. The recommendations also note the importance of product quality assurance, with its many well-established processes and procedures and call for: increasing post- market surveillance to assess the quality of the products throughout the supply chain especially after in-country delivery; expanding condom testing; engaging with the World Health Organization to widen the number of manufacturers of innovative contraceptives; and ensuring a wider choice of methods. Accelerated efforts are urged regarding registration of WHO-prequalified methods, collaboration with National Regulatory Authorities and creation of national policies on generic medicines. 13 to 23 Registration of the 2-rod levonorgestrel implant increased 2018 to 2019 in UNFPA Supplies countries 2019 23 132018 2019 37 222018 122017 UNFPA SUPPLIES ANNUAL REPORT 201912 Range of contraceptive methods procured through UNFPA Supplies EXPANDING THE CHOICE OF METHODS TO REACH MORE WOMEN IN CAMEROON The strong enabling environment for family planning in Cameroon set the stage for a national scale-up of DMPA-SC, an injectable contraceptive. Government approval of a task- shifting policy to allow Community Health Workers (CHWs) to provide the method was key, as was its approval of a self-injection policy in 2017. As of 2019, nearly 500 trainers have completed “training of trainers” and training has reached 2,448 health service providers and 2,385 CHWs. Some 3,250 health facilities have the capacity to offer DMPA-SC at the community level through CHWs. In addition, 188,320 family planning clients have received training in self-injection, which has been rolled out in all 10 regions and 189 districts. © UNFPA Cameroon Integrating DMPA-SC into Cameroon’s family planning package has enabled more women to choose a method that suits them. Range of contraceptive methods procured through UNFPA Supplies IMPLANTS Etonogestrel 1-rod Levonorgestrel 2-rod (5 year) Levonorgestrel 2-rod (3 year) 21,477,076 CYP MALE AND FEMALE STERILIZATION PROCEDURES Non-scalpel vasectomy and tubal ligation 59,521 MALE CONDOMS Coloured, flavoured, ribbed 1,999,810 CYP FEMALE CONDOMS Latex, nitrile, with sponge or ring, coloured, fragranced 78,570 CYP 41.9 million couple years of contraceptive protection INJECTABLES DMPA 3-month IM (intramuscular) DMPA 3-month SC (subcutaneous) NET-EN 2-month IM 9,363,293 CYP IUDs Copper 6,374,491 CYP EMERGENCY CONTRACEPTIVE PILLS 114,831 CYP ORAL CONTRACEPTIVE PILLS Combined oral / Progesterone only 2,319,850 CYP 13 UNFPA SUPPLIESANNUAL REPORT 2019 SCALING UP SUBCUTANEOUS INJECTABLE CONTRACEPTION Subcutaneous DMPA, or DMPA-SC, is an injectable contraceptive that can increase contraceptive choices when offered as part of a broad variety of methods. With training and support, women can safely and effectively self-inject DMPA-SC, or choose to receive care at their health facility. UNFPA continued in 2019 to support countries to implement national scale-up plans to make DMPA-SC available in public facilities, private clinics and private drug stores, including for self-injection. The scale-up initiative focused on integration of the method into the supply chain and extensive training for health-service providers and community health workers to expand access and availability. Since DMPA-SC was added to the procurement catalogue in 2016, UNFPA works with 42 countries that have included DMPA-SC as part of their options for women, including 37 in the UNFPA Supplies programme. POLICY 42 countries Inclusion in national EML or supportive of DMPA-SC as part of methods available 23 countries • Costed Implementation/ scale-up plans • Supportive of self-injection • Authorize community health workers to provide the method PROVIDERS 27 countries 39,743 nurses/midwives trained (2019) (total cumulative 60,827) 23 countries 48,180 CHWs/CBDs trained (2019) (total pool of at least 83,180) SUPPLY 20 countries Requests were part of the national quantification process 21 countries Data were collected through the national LMIS NEW IN 2019 Ten countries introduced DMPA-SC into their health systems for the first time in 2019: Argentina, Central African Republic, Chad, Ethiopia, Guinea, Guinea-Bissau, Lesotho, Liberia, Namibia and Senegal. Their respective ministries of health have added the method to their national list of contraceptives. Data as of December 2019. UNFPA SUPPLIES ANNUAL REPORT 201914 there has been extensive outreach to countries to add it to their available methods. UNFPA continued working with a range of partners through the DMPA-SC Donor and Operations Groups to provide financial and technical assistance in the implementation of roll out plans. The success of DMPA-SC injectable contraception was evident in 2019 with more users, more training and more procurement orders, although some capacity limitations were noted. In 2019, UNFPA Supplies supported capacity development for the introduction of injectable methods through extensive training of health service providers. In Malawi, where the introduction of injectable methods expanded from 7 to 28 districts, specialized “training of trainers” sessions were carried out at both national and regional levels. Thousands received training in Uganda, where DMPA-SC has been included in the national information system and essential medicines list and integrated into distribution systems rolled out to public sector sites in humanitarian settings with UNFPA and the Children Investment Fund Foundation (CIFF) support, with the self- injection option to be continued in 2020 by UNFPA Supplies. In Rwanda, the national plan calls for the full integration of DMPA-SC in all delivery channels, or more than 1,032 service delivery points, by the end of 2021, with training of health workers scheduled to start at the end of 2020. In South Sudan, DMPA- SC is part of national family planning training and distribution plans. EXPANDING ACCESS TO CONTRACEPTIVE IMPLANTS Demand for implants has continued to grow in the past five years, spurred by the Minimum Volume Guarantee agreements on price and the division of labour among partners to facilitate availability and access. The number of countries ordering contraceptive implants increased, with 12 countries requesting 2-rod levonorgestrel implants in 2019, up from 4 in 2017. Training for the insertion and removal of contraceptive implants has extended this contraceptive method to more users. Demand for implants exceeded production capacity in 2019, and the majority of the orders had to be delivered as split shipments, some extending to 2020. There was only one supplier for single-rod implants in 2019, with manufacturing capacity of 5 million units, yet 2 million additional units were requested by countries. Likewise, although there were two suppliers of 2-rod implants (3- and 5-year duration of use), strong demand pushed their manufacturing to maximum capacity. To manage these supply and demand issues, UNFPA worked closely with USAID and the Coordinated Supply Planning Group (CSP) to prioritize orders according to the capacity of the programme to utilize the requested quantities, which allowed for shipments to be staggered; the partners also scaled back on activities intended to widen the method coverage. 8 to 46 Countries adopted safe medical waste disposal guidelines and protocols from 2016 to 2019 2019 46 432018 382017 82015 15 UNFPA SUPPLIESANNUAL REPORT 2019 Registration of the 2-rod levonorgestrel implant increased from 13 countries in 2018 to 23 countries in 2019, and another 20 countries have submissions under review. Registration is an important step for countries that want to expand the method options available for women. Three kinds of implants are currently on the market, and more are needed that meet international quality standards. A rapid survey on factors driving demand and procurement trends for contraceptive implants was carried out in 2019 by the Implant Access Programme, of which UNFPA is a member, along with the World Health Organization, USAID, Jhpiego, FHI360, CHAI and The Bill & Melinda Gates Foundation. The survey explored the decision-making processes behind implant procurement and anticipated trends. It found several reasons why orders are higher for the 1-rod product: (1) ease of insertion/removal, with health care providers mentioning that insertion/removal is simpler; (2) it is the most common type of implant that providers receive training on; (3) consumption/procurement data on especially coupled with brand-name recognition means that orders are for a specific brand only; (4) policies to diversify method mix; and (5) product availability. ECHO STUDY ON HORMONAL CONTRACEPTIVE METHODS AND HIV ACQUISITION A joint statement was released on 13 June 2019 by WHO, UNAIDS and UNFPA welcoming the results of a large clinical research study that compared the risk of HIV acquisition among women randomized to three highly effective reversible contraceptive methods (the copper IUD, levonorgestrel five-year implant and DMPA three-month intramuscular injectable). The Evidence for Contraceptive Options and HIV Outcomes (ECHO) study was conducted in four African countries and published in The Lancet. The study found no significant difference in risk of HIV infection among women using one of the three methods. A notable finding in the study was the high acceptance of the reversible methods (especially the IUD and implants) by young women. The study did, however, find high rates of HIV incidence overall among the women in the trial pointing to a greater need for integration of family planning with HIV services. As a result of this, in 2019, UNFPA continued to work with WHO and the in-country task teams to address plans for strengthening integration of services according to country context, health system set up and feasible alternatives. © UNFPA Kenya/Doulgas Waudo The ECHO study found no significant difference in risk of HIV infection among women using one of three highly effective, reversible contraceptive methods. UNFPA SUPPLIES ANNUAL REPORT 201916 IUDS AND PERMANENT METHODS The number of countries procuring IUDs through UNFPA Supplies remained consistent when compared with past years, between 32 and 35 countries per year depending on stock levels. The volumes have also remained consistent, between 1.2 million and 2 million units. Most countries have taken steps to address the need for training on IUD insertion and removal, as well as the need for supplies. Ethiopia has extended task shifting and task sharing by introducing training for Health Extension Workers on IUD insertion and removal; the aim is to increase access to the method where it might not have been routinely offered. The Hormonal IUS interagency working group explored the introduction of this hormone-releasing IUD in countries that conducted pilot programmes in 2019: Kenya, Madagascar, Nigeria, Tanzania and Zambia. Several countries requested support through UNFPA Supplies for procurement of non- scalpel vasectomy kits and supplies for tubal ligation. In Papua New Guinea, 1,545 vasectomies were conducted in 2019. In Rwanda, 4,821 tubal ligations and 1,413 vasectomies were conducted in 2019, achieving 57,976 contraceptive-years of protection with support from UNFPA in collaboration with the Ministry of Health and USAID. The national health implementation SELF-ADMINISTERED INJECTABLES EMPOWER WOMEN IN LESOTHO ‘Manthati Sekoati, the nurse-in-charge at Mapholaneng Clinic in Mokhotlong, says that young people in Lesotho are often embarrassed to be seen accessing reproductive health care, and women face social pressures to have large families. If they can administer their own contraceptives at home, they are more likely to be empowered to choose the size and spacing of their families, she