West Africa: Final Regional Report

Publication date: 2007

WEST AFRICA: FINAL REGIONAL REPORT MARCH 2007 This publication was produced for review by the United States Agency for International Development. It was prepared by the DELIVER project. WEST AFRICA: FINAL REGIONAL REPORT The authors’ views expressed in this publication do not necessarily reflect the views of the U.S. Agency for International Development or the United States Government DELIVER DELIVER, a six-year worldwide technical assistance support contract, is funded by the U.S. Agency for International Development (USAID). Implemented by John Snow, Inc., (JSI) (contract no. HRN-C-00-00-00010-00) and subcontractors (Manoff Group, Program for Appropriate Technology in Health [PATH], and Crown Agents Consultancy, Inc.), DELIVER strengthens the supply chains of health and family planning programs in developing countries to ensure the availability of critical health products for customers. DELIVER also provides technical management of USAID’s central contraceptive management information system. Recommended Citation DELIVER. 2007. West Africa: Final Regional Report. Arlington, Va.: DELIVER, for the U.S. Agency for International Development. Abstract Funding from USAID/West Africa, USAID Africa Bureau, and USAID/Washington has enabled the DELIVER project to provide technical support at the regional level, primarily through the West Africa Health Organization and through regional supply chain training Country interventions in Burkina Faso, Cameroon, Togo, and Sierra Leone have also been conducted in close partnership with Ministries of Health, UNFPA, AWARE–RH and other partners, and have led to improvements in the reproductive health commodity security (RHCS) environment. At the regional level, technical assistance activities have focused on the development of a subregional RHCS strategic plan and planning and implementing a coordinated informed buying (CIB) procurement mechanism. Supply chain assessments, the building of logistics capacity, and RHCS strategic planning were key features of country interventions. Lessons learned as a result of these interventions include an understanding of how regional approaches can reinforce and complement country interventions. However, the role and reach of regional institutions is limited, necessitating parallel country responses to RHCS challenges. At the country level, focused technical activities—for example, the preparation of contraceptive forecasts—provide a catalyst for the country leaders to advocate with stakeholders for broader RHCS interventions. DELIVER John Snow, Inc. 1616 North Fort Myer Drive, 11th Floor Arlington, VA 22209 USA Phone: 703-528-7474 Fax: 703-528-7480 Email: deliver_project@jsi.com Internet: www.deliver.jsi.com CONTENTS Acronyms.v Acknowledgments.vii Executive Summary .ix Program Background.1 Regional Context .1 Key Players and Roles .1 Key Challenges .2 Goals and Objectives.5 DELIVER Objectives .5 Relationship to USAID and Client Objectives .5 DELIVER’s Role in Relation to Other Organizations.5 Summary of Interventions.5 Summary of DELIVER Funding and Staffing.6 Program Results.7 Element I: Improved Logistics System.7 Element II: Improved Human Capacity in Logistics .7 Element III: Improved Resource Mobilization for Contraceptive Security.8 Element IV: Improved Adoption of Advances in Logistics .10 Element V: Estimation of USAID Contraceptive Needs .13 Lessons Learned and Future Directions.15 References .17 Figure 1. ECOWAS Past and Projected Donor Financing and Costs for Contraceptives, Excluding Condoms (1996–2010).2 Table 1. Desirability of Pooled Procurement in Ghana and Burkina Faso .10 West Africa: Final Regional Report iii West Africa: Final Regional Report iv ACRONYMS AIDS acquired immunodeficiency syndrome AWARE–RH Action for West Africa Region–Reproductive Health CESAG Centre Africaine d’Etudes Supérieures en Gestion, Dakar, Senegal CIB coordinated informed buying CPT contraceptive procurement table CS contraceptive security ECOWAS Economic Community of West African States FHA Family Health and AIDS (project) HIV human immunodeficiency virus IRSP Regional Institute of Public Health, Cotonou, Benin JSI John Snow, Inc. KfW Kreditanstalt für Wiederaufbau (German Development Bank) MOH ministry of health PSM procurement and supply management RH reproductive health RHCS reproductive health commodity security SPARHCS Strategic Pathway to Reproductive Health Commodity Security UNFPA United Nations Population Fund USAID U.S. Agency for International Development UNICEF United Nations Children’s Fund WAHO West African Health Organization WARP West Africa Regional Program West Africa: Final Regional Report v West Africa: Final Regional Report vi ACKNOWLEDGMENTS DELIVER would like to thank the institutions and individuals that contributed to DELIVER’s work throughout the duration of the project. The U.S. Agency for International Development (USAID) has provided financial resources to carry out the technical assistance and activities at both the regional and country level. Without these resources, DELIVER could not have planned and implemented it action in West Africa and achieved the results described in this report. DELIVER has had a very good relationship with the USAID/West Africa office. The staff have been very responsive to DELIVER’s request and communications, and very supportive of the workplan activities we agreed upon. The reproductive health divisions of the ministries