The Strategic Pathway to Reproductive Health Commodity Security

The Strategic Pathway to Reproductive Health Commodity Security

Background

The Origins of “Contraceptive Security”

In 1998, a cooperating agency, John Snow, Inc., was asked by a private U.S. foundation if there was a global shortage of contraceptives, based on foundation staff’s anecdotal evidence of stockouts at reproductive health service delivery sites in various countries. JSI responded that the current situation was typically less one of actual shortage, than one of disruption and vulnerability in the many systems that need to work well, and work together, to ensure that contraceptives are available to clients. If only, it was said, contraceptives were thought of as an essential commodity - - like food, like water - - so that governments and donors would commit unequivocally to the availability of needed supplies and synchronize their financial, program planning, and delivery systems to secure it. That is how the concept of “contraceptive security” was born. [cite]

The analogy to food security is acknowledged as imperfect, since food is a basic necessity of all life with high demand, while access to contraceptives is arguably perceived as less a matter of life and death, and limited to more defined sub-populations. But the particular aspects of the analogy that are most useful are these:

• Access to life-sustaining food is universally understood to be a basic human right. At ICPD in 1994 and ICPD+5 in 1999, the world community committed to reproductive health as a human right, and reliable access to contraceptives is a critical component of realizing that right. [cite]
• Just as countries are obligated to their citizens to avert famine, they are obligated in the practice of public health to avert disruptions in the availability of contraceptives.
• In addressing food crises, donors are aligned to step in when poor countries cannot meet their people’s needs and early warning systems have been established to track signs of inadequacy in the food supply. This synchronization of systems and proactive use of data are possible in the realm of reproductive health as well.

Securing contraceptive availability in developing countries is further complicated because family planning services may be a low priority, donor-dependent, or even donor-driven public health intervention. How can the “security” concept be applied to such settings? This paper proposes a framework and an approach for making progress toward contraceptive security.

The paper is divided into three sections:

1. Background: The opening section provides the background on contraceptive security, and introduces the framework.
2. SPARHCS and the Program Cycle: The second section discusses how the SPARHCS framework can be used throughout the program cycle (the familiar planning-implementation loop) to address contraceptive security.
3. SPARHCS Diagnostic Guide: The final section provides a diagnostic guide for amassing and organizing the information required to assess a country’s contraceptive security situation.

The SPARHCS Initiative

Defining Reproductive Health Commodity Security

Beginning in February 2001, USAID and UNFPA launched an initiative to engage country partners, technical agencies, and other donors in an effort to further define “contraceptive security” and operationalize it at the country and global levels. Through a series of large conferences and smaller working groups, the initiative came to be called SPARHCS (“sparks”) - - the Strategic Pathway to Reproductive Health Commodity Security. And the definition of the envisioned goal became:

“…when every person is able to choose, obtain, and use contraceptives and other essential reproductive health supplies whenever she or he needs them.” [cite]

This definition of reproductive health commodity security bears further explanation.

First, it is a goal statement, all encompassing and far-reaching. It is something to strive for, requiring ongoing commitment and continuous progress.

Second, this definition is customer focused, defining security from the customer’s perspective. There are multiple perspectives on contraceptive security:

• The global donor perspective asks how can resources be allocated most effectively, efficiently, and equitably to meet growing demands worldwide?
• The country perspective asks what needs to be done so that the whole population’s needs will be met, this year, next year, and for the next five-to-ten years?
• The program perspective focuses on how a particular program can appropriately forecast, finance, procure, and deliver products to its clients.

But the real test of “contraceptive security” is when every customer gets the contraceptives he or she needs. The SPARHCS goal statement reflects that contraceptive security is a global objective, but it is reached one customer at a time.

Third, this definition broadens the concept from its origins of “contraceptive security” to “reproductive health commodity security.” This language, at UNFPA’s urging, more accurately reflects the ICPD and ICPD+5 goals of meeting the broader reproductive health needs of all men and women. [cite] Nevertheless, contraceptives are the first category of RH commodities to be identified for concerted action on a global scale; they are the sine qua non of family planning and they are of special interest to the donor community. So, while USAID and USAID Cooperating Agencies typically use “contraceptive security” for shorthand, UNFPA and its grantees and partners use “RHCS” - - yet all are focused on the same immediate objective: securing an adequate supply and appropriate range of contraceptives for developing countries’ growing requirements.

And finally, implicit in this definition is the notion that part of the work of contraceptive security is turning “need” into “demand.” There is a demand creation aspect inherent in moving customers to choose, obtain, and use contraceptives. Securing sufficient supplies to satisfy current demand in low prevalence countries does not fully realize the vision of contraceptive security.

