SPARHCS - Strategic Pathway to Reproductive Health Commodity Security

3. The SPARHCS Diagnostic Guide

The SPARHCS diagnostic guide supports stakeholders in conducting a joint diagnosis of a country's reproductive health commodity security status. The guide presents a set of questions and tables to help stakeholders assess their present situation, define expectations for the future, take into account significant trends from the past, and make future projections. Through this process, they can identify and assess the range of challenges and opportunities for reproductive health commodity security.

Given the complexity of reproductive commodity security, the guide is designed to facilitate diagnosis rather than be a checklist or questionnaire. Questions can be rewritten or deleted according to user needs; new ones can be added. The guide examines each element of reproductive health commodity security, as suggested by the framework: client utilization and demand, commitment, capital, capacity, coordination, context. A seventh section - commodities - is added to draw attention to the sources of RH commodities in a country. ⁶

Although some questions could easily be answered with "yes" or "no," that is not the aim of the guide. Rather, the questions are meant as prompts for stakeholders to probe further and to create a dialogue around each element, asking:

• What are the key strengths as they relate to availability of RH supplies?
• Can each strength be leveraged to improve RHCS?
• How feasible will it be for strategies to build upon each strength?
• What are the key problems?
• What would be the impact on RHCS of addressing each?
• How feasible will it be to address each problem, and what will be required?

Identifying key strengths indicates pockets of opportunity on which strategies can be built. Weaknesses define areas for assistance and improvement. Identifying opportunities and weaknesses is only one part of a SPARHCS diagnosis. Assessing the likely impact of each weakness on RHCS will facilitate building consensus on strategic priorities. Determining the feasibility to address each weakness helps ensure that a strategy gains the commitment of partners and funding for implementation. Some weaknesses will be easier than others to address, as some strengths will be easier to capitalize on.

The timeframes used for gathering and analyzing information vary. Commodity and financing requirements are typically projected three-years out. Forecasts for longer periods will be less reliable, but longer timeframes (e.g., ten years hence) may be good for contemplating systemic changes required for reproductive health commodity security. It is also important to identify certain trends from the past, as they provide a base from which to project into the future.

The time and level of effort required for a SPARHCS diagnosis will vary according to its purpose and scope. ⁷ It can be used to:

• conduct a baseline assessment,
• guide a longer process of inquiry and strategic planning,
• launch or revitalize interest in efforts to improve RHCS,
• build consensus around new priorities, or
• monitor, evaluate, and adjust ongoing activities.

A SPARHCS diagnosis may involve some combination of local or international consultants to provide technical assistance, gather and analyze data, and facilitate stakeholder discussions. A considerable amount of data gathering and analysis can be completed through desk-based review of survey reports, contraceptive procurement tables (CPTs), and other reports/publications, and through analyses done specifically for the assessment. Further work may require some combination of key informant interviews⁸, focus groups, field visits to supply chain points and service delivery sites, and stakeholder briefings or workshops to present and discuss findings. The last are particularly important to build ownership and commitment to the process, and should include a full range of providers and NGOs, including women's advocacy groups.

The SPARHCS diagnostic guide is presented on the following pages. Though many questions are written specifically for contraceptives and condoms - a reflection of how SPARHCS has so far been most commonly applied - they can be modified for other reproductive health supplies. The answers to some questions may not be known. These will help identify priorities for new data collection and analytical work to support strategic planning. These could include, for instance, a logistics assessment, market segmentation analysis, willingness/ability to pay study, or national reproductive health account sub-analysis.

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A. Client Utilization and Demand

This section develops profiles of clients (current and potential) for reproductive health products. It examines distributions of use and unmet need by age, residence, education, standard of living, etc. It also asks questions about how efficiently providers are serving the whole market of clients, as well as about access, discontinuation, and the impact of activities to increase demand for products. This information will help determine strategies to, for example, expand method mix, address unmet need, and better target financial resources to ensure maximum reach.