said. Self-injected contraceptives can reduce stigma and increase women’s ability to decide to use contraception. During last summer’s cropping season, Lesotho’s Mokhotlong district was one of the hardest hit by severe drought. Large numbers of livestock, a main source of livelihood, were lost. Ms. Mokoena, a health worker, says the economic uncertainty has fuelled demand for contraceptives among the district’s women, including interest in injectable contraceptives that women can administer themselves. This new form of family planning is uniquely suited to rural areas without easy access to health services and is increasing the options available to women. UNFPA and the Ministry of Health have been training health workers to teach women to inject contraceptives themselves. Ms. Mokoena says she has been speaking to public gatherings about it, and the response has been largely positive. © UNFPA Lesotho/Violet Maraisane Nurse-in-charge, ‘Manthati Sekoati, points to the self- administered injectable contraceptive on a chart of family planning options available to women in the area. 17 UNFPA SUPPLIESANNUAL REPORT 2019 How a new contraceptive method is introduced advocacy and technical assistance policy and strategy ALERT countries that a new quality- assured contraceptive method is available from the UNFPA Product Catalog ASSIST with in-country approval process including product registration or waivers to import the product ENSURE service readiness with training at all levels, provision of IEC materials and plans for quality assurance monitoring – through support to Ministry ENGAGE in advocacy for inclusion in Essential Medicines List, treatment guidelines, FP registers and data collection tools EXPAND the choice of safe and effective methods of modern contraception available to women and adolescent girls SUPPORT procurement from quantification to distribution, logistics management information systems and other supply chain functions DEVELOP and roll out costed implementation plan and target locations, facility types and number of service providers – through support to Ministry UNFPA SUPPLIES ANNUAL REPORT 201918 agency, Rwanda Biomedical Centre, adopted a mentorship approach to build capacity for provision of these methods and regularly organized knowledge-sharing sessions. REACHING YOUNG PEOPLE AND MARGINALIZED GROUPS Reaching the last mile entails expanding access and reaching young people and marginalized groups in the 46 programme countries. Countries are working with the UNFPA Supplies programme to tackle these challenges from a number of different directions, as in the following examples. In Bolivia, UNFPA Supplies supported initiatives by UNFPA to implement guidelines on the provision of adequate health care to victims of sexual violence, including availability of emergency contraception, post-abortion family planning counselling and contraceptive service provision. UNFPA brought to the Government’s attention the need for action to end child marriage and child pregnancies, and helped develop indicators for implementing a related surveillance system and public policies. Also, in 2019, UNFPA Supplies delivered technical assistance to the Bolivian Ministry of Health to update the national guide for comprehensive care for adolescents. In the Democratic Republic of the Congo, UNFPA Supplies supported the ongoing UNFPA commitment to implementing the “KITUMAINI” (hope) initiative. The initiative raises awareness among adolescents on family planning and sexual and reproductive health issues, including risks related to early pregnancy and how to prevent STIs and HIV. It also offers the opportunity for adolescent girls in-school and out-of-school (often first-time mothers) to learn skills such as hairdressing and sewing. In Central African Republic, UNFPA Supplies ensured that emergency contraception was available in health facilities to better meet the needs of women and girls who have been victims of sexual violence. The UNFPA Mozambique Innovation Team supported the launch of DIKA in June 2019, an application created by young people in Mozambique to disseminate information about sexual and reproductive health and serve as a consultation tool for adolescents and youth. Also in 2019, UNFPA worked with the Ministry of Education to implement the “school approach” in which maternal and child health nurses in public schools offer monthly outreach activities providing reproductive health information, contraceptives, HIV counselling and vaccination. UNFPA Supplies supported the mobilization of 15 Visiting Service Providers (VSPs) in Nepal in 2019, reaching remote locations in three districts with low use and availability of family planning services. The VSPs provided long-acting reversible contraceptive (LARC) services (primarily contraceptive implants) to 2,833 women and girls, more than half from marginalized communities. 19 UNFPA SUPPLIESANNUAL REPORT 2019 02 © UNFPA CHAPTER TWO Supply chain strengthening for access and choice Clement Rurangwa, store manager at Mayange District Pharmacy, Bugesera, Rwanda, outlines the order management system he uses for reproductive health supplies Access and choice rely on strong supply chains all along the path from manufacturer to individual contraceptive user. The most difficult part of the supply chain is reaching the last mile, with many elements that must stretch that far, including transportation, trained health providers and quality-assured contraceptives. Guided by the UNFPA 2017 Supply Chain Management Strategy, UNFPA Supplies continued to assist countries in strengthening their global procurement and distribution operations, and provided financial and technical support to country programmes to improve their supply chains and ensure products reach the intended beneficiaries. TOWARDS RELIABILITY AND SUSTAINABILITY OF NATIONAL SUPPLY CHAINS Strengthening supply chains to meet the growing demand for family planning requires efforts at many levels. To measure progress in this area, the UNFPA Supplies programme tracks indicators such as the existence of a costed supply chain strategy, shelves stocked with supplies, and systems for forecasting and procurement. Having no stock-outs is one sign that a country’s supply chain is functional. • 12 countries have in place a supply chain management strategy with a costed implementation plan with a human rights approach, up from 11 in 2018. • Burundi, Guinea-Bissau, Mali, Nigeria, Sao Tome and Principe and Sudan experienced no stock-outs in 60 per cent or more of service delivery points within a three- month window in 2019. • 43 countries have a functioning commodity forecasting and procurement system, up from 40 in 2018. • 45 countries made no ad hoc requests to UNFPA Supplies for commodities (except in humanitarian contexts). Stock-outs of popular contraceptive products are common and persistent across many countries, due to various inefficiencies and bottlenecks. The two most common reasons in 2019 were transportation delays from the warehouse (which impedes timely restocking at the service delivery point) and not placing an order on time (mostly due to low client demand or lack of trained staff available to provide a method). A reliable stock of contraceptives helps to ensure that a woman will have access to her method of choice and, if she experiences side effects or has other concerns, she will have access to a different method. Voluntary choice is an important element in user satisfaction and method continuation. 21 UNFPA SUPPLIESANNUAL REPORT 2019 BETTER LOGISTICS MANAGEMENT INFORMATION SYSTEMS UNFPA Supplies supports the creation, maintenance and troubleshooting of supply chain management technology. Better logistics management information systems (LMIS) have been a programme priority from the start. Electronic data collection and systems allow frequent sharing of updates related to purchase orders, stock inventory, product consumption, and shipment and delivery statuses across a complex network of supply chain actors. In the 46 programme countries in 2019: • 40 countries have eLMIS (electronic, automated and computerized logistics management systems), up from 36 in 2018. • 31 countries have a logistics system meeting six fundamental criteria, up from 30 in 2018. • 34 countries have staff trained in LMIS in most service delivery points. In Zambia, the national system was extended to primary-level service delivery points in 2019 for the first time. Lesotho joined the 31 countries with a fully functional eLMIS. MYANMAR: STRENGTHENING THE REPRODUCTIVE HEALTH COMMODITY LOGISTICS SYSTEM UNFPA supported the scale-up, testing and functionality of a national Reproductive Health Commodity Logistics System (RHCLS) for Myanmar in 2019, in coordination with the John Snow Research and Training Institute Inc. and the Maternal and Reproductive Health Division of the Department of Public Health. The LMIS is currently functional in 178 townships of 12 states or regions. In addition, an eLMIS is functional in 148 townships of 10 states or regions; this includes the addition of 44 townships in Chin State and Sagaing regions during 2019. The stock status of family planning supplies and other reproductive health commodities were regularly reviewed throughout 2019. Data generated from the eLMIS informed a resupply and distribution plan in addition to a plan for the reallocation of commodities from overstocked locations to those facing shortages or stock-outs. Although the UNFPA facility- based survey recorded an increase in stock-outs in 2019, this was due to specific challenges in condom availability and local transportation. In practice, the availability of commodities as well as the percentage of health facilities that can offer family planning and lifesaving maternal health commodities increased. The status of RH commodity security in Myanmar has significantly improved. A woman receives counselling on different methods of contraception in Myanmar, where a stronger logistics management information system will improve access and availability. © UNFPA Myanmar. UNFPA SUPPLIES ANNUAL REPORT 201922 TIMELY PLANNING AND RESPONSE Meeting regularly to discuss forecasting and quantification issues is one aspect of UNFPA Supplies support, and in 2019 three key mechanisms facilitated this work. • UNFPA Supplies introduced the Commodity Quarterly Review process for the 46 programme countries in 2019. This review captured data on stock levels, consumption rates, pipeline orders, geographical distribution as well as service coverage for each of the commodities – disaggregated by the implementing partners. • In a quarterly exercise to pinpoint areas for improvement, 36 countries applied the “Supply Chain Maturity Model” across different sectors and partners, and assessed stock levels to identify supply chain weak points. • UNFPA Supplies was instrumental in the 2019 launch of the UNFPA Supply Chain Management Online Portal. The portal is a new resource to promote peer learning and provide easy access to resources and information relevant to the supply chain, including policy documents, tools, templates and forms. EVIDENCE-BASED PRACTICES TO STRENGTHEN SUPPLY CHAINS Supply chain management organizes the vast network of supply chain actors – procurers, manufacturers, shippers, distributors, warehouse agents, facility managers and service providers – in a system to ensure timely delivery of products from the port, to central and subnational warehouses, and to service delivery points and communities. An issue paper titled “Improved Availability and Reliable Supply of Quality of Contraceptives” MOZAMBIQUE EXPANDS ELECTRONIC LMIS With strong commitment by the government and partners, Mozambique has introduced a national eLMIS (an electronic computerized logistic management information system) to support supply chain tracking at several levels. The eLMIS was piloted in 2017 reaching 157 health facilities, greatly expanded in 2018 with UNFPA support to reach 643 new health facilities and expanded again in 2019 for a total of 1,022 facilities using the eLMIS. The system tracks availability of medicines, including reproductive health supplies at health facility level, identifies potential stock-outs and expirations and promotes the implementation of immediate corrective measures. This tool also enables health facilities to process requisitions and guarantee effective warehousing procedures. © UNFPA/Amancio Vilankulos. Constangelina Basílio with her son, Magalhães. Ms. Basílio nearly died while giving birth to Magalhães. She now works as a community health activist, teaching women about the health benefits of family planning. “I also inform [local women] to go to the clinic to receive information that will help them to delay and space pregnancy, and to access different contraception methods for free to better plan their families,” she said. 23 UNFPA SUPPLIESANNUAL REPORT 2019 was developed and shared with participants at the UNFPA Global Consultation on Ending Unmet Need for Family Planning in June 2019. The group issued the following recommended actions on supplies and supply chain strengthening: • For more effective and efficient supply chains, identify key areas where UNFPA has scope to support. Conduct supply chain maturity assessments and prioritize actions on two to three bottlenecks. • Ensure reliable access to contraceptives and lifesaving maternal health medicines to the last mile. Address distribution and other challenges in reaching hard-to-reach populations, including in humanitarian settings. Interrelated elements of the reproductive health supply chain Source: High Impact Practices in Family Planning (HIP). Supply chain management: Investing in the supply chain is critical to achieving family planning goals. Washington, DC: HIPs Partnership; 2020 Transportation & Customs Clearance Procurement (locally funded or from donors) Dispensing & Inventory Management Coordination with Global Procurers/ Partners Warehousing & Receiving Manufacturing & Supplying Order & Shipments Tracking Forecasting & Supply Planning Distribution UNFPA SUPPLIES ANNUAL REPORT 201924 Measures to reach the last mile met with success in the Democractic Republic of the Congo and in Nigeria in 2019. In the DRC, contraceptive coverage for family planning services reached 100 per cent in South Kivu and Tshopo in a coordinated effort of UNFPA, USAID and other partners to serve communities in these hard-to-reach regions. Reflecting a commitment to reach the last mile for universal access to reproductive health care, UNFPA supported construction of two maternity hospitals in two islands of the Congo River to deliver family planning and other reproductive health services to communities in the area. The project will also purchase a “family planning boat” for service delivery in other isolated islands and the evacuation of pregnant women to the mainland. UNFPA Supplies provides support for procurement of commodities and provision of services. In Nigeria, an initiative to increase last- mile distribution of contraceptives to nine states was expanded in 2019, building on the success of a pilot in five states in 2018. In related work, capacity development focused on preparing health logisticians at all levels in nine states to use the National Health eLMIS data for evidence-based decision-making. The IMPACT model was used in training for 140 supply chain managers in 2019. IMPACT stands for Information Mobilized for Performance Analysis and Continuous Transformation. IMPACT teams met regularly throughout the year to review data and solve supply chain problems. Improvements were recorded in both demand for and use of data and in the reporting rates in the national health LMIS. © UNFPA/Nigeria/Kori Habib. GOING THE LAST MILE IN DEMOCRATIC REPUBLIC OF THE CONGO AND NIGERIA Hajja Fati has her contraceptive implant removed. It had enabled her to finish school, which in turn improved her family’s financial prospects. Now, she said, she and her husband feel it is the right time to get pregnant. “I am ready to have another child, and so it’s a well-planned arrangement that is ok for us,” she explained. Improved last- mile distribution of contraceptives in Nigeria enables women like Ms. Fati to choose whether and when to become pregnant. This is all the more important in northeastern Nigeria, where Ms. Fati lives, where half the population required humanitarian assistance in 2019. 25 UNFPA SUPPLIESANNUAL REPORT 2019 UNFPA Supplies also contributed to updating the High Impact Practice (HIP) on family planning and supply chain management, with a focus on action strengthening supply chain performance and meeting the product needs for family planning and other health programmes. The HIP calls for action in key areas: • Increase data visibility and use for continuous improvement. • Speed-up product flow through the supply chain and reduce inventory. • Build and support a competent, professional supply chain workforce. • Capitalize on private sector supply chain capacity, where appropriate. Disruption at any point along the supply chain can result in a lack of product availability, leaving a woman stranded without her contraceptive method of choice. GAINING PROGRAMME VISIBILITY VIA LAST MILE ASSESSMENTS The ability to deliver to the last mile has become an organizational priority across UNFPA, visible in programming and financial commitments. The aim is to ensure that countries receive the assistance they need for ending the unmet need for family planning even among those who are hardest to reach. Delivering supplies and services to the last mile requires strong supply chains and an understanding of the risks and risk mitigation measures needed. • Extensive new last mile assessments looked closely at how the supply chain is working in 16 UNFPA Supplies-supported countries that receive the largest volumes of donated reproductive health supplies. All 16 planned assessments for 2019 were completed and reports shared with participating countries. The assessments tracked the management of commodities once they enter a country all the way to the point of distribution, shedding light on bottlenecks and seeking strategies for mitigating risks. They identified a number of challenges including a lack of reliable data, limited tracking of stock-outs, inability to reconcile amounts received with amounts delivered, shortages and excess stocks, and other issues commonly found in countries with weaker logistics management information systems. UNFPA engaged with a third-party firm to carry out these assessments, which were conducted by UNFPA in partnership with local UNFPA country offices, governments and key implementing partners. Funding was provided through UNFPA Supplies and UNFPA core resources. While the assessments were being carried out, the last mile assurance process (LMA) was developed and rolled out. The LMA is a UNFPA organization-wide process intended to give the organization more visibility into country supply chains and to ensure last mile 16 Last Mile Assessments Completed in 2019 in UNFPA Supplies countries that receive large volumes of supplies UNFPA SUPPLIES ANNUAL REPORT 201926 GLOBAL FP VAN Data platform for supply chain visibility and decision-making COUNTRY PROCURERS MANUFACTURERS CLOSING THE LOOP delivery of the donated health supplies it provides. The process has produced supply chain maps, risk assessments, programme supplies reports, guidance notes, webinars and fact sheets. ENHANCING DATA FOR DECISION-MAKING Strengthening supply chains to meet the growing demand for family planning will require better data insight into the movement of products. Routine data collection from service delivery point is also important and helps managers understand stock levels (how much product is sitting in inventory) versus being regularly consumed. Global Family Planning Visibility and Analytics Network In January 2019, the Reproductive Health Supplies Coalition launched the Global Family Planning Visibility and Analytics Network (Global FP VAN), a new resource that integrates and aggregates supply chain inventory and order and shipment data from many different health systems into a single platform. The Global FP VAN intends to merge data from across more than 20 siloed systems and tools – the same data that the CARhs and CSP groups (section 2.6) historically had to gather and triangulate manually under complex confidentiality agreements. By early 2020, the two groups had merged and over 100 Global FP VAN users could track over 2,000 orders and 1,800 shipments from across 115 countries. Three countries (Ghana, Malawi and Nigeria) received master trainer training, integrated the Global FP VAN into their health system strengthening work, and started using the platform for internal decision-making. Benefits of the Global FP VAN extend beyond its over 100 active official users. In early 2019, it launched “RH Viz”, a set of public dashboards that pull data from the network and allow users to analyse more than $2 billion worth of contraceptives orders and shipments globally. In addition, legal parameters are now being developed to replace the bilateral confidentiality agreements of the past, which could transform the way the global community works and shares information. UNFPA Supplies contributed funding and technical assistance in 2019. From 2020, funding contributions to the Global FP VAN will be supported through core resources as a corporate UNFPA priority. Commodity Requirement Tool UNFPA Supplies continued to use the Commodity Requirement Tool (CRT) to identify risks of stock-out and surplus, funding gaps and duplication of orders, and recommended action to resolve these issues. The CRT, introduced in 2018, supports annual commodity planning and management and calculates commodity requirements using data from implementing partners on stock levels, pipeline orders, consumption rates, DHS data on population size and contraceptive prevalence rate per method, geographical coverage, programme 27 UNFPA SUPPLIESANNUAL REPORT 2019 coverage and future expansion projections. By using this tool in combination with the Quarterly Commodity Review (newly introduced in 2019), UNFPA was able to identify potential risks of overstocks, as in the case of two-rod implants in Guinea. This helped UNFPA advocate with key partners towards scaling up their programming initiatives to expand product uptake, increase geographical coverage and address delays in shipping of orders. Data innovations Several countries introduced innovative new ways to collect data in 2019, in some cases using mobile technology to measure stock levels. In Uganda, this included the development, deployment and testing of DrugDash, a mobile and web-based system that enables district health officers and health workers to access real-time data on family planning stock at facility level, within and between health facilities in districts. The pilot test in three districts reported enhanced stock status at district level, which is significant for improving access to a choice of family planning methods. In Sierra Leone, responding to stock and data challenges at service delivery points, UNFPA Sierra Leone and the Ministry of Health developed a national Commodity Distribution System. Activities related to this system included engaging and training primary-level health facility staff, conducting on-the-job training with mentoring and supervision, and establishing a nationwide distribution monitoring