Elements of Family Planning Success

Over the last four years, the DELIVER project in Mali assisted the Ministry of Health (MOH) and its stakeholders to carry out appropriate activities to improve the program. Major achievements, described in this report, include logistics assessment, strengthening of the logistics management information system, and monitoring of national inventory. Throughout the life of the DELIVER project, supervisory visits were conducted by a team composed of DELIVER's resident advisor, a representative of the Direction de la Pharmacie et du Medicament, and a regional pharmacist. These visits contributed to the improvement of both the logistics system and human capacity. Through OJT, DELIVER was able to improve the skills of various personnel at all levels of the supply chain to enable them to carry out their duties. DELIVER worked to implement the Mali Strategic Contraceptive Security (CS) Plan by coordinating stakeholder activities, various Government departments, private-sector partners, and donors. In addition, DELIVER fostered engagement of political leadership for contraceptive security at all levels of Government, civil society, donors, decision makers, and opinion leaders. DELIVER carried out a number of studies and assessments in Mali to identify CS issues in general and logistics issues in particular. These assessments included the Logistics Indicator Assessment and Logistics System Assessment Tools, market segmentation, and informed buying. Some of the studies were aimed at finding solutions to CS issues and measuring the performance of the program. This report outlines major recommendations from these assessments. DELIVER also assisted the MOH in Mali over the last four years to estimate contraceptive requirements. These requirements were estimated for USAID-procured products but also for other donors such as the United Nations Population Fund. The Malian forecasting team is now able to do the estimation and procurement planning with little or minimal assistance from DELIVER. Important progress has been made in recent months in collecting dispensed-to-user data for the estimation of contraceptive requirements. Looking into the future, DELIVER has designed a transition plan for the Mission and the MOH. The DELIVER project closed out in September 2006. The transition plan covers the period October 2006 to September 2007 and is described in this report. (author's)

The Philippines is working to sustain recent gains in access to and use of family planning services through a Contraceptive Self-Reliance (CSR) strategy that must adjust for the impending phaseout of USAID's contraceptive donations. DELIVER, working through the Local Enhancement and Development (LEAD) for Health project, has helped local government units (LGUs) at the provincial and city levels - where responsibility rests for providing health services - to prepare CSR plans that consider the growth in demand for contraceptives, the impact of donor phaseout, and the resources needed to meet demand. In addition, DELIVER has adapted the national Contraceptive Distribution and Logistics Management Information System (CDLMIS) to allow the Department of Health to allocate the remaining donated supplies based on new poverty criteria, and to monitor new LGU contraceptive procurements. DELIVER has also provided training to national and LGU staff in how to use the CDLMIS to manage, monitor, and procure contraceptive supplies. Because the public sector provides more than two-thirds of the contraceptives used in the county, the sustainability of the family planning program in the Philippines will be heavily dependent on the success of the CSR strategy at the local level. The national government has decided not to procure contraceptives, so all financing and procurement decisions will be made by provincial, city, and municipal authorities, whose commitment to family planning services varies widely. (author's)

This report summarizes DELIVER's key role as the distributor of USAID's donated condoms and manager of the logistics system for public-sector condoms and antiretroviral (ARV) distribution for Zimbabwe's Ministry of Health and Child Welfare (MOHCW). DELIVER worked closely with the MOHCW and the U.S. Government to improve the availability of HIV/AIDS condoms in rural health centers and other public sector sites. DELIVER was tasked with improving logistics system performance, human capacity in logistics management, and resource mobilization for commodity security. DELIVER's role was expanded to support the development, roll-out, and expansion of the National Antiretroviral Therapy (ART) Program beginning in 2003, specifically in the areas of site readiness assessments, quality assurance, logistics management, and condom distribution. DELIVER's objectives for the five phase 1 sites focused on HIV care and antiretroviral (ARV) therapy support activities for clinical readiness, overall planning and management, and managing, procuring, and distributing ARV medicines. (author's)

USAID/Tanzania's program focus is on preventing the spread of HIV/AIDS and increasing the use of reproductive and child health services. In concert with USAID's health objectives, DELIVER's activities in Tanzania concentrate primarily on three main areas of intervention: the development of a health management integrated logistics system, Commodity Security (in particular contraceptives), and the quantification and procurement of antiretroviral drugs. In addition to these main areas, DELIVER provides ongoing logistics-related technical assistance to numerous USAID supported partners and programs. This final country report explores program results for DELIVER in Tanzania and offers lessons learned and directions for future programs. (author's)