The tables and questions focus on contraceptives, but can be modified for other RH supplies. They are meant to give users overviews of use and unmet need. Data about past trends and the present may be available from national surveys, like the Demographic and Health Surveys or Reproductive Health Surveys, though perhaps with secondary analysis. Future estimates provide important information for planning commodity requirements. They can be more difficult to obtain and require new analytical work specifically for the assessment.

Users can modify the tables - deleting some cells or adding new ones - using the CD-ROM or web versions of the guide.

A.1.1. Is method use tilted towards short-term, resupply methods? Or, long-term and permanent methods? What are the implications of the method mix for RHCS? For example, short-term methods require more frequent and reliable systems of forecasting, financing, procurement, and distribution to supply programs.

A.1.2. What is the profile of users in each sector (public, NGO, social marketing, commercial) according to their age, income/standard of living, residence, and education?

A.1.3. How well and how efficiently do service providers collectively cover the whole market in terms of clients' income, their location, the methods they want, and where they prefer to obtain them? Is each provider type serving the client groups and supplying the RH products that fit best with the providers' comparative advantage and objectives?

• Is the public sector concentrating its resources on serving the poor, or where there are no private sector alternatives?
• Is the widespread availability of free or subsidized products interfering with expansion of commercial markets?
• Is there access to affordable, quality services for clients who are able and willing to pay for RH supplies?

A.1.4. Are there differences in coverage by public and private sector programs that may limit client choice? For example, are clients in rural areas limited to public sector sources?

A.2.1. What is the percentage of current non-users of contraception who intend to use a contraceptive method in the future?

A.2.2. Of the total demand for contraception (current use plus unmet need), what percentage is being satisfied?¹²

A.2.3. What are the main reasons for unmet need (e.g., fear of side effects, perceived spousal objections, religious reasons, lack of access, etc.)? Do gender and ethnic norms create barriers to women's and men's use of contraceptives and other RH commodities? And, if so, how?

A.2.4. What are the key activities (current and planned) to address unmet need? What are their results to date? What future results are expected? How are they expected to affect use of public versus private sources?

A.3. Service Access and Utilization

A.3.1. Do all clients who want contraceptives and other RH supplies have physical access to them? If not, what and where are the main shortcomings in the public sector, in the private sector, in urban vs. rural areas, in different geographic regions?

A.3.2. How often are clients turned away or referred to other facilities because basic services or products (as expected according to norms and standards) are not available at their preferred source? Or, because a provider of the preferred gender is not available?

A.3.3. What are contraceptive discontinuation rates among different groups (e.g., by age, socioeconomic or education status)? What are the reasons for discontinuing use of contraceptives (e.g., lack of satisfaction, side effects, spousal objections, lack of physical access to a facility or other resupply source, lack of product, financial constraints, did not get preferred method)?

A.3.4. Where total demand for family planning (met need plus unmet need) remains low, will securing sufficient supplies to satisfy this level of demand fully realize stakeholders' vision for RHCS? How will activities to increase use of family planning affect the demand-supply relationship? Is supply keeping up with new demand? Will future supply keep pace?

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B. Commodities

This part examines the sources of RH commodities in a country and the relative contributions of different public and private sector channels. The table considers past trends and asks about future expectations; it may need to be duplicated for each of the different commodities under consideration in the assessment (contraceptives, STI drugs, etc.). Such an analysis can help determine each sector's role in the provision of RH commodities. Questions are also asked about how stockouts are prevented, how product quality is ensured, and how products are registered.

B.1. Sources of RH Commodities

B.1.1. What family planning methods does each program - public, NGO, social marketing, commercial - offer?

• Are some sectors largely oriented towards resupply methods (e.g., pills, condoms, injectables) and hence more dependent on frequent and reliable financing, procurement, and distribution to keep programs in full supply?
• How many different brands for a given method are being subsidized - whether by government or donors - through public, NGO, and social marketing programs?
• How are they differentiated? Are they all actively considered necessary by some constituency and by what criteria?