system for family planning supplies to the last mile. Quantification working group meetings and a midyear supply plan review were backed up with data collected by district supply teams. Use of a pharmaceutical dashboard for data entry enabled users to view stock status and stock-out rates at SDPs and district medical stores and informed decision-making for distribution and quantification. PARTNERSHIPS ARE CRITICAL TO STEADY, RELIABLE, QUALITY SUPPLIES The public health supply chains in many countries have three to four “tiers” (e.g. central, provincial, district, service and delivery levels). Warehouses and storage are found at each level, which means the inventory spends time “stopped” in warehouses. This raises a number of concerns, including increased supply chain costs, and increased probability of damage, theft, expiration and stock-outs. Two key partnerships help UNFPA Supplies address these concerns, as part of efforts to speed-up product flow through the supply chain and reduce inventory. Coordinated Assistance for Reproductive Health Supplies (CARhs) UNFPA actively engaged in the CARhs partnership in 2019 to deal effectively with shortages and overstock situations through UNFPA SUPPLIES ANNUAL REPORT 201928 coordination with donors and implementing partners. Between January and December 2019, the CARhs group resolved 523 requests for information, technical support, and funding through review and analysis of stock status reports from over 62 family planning programmes in 31 countries. Overall, 121 supply imbalance issues reported by countries were reviewed and resolved. Coordinated Supply Planning Group (CSP) In 2019, CSP reviewed and addressed requests and orders for 37 countries, responding to flagged issues. CSP is a cross- organizational team that strives to prevent family planning commodity stock imbalances by using shared supply chain data and information to better coordinate shipments and the allocation of resources within and among countries. CSP members include representatives of the UNFPA Procurement Services and Commodity Security Branches (UNFPA Supplies Secretariat), USAID, CHAI, John Snow, Inc. (JSI), the Global Health Supply Chain Procurement and Supply Management project (GHSC-PSM), and the Reproductive Health Supplies Coalition (RHSC). CSP members work together on two main activities: monitoring supply outlooks for programmes in 39 countries and analysing country and programme funding gaps. A joint video with MSI was filmed in Uganda, showcasing the importance of the UNFPA and MSI partnerships around commodities and services. Salume, a student and business owner, chose a contraceptive implant lasting three years. 29 UNFPA SUPPLIESANNUAL REPORT 2019 03 © UNFPA Haiti CHAPTER THREE Expanding access to contraceptives in humanitarian settings In southeastern Haiti, Nélia has decided to use a long-acting contraceptive implant. Health worker Jacqueline Etienne prepares to insert it into her arm. In Haiti, mobile clinics are proving the best way to reach rural and humanitarian-affected populations with family planning services including a choice of contraceptives. Reaching the last mile requires measures at many levels, from pre-positioning emergency RH kits as part of a humanitarian response plan, to sending out mobile health teams over poor roads in perilous conditions to deliver much-needed reproductive health supplies. Under crisis conditions, disruption to supply chains is common. The programme continued in 2019 to focus on equity across all interventions, addressing the most vulnerable and hard-to-reach populations, including those in humanitarian crises. SUPPLY CHAINS IN HUMANITARIAN SETTINGS UNFPA Humanitarian Supplies Strategy The first draft of the new UNFPA Humanitarian Supplies Strategy (HSS) was developed in 2019. Building on the extensive and long-standing UNFPA presence in countries, the HSS provides a strategic approach for UNFPA’s humanitarian action to help meet women’s and girls’ supply needs during preparedness, response and recovery from crises. UNFPA is well-positioned to bridge the humanitarian– development nexus through more streamlined and integrated supply chain management activities across all divisions and levels, and in coordination with external public, NGO and commercial sector partners. The Strategy reflects the evaluation of UNFPA capacity to respond to crises (2019) and is also in line with the United Kingdom Department for International Development (DFID) Review of UNFPA Supplies in Humanitarian Settings (2018) that recommends better alignment under a strategic and well-planned approach, particularly for humanitarian response. It provides 20 strategic recommendations, a narrative that will help decision makers envision a continuum from crisis through recovery and links to the 2030 Agenda for Sustainable Development. These recommendations will be incorporated, where relevant, in the design of the new country support model of the third phase of the UNFPA Supplies programme. REPRODUCTIVE HEALTH KITS: ESSENTIAL SUPPLIES IN CRISES During the acute phase of emergencies, ready-made reproductive health kits provide lifesaving sexual and reproductive health services. In 2019, UNFPA Supplies supported provision of Inter-Agency Reproductive Health Kits for Crisis Situations to 18 countries. RH kits are designed to respond to various population sizes and needs; the most basic of these is the clean delivery kit provided to visibly pregnant displaced and refugee women and adolescent girls. The largest kit weighs over a ton and can equip a surgical maternity ward. The family planning kits contain male and female condoms, oral contraceptives, subcutaneous and intramuscular injectable contraceptives, and intrauterine devices. 29 of 46 UNFPA Supplies countries experienced fragility, conflict or natural disaster in 2019. 31 UNFPA SUPPLIESANNUAL REPORT 2019 In both humanitarian and development settings, UNFPA Supplies monitors stock- outs among the many implementing partners who distribute supplies procured through the programme. • Stock levels improved in 2019 in humanitarian and fragile contexts for all RH kits provided to implementing partners by UNFPA Supplies and other UNFPA sources – with implementing partners in 32 of 37 countries facing humanitarian contexts reporting no stock-outs. UNFPA updated the specifications for the Inter-Agency Reproductive Health Kits in 2019, including designing complementary commodity kits for specific contexts and widening the choice of contraceptives for those in humanitarian settings by offering subcutaneous DMPA and implants not available in the standard RH kits. These new kits will be rolled out in the second half of 2020. In addition, UNFPA updated the related guidelines and field manual for all partners using RH kits and strengthened the capacity of focal points for reproductive health commodity security in UNFPA Supplies provided RH kits to reach 2.8 million women in 2019 CONTRACEPTIVES Kit 1 Male and Female Condoms Kit 4 Oral and injectable contraception Kit 7 Intrauterine devices (IUDs) STI TREATMENT Kit 5 Treatment of sexually transmitted infections Kit 2 Clean Delivery Kit 6 Clinical delivery assistance Kit 8 Management of miscarriage and complications of abortion Kit 9 Suture of tears and vaginal examination Kit 10 Vacuum extraction delivery Kit 12 Blood transfusion kit** Kit 11 Referral level kit for reproductive health MATERNAL HEALTH CARE *Includes emergency contraceptive pills / **Includes HIV tests 2.8m women & girls reached in 2019 2.1m 2018 1.4m 2017 1.3m 2016 TREATMENT FOR SURVIVORS OF SEXUAL VIOLENCE Kit 3 Post rape treatment* UNFPA SUPPLIES ANNUAL REPORT 201932 27 countries could provide training in 2019 to conduct comprehensive Minimum Initial Service Package (MISP) training as a result of UNFPA Supplies support. 40 countries had capacity to offer basic MISP following training funded through UNFPA Supplies. UNFPA Supplies countries in humanitarian settings. UNFPA and partners worked to set the required guidelines and training for introduction of the revised RH kits, including their role in lifesaving humanitarian response. In 2019, UNFPA also focused on freight delivery for RH kits, supported the transition from RH kits to procurement of reproductive health supplies through strengthened national supply chains, and addressed the different logistics needs of mixed settings experiencing both development and humanitarian situations. MISP Calculator and RH Kits Calculator` Two tools for use in supporting the sexual and reproductive health needs of populations in crises were revised in 2019. The MISP calculator supports programming when there is a lack of available data for a population facing crisis on key areas such as the number of women of reproductive age, how many women are pregnant, HIV prevalence or number of women at risk of sexual violence. The tool uses available data from other contexts, applies assumptions agreed by the Inter-Agency Working Group on Reproductive Health in Crises (IAWG) that are applicable to the context, and produces estimates of population needs for UNFPA and partners to use in planning programme, response, advocacy and fundraising. The second tool, the RH Kits Calculator, builds on the MISP calculator and supports ordering of supplies to meet the needs of the population at all levels, from communities to referral hospitals. It was revised in 2019 and will be released in 2020. FAMILY PLANNING IN HUMANITARIAN AND FRAGILE CONTEXTS The UNFPA Global Consultation on Ending Unmet Need for Family Planning in June 2019 addressed the particular challenges and opportunities for accelerating access to family planning in humanitarian settings. Discussion was informed by an issue paper. The consultation identified and agreed to a set of recommended actions to “ensure availability of good quality, human rights- based family planning services”: • Ensure that sexual and reproductive health, including family planning, is integrated into national and subnational disaster risk reduction strategies as well as in preparedness, response and contingency plans within the United Nations Sustainable Development Cooperation Framework (UNSDCF) and universal health coverage (UHC). • Advocate for sustained, multi-year and flexible financing for family planning across the humanitarian-development nexus with a focus on preparedness and transition phases, and promote domestic funding and finance bridging mechanisms, such as “transitional funds”. • Reinforce quality of care as the foundation for integrated and universal sexual and reproductive health package of services, throughout a strong health system that guarantees the availability of contraceptives to the last mile, driven by 33 UNFPA SUPPLIESANNUAL REPORT 2019 geo-localized and locally owned family planning programmes that meet the needs of affected populations including vulnerable groups. With support from UNFPA Supplies, countries incorporated these actions into their 2020 annual workplans and ongoing activities towards the 2030 Agenda. A thematic paper prepared in advance of the consultation contributed to ongoing efforts to build the evidence base for advocacy. UNFPA Supplies also supported development of a High Impact Practice on Family Planning in Humanitarian Settings: A Strategic Planning Guide that underscores the lifesaving impact of family planning. The guidance leads key decision makers through a strategic process to identify actions that improve family planning access in places at risk of experiencing, and towards recovering from crisis events. It also offers a list of preparedness actions, crisis response actions and coordinated transition actions. COUNTRY RESPONSES IN HUMANITARIAN AND FRAGILE CONTEXTS With almost