of health have been cooperative, both in planning and implementing the activities. They have taken ownership of all activities, including the design and implementation of the strategic plans. The heads of these institutions have used their personal cell phones and e-mail accounts to communicate with DELIVER to ensure that activities are well planned and carried out. No achievement could have been possible without their enthusiasm and commitment. DELIVER has had a good and fruitful collaboration with the Action for West Africa Region– Reproductive Heath (AWARE–RH) project. Together, the two projects have made significant achievements in logistics and contraceptive security in West Africa. DELIVER has also collaborated with other cooperating agencies and the United Nations Population Fund in a number of other countries to develop contraceptive security strategies notably in Cameroon, Burkina Faso, Togo, and Sierra Leone. Since early 2003, DELIVER’s partnership with the West African Health Organization (WAHO) has been fruitful, as witnessed by the many achievements, including the subregional strategic plan; the development of coordinated informed buying; and a commitment from donors to help fund these programs. West Africa: Final Regional Report vii viii West Africa: Final Regional Report EXECUTIVE SUMMARY DELIVER has received field support funds from USAID/West Africa and USAID’s Africa Bureau to provide technical support to the West Africa Health Organization (WAHO) and individual countries in West and Central Africa to improve reproductive health commodity security (RHCS). DELIVER provided technical assistance at both regional and country levels. Activities carried out included forecasts of contraceptive requirements in Burkina Faso, Cameroon, Togo, and Sierra Leone. The forecasts are conducted in response to USAID’s need to purchase the required supplies for the countries being assisted. Contraceptive procurement tables are produced to inform United Nations Population Fund (UNFPA), MOH, and other providers of the procurement plans. DELIVER, in collaboration with the AWARE–RH and POLICY II projects, has assisted country MOHs to develop contraceptive security strategic plans in Burkina Faso, Cameroon, Togo, and Sierra Leone. On the basis of these strategic plans, the countries are mobilizing necessary resources to ensure that every woman and man is able to choose, obtain, and use reproductive health products when she or he needs them. DELIVER conducted workshops to build the capacity of institutions and individual professionals on contraceptive security and HIV/AIDS logistics. The paramount regional activity remains DELIVER technical assistance to WAHO. As a result of this support and other forms of technical assistance provided by DELIVER, WAHO was able to develop a strategic plan for RHCS and begin work on a coordinated informed buying (CIB) system in the subregion. The CIB system receives funding and technical support from USAID. The subregional strategic plan is supported by a number of funding agencies, including USAID and UNFPA. There are lessons to be learned and future directions to consider from these regional activities: • When advocacy is well designed and well implemented, the targeted audience responds positively, as was the case with the Ministers of Health of the Economic Community of West African States (ECOWAS) for RHCS. • Regional institutions are often not equipped to provide technical assistance to countries. • Future directions would include strengthening the WAHO to enable it to provide technical assistance in RHCS and logistics and to assist the countries to implement their strategic plans for commodity security. West Africa: Final Regional Report ix West Africa: Final Regional Report x PROGRAM BACKGROUND REGIONAL CONTEXT West Africa continues to face enormous development challenges. Economic losses due to high maternal mortality rates have been estimated at U.S.$22 million per year. A significant percentage of the Economic Community of West African States (ECOWAS)1 population live on less than U.S.$1.00 a day, and do not have access to safe drinking water. Deaths due to preventable diseases remain a public health and development challenge. And HIV/AIDS prevalence rates, while not as high as those seen in the hardest- hit countries of Eastern and Southern Africa, are nevertheless a cause for serious concern. A number of factors contribute to the high maternal and infant mortality rates, including limited access to and use of reproductive health (RH) services and the resultant decline in health status. Total fertility rates remain high in the subregion at 5.8 births per woman, although desired fertility is considerably lower. This is reflected in low regional contraceptive prevalence rates—less than 10 percent for all ECOWAS countries, except Ghana at 19 percent and Cape Verde at 46 percent. High unmet demand for family planning ranges from 18 percent in Niger to 40 percent in Togo. Although current overall use of family planning and RH services in the subregion is low, the number of users will increase dramatically, given the high population growth and the large number of couples entering their reproductive years. Even as demand grows, funding for RH has been erratic and declining during the last five years, with projected funding levels below projected needs. To address this reproductive health crisis, the West African Health Organization (WAHO),2 at the request of the ECOWAS