Elements of Successful Family Planning Programs
Interview with Alan Bornbusch
Interview conducted on March 7, 2008 by Heather Sanders
Heather Sanders: Could you tell us a little bit about what contraceptive security is?
Alan Bornbusch: A traditional sense of contraceptive security would be, or has been, a reliable supply of contraceptives. However, since 2001 a more holistic and comprehensive understanding of contraceptive security has taken root. Contraceptive security exists when people can chose, obtain and use contraceptives they need for family planning and prevention of sexually transmitted diseases and HIV. This more holistic and integrated approach to contraceptive security really introduces three important concepts. One is choice, that family planning users should have a choice of methods and of contraceptive supplies. They should be able to obtain them, meaning that not only are the supplies physically present at a clinic or hospital or in the hands of a community-based worker but that they are also affordable, which for some people could mean free or subsidized. Thirdly, the concept of use is brought into this definition as well, meaning that informed use is important to the effectiveness of the method and client satisfaction.
HS: And what do you mean exactly by informed use?
AB: It means that people are able to make an informed choice between methods. That they are counseled, for example, on side effects and potential side effects, whether different methods will prevents STIs or not, that they can also make choices based on factors that fit their particular lifestyles. Also, are they seeking to limit the number of children they have, in which case certain methods may be more appropriate than others, or are they looking more to space the children that they plan on having.
HS: What is USAID's role in contraceptive security?
AB: We have three major roles - we provide technical assistance and training to strengthen supply systems in the countries where we work and also to improve the enabling environments for those supply chains to work well and efficiently. We also have a global leadership role where we collaborate with regional leaders and partners to advocate for contraceptive security and to strengthen their programs for contraceptive security, and thirdly, and these are in no particular order, we also finance, procure and deliver to country programs which we support a range or contraceptives and condoms.
HS: Could you give an example of one such regional collaboration between USAID and some nation?
AB: For example, we have worked closely with the West Africa Health Organization to develop a regional strategy for contraceptive security, or in that particular case we call it reproductive health commodities security, that identifies what would that organization's role be from a regional platform to support countries to improve the supply of reproductive health commodities.
HS: What are some of the obstacles to maintain a continuous supply of contraceptives?
AB: Really the most important thing to advancing on contraceptive security is commitment and where that is not present, that is really the most important obstacle that one needs to confront. Without commitment to contraceptive security as a public health problem, you will not see the actions and investments to address some of the other obstacles. For example, the lack of financing for contraceptives, the lack of affordable contraceptives for all the users in the country, lack of policies that support equitable access to contraceptives. Inequity in contraceptive security has become an important priority for us in the past few years and then you would not see without that commitment the investment to strengthen supply chains and to deliver or distribute the right products at the right time and in the right quantities.
HS: You mentioned supportive policies for contraceptive security. What are some examples of supportive policies?
AB: Well, for example, speaking in a more generic sense, policies that support access to contraceptives for those who are most in need of free or subsidized supplies. Policies that clearly identify what is the public sector’s role in ensuring contraceptive security. It is not necessarily to ensure supply or access for everyone. There is also the private sector that has a significant role in many countries to provide contraceptives. The public sector also has an important role but it is important from the policy perspective that that role is defined and what is the public sector's role vis-à-vis the private sector. Without this coordination you can have inefficiencies, and we have also seen in some situations where access to contraceptives to those most in need of free or subsidized contraceptives is compromised.
HS: Where does contraceptive security typically breakdown?
AB: If you map the global supply chain for contraceptives from the raw materials to the end user or the client, as has been done in several analyses, many of the so-called choke points are in the in-country part of that supply chain. There are choke points more upstream from that point as well but really, the major ones we see now are more at the in-country level and they have to do with the capacity of countries in a timely and efficient way to procure and distribute contraceptives. And, just as two examples, with the shifts in developmental assistance toward basket funding a budget support for health programs, country governments are now looked to to assume new responsibilities for the procurement of contraceptives. This is a good trend, but on the other hand, expectations can get a bit ahead of the shifts in development financing, where country governments are not quite ready to assume these new responsibilities and a certain amount of capacity building is necessary. So absent that we can see a major choke point there at the point of country procurement. Further downstream, country supply chains are being severely challenged now by other trends, for example, integration of supply systems, where countries are moving from having wholly separate, vertical supply systems for family planning on the one hand, HIV on the one side, malaria, and so on. Moving from that towards a more integrated supply system. However, no one of those vertical systems is really prepared to expand and take on the responsibilities of distributing all of these other supplies as well. So they are being severely challenged now by that. Decentralization is another trend that is challenging supply systems, where the decisions for supply management are now expected to be made at lower levels, when again, they do not the have necessary experience in doing that and a certain amount of capacity building is needed to prepare them to assume those new responsibilities.
HS: How do program managers or other people who are involved in contraceptive security ensure a reliable supply of contraceptives?