two thirds of UNFPA Supplies countries in situations of fragility, conflict, natural disaster and other emergencies, the programme supported a range of responses in 2019. In Benin, the MISP was implemented in areas affected by landslides. UNFPA strengthened capacities at municipal level in the preparedness and response to emergency situations and disasters, focusing the areas of Cobija, Cochabamba and Tupiza. EXPANDING CONTRACEPTIVE ACCESS IN A CAMP FOR THE DISPLACED The Somali Region of Ethiopia has extremely low rates of contraceptive use and very high fertility, with women having some seven children on average. The region also hosts the largest number of displaced persons in the country. Access to voluntary family planning is especially important for women in these contexts, where the dangers of pregnancy and childbirth are exacerbated. In 2019, UNFPA Supplies supported the supply of reproductive health kits containing contraceptives including male condoms, oral contraceptives, injectable contraceptives and intrauterine devices. UNFPA Supplies also supported training of health-care providers, community leaders and women’s advocates to provide accurate messages about family planning and information about women’s rights. Mrs. Trik Dulene benefited from one such training programme and feels that she has been able to make a difference for women in the Kologe II displacement camp. “I talk to women about delaying their pregnancies – at least until they get out of here and start earning their own incomes,” she told UNFPA. Community member Trik Dulene (sitting) in the Kologe II displacement camp where she teaches women about family planning. © UNFPA Ethiopia. UNFPA SUPPLIES ANNUAL REPORT 201934 In Burkina Faso, a surge in violence in 2019 displaced nearly half a million people. As part of its humanitarian response, UNFPA Supplies supported RH kits with contraceptives and other supplies. In Chad, three of six UNFPA-supported intervention provinces are humanitarian zones, with refugees and displaced from the Boko Haram crisis and others. In 2019, UNFPA contributed to supporting midwives to acquire the necessary skills and commodities to scale up the provision of services and supplies for family planning and other reproductive health needs in refugee camps and for crisis-affected communities. In Ghana, flooding led to a UNFPA partnership with the National Disaster Management Organization to deliver kits containing condoms and hygiene supplies to communities in the northern region. In Iraq, though beyond its programme countries, UNFPA Supplies supported UNFPA’s humanitarian response to facilitate the transition from MISP approaches, including shifting from reliance on RH kits to bulk (regular) procurement of reproductive health commodities. In South Sudan, more than 100 participants gained an understanding of the benefits and logistics of reproductive health services and supplies, including for family planning, at a workshop in Juba. The December 2019 event was attended by parliamentarians, women’s group leaders and representatives from the South Sudan Council of Churches and Islamic Council as well as youth, teachers, traditional chiefs and health workers. ENSURING SUPPLIES IN YEMEN The crisis in Yemen remains the world’s largest humanitarian emergencies. In 2019, over 80 per cent (24 million) of the country’s 30 million people were in need of humanitarian assistance. In 2019, the roll-out of the RH/LMIS system that was initiated in 2018 continued, reaching 20 of the 22 governorates of Yemen (291 of 333 districts) by the end of the year. Data on commodity availability and service use was entered by trained logistics focal points – some 331 received training at district level in 2019 and were provided with the required computer hardware. Also in 2019, the newly revived Reproductive Health Commodity Security Technical Committee carried out quantification and forecasting of RH commodities for the year 2020 using the Commodity Requirements Tool. © UNFPA Yemen Midwife Rawthah Ahmed performs house calls in a conflict-affected village in Yemen, where humanitarian needs are greatest. 35 UNFPA SUPPLIESANNUAL REPORT 2019 04 © UNFPA Tanzania/Karlien Truyens CHAPTER FOUR Towards sustainable financing for family planning Nurse Ramla Mjaka consults with Jaria Hamad, a mother of four, about voluntary family planning at Uondwe Health Facility, Pemba Island, Zanzibar, Tanzania, where the fertility rate is high. In 2019 the Government and partners supported the development of an action plan for a Total Market Approach to increase affordability of family planning services and supplies. Investment by the government in this plan, accompanied by the presence of specialized health facilities supported by UNFPA, is giving families the power to choose. The resources to sustain family planning programmes – reaching the last mile, sustaining gains, meeting needs – must come from diverse sources in countries that have been dependent on external assistance. In 2019, UNFPA worked to increase the financial resource envelope for family planning, looking towards domestic funding sources including insurance schemes, global funding, prioritizing collaboration and partnerships, and seeking greater effectiveness and efficiency. The programme provided technical assistance to countries to support their efforts to sustainably strengthen the resource environment for family planning. INNOVATIVE APPROACHES FOR SUSTAINABLE FINANCE: COUNTRIES TAKING ACTION The UNFPA Conceptual Framework on Sustainable Financing for Family Planning identifies three main pillars to secure sustainable investments in family planning: • making the case for investing in family planning, or “reframing”; • expanding the sources and amounts of financing, including domestic resources; • ensuring the best, most efficient use of all available resources, from procuring contraceptives to reaching those left behind. UNFPA Supplies documented examples of actions taken in line with the conceptual framework to secure sustainable financing for family planning that were published in Gates Open Research. The examples contributed to the evidence base for actions that programme countries can take including through integrating family planning into multisectoral investments, and advancing innovative financing models to secure additional domestic resources. MAKING THE CASE FOR INVESTING IN FAMILY PLANNING Increased domestic resource mobilization through evidence generation UNFPA Supplies takes an active role in supporting countries as they make the business case for investing in family planning, assisting with rigorous analysis of costs and benefits that are required to drive policy reforms and increased domestic financing. This work includes preparations for national transitions from donor funding as well as aligning with global resources. In 2019, for example, UNFPA Supplies supported country offices to engage with the Global Financing Facility (GFF) process and demonstrated how to build evidence around investing in family planning through the GFF Investment cases. Family planning business cases for three countries in Africa A business case for family planning in Rwanda was developed in 2019 with technical and financial support from UNFPA and the Government of Belgium, along with USAID, WHO and key national partners. It was the first comprehensive study and 37 UNFPA SUPPLIESANNUAL REPORT 2019 investment case undertaken to assess the benefits and financial sustainability of family planning programmes in the country. The Ministry of Health called on stakeholders to use the business case for evidence-based advocacy and to mobilize more resources in order to achieve universal access to family planning. The study presents an estimated impact of family planning on the sectors of health, education, infrastructure, agriculture and economy (i.e. poverty and employment) and makes a powerful argument for investing in family planning to achieve the Sustainable Development Goals. As part of efforts supported through the UNFPA Supplies Ouagadougou Partnership Commodity Matching Fund, business cases were developed for Burkina Faso and Mali placing voluntary family planning in the context of existing national laws, policies and development plans. The analyses focus on savings from costs averted by the use of contraception (e.g. direct costs of births, infant deaths and maternal deaths averted) combined with reduced education costs resulting from reduced need for teachers and school infrastructure. It is noted that extending these analyses to other economic domains would increase the projected savings. The Burkina Faso business case estimates CFA 111 billion (approximately US$183 million) could be saved by 2030, and each CFA franc invested gives a return on investment (due to future spending averted) of between CFA 24 and 100 – a rate of return that dwarfs other public investments. In Mali, using a similar methodology, calculations show that if use of modern contraception increases by 50 per cent by 2030, this will translate into cumulative gains by 2030 estimated at CFA 439 billion (approximately US$724 million) in terms of public spending, as well as lives saved and improved. Building the evidence base for seven countries in Latin America Joint procurement for reproductive health supplies was identified by UNFPA and the Latin American and Caribbean Forum for Reproductive Health Commodity Security (ForoLAC) as having potential to yield significant cost-savings, among other benefits. A series of fact sheets titled “Performance and Optimization of Investments in Sexual and Reproductive Health” was developed in 2019 for Argentina, Chile, Ecuador, El Salvador, Guatemala, Mexico and Nicaragua. The fact sheets provide an evidence base for government investment in reproductive health supplies as a strategic intervention, and highlight health and social impacts yielding high economic returns critical for achieving the Sustainable Development Goals. For example, if 10 Latin American Countries were to pool procurement for combined oral contraceptives at the lowest price in the region, total savings would have been $3.5 million for this single product. UNFPA and ForoLAC held meetings with technicians from 13 countries and then developed a plan to improve national purchases, strengthen public investments, $183m Savings estimated in the Burkina Faso Family Planning Business Case UNFPA SUPPLIES ANNUAL REPORT 201938 and establish a public pricing price base for sexual and reproductive health supplies through SEPREMI, a new business intelligence tool launched in June 2019 by ForoLAC and developed by national procurers across the region to help them negotiate more effectively with pharmaceutical manufacturers. In addition, the planning tool MiPlan was designed to facilitate domestic resource mobilization by identifying target populations, evaluating past performance, running simulations considering changes in resources or acquired supplies or prices, and forecasting potential impact Advocacy for family planning in UHC, national plans and budget lines Countries in the UNFPA Supplies programme continued to make the case for investing in family planning. The Government of Kenya incorporated family planning in the universal health coverage (UHC) package in 2019. The Government’s decision followed advocacy in which UNFPA, donors, development partners including USAID, the United Kingdom’s DFID, The Bill & Melinda Gates Foundation and other stakeholders played a central role. The benefit package is being rolled out in four pilot counties, with plans to reach the other 43 counties in 2020. In Sierra Leone, UNFPA engaged in a resource mobilization drive, the Saving Lives in Sierra Leone project, with