Ministers of Health, developed a strategy for reducing maternal and prenatal mortality in the West African subregion. The strategy addresses a number of critical approaches to improve maternal health, and it enables WAHO’s member-states to meet the millennium development goal of reducing maternal mortality by 75 percent by 2015. KEY PLAYERS AND ROLES • Key players in the region include WAHO and the country ministries of health (MOHs). Cameroon is the only country outside ECOWAS in which DELIVER worked. • Country MOHs, with input from their stakeholders, develop health policy and programs that address their needs and priorities. • Bilateral and multilateral donors assist individual countries to design and implement their health programs, and they provide technical assistance and resources to WAHO to develop its plans to complement those of the countries. Key international organizations providing assistance are USAID, the United Nations Population Fund (UNFPA), the Department for International Development (DFID), the Kreditanstalt für Wiederaufbau (KfW), the World Health Organization (WHO), UNICEF, the World Bank, and the International Planned Parenthood Federation (IPPF). 1 ECOWAS is a regional group of 15 countries, founded in 1975. Its mission is to promote economic integration in "all fields of economic activity, particularly industry, transport, telecommunications, energy, agriculture, natural resources, commerce, monetary and financial questions, social and cultural matters." 2 WAHO was created to be the health branch of the 15 ECOWAS countries, and therefore assist the 15 countries to address their health needs. West Africa: Final Regional Report 1 KEY CHALLENGES Financing Gap to Procure Contraceptives The growth in the number of family-planning users in West African countries has important financial implications. As use increases, the cost of the commodities also increases. It is estimated that the funding required will more than double over the next 15 years. This funding will need to come from a combination of governments, donors, and clients. Unfortunately, while the amount of funding required to finance these services and commodities will increase, donor funding, which has not been stable in recent years, does not appear likely to keep pace with the funding requirements. Figure 1 reveals that the funding shortfall will be enormous during the next 10 years if current trends in donor support are maintained. Figure 1. ECOWAS Past and Projected Donor Financing and Costs for Contraceptives, Excluding Condoms (1996–2010) 4 8 12 16 20 24 28 $US Millions 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Past donor financing Constant donor financing (based on financing 1999–2002) 3% annual increase in financing Projected cost of contraceptives (when purchased independently by countries) Projected cost of contraceptives (under pooled procurement) Inadequate Logistics Systems Although many countries in the subregion have logistics systems in place, the effectiveness of these systems varies. Assessments have revealed weaknesses in human resources, data management, warehousing, and transportation (DELIVER 2002). Moreover, integration of product lines and decentralization are posing new obstacles to effective supply chain management. The systems will be further strained as they respond to the HIV/AIDS pandemic. These weaknesses in the logistics systems lead to stockouts at service delivery points, as shown by the results of product availability assessments in several African countries. Stockouts occur when product is not available. West Africa: Final Regional Report 2 Weak Reproductive Health Policies Subsequent to the Cairo and Beijing conferences, most countries adopted policies that support family planning and women’s rights and lifted most restrictions affecting family planning service providers and prescribing practices. However, budget allocations for RH services and commodities remain insufficient. Tariffs, taxes, and duties remain prohibitively high in some countries, and some legislative restrictions remain. Change in Donor Focus The former USAID-funded project, Family Health and AIDS (FHA), ended in 2004 and was replaced by the West Africa Regional Program (WARP). FHA was heavily focused in four countries, providing contraceptives and technical assistance to them. WARP will deal with all 15 countries and will not focus on a particular country or group of countries. However, the transition from FHA to WARP is difficult for the four FHA countries, especially Cameroon and Togo, who have been receiving products. The transition should not cause an abrupt stoppage of contraceptive supplies to those countries. Subsequently, USAID policy has been to support contraceptive security in countries such as Cameroon and Togo and continue to provide products through 2005, while the countries develop their contraceptive security strategic plans. West Africa: Final Regional Report 3 West Africa: Final Regional Report 4 GOALS AND OBJECTIVES DELIVER OBJECTIVES To provide technical assistance to— • Burkina Faso, Cameroon, and Togo, to estimate their contraceptive needs and to develop their strategic plans for contraceptives • other countries for CS-related activities, at the request of USAID/West Africa • WAHO, to sensitize ECOWAS health ministers in reproductive health commodity security (RHCS) and develop a subregional RHCS strategic plan. RELATIONSHIP TO USAID AND CLIENT OBJECTIVES DELIVER objectives are direct