The Ministry of Health (MOH) in its medium-term health strategy ending 2001 identified the need to integrate the vertical supply systems for public-sector health commodities and make them more efficient. To support the MOH objective, DELIVER assessed the effectiveness of the four vertical supply chains (contraceptives, essential medicines, non-drug consumables, and vaccines) through process mapping to indicate all the steps required in moving supplies through the pipeline to the clients and, realizing the need for integration, went ahead to work with the MOH to develop an integrated supply system based on a scheduled delivery system throughout all levels. Standard operating procedures, a logistics management information system (LMIS), and a novel preprinted Requisition, Issue, and Receipt Voucher were developed to facilitate implementation of the new supply system. One thousand fifty-five personnel from regional and service delivery point levels have been trained to use it, in addition to 33 trainers who will support further training. With the increasing demand for contraceptives and the limited resources of the partners, DELIVER has championed the concept of contraceptive security (CS); with the MOH and the Ghana Health Service, they have developed a national contraceptive security strategy for contraceptives. An Inter-Agency Coordinating Committee for Contraceptive Security (ICC/CS) has been established to coordinate and oversee the implementation of CS activities. As a result, from 2003 to 2006, through DELIVER's support to ICC/CS's advocacy, the needed financial resources were mobilized to fill the gap for contraceptives procurement. In the area of HIV/AIDS, DELIVER has contributed to in-country programs by putting in place an LMIS for the HIV/AIDS test kits and antiretrovirals, in addition to providing support in forecasting, procurement planning, and pipeline monitoring. DELIVER has also supported the training of personnel at the various treatment, counseling, testing, prevention of mother-to-child transmission, and sentinel sites in logistics management of the commodities they use. With these in place, an April/May 2006 logistics indicators assessment of facilities showed that 17 percent of testing sites were out of stock for test kits during the day of the visit and 33 percent had experienced a stockout of test kits during the three months preceding the day of the visit for the two most common test kits used in the system (Determine and Rapi-test). To ensure that the vast range of HIV/AIDS commodities will be regularly available to the growing number of clients, DELIVER has assisted MOH to develop a National HIV/AIDS Commodity Security Strategy, which was approved by all the stakeholders in July 2006. (author's)

DELIVER's technical support has significantly improved the Ministry of Health's (MOH) contraceptive availability in all the service delivery points. This successful experience in family planning logistics has also improved the process of integration for the other essential drugs. In June 2006, the Information System for the Integrated Logistics System for Essential Drugs and Contraceptives (SIGLIM) was implemented in five regions with the expectation of being extended to the rest of the country in 2007. DELIVER has also strengthened the postpartum family planning services in 22 Mother and Child Health Care (MCHC) hospitals. DELIVER provided support to Profamilia staff in the use of management tools to evaluate their logistics system and forecast their contraceptive needs. The staff have been trained on how to use the LAST and how to use the software PipeLine, which is now being used with an established community-based distribution services in nine clinics. Since 2005, assistance to the Social Security Institute (INSS) started with an assessment of the family planning logistics system and services in the companies that provide private medical services (EMPs in Spanish). Based on the findings, a training program and supervision system have been developed to further develop the commodity logistics system. In July 2003, the National Contraceptive Security Committee was created and constituted by officials from the MOH, INSS, Profamilia, donor agencies, and cooperating agencies. During 2005, the contraceptive security committee held 14 meetings, designed a Contraceptive Security Strategic Plan 2005-2008 and a proposed implementation plan, developed a manual describing roles and responsibilities for the committee members, and proposed meetings with and presentations to policymakers. (author's)

Since 2003, DELIVER in Ethiopia has worked continuously with two of the Federal Ministry of Health's key departments: the Pharmaceutical Supply and Logistics Department and the Family Health Department. The DELIVER program includes three main elements: design and implementation of the Ethiopian Contraceptive Logistics System, support to contraceptive security, and active involvement in the development of a Health Commodity Supply System Master Plan. With the technical assistance from the United Nations Children's Fund, DELIVER, and other partners, the final Health Commodity Supply System Master Plan was completed and approved by the Ministry of Health in October 2006. Implementation is scheduled to begin in early 2007. (author's)