support from DFID, to secure additional resources for family planning and reproductive health commodity security initiatives. The project mobilized approximately $3 million in funding for contraceptive procurement for 2019 and 2020. UNFPA also engaged in active and ongoing advocacy to secure domestic resources through a dedicated budget line for commodity procurement. In Zambia, UNFPA worked with the Government to ensure that family planning is included in the Seventh National Development Plan (2017–2021). These advocacy efforts were augmented by the launch of key strategic frameworks. The Costed National Health Supply Chain Strategy allows community-based distributors to administer injectable DMPA (both intramuscular and subcutaneous). Also, a new policy allows for self-administration of injectable subcutaneous DMPA, increasing privacy and convenience for women and adolescent girls. ICPD25 Summit Policymakers Dialogue on Ending Unmet Need for Family Planning To drive accelerated progress and ensure sustainability through transition to domestic financing, UNFPA Supplies convened an ICPD25 Summit dialogue for policymakers with a focus on policy changes and funding needs for family planning. The discussion, including ministers from Gambia, Kenya and Rwanda and representatives from the European Union and Norway, was informed by inputs from the private sector, civil society and academia, and revolved around building a shared vision and commitment to family planning as the foundation for achieving the Sustainable Development 39 UNFPA SUPPLIESANNUAL REPORT 2019 Goals. Speakers highlighted the various innovations and approaches countries are taking in their transition to middle-income status to expand access to reproductive health services, especially family planning, as part of achieving universal health coverage. EXPANDING SOURCES: MOBILIZING FOR MORE DOMESTIC FUNDING RESOURCES Transitioning to a sustainable approach in domestic resource mobilization requires a sum of multiple efforts including multisectoral coordination, strong political will, fiscal space planning capacity and long- term commitment. Countries supported by UNFPA Supplies are encouraged to raise the level of domestic funding for family planning, which is a commitment visible in budget lines for contraceptives. • 28 countries allocated funds through national budget lines for contraceptives and 13 countries for maternal health medicines in 2019. • Countries in UNFPA Supplies allocated more domestic resources for procurement of contraceptives, with allocations of $43.8 million in 2019 compared with $41.8 million in 2018. • Countries supported through the UNFPA Supplies programme spent some $5 million more on procurement of contraceptives using domestic funds, with expenditures of $30.3 million in 2019 compared with $24.9 million in 2018. Higher allocations than the previous year were recorded in eight countries supported by the UNFPA Supplies programme: Benin, Bolivia, Côte d’Ivoire, Lao PDR, Malawi, Mauritania, Mozambique and Niger. Countries made these commitments despite challenging financing and competing policy constraints, recognizing the importance of reducing dependency on external funding as part of a transition towards more sustainable financing in the future. UNFPA Supplies continued to explore the use of national supply plans, in addition to national budget lines, as an opportunity for governments to make financial commitments to funding quantities of commodities. Recent analysis of plans for 2019 and 2020 identified 27 programme countries with such a commitment in their plans, which suggests an opportunity for the programme to work with the remaining countries to incorporate this domestic funding element in their national supply plans as of 2021. Domestic funds are making a difference in many countries, as in the following examples of 2019 progress: • In Madagascar, the Government quadrupled its budget for contraceptives, following UNFPA Supplies-supported conferences and discussions. • In the Democratic Republic of the Congo, advocacy efforts encouraging the $24.9m to $30.3m Increasing domestic fund use for contraceptive procurement by countries 2019 30.3 million 24.9 million2018 UNFPA SUPPLIES ANNUAL REPORT 201940 New domestic financing was met with a matching $4.46 million in Burkina Faso, Côte d’Ivoire, Guinea, Niger and Togo through the UNFPA Supplies Ouagadougou Partnership Commodity Matching Fund, an initiative that creates an incentive to boost domestic resources for family planning. Supported by The Bill & Melinda Gates Foundation and other technical and financial partners, the 2:1 matching fund mechanism allocates $2 for every additional dollar of domestic funding from the previous year, delivered as contraceptives up to $15 million in value through the UNFPA Supplies programme. It also offers another $3 million in technical assistance support for family planning uptake and sustainable finance. 2019 was the first year of operation of this three-year initiative (2019–2021). UNFPA initiated and completed a verification process to ensure the eligibility of countries for participation, and reviewed each country’s annual national supplies and procurement plans. Five of nine countries in the Partnership were identified as eligible for matching funds in 2019 and, as a result, received donated contraceptives funded by the initiative at a total value of $4.46 million (commodity cost and administrative cost). A communication and advocacy plan, operational plan and two family planning business cases (Burkina Faso and Mali) were also developed in 2019. © UNFPA Guinea THE UNFPA SUPPLIES OUAGADOUGOU PARTNERSHIP COMMODITY MATCHING FUND Nurse Mariama Sire Kaba consults with a client on the range of quality contraceptive methods from which she can choose at the Matam Health Centre in Guinea. The Government’s commitment to procuring contraceptives with its own funds is critical to the long- term sustainability of its family planning programmes. In 2019, national spending on contraceptives was met with a contribution from the UNFPA Supplies Ouagadougou Partnership Commodity Matching Fund. 41 UNFPA SUPPLIESANNUAL REPORT 2019 Government to increase its budget for contraceptives met with success in 2019, with a national commitment to allocate and disburse $2.5 million per year starting in 2020. • In the Central African Republic, advocacy efforts helped to align family planning with the 10 areas of presidential impetus for universal health coverage. • By increasing domestic financing for contraceptives, and through UNFPA’s support for strengthening the country’s supply chain management system, Ethiopia has helped increase its contraceptive prevalence rate from 6 to 41 per cent (2000 to 2019; Ethiopia DHS) for married women aged 15-49. • In Gambia, a new national budget line provided $150,252 in 2019 increasing to $215,000 in 2020 for family planning supplies and services including training of service providers and monitoring and evaluation. Parliamentarians champion family planning UNFPA continued to support and engage parliamentarians to advocate for the rights and needs of the people, enacting and improving relevant laws and policies, and helping to create an enabling environment for ending the unmet need for family planning and mobilizing necessary resources. With the European Parliamentary Forum for Sexual and Reproductive Rights, UNFPA Supplies supported four national parliamentary dialogues in 2019 in Burkina Faso, Ghana, Kenya and Zambia with a focus on sustainable financing for contraceptives and the role of Members of Parliament in budget allocation and expenditure. National decision makers in Madagascar participated in conferences where debate led to action to ensure adequate funding for family planning services and supplies, including a fourfold increase in the budget line for contraceptives and a law to help involve the commercial sector in the supply and sale of contraceptives. UNFPA provided financial and technical support to events attended by ministries, parliamentarians, senators and development partners. UNFPA worked with the South Sudan Parliamentary Network for Population & Development in 2019 to urge the National Legislative Assembly to increase the health budget and funding for sexual and reproductive health, including family planning. The government subsequently included “ending unmet need for family planning” in its Nairobi ICPD Commitment and included contraceptives and other reproductive health supplies in the South Sudan Essential Medicines List and the Central Medical Stores Supplies Catalogue. Online campaigns draw attention to need for donor resources Donor funds remain critical to meet family planning needs even as programme countries are stepping up to support their UNFPA SUPPLIES ANNUAL REPORT 201942 growing populations of reproductive age, and transitioning to domestic funding for family planning. UNFPA Supplies partnered with Global Citizen, a citizen engagement platform, to raise awareness of unmet need for family planning and to launch a campaign, #SheCanPlan, for funding support to UNFPA Supplies. The intensive United Kingdom campaign resulted in over 200,000 signatures on a petition calling for funding support to the programme that was presented to the Government ahead of their announcement of a new £425 million funding commitment to UNFPA Supplies for 2020 to 2025. The Canadian Global Citizen campaign invited people to “Call on the Prime Minister to step up support from Canada for UNFPA Supplies because #ItsHERchoice”. Some 36,000 members of the Global Citizen movement took action on the campaign and in June 2019, Canada announced a 10-year commitment to the rights and health of women and girls. Another petition that called for funding to UNFPA Supplies garnered more than 200,000 signatures and was handed to Ms. Henriette Geiger, Director of People and Peace, Directorate-General for International Cooperation and Development from the European Commission at the ICPD25 Summit in November 2019. ENSURING EFFICIENT USE OF ALL RESOURCES UNFPA Supplies supports countries to ensure the best, most efficient use of all available resources as a key factor in achieving sustainable financing, including support for reaching the last mile to achieve equitable access for those left behind. UNFPA Supplies Bridge Funding Mechanism Bridge funding ensures that the programme has sufficient cash on hand to expeditiously procure commodities as needs arise, and to work more efficiently with community manufactures to meet these needs on time. Introduced in 2018, this mechanism allows UNFPA to access funds that have been committed by donors even before they are received. • The UNFPA Supplies Bridge Funding Mechanism, supported by the United Kingdom and The Bill & Melinda Gates Foundation, was used by 21 countries at high risk of stock-outs in 2019, gaining ready access to $17.9 million that reduced shortages of 61 stock items. Cost reduction and cost savings are measurable. Procuring generics, and reducing prices A number of generic manufacturers for oral contraceptive pills were available in 2019. UNFPA supported countries to navigate registration and waivers but some such as Madagascar need continued support with complex registration processes, and Kenya with certificates of compliance. 