B.1.2. Are products that should be maintained at full supply? Or, does rationing occur?

• Have stockouts of products occurred within the last year in any of the programs?
• If so, which products, what programs, at what level(s) in the supply chain, for how long, and why?

B.1.3. How reliable are supplies in each program? Is supply reliability limiting program expansion?

B.1.4. Have significant amounts of any products in any program expired within the last year? Which products, what programs? Where in the supply chain? And, why?

B.1.5. What policies and quality control procedures and capacities are in place to ensure product quality for each product, in each program, and throughout each supply chain?

• How are complaints about product quality handled and investigated?

B.1.6. What are the policies that affect importation of contraceptives and other RH supplies? Are tariffs applied to imported RH supplies?

B.1.7. What are the procedures for product registration/licensing?

• Are they well understood, transparent, and efficient?
• Are the time and costs required for registration perceived by the private sector as "normal" or unduly burdensome? Could they be streamlined?

B.1.8. Are there local manufacturers of any RH products? Which ones?

B.1.9. Which donors have been or are involved in supplying RH commodities? What products have each provided last year, this year, and next year? Are there any long-term donor commitments or plans for supplying RH commodities? By who and for what products?

B.1.10. For the commercial sector, what is the percentage of total revenue from family planning and other RH commodities? What is the investment in them (marketing, innovations)? What are local manufacturers' plans for expanding their production capacity or distribution base? Does the commercial market have the willingness and potential to expand? What are the barriers to expansion?

B.1.11. For NGO and social marketing programs, what is the percentage of total revenue from family planning and other RH commodities? What cost recovery systems (e.g., pricing, fees, cross-subsidies) do they have in place or intend to implement? Are there waiver systems for the poor? What are their plans to expand family planning and other reproductive health services and associated products in their programs?

B.1.12. Who is the intended market for each private sector provider, both current and planned?

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C. Commitment

Of all the elements in the SPARHCS framework, commitment is perhaps the most difficult to assess by itself. Rather, the best evidence may be when other elements are in place. When, for instance, there is a supportive policy and regulatory environment, sufficient capital to meet client needs, and the necessary human and systems capacities. Still, there are some questions that can be asked about political commitment, commitment from within the private sector, and capacity for advocacy for RHCS. It is important to keep in mind that commitment to RHCS is not the same as commitment to family planning/reproductive health. Rather, it is about the policy level embracing the need to make and keep supplies available to clients, both women and men.

This section also looks at the extent to which there is commitment to RHCS under health sector reforms and development assistance for poverty reduction and sector wide approaches.

C.1. Commitment in the Public and Private Sectors

C.1.1. What is the political commitment to reproductive health commodity security?

• Who are key leaders/champions for reproductive health commodity security within government? At what levels?
• How does leadership initiate and support efforts to achieve reproductive health commodity security?
• Why are leaders motivated to support RHCS? How deep is their commitment to meeting women's and men's RH needs?
• Are leaders committed or opposed to using government funds to support reproductive health commodity security? Is there a budget line item for contraceptives and/or other reproductive health supplies? Has government funding for them and related services increased or decreased over time?

C.1.2. Are there leaders/champions within the private sector, for example among major employers or labor organizations?

C.2. Advocacy

C.2.1. Are civil society organizations mobilized and do they have the capacity to advocate for reproductive health commodity security?

• Are they able to act as sources of information for decision making? Do they act as "watchdogs" for improvements in RHCS?
• Are all segments of society, particularly the disenfranchised, represented by civil society organizations that are advocating for RHCS?
• Are RH commodity issues regularly included in broader health advocacy efforts and civil society dialogues?

C.2.2. How often and how well do the media cover family planning/reproductive health issues? Is reproductive health commodity security covered?

C.3. Health Sector Reform and Development Assistance

C.3.1. Are family planning/reproductive health services and supplies included in a Poverty Reduction Strategy Paper (PRSP)?

