USAID Contraceptive Security
Publication date: 2008
Contraceptive Security by Alan Bornbusch Contraceptive Security Team Leader US Agency for International Development (USAID) Introduction What is contraceptive security? Why is it a challenge? Meeting the Challenge Framework USAID investments Success stories What can Missions and CAs do? The Contraceptive Security Team Tools Partners Measuring Impact What is Contraceptive Security? Contraceptive Security exists when people are able to choose, obtain and use quality contraceptives, including condoms, for family planning and HIV/STI prevention Four things about contraceptive security Clients Long term commitment Not same as donor independence Reproductive health commodity security Why is addressing contraceptive security a challenge? Growing Demand for Contraceptive Supplies Source: Meeting the Challenge: Contraceptive Projections and the Donor Gap and and Interim Working Group on Reproductive Health Commodity Security (IWG) Need is Growing in the Poorest Regions Source: Meeting the Challenge: Contraceptive Projections and the Donor Gap and and Interim Working Group on Reproductive Health Commodity Security (IWG) The Donor Funding Gap How do we meet these challenges? What is Needed to Secure Supplies? How Does USAID Support CS? On an annual basis, USAID spends about $110 million for contraceptive security Contraceptive and condom procurement Male and female condoms Oral contraceptives Injectables Implants IUDs How Does USAID Support CS? Technical Assistance, Capacity Building, Research/Analysis/Evaluation Donor coordination (global, country-level) Awareness raising, advocacy, policy dialogue Strategic planning, M&E Commodity forecasting Financing Logistics Social marketing Commercial market development Contraceptive technology Operations research Best practices, lessons learned Success Stories - Bangladesh Mission Approach: Long-term planning Greater private sector participation Contraceptive donations Support quality, affordable long-term and permanent methods RESULT: Government of Bangladesh (GOB) is using SWAp funds to procure public sector contraceptives and condoms for SMC, GOB’s commodities stock out rates down to about 2% Success Stories - Mexico “Buy Mexico” regulations made it difficult for public sector to buy cheaper foreign-made contraceptives Situation highlighted in a 2001 conference, made public by a Mexican journalist, and awareness raised through extensive media coverage Federal health authorities declared contraceptives a “national security” item, releasing the “Buy Mexico” rules RESULT: States may now buy contraceptives from international suppliers, and participate in bulk purchases Success Stories - Ghana Donors have been responsible for nearly all contraceptives in Ghana, but demands are rising faster than donations USAID/Accra provided T.A. for a two-year process to develop a national CS strategy Interagency Coordination Committee for Contraceptive Security (ICC/CS) created RESULT: CS awareness raised, CS issues integrated into MOH’s Programme of Work, national CS strategy launched 2004, Government allocates internal revenues for contraceptives What Can Missions and CAs Do? Raise awareness of CS as a national priority Conduct a SPARHCS assessment and support strategic planning for CS Provide support for CS strategy objectives. Support ongoing awareness raising, advocacy, policy dialogue Logistics strengthening Increasing government ownership and support Enabling private/commercial sector participation Etc. Contraceptive Security Team Contraceptive Security Team Global Partners Countries/ Missions Cooperating Agencies Alan Bornbusch Joan Robertson Tanvi Pandit Stephanie Seifried Tools Contraceptive Security: Ready Lessons SPARHCS: Strategic Pathway to Reproductive Health Commodity Security DHS/RHS projection template for contraceptive requirements Contraceptive security indicators, index National health account sub-analysis of reproductive health Toolkits for awareness raising and advocacy by NGO networks and media International Partners Multi-lateral Partners European Union UNFPA World Bank WHO Bilateral Partners Canada Netherlands Germany Japan U.K. Foundations Gates Packard Hewlett Wallace Global Fund UNF Other Organizations DKT IPPF Marie Stopes International PSI Manufacturers The Supply Initiative: World Population Foundation (DSW), European Committee for Population and Development (ECPD), JSI, PAI, PATH Reproductive Health Supplies Coalition: Donors, Multilaterals, Foundations, Service Delivery Organizations, Manufacturers, Countries How Will We Measure Impact? Strategies in PHN Countries Coordinating bodies in PHN Countries Countries using WB/SWAp/PRSP credits to maintain supplies to clients More countries allocating their own revenues for commodities Increased private sector participation Better donor planning of resource allocation and shipment decisions Better targeting of public subsidies Lower stock-out rates at service delivery points Increased CPR and reduced inequities in access and use Increased availability of supplies to people ! * * * Contraceptive security exists when people are able to choose, obtain and use high quality contraceptives, including condoms, when they want them for family planning and HIV/STI prevention. The concept of contraceptive security was born in the late 1990s out of an analogy to food security. The term was first coined by Carolyn Hart in 1998, at the time with the FPLM Project at JSI. It was suggested that contraceptives should be thought of as essential commodities – like food, like water – so that governments and donors would commit unequivocally to the availability of needed supplies and coordinate their financing, program planning, and delivery systems to secure them. * There are four elaborations to