21 Countries at high risk of stock-outs used $17.9m in bridge funding to reduce shortages of 61 stock items in 2019 43 UNFPA SUPPLIESANNUAL REPORT 2019 • UNFPA was able to reduce prices for key contraceptives in three out of seven product categories in 2019, compared with 2018 prices, namely male condoms, oral contraceptives and injectables. • UNFPA also generated $3.4 million in savings through price negotiations with manufacturers and efforts to bring to the market lower-cost generic products that meet standards. Third party procurement is growing Through UNFPA Procurement Services, governments and NGOs can access UNFPA’s knowledge and purchasing capacity so that they can make the best use of their own financial resources and donor funds to procure reproductive health supplies. Third party procurement (TPP) is when countries rely on UNFPA to carry out procurement using funds they allocate themselves, including from domestic resources. • The use of TPP by countries to purchase commodities from UNFPA Procurement Services increased from 6 per cent in 2016 to 15 per cent in 2019. Governments and NGOs find several benefits from using UNFPA Procurement Services, notably the reliable system, quality assurance and cost-effectiveness. UNFPA Procurement Services is built on partnerships and is not for profit. PUBLIC–PRIVATE PARTNERSHIP FOR BETTER DATA IN KENYA Data quality and visibility improved all along the supply chain following a pilot test based around a public–private partnership (PPP) that enabled two national supply chain systems, one at national and the other at county level, to be linked. The Kenya Medical Supplies Agency (KEMSA) and Coca-Cola Beverage Africa digitized the Facility Consumption Data Report and request form (FCDRR) in Homa Bay, the pilot county, where county pharmacists now perform daily quality checks are able to view data for decision-making in one place, compared with individual stock status reviews. With support from UNFPA, interoperability has been achieved between the KEMSA LMIS and District Health Information Software (DHIS), making DHIS2 data visible at the national level and readily shared with the Ministry of Health. The approach is expected to contribute to efficiency in reducing wastage and stock-outs, achieving better health outcomes and improving supply chain services to the last mile. In Kenya, a public-private partnership for better data is expected to help improve health outcomes and supply chain services to the last mile, ensuring that all Kenyans have equal. © UNFPA Kenya/Douglas Waudo UNFPA SUPPLIES ANNUAL REPORT 201944 Private sector engagement UNFPA Supplies continued to support development of a return on investment (ROI) tool in 2019. The ROI tool helps in making the case for provision of workplace sexual and reproductive health services, not only benefiting the health and well-being of the workforce, but also making good business sense through employee retention and productivity. The tool will be targeted towards businesses with large female workforces, such as garment manufacturers and tea-growing companies in Asia and the Pacific, building on the success of pilot programmes. In the Democratic Republic of the Congo, UNFPA contributed to advocacy directed towards mining companies in 2019, urging the companies to integrate family planning services into the funding contract they sign with communities as part of their corporate social responsibility. A recent national law requires mining companies to support socially responsible programmes, and prominent leaders are calling on the companies to invest in family planning. In Kenya, a public–private partnership established between Kenya Medical Supplies Agency (KEMSA) and Coca-Cola Beverage Africa has contributed to improved family planning commodity visibility and monitoring of the availability of supplies at the last mile. The initiative also built on the partners’ best practices to strengthen the supply chain for contraceptives. MADAGASCAR QUADRUPLED ITS CONTRACEPTIVES BUDGET IN 2019 A striking increase in domestic funding for family planning followed discussions and discourse that the Ministry of Health, Ministry of Finance, Planning and the Economy, parliamentarians, senators, development partners and civil society representatives. The Government subsequently quadrupled its budget allocated to the purchase of contraceptives from 2019 to 2020. This high-level advocacy and policy support from UNFPA also contributed to the Ministry of Finance passing a law exempting contraceptives from taxes, bringing them in line with the policy for other health products. This policy reduces the financial burden on commercial and NGO sectors importing and distributing products. Mary Sosety, 35, of Fort Dauphin, Madagascar, chose to use an injectable contraceptive to space the births of her two children, seven years apart. “Now we have two daughters and we are determined not to have any children, and after the discussions we had with my doctor I seriously and voluntarily plan to adopt either a long-term method or a definitive method,” Mary said. © UNFPA Madagascar. 45 UNFPA SUPPLIESANNUAL REPORT 2019 TOTAL MARKET APPROACH In Tanzania, as part of efforts to harness different sectors to increase affordability of family planning services and supplies, the Government and partners supported the development of an action plan for a Total Market Approach (TMA) following a feasibility study in 2017. The plan was incorporated into the reviewed National Family Planning Costed Implementation Plan (CIP II) and included strengthening private sector and public sector linkages for TMA. The Ministry of Health and National AIDS Control Programme (NACP) developed a draft guideline on TMA for the orientation of service providers. The visibility of TMA in Tanzania has increased following the engagement of a health insurance company that integrated family planning into its benefits package; two other companies are considering a similar approach. Currently, UNFPA is collaborating with the government, SHOPS-Plus (Strengthening Health Outcomes through the Private Sector) and other family planning partners in discussions to advance TMA in the country. A task force for TMA has been established. The Total Market Approach was also of interest in Lesotho, where the Ministry of Health developed a condom strategy with support from UNFPA that adopted the parameters of TMA and involved the private sector for distribution. The Ministry of Health also expanded the membership of the RHCS Technical Working Group to include private wholesalers to play a role in distribution. In Kenya, data quality and visibility improved all along the supply chain following a pilot test based around a public–private partnership (PPP) that enabled two national supply chain systems, one at national and the other at county level, to be linked. Kenya Medical Supplies Agency (KEMSA) and Coca-Cola Beverage Africa digitized the Facility Consumption Data Report and request form (FCDRR) in Homa Bay, the pilot county, where county pharmacists now perform daily quality checks are able to view data for decision-making in one place, compared with individual stock status reviews. With support from UNFPA, interoperability has been achieved between the KEMSA LMIS and District Health Information Software (DHIS), making DHIS2 data visible at the national level and readily shared with the Ministry of Health. The approach is expected to contribute to efficiency in reducing wastage and stock-outs, achieving better health outcomes and improving supply chain services to the last mile. UNFPA SUPPLIES ANNUAL REPORT 201946 05 © UNFPA Sierra Leone CHAPTER FIVE Strengthening the programme A community-based service provider in Sierra Leone counsels a client on her family planning options. In 2019, UNFPA continued to support implementing partner the Planned Parenthood Association of Sierra Leone to provide integrated sexual reproductive health services including family planning services to women and girls living in hard to reach and underserved communities through outreach services. Of 25,280 new users of family planning, 14,278 were adolescents. As the programme prepares for its third phase, 2021 to 2030, planning is guided by the global commitment to leave no one behind in the pursuit of the Sustainable Development Goals, to reach first those who are furthest behind. For UNFPA Supplies, this is the work of reaching the last mile to ensure that the commodity procurement and technical assistance provided through the programme reach young people with disabilities, indigenous and migrant women, crisis-affected communities and others overlooked by progress due to age, residence, ethnicity, disability or income. CONTRIBUTIONS TO THE GLOBAL MOVEMENT FOR FAMILY PLANNING UNFPA Supplies took an active role in celebrating the ICPD25, the twenty-fifth anniversary of the International Conference on Population and Development. UNFPA Global Consultation on Ending Unmet Need for Family Planning Following development of six thematic papers, webinars and working groups, more than 100 participants from 42 countries gathered and collaborated across sectors at the UNFPA Global Consultation on Ending Unmet Need for Family Planning, held June 2019 in Antalya, Turkey. The group identified impact-oriented actions, gathered inputs to shape strategies and exchanged knowledge of good practices on how to accelerate progress towards ending the unmet need for family planning – all to build and share a vision in support of the ICPD vision and the 2030 Agenda for Sustainable Development. The consultation was informed by a database of key family planning indicators for programme countries, the Atlas of Opportunities, which was developed in partnership with Avenir Health. In addition, six thematic papers were shared in advance of the event on the topics of demand generation, enabling environment, quality services, secure supplies and contraceptive use by adolescents. From the Consultation, the Youth Coalition for Sexual and Reproductive Rights developed a short guide to support youth to be their own effective advocates for adolescent sexual and reproductive health and rights, with a focus on contraception. The Global Consultation was part of a series of consultations leading up to the major event marking the ICPD25, the Nairobi Summit, which yielded more than 100 commitments towards “zero unmet need for family planning information and services, and universal availability of quality, affordable and safe modern contraceptives” including commitments on domestic financing for family planning and improving access to quality family planning services and commodities as a part of universal health coverage. UNFPA NEWSLETTER A newsletter was issued daily at the UNFPA Global Consultation on Ending Unmet Need for Family Planning UNFPA’s Consultation on Ending Unmet Need for Family Planning ANTALYA, TURKEY | 17 – 20 JUNE 2019 ISSUE #1 | 18 JUNE 2019#FPCONSULTATION #ICPD25 #GLOBALGOALS UNFPA, the United Nations Population Fund, led by the Technical Division together with the Regional Office for Eastern Europe and Central Asia, has launched a consultative process to accelerate efforts to end unmet need for family planning by 2030. This consultation is part of a broader series of discussions UNFPA intends to have with key stakeholder groups between now and the Nairobi Summit on ICPD25 in November. The consultation process provides space for UNFPA and its partners to have candid conversations and find solutions to address the realities facing the family planning community. This consultation brings together colleagues from across UNFPA offices, alongside key thought-partners from the sexual and reproductive health and rights community, to identify actions that will have high impact towards ending unmet need for family planning across different programme country contexts, and to plan and agree on interventions that can be accelerated uniquely by UNFPA at global, regional, and country levels. This newsletter aims to provide you daily select highlights from the consultation. To track the conversation live, please follow the @UNFPA_Supplies