requests from USAID/West Africa and the Africa Bureau. In particular, USAID guidance for activities in Togo and Cameroon has been instrumental in developing work plans. In addition, DELIVER objectives respond to USAID/West Africa Intermediate Results (IRs): • IR1: Improved approaches to family planning/RH/sexually transmitted infection/HIV/AIDS; contraceptive security introduced and disseminated region-wide • IR2: Increased regional stakeholder advocacy for policy change • IR3: Increased capacity of regional institutions and networks. DELIVER’S ROLE IN RELATION TO OTHER ORGANIZATIONS DELIVER seeks to use its comparative advantages to coordinate with other organizations to leverage resources for MOHs in the countries where it provides technical assistance and assist WAHO with mobilizing resources for RH products. DELIVER seeks to assist countries and regional institutions to strengthen their logistics capacities. SUMMARY OF INTERVENTIONS DELIVER interventions can be summarized as follows: • estimate commodity requirements for USAID and other donors • develop commodity security strategic plans for individual countries • assist WAHO to develop an RHCS strategy • train in-country and regional institution staff in commodity security and logistics • advocate for contraceptive security with high-level decision-makers and policymakers at regional and country levels • carry out logistics assessments • carry out contraceptive security assessments. West Africa: Final Regional Report 5 SUMMARY OF DELIVER FUNDING AND STAFFING Staffing DELIVER does not have staff on the ground, but rather uses a team of technical advisors based in Washington, DC, who are assigned on an as-needed basis to particular tasks. Funding The total funding is $1,827,000 for USAID/West Africa and $950,000 for the Africa Bureau. Africa Bureau funding is earmarked to support WAHO, whereas USAID/West Africa funding supports work in individual countries for some regional activities. West Africa: Final Regional Report 6 PROGRAM RESULTS ELEMENT I: IMPROVED LOGISTICS SYSTEM There were no activities under this element with USAID/West Africa funding. These activities have been carried out as part of the relationship between DELIVER and USAID Missions in West African countries (such as Ghana, Mali, and Nigeria). ELEMENT II: IMPROVED HUMAN CAPACITY IN LOGISTICS DELIVER has conducted several regional workshops and training sessions to build regional institutional and MOH capacities in logistics and contraceptive security. Descriptions of these workshops and training sessions follows: • Regional Training in Commodity Security in September 2003 for key personnel from Burkina Faso, Cameroon, Guinea, Togo, Benin, and Mali, plus two regional organizations—the Regional Institute of Public Health (IRSP), Cotonou, Benin; and Centre Africaine d’Etudes Supérieures en Gestion (CESAG), Dakar, Senegal The workshop was designed to bring together key contraceptive security personnel from four countries— Benin, Burkina Faso, Guinea, and Senegal—to prepare action plans leading to the development of a CS strategy for their respective countries. Representatives from Mali, Cameroon, and Togo participated to share their experiences in developing CS strategies with the other participants. The DELIVER advisors provided technical facilitation for four days of the five-day workshop; the fifth day was devoted to HIV/AIDS commodities. The main workshop output was four action plans developed by the teams from Benin, Burkina Faso, Guinea, and Senegal. The Action for West Africa Region–Reproductive Heath (AWARE–RH) project followed up on the implementation of these action plans and the development of strategic CS plans in these countries. DELIVER provided technical assistance to AWARE–RH and the respective countries. In addition, DELIVER provided monitoring and continuing technical assistance to Cameroon, Mali, and Togo, countries already advanced in the planning stage. Regional Commodity Security Media Workshop Workshop participants were journalists, technical experts, and parliamentarians from five countries— Burkina Faso, Côte d’Ivoire, Mauritania, Mali, and Senegal. The workshop took place May 2–6, 2005, in Dakar and Saly in Senegal. DELIVER and Africa Consultants International representatives worked from April 27 to May 1 in Dakar to finalize the preparation of the workshop. The main objective of the workshop was to strengthen the capacity of journalists and that of other participants in the area of commodity security. Specific Objectives 2. Inform participants about the issues surrounding RH commodity and contraceptive security. 3. Encourage dialogue and exchange of ideas among team members and across teams. 