The RHCS Framework

Having agreed upon a definition of reproductive health commodity security that is all encompassing and complex, the SPARHCS initiative set out to develop a framework that describes the important relationships inherent in commodity security. There are many elements involved in securing contraceptives so that all people are reliably able to choose, obtain, and use them, as the diagram below indicates.

The Reproductive Health Commodity Security Framework

Within a context of the broader Environment, commitment and Leadership ensure financing from Governments, Donors, andprivate Households.Forecasting and Procurement are conducted, so that programs in the Public Sector, NGOs, Social Marketing, and Commercial Sector have contraceptives. Through processes of Distribution, Service Delivery, and Demand Creation, Client Utilization is achieved. The arrow connecting Client Utilization and Household Finance reflects that individuals take on the responsibility for their own supplies.

Securing the reliable, long-term availability of contraceptives requires interactions between and among this complex set of stakeholders and processes, through Coordination and with Policy support.

Looking at the graphic, note that:

• Environment is the context, depicted by the large perimeter box.
• Coordination, Policy, and Leadership are facilitating factors, depicted across the top and down the sides of the main graphic.
• The rows correspond to stakeholders, at three levels.
• The wide arrows between the levels of stakeholders represent processes.
• The line from Client Utilization up to Household Finance signifies that clients are key participants in contraceptive financing, through their purchase of products and payment of other user fees.
• Coordination needs to take place among stakeholders on the same level, as well as between levels.
• Policy affects all stakeholders and processes.
• Leadership appears above Government Finance and Donor Finance because those stakeholders must exert leadership for any of the necessary processes to unfold.

Each element of the RHCS framework is elaborated in further detail in the diagnostic guide section later in this document. For orientation’s sake, here is a brief overview of how they all fit together conceptually in the RHCS framework, as it might be used in a SPARHCS assessment of a country’s contraceptive security.

Client Utilization

It makes sense to begin an overview of this framework at the bottom, since the proof of contraceptive security is when individual women and men are consistently able to choose, obtain, and use the supplies they need. Ensuring that clients are able to, and do, utilize contraceptives when they need them encompasses is the real meaning of contraceptive security. In this framework, Utilization encompasses demographic data on contraceptive prevalence and examines how freely customers choose and obtain their supplies. Clearly contraceptive use is not monolithic; indeed it must be segmented in many different ways in order to understand how progress can be made toward greater security. How is current utilization characterized? What needs remain unmet? What is the potential to increase utilization?

Moving up the framework, Utilization is the result of successful efforts in Demand Creation, Service Delivery and product Distribution.

Demand Creation

By definition, contraceptive security exists when all demand and need is met. For those whose needs have been turned into demand for services, and are currently satisfied clients, access must be maintained. For those not using services now but who want to or intend to use soon, they must become satisfied clients. For those who have a need for services (e.g., they say they don’t want to become pregnant now) but are not doing anything to prevent it), their need must somehow be turned into satisfied demand. Are the right things being done to enable people to bring their behavior into line with their intentions and needs? Demand creation is critical in helping clients achieve reproductive health, but it is ultimately important from the financing perspective. As utilization grows and increasing demand is met, options for funding, especially from individuals, also grow.

Service Delivery

This component of the framework examines the range of access and quality service considerations that directly affect clients’ ability to choose, obtain, and use contraceptives. The ideal result of Service Delivery would be a satisfied client making an informed choice. Are service providers’ skills and service facilities adequate to satisfy clients’ needs? Are providers well trained in clinical skills and counseling related to method choice? Do providers have adequate equipment and supplies to offer good quality contraceptive services? How does the service delivery process address barriers to access to and utilization of contraceptives?

Distribution

Providers cannot do their jobs without the support of a logistics system that reliably distributes to them all the products they require: contraceptives and other essential medicines, consumable supplies, and equipment. This is the essence of the “No Product? No Program” motto. Needed products simply must be on hand when clients come for them; having product at the central or regional warehouse does no good if there is a stockout at the service delivery point at the time of a client’s visit. So, how well do the logistics systems distributing to service delivery programs ensure product availability? How effective, reliable, and efficient is distribution?

Service Provider Channels: Public Sector, NGOs, Social Marketing, Commercial Sector

The real creators of supply and demand for contraceptives are the purveyors of reproductive health goods and services. Activities to make contraceptives available (“supply”), and to reach new users (“demand”), take place in a variety of settings: the public sector, nongovernmental organizations (NGOs), social marketing programs, and the commercial sector. Each channel employs different providers and outlets to reach different customers. The RHCS framework looks across this public/private spectrum of entities, and asks: What roles do they play? How do they relate to each other? Do they work together? How do they compete? How do current service providers segment the market, in terms of clients’ income, their location in rural or urban settings, the methods they use, and where they obtain them? Does the array of service delivery channels reach all segments of the population, or are some left unserved? How is oversight practiced?