make about contraceptive security. It is first and foremost about clients. Unless people can choose, obtain, and use the contraceptives they want, there can be no contraceptive security. It is a goal to strive for, requiring ongoing commitment and continuous progress. It requires constant adaptation and resilience. Few if any countries can be said to actually reach contraceptive security. A common perception is that contraceptive security is the same as donor independence for contraceptive supply. This is not the case. Progress towards contraceptive security may mean shifts in financing and source of supplies, but these need not be in the direction of less donor involvement. Contraceptive security does not predefine the precise mix of financing and supply sources for a country. This will vary among countries and across time. Lastly, many stakeholders use the term reproductive health commodity security instead. The concept is the same, except it is applied to a broader range of essential RH supplies. These can include, as some examples, STI drugs, safe delivery kits, and the growing range of HIV/AIDS commodities. * The challenges to contraceptive security are many. Let’s begin, appropriately, with the clients. * Use of contraception has risen dramatically as a result of our own successes in making quality, affordable family planning services available to people. It is projected to rise still further due to population growth and increased demand. Barely ten years from now, use is expected to rise by nearly fifty per cent over what it was in 2000. That is, if the supplies are made available to people. Given that already shortages are occurring, the sheer magnitude of the task is clear, the more so if we add into this projections of increased condom use for HIV and STI prevention. * Growth in use is expected throughout the world, but most especially in poorer regions. Use in sub-Saharan Africa may grow well in excess of the global average, more than doubling. The implications for contraceptive security are stark when we realize that ultimately someone must pay for contraceptives and the resources from within some of these regions are not huge. * Indeed, financing shortfalls are what first galvanized the global community to focus on contraceptive security, starting with an international conference in Istanbul in 2001. This graph was prepared for that conference and shows the projected increase in financing required for subsidized contraceptives in 87 developing countries. Two scenarios of donor financing are shown to indicate that the shortfall could reach as high as 210 million dollars annually. Like any similar set of projections, these make their own assumptions. Regardless, the general picture is that there are already shortfalls (24 million dollars in 2000) and they will likely increase without mobilizing significant new resources from governments, households, and donors. But, the challenge is not one of financing alone. It is also often one of disruptions and vulnerabilities in the systems that need to work well, and work together, to ensure that contraceptives are are available to people. * So, how is USAID meeting these challenges? * There are many elements besides financing that are involved in securing supplies, as shown in this figure for reproductive health commodities in general. In every country, there is a context that affects the prospects for contraceptive security – social and economic conditions, political and religious concerns, competing priorities. Commitment by governments, donors, and others is a fundamental underpinning for contraceptive security. Without it, stakeholders will not see the need to invest the necessary capital, to coordinate around the issue, or to develop the necessary capacities. Coordination involving government, donors, and the private sector helps ensure effective allocation of resources. Government, households, third parties – like employers and insurers – and donors are all sources of financing. Capacities must exist for a range of functions – forecasting, procurement, distribution, and service delivery are a few. Public sector, NGO, social marketing, and commercial sector channels can then work to serve the “whole market” of client demand – from those who need subsidized contraceptives to those who can and will pay for commercial products. Clients, as product users, are the ultimate beneficiaries of contraceptive security as well as drivers of the system through their demand for supplies. * USAID annually spends about $110 million dollars on activities directly related to contraceptive security. The largest amount – $70-80 million – supports the procurement and delivery of contraceptives and condoms for USAID- and other US government- sponsored programs. By dollar value USAID is typically the largest donor of contraceptives. * Another $30 million supports a wide range of activities through central and bilateral projects. These are in the areas of technical assistance; capacity building; and research, analysis and evaluation. Some examples of areas we work in are donor coordination, advocacy, contraceptive forecasting, public and private sector financing, developing private markets, and operations research. * Now, here are 3 examples to illustrate the results that can be achieved by investments in these areas. Dramatic increases in contraceptive use and social acceptance of family planning in Bangladesh have made the country a success story. They have also, though, created a large and still growing “mortgage” of supply needs. To focus attention on contraceptive security in Bangladesh, USAID/Dhaka, building on more than ten years of investment in logistics, has adopted a multidisciplinary approach to securing contraceptive supplies for the long-term. This includes technical