and @unfpaeecaro accounts or #FPConsultation #ICPD25 and #GlobalGoals. UNFPA Embarks on Consultative Process to End Unmet Need for Family Planning VIDEO OF THE DAY Dereje Wordofa, UNFPA’s Deputy Executive Director Programme, Welcomes Participants to the Family Planning Consultation Attendees at UNFPA’s Family Planning Knowledge Expo © UNFPA UNFPA SUPPLIES ANNUAL REPORT 201948 FP2020 partnership In 2019, UNFPA was actively engaged in the Family Planning 2020 (FP2020) partnership, including shaping the vision framework for the movement towards 2030. UNFPA also continued to successfully meet its Family Planning 2020 (FP2020) commitment to allocating more resources to family planning. • UNFPA spending on family planning in 2019 amounted to some $398.5 million (41.7 per cent of UNFPA total programme expenses), including $65.7 million from core resources. Spending included $267.8 million (28 per cent of UNFPA total programme expenses) directly related to family planning activities such as creation of enabling environments for family planning, supply, provision of services and family planning systems strengthening, which are captured by UNFPA systems under the “family planning” thematic area. In addition, activities with an impact on family planning results were conducted in other areas of work under the UNFPA mandate. These activities accounted for an additional $130.7 million (13.7 per cent of UNFPA total programme expenses). UNFPA Supplies supports around a third of users of modern contraceptives in the 69 FP2020 countries where maternal mortality and unmet need for family planning are among the highest in the world. In 2019, an additional 24.5 million women and girls (aged 15-49) used modern contraception in the 46 UNFPA Supplies countries, compared with 20.8 million additional users in 2018. This brings the total number of users in these countries to 68 million since 2012. This reflects the work of many partners and the increasing progress towards the FP2020 goal. • Across UNFPA country and regional offices and at headquarters, 206 staff were dedicated to family planning and reproductive health commodity security in 2019. Of these individuals, 166 had at least three years’ experience in supply chain management, up from 154 in 2018. Reproductive rights and choices have become a reality for more women than ever, yet vast numbers of women around the world are not empowered to make fundamental decisions about their own bodies. A UNFPA report published in 2019 provided data on women’s ability to make decisions in three key areas: sexual intercourse with their partner, contraception use and health care. Across the 51 countries where this information is available, only 57 per cent of women who are married or in a relationship are able to make their own choices over all three areas. STRATEGIC COMMUNICATIONS TO RAISE AWARENESS OF IMPACT Implementation of the programme’s communications strategy in 2019 directly supported global advocacy for family planning and raised visibility for UNFPA Supplies’ impact with a range of key stakeholders. Programme results were disseminated across a diverse range of 20.8m to 24.5m Additional women and girls used modern contraception in the 46 UNFPA Supplies countries 2018 to 2019 49 UNFPA SUPPLIESANNUAL REPORT 2019 media channels – including Twitter, UNFPA. org and dedicated Google Sites, and at numerous high-level events including the launch of the vision document for UNFPA Supplies towards 2030 at the Nairobi Summit on ICPD25, IBP Consortium partners meetings, UNFPA Executive Board side events, parliamentary dialogues, the Global Citizen New York Festival and the Nairobi Summit on ICPD25. The advocacy narrative report for UNFPA Supplies for 2018 was one of the most downloaded publications from the UNFPA website in 2019 at over 700 downloads. Six thematic papers and numerous other assets, including daily newsletters and participant videos, raised awareness of 25 recommendations issued at the UNFPA Global Consultation on Ending Unmet Need for Family Planning in June 2019. In addition, UNFPA Supplies supported development of a number of videos to highlight the need for family planning and commodities that were shared at events and through social media and include: “Expanding access to family planning in rural Nepal”, “The Road to Choice” developed with MSI and filmed in Uganda, and the “Imagine a World” video, shown at the opening ceremony of the Nairobi Summit. PROGRAMME MANAGEMENT UNFPA Supplies continued to improve practices and processes to achieve greater effectiveness and efficiency in programme management, as recommended through the change management process for the programme that began in 2017, with a focus on accountability towards the programme goals and outcomes and ensuring effective fund utilization and value for money. These efforts also encompassed implementation of recommendations made by the UNFPA Supplies Mid-Term Evaluation (2018). Improvements were made in data collection and analysis, quarterly monitoring and reporting to the Donor Accountability Council. The programme continued its differentiated approach to supporting countries while ensuring flexibility to respond to emerging needs in commodity procurement and technical assistance. In 2019, UNFPA introduced various measures to identify and manage the potential risks in its supply chains to ensure health supplies and services were reaching intended beneficiaries. To that end, a risk framework was created with 23 risk factors to measure risk within the programme’s 46 country programmes. This risk framework will be used in 2020 to assess risk and put in place risk mitigation plans for each programme country. Oversight of the programme was strengthened with partners through four Donor Accountability Council (DAC) meetings and three Steering Committee meetings. All of the recommendations made by the DAC and Steering Committee were implemented. Ongoing activities included updates on workstream progress and country engagement working groups, tracking 23 Risk factors for supply chains were included in a new risk factor framework for UNFPA Supplies countries. UNFPA SUPPLIES ANNUAL REPORT 201950 spending on maternal health medicines (UNFPA and other UN agencies), analysis of implants procured using domestic versus donor funding, and ICPD25 preparation for the Nairobi Summit. Also in 2019, UNFPA Supplies worked to finalize a transition plan for the move towards the new governance structure. DATA COLLECTION, ANALYSIS AND MONITORING Country offices used the digital Systmapp platform for their quarterly reporting as part of the UNFPA Supplies Quarterly Programme Management (QPM) process. The QPM was introduced in 2018 to check on the operational aspects of the programme and review progress and results in specific areas. Another review happening four times a year as of 2019 is the Commodity Quarterly Review that monitors stock levels and national supply plans for the 46 programme countries. UNFPA Supplies facility-based surveys collected data in 23 countries in 2019. Findings of the surveys were disseminated to partners and used for programming. In addition to providing information for UNFPA Supplies indicators, the survey data provided data for global reporting through FP2020. UNFPA Supplies also supported in-country Netherlands Interdisciplinary Demographic Institute (NIDI) surveys to collect information on financial resources allocated and, in particular, those spent on family planning. In 2019, 48 countries undertook NIDI surveys. BUILDING ON STRENGTHS TO DRIVE PROGRESS TOWARDS THE 2030 AGENDA The process of developing the next phase of the programme was well under way in 2019. A Transition Oversight Group, comprising key stakeholders from the Steering Committee, began its work in guiding the visioning for the programme’s third phase towards 2030, building on strengths of the programme and its transformational impact on the lives of millions of women every year. These efforts are embracing the need to be responsive to a shifting global development architecture, and to demonstrate greater value for money for donor funds. Together with the Supplies Steering Committee, a new governance structure was proposed to enhance engagement of key stakeholders in strategic decision-making for the programme from 2021. The foundations of a new country engagement model were also developed, built with lessons learned from programme implementers at the global, regional and country levels. Development of the programme’s future vision is also taking into consideration recommendations from a review of “UNFPA Supplies contributions to gender equality” that was supported by Global Affairs Canada, and a UNFPA assessment to strengthen the human rights-based approach to family planning conducted in response to findings of the UNFPA Supplies Mid-term Evaluation. 51 UNFPA SUPPLIESANNUAL REPORT 2019 These efforts reflect UNFPA’s commitment to results-based management and alignment of all resources and programmes within the organization’s three transformative results in support of achieving the 2030 Agenda and empowering people and communities everywhere to make their own reproductive choices and prepare for a brighter future. Contributions to the programme increased in 2019 by 30 per cent over 2018. UNFPA Supplies received nearly $220 million. Despite this gain, however, the target of $252 million was not met, leaving a funding gap of $32 million. UNFPA Supplies received support from 19 donors in 2019, a record number that included four foundations and 15 United Nations Member States. Donors included Australia, Belgium, The Bill & Melinda Gates Foundation, Canada, Children’s Investment Fund Foundation (CIFF), Denmark, European Union, Liechtenstein, Luxembourg, the Netherlands, Norway, Portugal, Regione Lombardia (Italy), Slovenia, Spain, the United Kingdom and the Winslow Foundation, along with private contributions and an anonymous donor. The programme welcomed two new donors, the doubling of commitment by another donor (Spain), increases in commitment by eight doors, and the return of a former donor. Eight donors made multi-year contributions: Australia, Belgium, Canada, the European Union, the Netherlands, Norway, the United Kingdom and CIFF. At the end of the year, 75 per cent of the total resources had been utilized for provision of reproductive health commodities, and 25 per cent had been used for technical assistance activities, human resources and stock surveys, in line with agreements and the same as the previous year. Since its inception in 2007, UNFPA Supplies has mobilized more than $1.3 billion from donors. We remain grateful for their continued support. FINANCIAL SNAPSHOT Output 1 Enabling environment $8,332,459 / 5% Output 2 Procurement of RH supplies $124,543,209 / 79% Output 5 Programme managment $10,087,665 / 6% 2019 UTILIZATION US($) Output 4 Supply chain management $7,609,956 / 5% Output 3 Service delivery $7,473,601 / 5% UNFPA SUPPLIES ANNUAL REPORT 201952 UNITED NATIONS POPULATION FUND 605 Third Avenue New York, NY 10158 Tel. +1 212 297 5000 www.unfpa.org @unfpa ©UNFPA June 2020 Cover photo: Two women in the Democratic Republic of the Congo have chosen the oral contraceptive pill after their counselling session with a trained provider offering a range of methods. © UNFPA Democratic Republic of the Congo Back cover photo: The Marshall Islands has one of the highest rates of adolescent pregnancy among the Pacific Islands Countries. This youth session on Arno Atoll on sexual and reproductive health includes information about contraception and is part of UNFPA-supported activities to tackle the issue. © UNFPA Pacific Subregional Office

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