Forecasting and Procurement

In order to ensure that service delivery programs have adequate quantities of supplies to manage, Forecasting and Procurement must take place, using financing available from a variety of sources. Forecasting means that every program must be able to estimate its product requirements by specific brand for the near- (1-2 years), medium- (3-5 years), and long-term (6-10 years into the future). Forecasting should be relatively accurate in the near term, and will be more notional further into the future. Are programs able to forecast for three to five years hence? Do they continuously update their projections on the basis of more current data? Another key skill necessary for contraceptive security is the ability to conduct timely and efficient Procurement. Increasingly, government and NGO programs are tasked with procuring products themselves, using donor funds, grants or loans, or budgetary resources. The procurement process ideally results in the timely acquisition of the best quality products at the lowest possible price. Are programs or procurement units able to select the appropriate products, prepare sound product specifications, conduct negotiations for financing and purchase agreements, and test for quality assurance throughout manufacturing and upon receipt? What is the current capacity of these programs to conduct timely, efficient, cost-effective, and transparent procurement?

Government, Donor, and Household Financing

Contraceptive security obviously requires funding—ultimately, someone always has to pay for products that are provided. And current financing levels are, in many cases, inadequate or unsustainable, or both. The RHCS framework takes into consideration financing for contraceptives from all sources. The Government may pay for reproductive health supplies and services with general revenues or loan funds. Donors may provide financing or donate products. Households are the ultimate source of private finance, whether through the purchase of subsidized products; participation in the fully commercial marketplace, which allows businesses to invest in the provision of reproductive health supplies; or the payment of other fees, such as user fees at service sites or insurance premiums. What are current arrangements for financing contraceptives from these three sources? What are the prospects for increasing contraceptive funding from all sources? What role does third party financing play in covering contraceptives?

Leadership

Contraceptive security cannot be attained or sustained without strong political commitment and leadership within a country. There needs to be a clearly articulated public health policy commitment that making and keeping contraceptives available to all people is a community priority. The government need not deliver all goods and services, but the basic commitment to contraceptive security is a commitment from a government to its people. Political and government leaders must demonstrate this commitment, but contraceptive security also depends upon formally and informally influential people at all levels across a range of stakeholders assuming leadership. What is the nature of the political commitment to contraceptive security? Who provides leadership? Where can champions for contraceptive security be found, or developed? How well is collaboration in pursuing a common public health agenda fostered among key stakeholders?

Coordination

Contraceptive security, in a world of limited resources, requires a multiparty, multisectoral, collaborative undertaking, ideally based upon joint action planning. The main purpose of the SPARHCS approach is to align all the various funders and providers of reproductive health goods and services around the notion of contraceptive security. Looking at the diagram, this means coordination needs to take place among the stakeholders at the same level, as well as between levels. Coordination is required among donors internationally and within a country; within governments, among programs, and across sectors within a country; and up and down the supply chains that serve different service delivery channels. Donor coordination, market segmentation[1], and supply chain integration are key to contraceptive security. In the SPARHCS context, market segmentation can be a collaborative undertaking to inform the establishment of effective coordination mechanisms. What types of formal and informal coordination mechanisms exist among stakeholders?

Policy

The policy environment affects all aspects of contraceptive security, and spans the effort from global debates to the options and practices of individual consumers. The SPARHCS approach examines relevant national public policies, government regulations, and programs’ operational requirements that both support and impede the attainment of contraceptive security. Do national policies and regulations recognize and facilitate contraceptive security? Are there operational barriers that constrain clients’ ability to choose, obtain, and use contraceptives?

Environment

The SPARHCS objective is a public health objective; the SPARHCS approach assumes that family planning services are an acknowledged part of the public health offerings of a given country. But everything takes place within the context of a broader environment and SPARHCS analysts must assess that environment. How does the level of socio-economic development affect resources available to the public sector? How is competition for scarce resources managed in the public sector? What are the public health priorities? How do socio-economic and cultural factors impact individuals’ ability to choose, obtain, and use contraceptives? Is the health sector undergoing reform? How does the HIV/AIDS epidemic affect the health environment? And where does family planning fit, in terms of needs, priorities, political support?

What is the SPARHCS approach?

The RHCS framework underpins the SPARHCS approach, which is not a roadmap to contraceptive security, nor a set of fixed process steps, but an organized way of thinking about a complicated public policy objective. The SPARHCS approach is to propose and promote a common objective (contraceptive security, as defined), to gather and organize information relevant to that objective, and to involve stakeholders from a variety of disciplines and sectors to process those findings and develop coordinated strategies to make progress.

The added value, or the innovations, in the SPARHCS approach are several: