SPARHCS - Strategic Pathway to Reproductive Health Commodity Security
2. A Framework for Reproductive Health Commodity Security
The prospects for RHCS are affected by country contexts, within which RHCS requires commitment, capital, coordination, and capacities.
The SPARHCS framework - at the center of which is the client - highlights the many elements that are involved in securing reproductive health supplies and provides the conceptual basis on which to build a RHCS strategy. Let us begin with the outermost circle in the following figure and move towards the client. In every country, there is a context that affects the prospects for RHCS - on the one hand, national policies and regulations that bear on family planning/reproductive health and particularly on the availability of RH supplies, and on the other, broader factors like social and economic conditions, political and religious concerns, and competing priorities. Within this context, commitment, evidenced in part by supportive policies, government leadership, and focused advocacy, is a fundamental underpinning for RHCS. It is the basis from which stakeholders will invest the necessary capital (financing), coordinate for RHCS, and develop the necessary capacities - the third circle in the figure.
The boxes in the figure elaborate on each of these three components. Coordination involves government, the private sector, and donors to ensure more effective allocation of resources. Households, third parties (e.g., employers and insurers), governments, and donors are all sources of capital. And, capacities must exist for a range of functions - policy, forecasting, procurement, and distribution; service delivery; and monitoring and evaluation, to name a few.
Clients are the ultimate beneficiaries of RHCS.
Moving closer to the client in the figure, capital, coordination, and capacities form the basis for the public sector, NGOs, social marketing, and commercial sector to efficiently supply the needs of the whole market of client demand, from those who need subsidized products to those who are able to pay for commercial products. Clients (women and men) - at the center of the figure - are the ultimate beneficiaries of RHCS (as product users) and, as shown by the double headed arrows, the drivers of the system (through their demand).
Reproductive Health Commodity Security Framework
Each component of the SPARHCS framework is discussed in further detail below, starting with the center - clients - and ending with the contextual concerns that affect RHCS.
A. Client Utilization and Demand
How do clients vary in their met and unmet needs for RH supplies?
In any country there is a multiplicity of reproductive health needs - for different products and services, at different prices, and from different sources. Met and unmet need vary by many client characteristics - income or standard of living, age, sex, parity, rural versus urban, religion, cultural expectations regarding sexuality and childbearing, state or province, source of method, etc. These variations must be understood in order to understand how progress can be made toward greater commodity security. The SPARHCS diagnostic guide poses such questions as: How is current use characterized? Who are current users of RH supplies? How is unmet need characterized? It also asks whether clients who want to use RH products have physical and economic access to them, what gender norms influence women's and men's abilities to use contraceptives and other RH commodities, and about contraceptive discontinuation rates among different groups.
Reproductive health commodity security exists for people when their demand is met. For individuals whose "needs" have turned into "demand" for services and products, and are currently satisfied clients, access must be maintained. For those not using services and products now but who want or intend to use them, access must be provided. Meeting client demand is critical in helping clients improve their reproductive health, and it is important from a financing perspective as well. As utilization grows and increasing demand is met, the requirements for funding and the options for funding, especially from individuals, also grow.
How well is the whole market of demand for RH supplies covered by providers in the public and private sectors?
SPARHCS looks at how activities to increase use are affecting the demand-supply relationship. What is being done to enable people to access services according to their intentions and needs? SPARHCS also asks stakeholders to consider whether securing sufficient contraceptive supplies to satisfy low demand in low prevalence settings fully realizes their vision for RHCS.
Reproductive health supplies are delivered to clients through a variety of service channels: the public sector, NGOs, social marketing programs, and the commercial sector. Rationalizing the market among these channels can increase access and the efficient use of resources to meet the full range of client demand. The SPARHCS framework and diagnostic guide look across the public/private spectrum, and ask: What roles do the different providers play? How do they relate to each other and coordinate to respond to the range of family planning and other reproductive health needs in a country? How well and how efficiently do service providers collectively cover the whole market and its segments in terms of clients' socioeconomic status, their gender-or age-related barriers, client location, the methods they want, and where they obtain them? Are some segments of the population left unserved?
B. Commitment
What is the commitment to RHCS in the public and private sectors?
Ensuring that the different service channels have the capital, capacities, and are coordinated to respond effectively to clients' needs begins with commitment and leadership, particularly from governments, program planners, and key leaders. There needs to be a clearly articulated policy commitment to making and keeping contraceptives and other essential supplies available to people as a public health priority. Political and government leaders must demonstrate this commitment through budget increases, policy improvements, leadership of coordination, and RHCS strategies that are implemented. RHCS also depends upon influential people at all levels in the public and private sectors acting as RHCS "champions" - well-respected, dedicated individuals who advocate for commodity security and work to achieve high-level political commitment and adequate funding for ensuring a full supply of RH commodities. The SPARHCS diagnostic guide poses such questions as: What is the nature of the government commitment to RHCS? Who provides leadership? Where can "champions" for RHCS be found, or developed, in the public and private sectors? Are civil society organizations, particularly women's advocacy groups, and the media mobilized and do they have the capacity to advocate for commitment to RHCS?
What are the impacts on RHCS of health sector reforms and new development assistance instruments?
Further, is there commitment to RH commodities in the face of changes in development assistance and health sector reforms? Is there explicit attention to RH commodities in national strategies and assistance mechanisms for health and development, such as PRSPs and SWAps? To what extent are health sector reforms - like decentralization, privatization, and integration - either threats or opportunities for reproductive health commodity security? Are RH commodities being "orphaned" under these changes?