4. Increase the quality and quantity of news coverage on this issue in order to increase political and financial commitment toward ensuring adequate supplies. Workshop Output The primary output from the workshop was a country plan that details media-related activities that the participants—media, technical experts, and parliamentarians—would jointly plan and undertake. The West Africa: Final Regional Report 7 realization of these activities was facilitated by a small grant (roughly $4,000) provided by the Population Reference Bureau. In addition to country plans, each participating group was expected to— • identify best practices for disseminating effective information in support of contraceptive security • produce a Media Flash that highlights issues of interest to journalists within the framework of contraceptive security • participate as audience members in a radio show on repositioning family planning for dissemination on local stations and conduct informal interviews with technical experts, parliamentarians, and facilitators • establish an electronic forum for information sharing • regularly publish information in the media that support contraceptive security. Follow-up shows that countries have implemented their plans. Global Fund Procurement and Supply Management Workshop In collaboration with the Global Fund to Fight AIDS, Tuberculosis and Malaria, a procurement and supply management (PSM) workshop was held to assist Global Fund applicants from various francophone countries to develop and refine their round 5 PSM plans. The results of the workshop were draft country plans that adhere to established guidelines, thereby facilitating the signing of related grants. Depending on specific country needs, plans focused on HIV, tuberculosis, and/or malaria. Countries that had already approved plans worked on the implementation issues of their plans and their needs for technical assistance. For the workshop, DELIVER— • prepared and presented technical sessions on distribution, inventory control, and management information systems, as well as lessons learned in antiretroviral management • promoted and provided technical assistance toward the inclusion of logistics systems considerations in participant-country PSM plans • served as on-site resources for addressing issues related to logistics and commodity. Supply Chain Management for HIV/AIDS, Tuberculosis, and Malaria Programs Course This course was offered in Dakar, Senegal, and was in Dakar, Senegal and was led by DELIVER, with participation from Management Sciences for Health, AWARE–RH, USAID/West Africa, and two regional training and research institutions, CESAG and IRSP. Twenty participants from 10 countries (Ghana, Senegal, Mauritania, Togo, Cameroon, Burkina Faso, Côte d’Ivoire, Gabon, Niger, and Guinea- Conakry) participated in the two-week course, which focused on logistics management systems, inventory control systems, and forecasting and quantification. By the end of the course, participants identified follow-up actions for improvement in their countries. ELEMENT III: IMPROVED RESOURCE MOBILIZATION FOR CONTRACEPTIVE SECURITY DELIVER has worked on resource mobilization for contraceptive security at both the country level and the West Africa subregional level. West Africa: Final Regional Report 8 Country Level In Burkina Faso, Cameroon, Togo, and Sierra Leone, DELIVER has collaborated with national and international partners of the MOHs to raise decision-makers’ and policymakers’ awareness about contraceptive security. The effort includes discussing the funding gap for contraceptives and how to mobilize MOH stakeholders to plan to bridge the gap. • In each of the countries, a national commodity security committee has been created. • In each country, DELIVER, in collaboration with AWARE-RH, has assisted the local contraceptive security committee to develop a contraceptive security strategic plan. In each country, UNFPA and other partners contributed to the development of the strategies. • The strategies were based on the Strategic Pathway to Reproductive Health Commodity Security (SPARHCS) guide, and included the following components: policy, commitment, finance, service delivery, logistics, coordination, and demand for services. • Priority issues were determined, based on findings from a contraceptive security assessment; strategic and operational objectives were then determined. Activities, implementing institutions, and indicators have been determined. An overall budget for the plan has been estimated. • In countries where the plans have been validated, governments are making efforts to earmark funds for contraceptive purchases. The country efforts are complemented by partners’ contributions. Regional level WAHO and its partners—UNFPA, USAID, the World Bank, the KfW, DELIVER, and AWARE–RH— established the West Africa Regional Initiative for RHCS. The purpose of this initiative is to improve the availability of RH commodities in the region and assess the benefits and feasibility of regional RHCS strategies. Within this initiative, DELIVER’s mandate from USAID is to provide technical assistance to help WAHO develop the subregional RHCS strategy and implement a coordinated informed buying (CIB) system. DELIVER has also developed data and advocacy tools for contraceptive security in West Africa, which was used to sensitize the ministers of health on the issue at their annual meeting in Banjul in 2003. As a result of the advocacy work, the ministers recommended further contraceptive security analysis, and in subsequent DELIVER presentations to the ministers at their meetings (in 2004 in Accra, and 2005 in Dakar), they recommended that WAHO develop a subregional RHCS strategic plan and a CIB system of RH products. The subregional strategic plan has been developed by WAHO, with technical assistance from DELIVER, ECOWAS RH program managers, and international donors, including USAID and UNFPA. The subregional approach will reflect and complement country efforts and reinforce the national-level activities. The SPARHCS framework was modified to reflect subregional strengths. The thematic areas were identified in a previously developed RHCS concept paper, with scope for supporting ongoing country work. The new framework