Current Status of Reproductive Health Commodity Security (RHCS) in the EAC Region EAST AFRICAN INTER PARLIAMENTARY FORUM ON HEALTH POPULATION AND DEVELOPMENT 14 TH NOVEMBER 2013

Current Status of Reproductive Health Commodity Security (RHCS) in the EAC Region Definition of RHCS Framework to assess attainment of RHCS How is the EAC region doing in comparison to others? Key message Recommendations for the EAC Partner States Recommendations for the Members of Parliament & Policy Makers at the Regional Level, and in Partner States

Definition of RHCS “Reproductive Health Commodity Security (RHCS) exists when people are able to choose, obtain and use the reproductive health supplies they want” - Hare et al, 2004 RH commodities include equipment, pharmaceuticals and supplies for obstetrics and maternal care, sexually transmitted infections, abortion services and contraceptives.

Framework to assess attainment of RHCS CONTEXT COMMITTMENT CAPITAL CAPACITY COORDINATION Adapted from Hare et al 2004 CLIENT S Public sector Private sector NGOs Social marketing

Key Messages

Context All Partner States have policies to guide attainment of RHCS Implementation challenges include supply and demand side barriers -Demand side barriers (socio-cultural beliefs and practices, myths and misconceptions) may be addressed with IEC programs, partnerships between religious and public facilities -Supply side barriers (limited resources and poor forecasting particularly at health facility level) culminate in commodity stock-outs. POLICIES

Commitment All Partner States have explicit top level government commitment for MNCH In Republics of Burundi and Rwanda there is explicit top level commitment for FP, while in the remaining Partner States the impetus is from the Ministry level In Republics of Burundi and Rwanda, RH activities are mandated to a Department, whilst in Uganda and Tanzania it is a Division/Section. In Kenya this recently changed to Unit level.

Capital Financing for RH commodities: Government contribution – levels vary according to commitment Using FP to trace government resource allocation to RH commodities: CountryAmount, US$ (fiscal year)% FP commodities budget Burundi60,000 (2012/13)2 Kenya8.8 million (2013/14)34 Rwanda505,000 (2013/14)13 Tanzania1.3 million (2012/13)10 Uganda N/A (2013/14)20

Capital Financing for RH commodities: Development partners contribute through SWAp mechanism Aid policy in Rwanda to ensure funds are allocated to country’s priorities Third party mechanisms E.g. success of community health insurance in Rwanda due to near-universal uptake

Capacity - Service Delivery (HRH) All Partner States have instituted measures to address access to services due to the HRH crisis and Task shifting e.g. provision of emergency obstetric care by clinical officers in Tanzania and Burundi Community-based approach for delivery of MCH, FP, HIV/SRH services e.g. CHWs to provide education, FP and referrals Republics of Burundi, Rwanda and Tanzania have instituted varying coverage of performance-based financing in health facilities to incentivise health workers to deliver high quality of care

Capacity - Service Delivery (Infrastructure) All partner states have requirements for the number of facilities offering basic and comprehensive EmOC and youth-friendly RH/FP services The challenge is inadequate geographical coverage; hence community-based approach and task shifting are critical to access to care

Capacity – Supply chain management Forecasting is not harmonised in the region – 3 Partner States conduct short term forecasting (annually) only and remaining also forecast for long term (3 years and 5 years) RH commodity distribution across the region is driven by facility requirements Supply chain management tools have been used to improve data for decision making in RHCS e.g. ILS Gateway (Tanzania) and CHANNEL (Burundi) Ultimate assessment of the strength of supply chain is stock levels. The 3 larger Partner States face stock outs at facility level due to capacity challenges (infrastructure, transport, human resources)

Coordination Coordination mechanisms at national level (chaired by MOH) effectively align donor funding and implementing agency activities with the Government RH programme, resulting in efficient use of limited resources (newly effected in Burundi) TWG composition: Government (chair), donors, implementing partners, Human rights organisations, religious bodies, CSOs Challenge is sub-national coordination due to inadequate capacity (HR, tools to translate policies into action, etc.)