AB: Well, I think that another thing program managers, particularly at a higher level, can do is to advocate for and raise awareness of the necessity of a reliable supply of contraceptives, inasmuch as it is a public health priority and addresses a country's health and larger development needs. They can advocate specifically for particular supply chain improvements that are necessary to make supply chains work better. They can provide the necessary information for informed budgeting. I think also that at lower levels, if we are talking about clinic managers, they can raise awareness to their supervisors about the impacts of the lack of a reliable supply on their clients, and what is the impact of this on their lives. And I think that the more that people all up and down the supply chain, if you will, are talking about this and raising awareness of the consequences they see of lack of reliable supply, we hope the more the message will heard higher up so that the key decision makers do take it upon themselves to make this a priority and make the necessary investments.
HS: You mentioned advocacy as an important component. Are you aware of any tools that program managers or upper level managers can use to advocate for a better supply chain?
AB: Absolutely. USAID and our partners have invested really since about 2001 in a number of advocacy tools to help managers work, for example, with the media, to engage with the media, to partner with the media, through those channels to raise understanding of what are the impacts of contraceptive insecurity and why contraceptive security should be a public health priority. We've also developed presentations and briefs that link reproductive health, family planning, and the availability of contraceptive supplies to the Millennium Development Goals, showing that investments to address family planning needs in a country are actually a cost-effective investment, to help achieve the Millennium Development Goals. So there's quite a few tools available now for in-country managers.
HS: What do you recommend program managers or clinic managers do in the event of a stock-out?
AB: Well, if a program manager is confronted with a stock-out, I think one of the very first things they need to do is, if you will, to call someone. Whether it's the district manager or whoever’s up above them, and say, "Hey, I have a problem. I am stocked-out of a particular contraceptive method. I think sometimes there is not that action, and people feel, "Well, my next delivery is a month from now, so I just wait for that month." And in the meantime, that particular method may not be available at their clinic or other facility. So, it's really important that a system has a way, whether it's a hot line or other ways, for managers to raise the alert. If you will, to set off the fire alarm, and to say "I have a problem." But beyond that, it's really important then, once that fire is put out and the stock out is addressed, it's really important to look at why did this happen. Clearly there has been some sort of system or human failure and it's really important to identify that and to - whether it's training or other measures - look at how this fire or stock-out can be avoided in the future. There are ways that managers all up and down the supply chain typically have to raise the alert and to order emergency supplies - and this includes all the way up to USAID. I mentioned earlier that we do directly finance, procure and deliver contraceptives, as does UNFPA and others. We all have mechanisms where we can get emergency supplies to countries if we are aware of a stock-out situation.
HS: Speaking of resource-poor areas, in your opinion, is it better for them to offer a more limited number of contraceptives and avoid stock-outs or is it always better to provide a larger amount of contraceptives for their clients?
AB: I think, again, the issue of choice is very central to contraceptive security and it was really one of the more important advances in 2001 when we took on this more holistic and integrated view of contraceptive security. I think that to say that providing more of a choice risks more stock-outs is something of an artificial trade-off to assert. For example, we are asking supply chains now to distribute massive amounts of more health commodities for malaria, HIV, and so on. And there we're saying stock-outs are not acceptable. So, given the centrality of choice to family planning, I think we also have to say we need choice, and stock-outs are unacceptable. So, therefore, I would argue that it is very important to ensure choice. Now, if we're talking about a particular clinic or other facility, or for example a CBD worker, then it's not really realistic, or feasible, or appropriate even, to expect that in each of those service delivery points there is a full range of method choice. For example, of course, we wouldn't expect community based workers to provide permanent methods of family planning, or even some long-acting methods. So, at that level, we would want to look at what is realistic, feasible, appropriate. But, at the program level, choice, again, is really a paramount concern.
HS: Can you give us some examples of programs that have overcome contraceptive security challenges?
AB: The bad news, if you will, is that contraceptive security is not easy. Again, going back to 2001 when we took on this broader view of contraceptive security, we really made the point over and over again that it's very complex, it's very multi-sectoral, there's a lot to do, and it - the problem - never goes away. Even in a country like the United States or in European countries, one can't say that they are 100% contraceptive secure. The good news, though, is that progress is being made. And there are quite a few good examples that we can look to for lessons learned. For example, in the Latin American region, with strong advocacy efforts from civil society as well as from government champions, a number of countries in the Latin American region now have created dedicated government budget lines for contraceptives, they are financing contraceptives and they are procuring them. In Bangladesh, a country that I know particularly well, because of decades of government and donor support for family planning, the in-country supply system there for contraceptives works quite well. To the point that stock-outs, until very recently I have to say, were not really an issue. They have become an issue recently because of reasons that I was talking about earlier, which is, we've had some difficulties with timing procurement at the central level. But once they arrive in the Bangladesh, they are very well distributed throughout the country. And we've also seen improvements in supply chains and in contraceptive availability in a number of sub-Saharan African countries.
AB: In Nigeria for example we've invested in streamlining the contraceptive supply system and that has led to significant improvements in availability in the focus states where USAID is and its partners are working. In Zimbabwe, through an innovative supply chain design and through donor support, contraceptive availability is actually very high. It’s among the highest in Sub-Saharan Africa right now. It took quite a bit of thinking and innovation and yes, donor support to make that system work.
HS: In the case of Bangladesh that you were talking about, what had they actually done that has allowed them to distribute the supplies once they arrive in the country?