assistance for long-term contraceptive security planning and coordination, increasing the role of NGOs and the Social Marketing Company (or SMC) in contraceptive provision, continued contraceptive donations to SMC with assistance toward its greater self-reliance, and efforts to increase awareness of and access to quality, affordable long-term and permanent methods. Most of the public sector’s contraceptives are now financed by the Government of Bangladesh using basket funds under a sector wide approach (or SWAp). These supplies are now distributed through a national supply chain that, as a result of USAID’s long-term support for logistics, has stock out rates of only about 2% at the lowest level warehouses in the system. * Bangladesh illustrates the results that can be achieved through long-term investments for contraceptive security. Events in Mexico in 2001 highlight the need for constant awareness raising and advocacy for contraceptive security. That year a Mexican journalist highlighted the threat of contraceptive shortfalls, brought about by “Buy Mexico” regulations. These made it difficult for the public sector to purchase contraceptives at lower prices from international suppliers. Print and broadcast coverage of the situation led federal authorities to declare contraceptives a “national security” item, in the same category as vaccines and essential drugs, thus releasing them from “Buy Mexico” rules. States now have the option of buying from international suppliers using UNFPA as a procurement agent. They can also participate in coordinated purchases with each other and NGOs. * Donors, primarily USAID, UNFPA and DFiD, have been responsible for almost all of the public sector contraceptives in Ghana. But Ghana’s needs have been growing such that the country is facing a potential annual funding gap of several million dollars by 2010. Since 2002 USAID/Accra has been supporting a process of awareness raising, assessment, and strategic planning for contraceptive security. A national interagency coordinating committee has been established and in 2004 a national contraceptive security strategy was provisionally adopted. Further, the government of Ghana is now financing contraceptives using both SWAp funds and its own revenues. * Missions, with support from CAs, can begin a contraceptive security program by raising awareness of the issue and using SPARHCS to conduct a contraceptive security assessment and develop a strategic plan for securing contraceptive supplies. SPARHCS – the Strategic Pathway to Reproductive Health Commodity Security – provides a framework and diagnostic guide to support stakeholders to assess their present situation, define future expectations, and identify challenges and opportunities for contraceptive security. This can form the basis for developing a contraceptive security strategy. With a strategy in place, Missions can partner with CAs for targeted support for specific objectives – for example, building local capacity for awareness raising, advocacy, and policy dialogue, strengthening public sector distribution systems, increasing financing by national governments, and supporting a coordinated approach that leverages the public and private sectors to efficiently serve the supply needs of the “whole market.” * Contraceptive security is a high priority of the Global Health Bureau and Missions, so much so that we have formed a team to work on it, to support Missions in design, programming, and evaluation; to help cooperating agencies benefit from lessons and experiences; and to work globally with donors. The Contraceptive Security Team is a valuable resource to advance and support strategic planning and implementation for contraceptive security in your countries. The four members of the team support select countries and provide guidance in specific technical areas. In addition the Team Leader, Alan Bornbusch, focuses on donor coordination, while Joan Robertson is a private sector and financing specialist, Tanvi Pandit specializes in logistics and Stephanie Seifried, as program assistant, is the glue that holds the team together. * The Contraceptive Security Team is collaborating with cooperating agencies to develop and make available a range of tools for contraceptive security planning and programming. The recently published Ready Lessons provides practical steps Missions and their partners can take to promote and support country-led programs for contraceptive security. It is a continuing series. As Missions and partners develop new tools and approaches, apply them in the field, and advance country programs, the Contraceptive Security Team will identify and disseminate new lessons. We invite you to participate in this learning process by sharing your experiences with the team. The other tools listed here are under development, with SPARHCS being the next to be published later in 2004. * While USAID’s procurement and delivery system for contraceptives and condoms as well as its technical assistance are exceptionally strong, the global needs are vast. The goal of contraceptive security cannot be achieved by any one organization. USAID is working closely with international partners to make more efficient use of our existing resources and to mobilize new and additional resources. SPARHCS – the tool for awareness raising, assessment, and planning for reproductive health commodity security – is itself the product of an international collaboration involving more than 20 organizations. * The measure of our success over the long term will be meeting people’s needs, shrinking the gap between demand and supply. In the interim we will need strategies, coordination mechanisms, increased financing, greater efficiencies, and other improvements, …. * … all adding up to increased availability of supplies to people.