The Ministry of Health (MOH) of Malawi is committed to establishing an integrated health logistics system, especially for products in the Essential Health Package (EHP). Over a six-year period, DELIVER provided technical assistance to the MOH in building an integrated logistics system, including the implementation of the reengineered logistics system; designing and implementing a new training program based on a revised set of standard operating procedures; and improving the EHP supply chain and information systems. (author's)

The Ministry of Health (MOH), with continuous technical assistance, improved its logistics system; they are giving priority to the beginning of an improvement plan for the contraceptive logistics system. Although the logistic indicators quantitative assessment showed a high incidence of shortages six months prior to the assessment (December 2005), corrective actions are already being developed; good results are expected in the next assessment. The Contraceptive Security Committee, a multisectorial group was formally established in October 2004. It has achieved much progress in sustaining the present and future supply of contraceptives. A Contraceptive Security Strategic Plan and its respective implementation schedule have been developed, and a Funds Protection Act has been signed for the procurement of contraceptives and delivery kits. The MOH and UNFPA have signed a Memorandum of Understanding (MOU) to carry out procurements; the MOU will optimize the financial resources. For 2006, the MOH assigned sufficient funds to cover 65 percent of its needs. Changes have been implemented in the information system. Trainers attended training workshops; the MOH regional trainers' team is implementing the training at the PES level to ensure that the documents are filled out correctly for the LMIS. DELIVER and the central level of the MOH are providing support and monitoring. (author's)

The South African National Department of Health (NDOH) asked the U.S. Agency for International Development/ Pretoria to provide technical assistance to eliminate condom shortages and stockouts and improve the quality of public-sector condoms. In response, the Technical Assistance Service Contract (TASC) and DELIVER project designed and implemented a logistics management information system that was driven by service delivery site consumption and inventory data, together with a quality assurance program based on international standards and specifications. These interventions resulted in guaranteed high-quality public sector condoms and a stockout rate of less than one percent, sustained over the past five years. TASC and DELIVER provided added value by also proposing, designing, and implementing a branded public sector condom with radically revised packaging, which has doubled distribution figures. More than one billion condoms have been distributed during the reporting period, averting an estimatedone million HIV infections. Because of these successes, TASC and DELIVER were asked to assist the NDOH in identifying patient information and reporting systems that could strengthen logistics systems and service delivery for the government's antiretroviral rollout program. TASC and DELIVER developed a proof of concept and field tested an innovative patient information and program reporting system based on a proven, South Africa-developed, combination biometrics/smart card technology. The resulting Secure Technology Advancing Treatment (STAT) system was field tested in both clinic and community outreach settings. This concept has now been integrated into the government's long-term strategic plan for a national electronic patient record. (author's)

In India, DELIVER worked in three states, namely Uttar Pradesh (UP), Uttaranchal, and Jharkhand, in northern India. However, many of the technical assistance activities during this report period were focused on UP and then on Uttaranchal. When DELIVER started working in UP, the largest state in India with 160 million people, contraceptive prevalence rate was barely 19 percent, and the entire public sector contraceptive logistics system was in disarray. Therefore, many of the interventions involved setting up systems, system streamlining, training, and system strengthening in working with local partners, such as the State Innovation in Family Planning Services Agency (SIFPSA) and the Indian Institute of Management, Lucknow. Since the Government of India (GOI) provides contraceptives to states through federal programs, the issue in UP was not having the funds or contraceptives, but of ordering an appropriate quantity of contraceptives, receiving them in timely manner through the federal government, and ensuring their delivery when needed. By 2005, the contraceptive prevalence rate in UP had risen to 29 percent. In working with the Ministry of Health and Family Welfare (MOHFW), DELIVER's interventions and strategies focused on developing awareness of and commitment to contraceptive security and institutionalizing and optimizing a logistics system. Contraceptive security work included assistance in developing a work plan and procurement policies, and streamlining and strengthening the public sector logistics system through training and development of the Supply Procedure Manual: An Instructional Manual for the Logistics People, the Storekeepers Manual, and a supervisory checklist. Setting up a logistics management information system (LMIS) and a logistics management cell (LMC) were part of the technical assistance strategy to build capacity. A primary thrust of technical assistance in India was using available local resources; however, continued support is needed in capacity building, system functioning, and monitoring and supervision as the program grows. (author's)