AB: The government and donors together in Bangladesh have invested massively in the past decade or more in training people and in providing training for a system that is extremely streamlined. For example two years back, we defined supply chain in parts by the number of tiers they have. We have central level (warehouse for example), then regional warehouses, then many more district warehouses, and then you have the facilities. So there could be four, five or many tiers in a supply chain. Each one of those is a potential bottleneck in a system of potential inefficiency. In Bangladesh, the government eliminated one of those tiers which makes for more efficient and more timely and more reliable supply. In addition, the government has outsourced or contracted out the transport of contraceptives to commercial carriers who can do it more cheaply, more efficiently, and more reliably than the government realized its own trucks could. And that has led to significant savings for the government and more reliable supply in the furthest regions particularly of Bangladesh. In a country like Bangladesh where it's very hard to get around the country because of the floods, and the commercial sector private carriers can get the job done quickly when it can be much more difficult for a government carrier to do that.
HS: In Zimbabwe, what has been most innovative in their supply stream?
AB: In Zimbabwe, the supply chain system that has been developed there now is called the Delivery Truck Topping Up System or DTTU and basically what it does is it institutes a regular schedule of deliveries through the country. There are several trucks and each has a monthly schedule of routes that it goes to and the truck actually has a laptop in it now, so when the truck arrives at a facility it does more than just drop off supplies. It works with the facility to check their stock, look at their records and then help them determine what their supply should be for that month, and then go into the truck and deliver it. So, its all kind of wrapped up with the truck delivery system and based on what is seen on the spot, as the facilities requirements, the facility is topped up to carry them through the next month. In that system now it's not where one level in the system has to wait for orders from the level below. We call that a pull system, and that can be very unreliable at times, for whatever set of reasons. A facility might not place their order in a timely way. In the Zimbabwe case we don't have that, there's no waiting for the order to come. The truck has a very regular schedule and makes its routes and goes to each facility and basically asks, "What is your stock? What do you need?" they go to the truck and deliver that on the spot.
HS: Can you talk briefly about push and pull systems and the difference?
AB: A push system is where the central warehouse, based on information it receives from the regional warehouses, it determines how much to supply them on a monthly schedule or some other frequency. Likewise regional warehouses will determine based on reporting up to them, what to deliver to the district warehouses. So you're basically pushing the product down. They're not doing in a naive way because there is a regular flow of information up the system so that the central warehouse has visibility into what's happening in the regional warehouses and they have visibility into what's going on in the district warehouses. So they're pushing the product down on a very regular basis. A pull system works essentially the opposite way where the central warehouses receive orders from the regional warehouses. They determine what they should be ordering, they are expected then to communicate up to the central warehouse as to how much they need and then the central warehouse responds with a delivery. In some cases the regional warehouses actually has to send their own trucks up to get the supply and the district warehouses have to send their own vehicles up to get their supplies from the regional warehouses.
HS: How willing are donors to fund contraceptive logistic systems and how can managers convince people to support CS systems?
AB: I think increasingly donors are very willing to support CS systems. They're a little less willing now to support separate vertical systems, as I mentioned earlier. And I think it's a good trend. We're all looking for efficiencies where different systems can be integrated, and donors are very willing now to invest in health systems strengthening including for supplies and we see that in GAVI, the global fund, and we see that in bilateral donors as well. So there is a lot of willingness here. So how can managers sort of leverage that? I think it come backs to making the case for the availability of contraceptives as a national priority. It's really for countries to make this case for donors, and to say this is one of our key public health priorities, to ensure the availability of contraceptives and other reproductive health...
What happens when a supply chain breaks down? Thereby they can make the case for supply chain investments. We're also right now looking at the development of tools to help higher level managers allocate their resources across different kind of inputs that are needed for family planning programs. After all, it's not just supplies that make a family planning program. There are many other program inputs that are needed. But at the moment there aren't good tools out there really for higher level managers to say, in this budget I should be allocating this much for supply chain improvements and this much for training service providers and allocating this much to training supervisors for monitoring and supervision. So we really don't have those good tools to inform such allocations but we're working on that.
HS: How would you respond to the statement, "No product, no program?"
AB: My initial reaction to that is right on, absolutely. But again I want to come back to an earlier point that I made that "no product no program" is a nice bumper sticker phrase, it's a very compelling point but I also think that it's important that when advocating for contraceptive security to make it clear that this is a very complex thing and while a four word motto is a good thing to have, it's a good way to start a presentation, it's a good way to end a presentation, we've really got to focus people on all of the substance between the beginning and end of the presentation. All of the complexities that are needed to ensure that products are there for users. And I come back to concerns of choice, concerns not only about the physical availability of supplies, but concerns of affordability. Concerns of policy and equity. My favorite phrase is, "This is a very complex and capacious issue. It's a very multi-sectoral issue. It involves the public sector, the private sector, governments, donors, civil society, technical agencies, and so on. And one of the great advances we've made since 2001 is to get that point across and to develop the tools to help countries understand what is needed, to improve contraceptive security and to make the necessary investments to see the improvements. And the good news is that we've seen improvements.