C.3.2. Are family planning/reproductive health services explicitly addressed in a SWAp? Is financing for contraceptives, condoms, and other supplies included?

C.3.3. What is the impact of health sector reform on provision of reproductive health and family planning services and supplies, including decentralization, health systems integration, and private sector involvement?

• What are the effects of shifting decision making responsibilities from central to local levels?
• Is the burden of public sector financing also shifting?
• What kinds of partnerships is the public sector building with the private sector for provision of health services (e.g., contracting)?
• Is the provision of reproductive health and family planning services and supplies explicitly addressed under these reforms? Or, are they are being "orphaned"?

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D. Capital

This section examines the full range of current and potential financing for RH commodities: government, household, donor, and third party. It looks at recent financing trends as well as future expectations. Importantly, it asks whether future financing will be adequate to ensure products are available to clients who want them. If, for example, donor support is declining, stakeholders should investigate what other sources of financing are able to keep pace with demand. A strategy can then be developed to ensure adequate funding is available to meet client demand. As for the table in the commodities section, the table may need to be duplicated for different commodities.

D.1. Government, Donor Funding

D.1.1. What is the current amount of public funding available for RH commodities? What are the expenditures?

• What is the share of family planning/reproductive health as a percentage of the total government health budget?
• Family planning as a percentage of the reproductive health budget?
• RH commodities as a percentage of the family planning budget?

D.1.2. What are the public sources of financing for contraceptives and other RH commodities, and what percentage of the total expenditure do each represent?

• How much is spent by the central government? Local government? Social security?
• How are the funds used?
• Are public resources being targeted to the poorest of the poor?

D.1.3. Are there cost recovery systems in place for public sector services and supplies? How do these systems function and how are the funds used? Is there a waiver system or other safety net for the poor?

D.1.4. Are public funds used to provide supplies or subsidize services through private providers (e.g., NGOs, social marketing programs)?

D.1.5. What contraceptive/commodity financial data do key decision makers have? How do they use it?

D.2. Household Funding

D.2.1. What are out-of-pocket expenditures on contraceptives, other RH commodities, and family planning/reproductive health services? How much are users paying for services and supplies, and what are they charged for?

• By standard of living or income?
• By rural-urban?
• By method?
• By source (public, NGO, social marketing, commercial)?
• By geographic area?
• Do women and men pay differentially for services?

D.2.2. Do women and men have equal access to household funds? If there are inequalities, what are the impacts for household funding of FP/RH services and supplies?

D.2.3. What is the ability- and willingness-to-pay among current users, as well as among clients with unmet need, for family planning/reproductive health supplies? By provider (public sector, NGO, social marketing, commercial)? By client characteristics (income/standard of living, rural-urban, education, etc.)?

D.3. Alternative Financing Mechanisms

D.3.1. What are the third party/health insurance schemes including social/national insurance, private insurance, and employer coverage?

• Who are the main third party payers? What kinds of individuals are covered by each? Who is eligible? How many people do they cover? How much do they spend?
• What is the coverage for family planning and other reproductive health services and commodities?

D.3.2. What alternative financing mechanisms are available to finance commodities (e.g., community-based financing)?

D.4. Current and Future Funding

D.4.1. How adequate is current funding for contraceptives and other reproductive health supplies?

• What is the current funding gap?
• How dependent are social marketing organizations, NGOs, and others on government and donor subsidies?

D.4.2. How adequate will future funding be?

• What are the expected significant changes in funding - sources and type?
• What are the expected/most reliable sources of funding over the next five to ten years, and what amount will each contribute?
• What will be the financing requirements for contraceptives, other supplies, operations, and capacity improvements to meet future demand?
• What is the expected gap?

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E. Capacity

This section focuses on the service provider, logistics, forecasting, procurement, and monitoring and evaluation capacities that are necessary for RHCS. All of these are necessary, whether for the public sector, an NGO, a social marketing program, or the commercial sector. Unless otherwise indicated, the questions should be asked separately for any program of national importance.