includes four strategic objectives: context, coordination, capacity building, and country support activities. The vision of this strategy is to achieve RHCS in West Africa. It is demonstrated in the document that increased use of RH products can reduce maternal and perinatal mortality and morbidity, supporting WAHO’s maternal health objectives. The scale, reach, and capacity to advocate for RHCS across the subregion complement and reinforce the implementation of existing efforts at the country level. The approach will serve as a catalyst for policymakers and program managers to share experiences and develop common methods to address the West Africa: Final Regional Report 9 challenges common to countries in the subregion. These include, but not limited to, access to RH commodities, inadequate logistics systems, insufficient commodity financing, a multiplicity of poorly coordinated activities in countries, and substantial national and operational policy barriers to RHCS. Key areas of work are identified where this subregional approach can add value to existing efforts. They include— • developing systems to enhance the sharing of RH commodity procurement information across countries • building human and institutional capacity • advocating for harmonized RH commodity policy and regulatory frameworks across ECOWAS members. The strategy was accepted by the ministers at their annual meeting in Abuja in July 2006, and implementation will begin in January 2007, following funding and workplanning meetings. ELEMENT IV: IMPROVED ADOPTION OF ADVANCES IN LOGISTICS To support the development of strategic plans at regional and country levels, DELIVER has used the findings of studies and assessments that it carried out in these countries. Country Level SPARHCS assessments were carried out in Burkina Faso, Cameroon, Togo, and Sierra Leone. Their findings highlighted the strengths and weaknesses within each SPARHCS component: policy, finance, coordination, demand, service delivery, and logistics. From these findings, the priority issues were identified and formed the basis for the development of the contraceptive security strategies in these countries. These assessments were done in collaboration with the MOHs of the countries and the AWARE–RH and POLICY project. Other assessments at country level include those related to pooled procurement of RH products in Ghana and Burkina Faso. Detailed information on the findings of each study is included in table 1. Table 1. Desirability of Pooled Procurement in Ghana and Burkina Faso Ghana Most officials found the concept worthy of pursuing if it helps to reduce prices to lower than currently obtained through the ministry’s procurement mechanism. Hence cost reduction was the most attractive benefit for almost all that were interviewed on the subject. Quality of products and the dependability of the procurement mechanisms were considered to be non- negotiable benefits, and hence must equal, if not improve on, current systems before pooled procurement can be considered. Burkina Faso There is unanimity in favor of the concept of regional pooled procurement of commodities, pool financing, and a regional training center for logistics. Interest stems from the potential benefits that can come from pooled procurement, which include ensuring the steady supply of commodities as a prime factor, lower cost, and quality assurance of the products. The idea of a regional distribution center, on the other hand, was viewed as counterproductive. The cost involved in setting up and maintaining a regional warehouse, staff salaries, distribution cost from the regional warehouse to the various countries, etc., would reduce the savings obtained through increased purchase volume. It was suggested that distribution should be from manufacturers directly to the various countries. West Africa: Final Regional Report 10 At the political level, interviews with the Minister of Health and other health sector officials demonstrated a very high commitment and the desire to move along subregional cooperation to benefit health care across the member nations. Ghana’s commitment to subregional cooperation was further demonstrated when they created a Ministry of Regional Cooperation and appointed a minister at the Cabinet level. A regional structure or consultants and an established procurement organization should be contracted for procurement and logistic information management. The need for a regional quality-control laboratory was expressed to guarantee that the products that arrived in the countries were still of good quality. REGIONAL LEVEL A key element of the subregional strategy is to improve the availability and reduce the cost of essential RH commodities through a CIB mechanism. The ECOWAS health ministers, at the July 2003 Fourth Ordinary Meeting of WAHO, asked DELIVER to study the different options for securing commodities in the subregion, including pooled finance and procurement, and examine the scope for private sector expansion. DELIVER subsequently conducted a desk-based study of pooled procurement options, which was supported by fieldwork in two ECOWAS countries, Burkina Faso and Ghana. Five procurement options were identified, in ascending order of complexity, cost, benefit, and risk: 2. informed buying 3. coordinated informed buying 4. group contracting 5. central contracting 6. pooled financing and procurement. Coordinated informed buying—when countries share information on prices and suppliers but