DELIVER activities in Mozambique focused on building capacity within the Central de Medicamentos e Artigos Medicos (CMAM) and the Ministry of Health. Specifically, the project's efforts aimed to strengthen Mozambique's public-sector forecasting, procurement, and storage and distribution of essential drugs, contraceptives, and HIV/AIDS commodities. Specific activities and achievements under DELIVER included managing the development and implementation of a complex integrated drug management software system customized for Mozambique's public health sector; carrying out the procurement and importation of antiretroviral drugs for the national treatment program in 2006; coordinating with the CMAM and others on improved health services delivery, product quality, and commodity security; and conducting a requirements analysis for the construction of a central warehouse to serve the northern region of the country. (author's)

As DELIVER comes to an end, the liaison between commodity security and the supply chain has become more evident. There can be no security without a responsive supply chain managed by dedicated, well-trained professionals operating in a supportive management environment. DELIVER activity in Nigeria focused on development of improved logistics systems for reproductive health (RH) and HIV/AIDS program commodities. Consistent with DELIVER and Federal Ministry of Health (FMOH) objectives, DELIVER worked with the FMOH/Department of Community Development Population Activities (RH) and FMOH/National AIDS/STD Control Program (HIV/AIDS) to implement programs of national scale by collaborating with larger partners. Improving human capacity in logistics among key stakeholders was a DELIVER core activity. Since 2002, DELIVER, working with the FMOH and other partners, has trained approximately 2,000 government and nongovernmental organization logistics managers on the FMOH contraceptive logistics management system (CLMS) and 363 logistics managers and service providers on a streamlined CLMS in 2006. In addition, 142 FMOH personnel were trained in quantification, procurement planning, and the newly designed logistics system for antiretroviral drugs and HIV test kits. (author's)

Since 2002, the Government of Rwanda, through the Ministry of Health, has been revitalizing its contraceptive logistics system to improve product availability to clients and to move toward reproductive health commodity security. As an initial step, a logistics system assessment was conducted in February 2002 to identify strengths and weaknesses of the system. A design workshop followed by a Country Strategic and Evaluation Plan framed the process for addressing weaknesses. After six years of implementation, much progress has been achieved. Commodities are available nationwide, the stockout rate has decreased to less than 10 percent, and storage conditions are widely improved. In addition, the contraceptive prevalence rate has increased from 4 percent to 10.3 percent. However, there are still areas needing improvement. The current report provides a picture of the Rwanda contraceptive supply chain. It also provides indications for lessons learned and future directions to improved reproductive healthin Rwanda. (author's)

Logistics is a mission-critical function in any health program. Health care management is a challenge in Nepal because of geographical adversities, resource constraints, and the recent conflict situation. The goal of DELIVER's technical assistance to the Ministry of Health and Population's health logistics activities is to improve the availability of contraceptives and other key program commodities at the health facility and community level, thereby increasing service utilization. Availability of key commodities at the service delivery points, increased reporting percentages, and improved storage standards at all levels of the health institutions are key to delivering essential health care services to the Nepalese people. DELIVER support focuses on capacity building and skills transfer to the government system for long-term sustainability of the program. (author's)

The Bangladesh family planning program has evolved over the course of 30 years to become recognized as one of the most effective programs in the world, despite extreme poverty, illiteracy, religious resistance, and the low status of women. This report documents the technical assistance provided by DELIVER to the Ministry of Health and Family Welfare (MOHFW) in logistics management, procurement, contraceptive security, institutional strengthening, and local capacity building. DELIVER's technical assistance and capacity building have largely contributed to establishing and sustaining an effective and functional logistics system for family planning. DELIVER has also played a pioneering role in raising awareness about contraceptive security and its importance to the Bangladesh family planning program. DELIVER's interventions and strategies focused on developing national awareness of and commitment to contraceptive security and institutionalizing and optimizing a logistics system that was developed under predecessor projects. The work toward contraceptive security included national and local advocacy, media advocacy, procurement assistance, donor and stakeholder coordination, and supply chain technical assistance. DELIVER's support has contributed toward significant improvements in logistics management, procurement capacity, and improved contraceptive security. However, continued support is needed for capacity building in public-sector procurement, introduction of modern technologies in automating logistics functions at the subdistrict level, and better and more effective coordination among donors and stakeholders. (author's)