Clients Contraceptive use amongst married women is still below national goals Unmet need for FP remains high (between 1 in 5 and 1 in 3 women) % married women (15-49 years)

Clients Contraceptive use amongst married women is still below national goals Unmet need for FP remains high (between 1 in 5 and 1 in 3 women) % married women (15-49 years) CPR Target 40%, 2015 CPR Target 56%, 2015 CPR Target 70%, 2016 CPR Target 60%, 2015 CPR Target 50%, 2015

Clients Majority of married women source contraceptives from public health facilities (except Uganda) % married women (15-49 years) using FP

Commodities All Partner States prioritise RH/MNCH. The minimum FP, EmOC and PMTCT commodities are included on national essential medicines list Skewed progress in FP due to focused external resource allocation

How is the EAC region doing in comparison to others? Source: Singh et al 2012.

Key message There is need to ensure demand creation and commodity security “No family planning product, no family planning program” –FP stakeholder, Rwanda

Recommendations for the EAC Partner States Area 1: Policy Implementation Area 2: Funding Area 3: Capacity HRH Area 4: Clients Area 5: Data for decision making & knowledge sharing in the region Recommdtn Area 1Recommdtn Area 2Recommdtn Area 3Recommdtn Area 4Recommdtn Area 5

Recommendations for the EAC Partner States Area 1: POLICY IMPLEMENTATION Establish mechanisms to track commitments by National Leaders and Government. Establish mechanisms for prioritisation of SRH commodities and programmes at sub-national level e.g. performance contracts Effectively disseminate SRH policies, strategies, standards and guidelines, particularly at sub-national level. Strengthen sub-national coordination structures (TWGs) to improve RH service delivery, particularly at sub-national level. Undertake decisive adolescent SRH policy implementation to enhance access to information and services by the youth, All Partner States are experiencing challenges with implementation of adolescent and youth SRH policies. Recommdtn Area 1Recommdtn Area 2Recommdtn Area 3Recommdtn Area 4Recommdtn Area 5

Recommendations for the EAC Partner States Area 2: Funding Commit increased funds to RH programmes. Recommdtn Area 2Recommdtn Area 1Recommdtn Area 3Recommdtn Area 4Recommdtn Area 5

Area 3: Capacity HRH Embrace proven mechanisms to tackle the acute health worker shortage, particularly in rural and remote areas. Strengthen technical capacity of health workers to improve RHCS. Decisively address supply-side barriers that inhibit utilisation of SRH services such as by scaling up successful practices e.g. task-shifting and community health workers. Recommendations for the EAC Partner States Recommdtn Area 3Recommdtn Area 1Recommdtn Area 2Recommdtn Area 4Recommdtn Area 5

Area 4: Clients Reinforce educational campaigns to address demand-side barriers of access and use of services. Strengthen efforts to map and reduce inequalities in access and utilisation of SRH services by removing barriers facing under-served groups e.g. cost, geographical distance Strengthen efforts to meet the SRH needs of special populations e.g. the elderly and people with disabilities. Recommendations for the EAC Partner States Recommdtn Area 4Recommdtn Area 1Recommdtn Area 2Recommdtn Area 3Recommdtn Area 5

Recommendations for the EAC Partner States Area 5: Data for Decision making and knowledge sharing in the region Strengthen Health Management Information Systems (HMIS) to improve completeness and accuracy of data for decision making. Channel adequate funding to health policy and systems research and strong M&E systems. Systematically conduct and document impact assessments of cost-effective interventions for addressing various service delivery bottlenecks and share lessons with Partner States. Recommdtn Area 5Recommdtn Area 1Recommdtn Area 2Recommdtn Area 3Recommdtn Area 4

Recommendations for the Members of Parliament & Policy Makers at the Regional Level, and in Partner States 1. Establish legal and procedural mechanisms that ensure alignment of SRH programmes at sub-national level (decentralized units) with national priorities and policies. 2. Establish or strengthen accountability mechanisms and procedures on the performance of reproductive health commodity security and SRH programmes that are suited to the mandate of responsible organs. 3. Advocate for increased allocation of resources for SRH and its commodities from both national budgets and external loans and aid. Recommendation 1, 2, 3Recommendation 4, 5 & 6

4. Support and encourage harmonisation of standards and prequalification of RH commodities in the EAC region to reduce costs, delays in delivery & utilisation. 5. Advocate for establishment of tracking mechanisms for SRH resources at sub-national level. 6. Champion and advocate for quality SRH services in their constituencies and participate in educating citizens in order to promote demand and use of SRH services Recommendations for the Members of Parliament & Policy Makers at the Regional Level, and in Partner States Recommendation 1, 2, 3Recommendation 4, 5 & 6

Thank you