conduct separate procurements—would have a lower administrative cost, involve reduced risk factors, and allow greater country-level independence in decision making (than option #5, pooled financing and procurement), but would generate fewer benefits. Pooled financing and procurement would be more costly to establish and manage, involve greater potential risk, and give countries less independence in their procurement decision-making, but it would provide the greatest potential savings. The options between these two mechanisms would involve increasingly greater costs, benefits, and risks. International experience suggests that pooled procurement works best when participating countries— • share a common language • deal with similar health conditions • use harmonized drug-registration procedures • have access to convertible currency • possess adequate in-country supply chain management systems • maintain a tradition of regional cooperation • make a commitment to finance and sole source their drug needs • operate in an environment without trade barriers, and with supportive policies and regulatory conditions. West Africa: Final Regional Report 11 While some of these preconditions do exist in ECOWAS, several are not yet in place. Each country has separate drug registration procedures, different essential drugs lists and lists of registered products, different standard treatment guidelines, and very different capacities for commodity forecasting and management. Furthermore, ECOWAS has a mixed record with regional financial and economic integration. Some elements (such as the external tariff) have been successful, whereas others (such as free intraregional trade and member financial contributions) have had less success. DEVELOPMENT OF A COORDINATED INFORMED BUYING SYSTEM At the meeting of WAHO health ministers in October 2004, the ECOWAS ministers of health recommended that WAHO should start with informed buying, with technical support from DELIVER and its partners. A web-based CIB system would keep start-up and operating costs down, while creating a framework for further evolution. The next stage, group contracting, could then be considered for a subset of commodities—such as contraceptives—where product standardization and registration across the region could be more easily achieved. Other products could be added as drug registration and essential drugs lists are harmonized. The advantage of this evolutionary approach would be that members would still retain some flexibility until real savings could be demonstrated. An important prerequisite would be to provide technical assistance to strengthen commodity forecasting and in-country supply chains. An assessment was carried out in 9 of the 15 ECOWAS countries to get their input, with over 85 individuals contributing to this design. Anecdotal information suggests that the sharing of various elements of pharmaceutical procurement already occurs among countries in the region, but in an ad hoc or limited manner. A CIB system would potentially capitalize on this kind of experience, build a systematic strategy of regional coordination for information sharing, and, ultimately, improve the buying power of all involved. The majority of key informants interviewed indicated that a CIB system would be valuable, either directly or indirectly, to national procurement activities. Across the board, those organizations and individuals interviewed articulated the benefits that they perceived to the country in having a CIB system in place. Most notably, managers indicated that the process of building the tool and coming together as like- minded professionals to work for the benefit of the region would be as much value-added as using the tool itself. CIB was noted for its potential to provide relevant information in helping to understand specific health commodity procurements that are occuring in the region and by bordering countries (versus general indices of prices). Key findings from the CIB study include the following: 1. CIB should start with information available. 2. All countries should be invited to participate. 3. Strong central coordination is necessary for CIB to succeed. WAHO is proposed for this role by those interviewed during the country assessment. 4. There is no legal or policy barrier to CIB. Implementation WAHO has appointed a CIB manager, who is posted at WAHO headquarters in Burkina Faso. The position is funded by USAID. A CIB design workshop was conducted, with participation from all 15 ECOWAS countries. The purpose of the workshop was to conduct detailed operational planning. It is expected that the system will begin operating in FY 2007 and expanded to include all 15 ECOWAS countries and additional products, as capacity is increased at subregional and country levels. West Africa: Final Regional Report 12 ELEMENT V: ESTIMATION OF USAID CONTRACEPTIVE NEEDS Estimation of USAID contraceptive needs was a key activity in Cameroon, Togo, Sierra Leone, and Burkina Faso. In each country (except Sierra Leone), there is a team composed of representative from the MOH and its partners. Contraceptive needs are estimated every year and reviewed six months later. The estimate takes into account consumption of the two past years and does the projection for the current year and following two years. Logistics data are collected from all regions of the countries (stock on hand, consumptions, losses, and adjustments), and, based on the analysis of these data, estimations are done