C. Capital
Current financing levels for reproductive health supplies are, in many cases, inadequate, unsustainable, or both. The SPARHCS framework and diagnostic guide consider financing from all sources. Households may purchase subsidized products, participate in the commercial marketplace, or pay other fees, such as user fees, insurance premiums, or co-payments. Governments may subsidize supplies and services with internally-generated revenues, donor grant funds, or loan credits. Donors may provide direct financing to support family planning programs or donate products. SPARHCS explores the importance of "capital" by raising such questions as: What are current arrangements for financing reproductive health supplies from these sources? What are the prospects for increasing (or in some cases lessening the need for) each? How are public funds used, and are there cost recovery mechanisms in place for supplies and services? What are the most reliable sources for commodity financing during the next five to ten years? And, what role do or could third parties, like employers and public or private insurers, and other alternative financing schemes, like community-based financing, play in financing commodities?
What are the prospects for financing of RH supplies by households, governments, donors, and third parties?
D. Capacity
Capacity in a number of critical functions directly affects clients' ability to choose, obtain, and use reproductive health supplies. Service providers can limit or promote RHCS. SPARHCS asks such questions as: Are providers' skills and service facilities adequate to satisfy clients' needs? 
Are providers well trained in clinical skills and counseling related to method choice? Are providers trained to identify and address gender-related barriers to contraceptive use and decision making? Do they have adequate equipment and supplies to offer good quality family planning and reproductive health services? Are providers trained in counseling for informed choice, taking into account barriers, like gender norms, to access and utilization of contraceptives and other products? How does provider capacity address barriers to access to and utilization of contraceptives and other products? Do providers show preference for or promote one method over another?
Service providers cannot do their jobs without the reliable operation of public and private sector supply chains delivering the "six rights": the right product, to the right place, at the right time, in the right quantity, in the right condition, for the right price. Critically, the right price may be different for different clients. Needed products must be on hand when clients come for them; having products 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. How effective, reliable, and efficient are logistics systems in ensuring product availability to clients who access different service delivery programs?
How developed are the human systems capacities for RHCS, in service delivery, logistics management, forecasting and procurement, monitoring and evaluation, etc.?
In order to ensure that service providers and logistics systems have adequate quantities of supplies, timely and coordinated forecasting and procurement must take place, using financing from a variety of sources. Are programs able to forecast their product requirements for the near-, medium-, and long-term? Do they continuously update their projections with more current data? Increasingly, government and NGO programs are tasked with procuring products themselves. What is their capacity to conduct efficient and transparent procurements that result in the timely acquisition of the best quality products at the lowest possible price? Are they able to reliably comply with international competitive bidding procedures? Are programs able to select the appropriate products, prepare sound product specifications, conduct negotiations for financing and purchase agreements, and establish quality assurance throughout manufacturing and upon receipt?
The areas listed previously are not the only capacities needed for RHCS. Capacity for advocacy for RHCS is considered under the "Commitment" component of the SPARHCS framework. Capacities for the collection, analysis, and use of data are crucial for planning, monitoring, and evaluating progress towards RHCS. Governments need the capacity to determine areas of unmet need, to determine where they need to intervene and where they do not, and how to program their resources effectively. "Data for decision making" capacities are needed both for program design and management, and for policy analysis. SPARHCS asks whether programs collect appropriate data and information for decision making for RHCS, whether there is a management culture of evidence-based decision making, and how information is used for policy-level analysis and decision making.
E. Coordination
How do government agencies, donors, and the private sector collaborate and act jointly for RHCS?
Reproductive health commodity security is based upon collaboration and joint action planning. Coordination is required at multiple levels and among different stakeholders - among donors internationally, and within a country among donors, between donors and government, within government, among programs, among technical agencies, and across sectors. Effective coordination helps avoid duplication of efforts and promotes information sharing across and between programs. SPARHCS asks such questions as: Does government play a central coordinating role? Are there mechanisms to ensure coordination happens? What are the specific outcomes expected from coordination (e.g., coordinated financing of different programs' needs, a more rational and sustainable segmentation of the contraceptive market)? SPARHCS also asks about the development and implementation of a coordinated RHCS strategy.
F. Context
The contextual concerns that affect the prospects for RHCS can be approached at two levels. First, what national policies and regulations bear on the ability of public and private sector programs to secure and deliver RH supplies? Are there, for example, unnecessary policy barriers regarding who can provide RH supplies and services? Are there unnecessary barriers on who is eligible for services, some of which may be the result of cultural norms and gender stereotypes (e.g., age, parity, marital status)? What policies affect particularly the private sector's ability to provide RH supplies? What service delivery policies and guidelines assure the capacity of providers to provide RH supplies?
What is the context for RHCS of national policies and regulations, social and economic factors, and other health priorities?
Second, there are the broader factors: How does the level of socioeconomic development in a country affect resources available for reproductive health supplies? What percent of the population is rural versus urban (a factor affecting private markets)? What are levels of educational attainment for women (one of the best predictors of contraceptive use)? What is the burden of HIV prevalence (a higher burden can mean more competition for financial resources as well as contributing to higher levels of poverty and poorer health status)? And, what are other priorities that family planning/reproductive health must compete with for resources?
