SPARHCS - Strategic Pathway to Reproductive Health Commodity Security

4. SPARHCS Applied: Country Examples

Examples of the different ways SPARHCS has been applied come from Madagascar, Indonesia, Latin America, and Nigeria. They illustrate the flexibility of SPARHCS, particularly in how the diagnostic guide can be applied, and - in the case of Nigeria - how a SPARHCS assessment can be used to develop a national strategic plan for RHCS.¹⁷

A. Conducting a Reproductive Health Commodity Security Assessment in Madagascar

Madagascar continues to face serious health problems. Child and maternal mortality rates are among the highest in sub-Saharan Africa, while contraceptive prevalence is just over 12 per cent. The new government, which took office in 2002, has placed health improvements among its top priorities. Commitment to family planning and reproductive health is now being expressed at the highest levels.

To support this renewed commitment, local experts and international consultants teamed together to conduct a comprehensive assessment of the country's reproductive health commodity security. The Ministry of Health first convened a national stakeholders' workshop with various ministries, UNFPA, donors, and other public and private sector stakeholders. The workshop renewed interest in reproductive health commodity security, gave an overview of what was known about it in Madagascar, and developed an approach for the assessment.

Over the following two weeks, five working groups - corresponding to the five components in Madagascar's reproductive health commodity security framework (demography, policy, demand, service delivery, finance) - conducted a diagnosis of their respective components using the SPARHCS guide (reorganized around these components). Each group - led by a local expert and international consultant - used some combination of document review, data analysis and modeling, key informant interviews, focus group discussions, and field visits. The assessment concluded with a second national workshop where the groups presented their findings. Small group discussions identified priority areas of action and made recommendations for the development of a strategic plan.

The SPARHCS framework and diagnostic guide proved flexible enough to allow Madagascar to customize their assessment with minimal effort. The assessment:

• reinforced stakeholders' commitment to reproductive health commodity security;
• increased participation among interested stakeholders;
• provided a detailed look at existing strengths and weaknesses for reproductive health commodity security, as well as at historical trends and future projections affecting contraceptive and condom use;
• developed a one-year plan of action for RHCS that was accepted by the Ministry of Health; and
• defined a broad outline for the next steps of developing a longer-term strategic plan.

By establishing a working group for each component in Madagascar's RHCS framework, the data collection process permitted more focused inquiry within each component. The national workshops helped stakeholders integrate across components and develop a coherent "story" on reproductive health commodity security in Madagascar.

Based on the recommendations made during the assessment's concluding workshop, three studies - a contraceptive stock status survey, willingness-to-pay survey, and market segmentation analysis - have since been conducted to help the government develop a contraceptive financing strategy as part of a broader national RHCS strategy. In addition, RHCS workshops have been held in two provinces to raise awareness of RHCS, disseminate information from the national assessment, and lay a foundation for later development of regional RHCS action plans.

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B. SPARHCS Under Health Sector Reform in Indonesia

Among the major challenges facing Indonesia's family planning program is decentralization of BKKBN, the government's coordinating agency for family planning activities. Local governments, numbering more than 420 districts and municipalities, now have responsibility to manage and implement a family planning program that has been highly centralized for more than 30 years.

To build the capacity needed to address contraceptive security issues in this new environment, BKKBN and partners - comprising a central Contraceptive Security Team (CST) - have adapted and streamlined the SPARHCS framework and diagnostic guide for use by district stakeholders. The CST has developed a process in which:

• District stakeholders are first introduced to the concept of contraceptive security, awareness is raised of the need to address contraceptive security at the district level, and the adapted diagnostic guide is reviewed.
• Two-person teams, composed of people from the public and private sectors, use the questions in the guide to collect data over two weeks. Each team focuses on one of five components: service delivery, policy, financing, logistics, supply.
• After data collection, a three-day "District Contraceptive Security Strategy Development Workshop" is held at the district level to review the findings, compare the current situation in each component with a desired status, and create two priority lists according to how serious a component is in preventing a district from achieving contraceptive security and how able a district is to address a component on its own. This forms the basis for a comprehensive district strategy that addresses the five components. The workshop is conducted by a Contraceptive Security Task Force consisting of provincial-level public and private stakeholders whose role it is to provide technical assistance to districts.

The tools to support this process have been compiled into a Contraceptive Security Tool-Kit and tested in Central and East Java. The results demonstrate that the SPARHCS framework and guide can be adapted and made feasible at local levels, where there are few resources. They enable stakeholders to gain a realistic picture of their contraceptive security situation and empower districts to address contraceptive security issues without central involvement. SPARHCS can thus support shifting responsibility and ownership for contraceptive security from central to local governments, while highlighting where local level actions, for example, in advocacy, can help propel needed changes at the central level.

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C. SPARHCS as a Tool for Regional Planning in Latin America

In 2003, USAID and partners began a two-year study to determine how contraceptive security could be addressed in Latin America and the Caribbean through a regional approach. The study was designed to answer:

• What are the priority contraceptive security issues that are shared by countries in the region?
• What regional interventions might be most effective in addressing these shared contraceptive security issues?
• How could regional assistance efforts be structured to produce maximum benefit?

The study was launched by a three-day conference in Nicaragua. Teams from nine countries were introduced to the SPARHCS framework and used it to begin their own situation analyses. The introduction of SPARHCS provided a common language and conceptual framework for five in-depth country assessments that followed the conference. This facilitated identification of crosscutting issues, as well as similarities and differences among countries that may need to be addressed at the regional level. This common approach also empowered country stakeholders to see themselves as part of a regional network of activists with a common agenda.

A number of countries formed or strengthened national contraceptive security committees or working groups after the conference. The working group in Peru, for example, is chaired by the Ministry of Health and includes representatives from divisions in the Ministry as well as the social security health system, armed forces and national police, NGO service providers and social marketing programs, UNFPA, USAID, and technical assistance agencies.

The first of the five SPARHCS assessments that followed the workshop was in Peru. ¹⁸ Its assessment investigated issues of general concern in the region, while also raising awareness about contraceptive security and generating practical recommendations for action by country stakeholders. A four-person team of two international and two local consultants:

• carried out a desk-based literature review and analysis of available data (e.g., from the Demographic and Health Survey, DHS, and Peru's logistics management information system or LMIS),
• projected future commodity and financing requirements, and
• interviewed key informants in Peru, made field visits, and held briefings with USAID/Lima and Peru's Contraceptive Security Committee (the in-country part of the assessment was done over a two-week period).

The assessment covered all of the SPARHCS components, but gave priority to issues of special concern in Peru as already determined at the regional workshop: the policy environment and high level leadership/commitment, advocacy, financing, targeting public subsidies, the private sector's role in contraceptive supply, and procurement and logistics.

In conjunction with the assessment, a market segmentation analysis was conducted. Its findings - disseminated to MOH officials, technical agencies, NGOs, and civil society leaders - showed that a significant proportion of those who receive free contraceptives from the public sector are from the topmost economic quintiles. Based on these findings, political will has grown within the MOH to consider strategies to direct public sector resources to the poor, and strengthen and stimulate private sector supply of contraceptives for clients who can afford to pay. Targeting of family planning services may be piloted in two regions, and the MOH is considering a service exchange/reimbursement agreement with the Social Security Institute for the substantial numbers of social security beneficiaries who receive free contraceptives from the MOH.

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D. A National Reproductive Health Commodity Security Strategy for Nigeria

In 2002, the first field test of SPARHCS was conducted in Nigeria. The assessment identified a large number of improvements needed to strengthen RHCS in Nigeria. To prioritize and develop an organized response to the improvements identified, a Technical Core group, comprising Nigerian stakeholders and decision makers in reproductive health, worked closely with a team of international consultants to develop a five-year national strategic plan for RHCS. To help focus the efforts of the Technical Core group, the international team provided a framework with some example objectives and activities for the strategy; the Technical Core group further developed the strategy adding additional objectives, activities, and detail.

The draft strategy was disseminated to a broad group of stakeholders, including civil society organizations, private sector representatives, and public sector officials from the federal to local government area levels for their comments. The Technical Core group incorporated their comments into a revised strategic plan. This plan was reviewed by policy makers during a four-day National Contraceptive Security Strategic Planning Workshop, where it was formally adopted by the Federal Ministry of Health. Having a broad group of stakeholders review the strategic plan prior to sharing it with policy makers for approval built awareness of and support for RHCS in different sectors. These stakeholders, to varying degrees, have become champions for RHCS in their respective areas of influence. Next steps following the plan's adoption include disseminating it country wide, presenting the plan to the National Legislative Committee on Population, and holding a donors conference to identify additional funding for the plan.

The strategic plan covers contraceptives and condoms for HIV/STI prevention, collectively referred to as RH commodities. For each of six components in Nigeria's RHCS framework - finance, policy, logistics, service delivery, demand, and coordination - the plan presents an overall strategic objective that describes the broad level of accomplishment desired within the component. Each strategic objective is broken down into a number of objectives that give details of the expected accomplishments for each component. Each objective is described in terms of:

• specific problems or opportunities on which the objective focuses,
• activities necessary to achieve the objective,
• agencies responsible for completion of the required actions,
• estimated budget,
• time when the activities are planned to be completed,
• output indicators that monitor completion of the activities,
• outcome indicators that describe the overall results once the products of the activities have been realized, and
• assumptions about preconditions, requirements, and circumstances that must exist for the successful implementation of the activities.

For example, the Finance Component has the strategic objective "to promote the provision of secure and permanent financial support for contraceptives among governmental, non-governmental and private organizations and individuals." It has three objectives, one of which is to ensure that decision makers are provided with current and reliable data on RH commodity financial requirements. The following section, reproduced from the strategic plan, shows how this objective is described in detail.

Component:

Objective:

Issues Addressed:

• Validity, reliability and comprehensiveness of financial data;
• To ensure that key policy/decision makers make use of the financial data in planning;
• Evidence based planning and decision making.

Coordinating Agency:

Assumptions:

• Favourable political environment
• Continued donor support
• Positive response from the key policy makers
• Collaboration between various levels of government and NGOs/private sector
• Financial management

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17. Readers who want more details about each example, including in-country contacts, should contact the USAID Contraceptive Security Team or UNFPA Commodity Management Unit.
18. The other assessments were in Bolivia, Paraguay, Nicaragua, and Honduras.