Other capacities that are critical for RHCS are addressed elsewhere in the guide. Advocacy is addressed under C. Commitment, capacity to develop supportive policies is addressed under G. Context, while coordination is its own section (F.).

E.1. Service Provider Skills

E.1.1. What percent of clients, with what profile, use different kinds of providers (OB/GYNs, general practitioners, midwives, nurses, community-based deliverers, pharmacists, drug store clerks)?

• For which supplies and services?
• How medicalized is the provision of contraceptives? What are the implications for access to contraceptives and program costs?
• Do the characteristics of providers (e.g., the mix of female and male providers) match with clients' needs and preferences?

E.1.2. What is the level of provider skill by service provider?

• Does provider training include counseling for informed choice, taking into account gender norms, logistics/reordering, and appropriate technical skills (e.g., IUD or implant insertion and removal)?
• Are facilities stocked with the appropriate contraceptives and other supplies given the skill level of health personnel to provide services according to standards of care?
• Is there provider bias against particular client groups or methods? If so, what are the implications for client access to contraceptives or other products?

E.1.3. Do supervisors check the quality of the providers' work and provide on-the-job training to improve their skills in counseling including attention to gender issues, storage, ordering, record-keeping, etc?

E.2. Logistics

E.2.1. For each program, how does the distribution system work and what capacities exist?

• Is the logistics system "push" or "pull"?
• How many levels are there in the supply chain? Can they be reduced?
• Is a maximum/minimum inventory control system in place? How much stock is held at each level?
• Are the storage conditions throughout the system adequate to manage the product load and prevent loss through damage and theft?
• Is transportation adequate at all levels?
• Is the distribution schedule appropriate?
• Is there a system where timely and accurate data on stock on hand and consumption are collected and used for reporting on use, for ordering resupply, and for making shipments at all levels?
• Are there guidelines/systems in place for inventory management and for handling expired or defective products?

E.2.2. For the public sector, is the contraceptive logistics system stand alone or integrated with other products? If donor resources diminish, can it be sustained?

E.2.3. What is the future capacity of each distribution system?

• Is the distribution infrastructure improving or deteriorating?
• Are the demands on the system likely to increase? Can the system expand to accommodate the increase?
• Do weaknesses in infrastructure (e.g., bad roads or too few wholesalers) limit the availability of supplies?

E.3. Forecasting

E.3.1. Are program commodity needs forecast two to five years in advance?

E.3.2. What data are used for forecasting need (e.g., consumption, losses/adjustments, stock on hand, sales data, demographic data, service statistics)? How reliable are the data?

E.3.3. How often are forecasts updated?

E.3.4. Who is responsible for forecasting and what skills and training do they have? Do they require donor assistance for completing their forecasts?

E.3.5. Are forecast data used to advocate for resources to ensure full supply (for those products that require it)?

E.4. Procurement

E.4.1. Who is responsible for procurement of contraceptives and other RH supplies? What kind of procurement training do they receive, if any? Is there coordination between logistics and procurement staff?

E.4.2. What data are used for procurement plans? Are appropriate products procured to address forecast need? Prevent stockouts?

E.4.3. How effective is donor coordination for procurement? Are there obstacles? Are donor lead times for procurements reasonable for programs to work with effectively?

E.4.4. Have there been donor-related disruptions in supply to programs? For what reasons? What is being done to avoid them in the future?

E.4.5. What are the procedures for government procurements (e.g., issuing tenders, evaluating bids, monitoring supplier performance)? How transparent, timely, and efficient are they? Do they comply with the international competitive bidding procedures of funders? Where do government procurements typically source contraceptives and other RH supplies? What prices are they paying? Do they have access to hard currency? What are lead times for government procurements? Are they reasonable for programs to work with effectively?

E.4.6. Have there been disruptions, or the threat of disruptions, in supply to programs due to delays or other difficulties in government procurements? For what reasons? What is being done in the future to avoid them?

E.4.7. What procedures are in place to assure product quality?