for three years. Contraceptive procurement tables (CPTs) are prepared for all agencies procuring contraceptives for the country. Estimation is done using logistics data as well as demographic data. The most appropriate estimation is then chosen. In Cameroon, Burkina Faso, and Togo, the national teams are able to do the estimation. PipeLine software is used for procurement planning after the estimations are done. The results of estimations and CPTs are shared with MOHs and other stakeholders. Estimations were also used to inform contraceptive security strategic plans. West Africa: Final Regional Report 13 West Africa: Final Regional Report 14 LESSONS LEARNED AND FUTURE DIRECTIONS Lessons learned include the following: • CPTs are the entry point to contraceptive security sensitization and strategic plan development. • CPT preparation often provides the opportunity in a given country for donors to coordinate their efforts relating to contraceptives. • The SPARHCS approach provides a useful organizing framework for country policymakers and different actors to understand the many systems that work together to make contraceptives available in a country. • As a result of advocacy and sensitization by DELIVER, country officials understand very well the issue of contraceptive security, and they have all taken action to improve availability of contraceptives by supporting the development of contraceptive security strategic plans. They also have started allocating funds to purchase contraceptives. • SPARHCS, by way of regional and country planning, has become a valuable training tool. Because it was developed collaboratively, it is an approach that is well accepted by all stakeholders • A well designed and well implemented advocacy plan and tool can be effective with high-level policymakers (such as ministers of health) • The role of some regional institutions may be limited to that of broker, catalyst, or advocate at the country-level, and therefore those institutions may not be fully able to provide technical assistance to the countries in needed areas. Future directions should focus on assisting— • WAHO to be able to provide technical assistance to the countries in the domain of contraceptive security, including estimation of products requirements • WAHO to implement the subregional strategic plan for RHCS • individual countries to implement their strategic plans for commodity security and develop their capacity to forecast RH product needs. West Africa: Final Regional Report 15 West Africa: Final Regional Report 16 REFERENCES Abdallah, Hany, and Whitehouse, Mimi. 2005. West African Reproductive Health Commodity Security: Development of a Sub-Regional Coordinated Informed Buying System (unpublished). Arlington, Va.: DELIVER, for the U.S. Agency for International Development. (Unpublished). Abdallah, Hany. 2005. West Africa Reproductive Health Commodity Security: Study Phase 1, Task Report: 1—Review of Pooled Procurement. Arlington, Va.: DELIVER, for the U.S. Agency for International Development. Addico, Gifty, Johnnie Amenyah, Alex Nassar, Mohammed Oubnichou, Raja Rao, and Erin Shea. 2005. West Africa Reproductive Health Commodity Security: Study Phase 1, Task Report: 9–Country Assessment Report–Ghana. Arlington, Va.: DELIVER, for the U.S. Agency for International Development. Aronovich, Dana, and Raja Rao. 2005. West Africa Reproductive Health Commodity Security Sub- Regional Strategy: A Concept Paper. Arlington, Va.: DELIVER, for the U.S. Agency for International Development. Aronovich, Dana, Aoua Diarra, Lisa Hare, Meba Kagone, and David O’Brien. 2003. No Product? No Program! Reproductive Health Commodity Security for Improved Maternal and Child Health. Arlington, Va.: DELIVER, for the U.S. Agency for International Development. DELIVER. 2002. Logistics System Assessment Survey Results: Mali, Nigeria, Ethiopia, and Kenya (2001–2002). (Series of assessments in the four countries). Arlington, Va.: DELIVER, for the U.S. Agency for International Development. (Unpublished). Kagone, Meba, Antoine Ndiaye, Ernest Ouédrago, Olga Sankara, Erik Takang. 2005. West Africa Reproductive Health Commodity: Security Study Phase 1, Task Report: 8—Country Assessment Report: Burkina Faso. Arlington, Va.: DELIVER, for the U.S. Agency for International Development. West Africa: Final Regional Report 17 West Africa: Final Regional Report 18 For more information, please visit www.deliver.jsi.com. DELIVER John Snow, Inc. 1616 North Fort Myer Drive, 11th Floor Arlington, VA 22209 USA Phone: 703-528-7474 Fax: 703-528-7480 www.deliver.jsi.com REGIONAL CONTEXT KEY PLAYERS AND ROLES KEY CHALLENGES Inadequate Logistics Systems Weak Reproductive Health Policies Change in Donor Focus DELIVER OBJECTIVES RELATIONSHIP TO USAID AND CLIENT OBJECTIVES DELIVER’S ROLE IN RELATION TO OTHER ORGANIZATIONS SUMMARY OF INTERVENTIONS SUMMARY OF DELIVER FUNDING AND STAFFING Staffing Funding ELEMENT I: IMPROVED LOGISTICS SYSTEM ELEMENT II: IMPROVED HUMAN CAPACITY IN LOGISTICS Regional Commodity Security Media Workshop Specific Objectives Workshop Output Global Fund Procurement and Supply Management Workshop Supply Chain Management for HIV/AIDS, Tuberculosis, and Malaria Programs Course ELEMENT III: IMPROVED RESOURCE MOBILIZATION FOR CONTRACEPTIVE SECURITY Country Level Regional level ELEMENT IV: IMPROVED ADOPTION OF ADVANCES IN LOGISTICS Country Level REGIONAL LEVEL DEVELOPMENT OF A COORDINATED INFORMED 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