Information on the expected accuracy of the contraceptive forecasting processes is useful for family planning supply chain managers to efficiently plan and procure contraceptive commodities and maintain uninterrupted supplies to meet clients' needs. This study examines the accuracy of the contraceptive forecasting processes of 81 family planning programs in 30 developing countries using time-series records between 1994 and 2005 on past contraceptive consumption and projected needs. Forecast accuracy is defined as the absolute percentage difference between the actual and projected quantity of a contraceptive dispensed. Analysis of 1,586 one-year-ahead contraceptive forecasts indicates that the expected median absolute percent error for one-year-ahead contraceptive forecasts for public sector family planning programs is about 25 percent. Multiple regression analysis indicates that the forecast accuracy of public sector programs has been improving over time, which is partly attributable to improvement of the family planning logistics management information system performance and to the use of forecasting software. (author's)

The DELIVER project in Bolivia has developed a system for the administrative logistics of medications and inputs for contraceptives, which over time has been integrated for essential medications and basic inputs. The system has become a national regulation, Unified National Supply System (SNUS), whose objective is to guarantee the timely availability of medications and inputs. DELIVER contributed to the fulfillment of the national regulation, developing skills and capabilities of the system for the administrative logistics of medications and inputs under the regulations of the SNUS. It was implemented by Institutional Municipal Pharmacies under the Subsystem for Administrative Logistics of Medications and Inputs (ISLA), which selects, programs, acquires, stores, and distributes medications and inputs until they reach the user. The information system for the ISLA is incorporated and uses the records of the SNUS, which are compiled from the prescription receipts, Kardex, the Monthly Operations Report and Consolidation of Quarterly Orders in the health establishments of the prioritized municipalities. In addition, DELIVER gave technical assistance to the municipal governments and the Local Health Directory (DILOS) to strengthen their management of control, inspection, and supply of medications and inputs, optimizing resources and improving the distribution chain. The module of logistics for medications and inputs, based on DELIVER's experience, has been included in the curriculum net of the public and private universities, as well as in the health technical schools. This has given improved the training of the pre-degree students in nursing, pharmacy, and biochemistry. To give continuity to the USAID order, with EngenderHealth and PROSALUD, activities were carried out that involved working with the municipal government authorities to stabilize the availability of contraceptives in the services; and to facilitate the estimation of needs and accessibility of suppliers, based on sexual and reproductive rights. The analysis of logistical indicators has been incorporated in the Committees for Information Analysis for annual evaluations; during field visits, the instrument was applied to evaluate logistical indicators. (author's)

The Kibingo Health Center and the Mugonero District Hospital are roughly seventeen miles apart, each perched atop two of the more than one thousand hills that dot the landscape of Rwanda. Once a month, Bosco Kalisa sets out on a two-day roundtrip walk to the District warehouse to pick up a new supply of medical commodities for his health center. Upon arrival in Mugonero, he hands the District Pharmacy Director a report detailing the number of family planning supplies distributed to clients in Kibingo during the past month, the quantity remaining in the health center's storeroom, and the quantity needed to meet expected demand for the following month. As Kalisa leaves with a basket of contraceptives and other essential medical supplies balanced carefully on his head, the District Pharmacy Director must guarantee that she can continue fulfilling orders from Kibingo and the other health centers under her supervision. She compiles the reports they've submitted and calculates how many new contraceptivesupplies to request from the national Department of Reproductive Health in Kigali. (author's)

El Salvador has already reached several important milestones in its efforts to achieve contraceptive security-the guarantee that all people who wish to use contraceptives can choose, obtain, and use them at all times. With support from the United States Agency for International Development (USAID), the Salvadoran Ministry of Health (MOH) has recently worked to expand people's access to contraceptives, particularly through community-based distribution. It has also helped to improve product management in health facilities by training service providers and by implementing a contraceptive logistics management information system. El Salvador's next challenge on the pathway to contraceptive security is to become financially self-sufficient in procuring reproductive health commodities. USAID is progressively phasing out its contraceptive donations to the country, and is providing technical assistance to guarantee that the MOH will be able to accurately forecast contraceptive demand and manage its own budget for meeting that demand. (author's)