E.4.8. Is there scope for efficiencies and cost savings by reforming or centralizing procurements across programs? For example, is one financing source paying more than another for the same product?

E.5. Monitoring and Evaluation

E.5.1. Do programs routinely collect appropriate data and information for management decision making, monitoring, and planning for RHCS? Is the data appropriately disaggregated by client characteristics (e.g., age, sex, location, etc.)? Is there a management culture that supports evidence-based decision making?

E.5.2. Is there a functional MIS for each program? Does it receive policy-level attention and support? Do higher levels provide feedback to lower levels about performance based on MIS data?

E.5.3. Does the policy level receive appropriate information? How? Does the policy level use it for analysis and decision making?

E.5.4. Is population-level data collected at an appropriate frequency, reported, and used to measure overall program performance and to make adjustments? Is it disaggregated by respondent characteristics (e.g., age, sex, location, socioeconomic status) and used to monitor inequalities in reproductive health, and in access to and use of FP/RH services and supplies?

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F. Coordination

This section addresses the need for coordination among a wide range of stakeholders and at multiple levels to achieve reproductive health commodity security. It asks questions about who should coordinate, how they coordinate, and what have been the results.

F.1. Who Coordinates, How, and Why

F.1.1. Who are the stakeholders that need to coordinate their activities (donors; government agencies; public, NGO, social marketing, and commercial sector providers; technical agencies; etc.)?

F.1.2. What formal and informal coordination mechanisms exist? What is the willingness to foster coordination?

• Among donors?
• Within government?
• Between donors and government?
• Among service providers in different sectors?
• Between government and service providers?
• Between government and civil society organizations?
• Among technical agencies?

F.1.3. Is there a committee or task force for RHCS? How influential is it? Who is it comprised of? Is there representation of disenfranchised groups?

F.1.4. Does the government, particularly the Ministry of Health, play a leadership role in coordinating key stakeholders? In particular, how well do different parts of the government coordinate for RHCS (e.g., Ministries of Health and Finance)?

F.1.5. What are the information flows that facilitate coordination?

F.1.6. What are the existing coordinated activities and their expected outcomes, such as better coordination of donor procurements or more rational and sustainable segmentation of the contraceptive market?¹⁶

F.1.7. To what extent and how are stakeholders involved in policy development? In advocacy and work with the media? Which stakeholders?

F.1.8. Have key stakeholders come together to develop a joint strategy for RHCS?

• Is the strategy generally known and supported in the government and among key stakeholders?
• Is it included in a broader strategy (e.g., a health sector program) or does it stand alone?
• Who led its development and who was involved?
• Who has responsibility for coordination and oversight of the implementation of the strategy?
• If there is no strategy, do stakeholders have the capacity to develop one? To monitor progress on RHCS and make adjustments?

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G. Context

The success of a RHCS strategy depends on a range of contextual factors affecting individuals' ability to choose, obtain and use RH supplies. To define the broader health, political, and economic environment as it affects RHCS, this section considers:

• policies and regulations that bear on the ability of public and private sector programs to secure and deliver reproductive health supplies; and
• basic demographic, health, and other development indicators.

G.1. Policies and Regulations

G.1.1. What are the official population or family planning/reproductive health policies and other stated positions?

• Are these supportive of securing reproductive health supplies? And if so, how?
• Are they supported by adequate programs and funding?
• How are the policies and programs implemented? What are/have been the implications for supplies?

G.1.2. Does the HIV/AIDS policy formally link to the population/family planning policy? Does it explicitly mention securing adequate supplies of condoms or other commodities?

G.1.3. For family planning/reproductive health and HIV/AIDS commodity issues, how are decisions made and who is involved? Are civil society groups, for example, women's health advocates, included?

G.1.4. Are contraceptives and other reproductive health supplies on the national essential drugs or medicines list (EDL or EML)? Which ones? Does being on the list bring any special status, such as waiver of duties, priority in budgeting or resource allocation decisions, waiver from procurement restrictions (e.g., "buy local")?

G.1.5. Are there age- or parity-related restrictions, requirements for parental or spousal consent, prescription requirements, or other policies or other restrictions that limit access and choice of contraceptives?

G.1.6. What policies affect, positively or negatively the private sector's ability to provide contraceptives? Other reproductive health supplies?

• Are there price controls?
• Are there limitations on distribution?
• Are there taxes and duties (excise, import, value-added tax) or exemptions that affect the private sector?
• Is there a ban or other restrictions on advertising?
• Are there other operational policies or regulations that adversely or positively affect the private sector?

G.1.7. What other regulations or operational policies affect delivery of supplies and services?

• Are there restrictive licensing requirements?
• Are there any restrictive dispensing regulations?
• Are there limitations by specific cadres of health professionals?

G.1.8. Do policies assure the capacity of service providers to provide contraceptives and other supplies?

• Do service delivery guidelines, protocols, norms, and standards specify appropriate products? Do they include quality assurance procedures and basic logistics principles such as ordering, recording, storage, handling, etc.?
• What are the training and certification requirements (pre- and in-service) specific to methods? Are they enforced?

G.1.9. What are the policies and regulations regarding distribution of public funds for family planning and reproductive health? What is the process for determining annual funding, levels and allocations?

G.1.10. Are there policies that restrict or regulate fees for family planning and other reproductive health services (levels, exemptions)? For contraceptives and other supplies?

• What financial management policies and guidelines exist for retention of fees, management of funds, facility budgeting, local procurement?

G.2. Demographic, Health, and Development Indicators

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6. The questions in the guide are organized by these elements. Using the CD-ROM and web versions, users can easily reorganize the guide to mirror how they are adapting the reproductive health commodity security framework. For example, as used in Madagascar the framework identifies demography, policy, demand, service delivery, and finance as key elements. In Nigeria, they are finance, policy, logistics, service delivery, demand, and coordination. And, at the district level in Indonesia, they are service delivery, policy, financing, logistics, and supply.
7. As a rough guide, two-to-three weeks in-country is a reasonable allowance for a SPARHCS diagnosis, allowing for data collection, analysis, and stakeholder discussions.
8. Key informants can include, to name a few, donor representatives, policy makers, program managers, service providers, logistics managers, advocates for family planning/reproductive health, and clients (women, men, married and unmarried, in a range of age groups).
9. Percentage of married women, or women of reproductive age, using contraception. Where data is available, users of the guide can examine contraceptive use by sex and marital status, adding rows to the table using the CD-ROM or web versions. Access to and use of condoms by men can be a special concern for HIV prevention programs.
10. Definitions of unmet need for family planning vary. In the Demographic and Health Surveys, unmet need refers to fecund women who either wish to wait two or more years before having another child (spacers) or wish to stop childbearing altogether (limiters), but are not using a contraceptive method. Broader definitions can include, for example, women who are using a method of family planning, but are in need of a more effective or preferred method.
11. This table examines the distribution of total unmet need. The distribution of unmet need for spacing versus limiting can be of interest as well. Need for spacing versus limiting can shift significantly according to certain client characteristics, for example, age and parity, with implications for method availability.
12. The percentage of total demand for contraception that is satisfied can be examined in more detail according to demand for spacing versus limiting as well as by client characteristics. Examples can be found in reports of the Demographic and Health Surveys.
13. Where "Government" can refer to national, state, provincial, or other local authority. Users can use the CD-ROM and web versions to modify the table accordingly.
14. Where "Government Budget" refers to financing through government budget processes. "Government" can refer to national, state, provincial, or other local authority. Users can use the CD-ROM and web versions to modify the table accordingly.
15. Where "Donor" refers to direct donor financing of commodities, generally through donor procurement mechanisms.
16. Market segmentation is addressed in more detail under A. Clients, the public sector's role in enabling other sectors to function more effectively in providing RH supplies is addressed under G. Context, and coordination of procurements is addressed under E. Capacity.