Analysis of the dynamics surrounding reproductive health supplies commitments

Publication date: 2015

Analysis of the dynamics surrounding reproductive health supplies commitments MARCH 2015 DRAFT DRAFT DRAFT Contents ACKNOWLEDGMENTS 1 KEY ACRONYMS 2 EXECUTIVE SUMMARY 3 Commitments analysis 4 Potential RHSC strategy/roles at country level 5 INTRODUCTION 7 Phase 1 7 Phase 2 8 MOTIVATION FOR COMMITMENTS 10 What motivates a country to make a commitment and for what purpose(s)? 10 Why does the global community seek commitments? 12 FORMULATION OF COMMITMENTS 14 How do countries decide on the content of commitments? 14 What processes/ actors are involved in developing commitments? 16 IMPLEMENTATION OF COMMITMENTS 19 What are the country processes and tools for implementation of commitments? 19 What are the enablers for successful implementation of commitments? 21 What challenges are faced by countries in implementation of commitments? 22 RESULTS/IMPACT OF COMMITMENTS 23 What are the monitoring and accountability mechanisms for commitments? 23 What are some early examples of results? 25 ANNEX 1: BIBLIOGRAPHY 26 ANNEX 2: STAKEHOLDERS INTERVIEWED 28 1 ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS DRAFT Acknowledgments We would like to thank the large number of people who were directly or indirectly involved in compiling the compendium and this document on the analysis of the dynamics around commitments. Special thanks go to the Advocacy and Accountability Working Group and coordinator Lou Compernolle who in 2012 underlined the need for the community to focus on Reproductive Health (RH) supplies commitments to drive change at the country level and helped shape this work. The resulting Delivering on Promises initiative represents part of RHSC’s approach to leveraging aspirations voiced on the global stage into powerful drivers for change. By working with partners at the country level, this initiative promises to assemble the diversity of technical skills and resources required to realise those commitments, celebrate the successes of governments that take appropriate action, support the formulation of more effective commitments in the future, and ensure that successes are replicated globally. We would also like to thank those people who set aside precious time to illuminate the often intricate processes that surround commitments. 2ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS DRAFT Key acronyms Acronym Full description AFP Advance Family Planning BMGF Bill and Melinda Gates Foundation CARMMA Campaign on Accelerated Reduction of Maternal Mortality in Africa CEPA Cambridge Economic Policy Associates CHAI Clinton Health Access Initiative CIP Costed Implementation Plan CoIA UN Commission on Information and Accountability CPR Contraceptive prevalence rate CSO Civil society organisation DFID UK Department for International Development DHS Demographic and Health Survey DRC The Democratic Republic of Congo EWEC Every Woman, Every Child FP Family Planning FP2020 Family Planning 2020 H2H HANDtoHAND Campaign HPP Health Policy Project ICPD International Conference on Population and Development IPPF International Planned Parenthood Federation IUD Intrauterine device LAC Latin America and the Caribbean mADDS mobile-Assisted Data and Dissemination System MCH Maternal and Child Health mCPR Contraceptive Prevalence Rate, Modern Method MDG Millennium Development Goals MNCH Maternal, Newborn and Child Health MoH Ministry of Health M&E Monitoring and Evaluation NGO Non-governmental organisation PMNCH Partnership for Maternal, Newborn and Child Health RH Reproductive Health RHSC Reproductive Health Supplies Coalition RMNCH Reproductive, Maternal, Newborn and Child Health SMART Specific, Measurable, Assignable, Realistic and Time-related TST Technical Support Team UNCoLSC United Nations Commission on Life Saving Commodities WHO World Health Organization 3 ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS DRAFT Executive summary The Reproductive Health Supplies Coalition (RHSC), with support from Cambridge Economic Policy Associates (CEPA), has developed a compendium of commitments on reproductive health (RH) supplies (the “Commitments Compendium”; available at www.supplypromises.org). The Compendium maps and analyses commitments made by governments and other institutions (including academic and research institutions, foundations, global partnerships, health care professional organisations, multilateral organisations, NGOs, and the private sector) under eight key global health initiatives.1 Despite the global ‘enthusiasm’ around commitments, the commitments landscape is opaque and opportunities to leverage and advance commitments are not systematically realised. In this context the RHSC commissioned this research piece to: (a) clarify the processes and rationale behind countries making and advancing on commitments, and shed light on their value within the development context; and (b) serve as the basis for development of the Coalition’s commitments strategy in terms of its role and engagement with stakeholders at the country level. This qualitative study builds on our previous Compendium work, and was undertaken over the period August-October 2014 through a combination of stakeholder consultations and focussed desk research. It seeks to understand the notion and value of RH supplies commitments, which we have analysed at each stage of their ‘life-cycle’ - motivation; formulation; implementation; and results/ impact (Figure 1 below). EXECUTIVE SUMMARY Figure 1: Commitments life-cycle 1 Maputo Plan of Action (2006); the Muskoka Initiative on Maternal, Newborn and Child Health (2010); Every Woman, Every Child (EWEC) (2010); the HANDtoHAND Campaign (2010); the Ouagadougou Partnership (2011); the UN Commission on Life-Saving Commodities (UNCoLSC) (2012); Family Planning 2020 (FP2020) (2012); and the International Conference on Population and Development (ICPD) Beyond 2014 (1994/ 2012-14). 4ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS DRAFT Commitments analysis Our overall finding is that commitments can be a powerful development tool for both the countries making commitments and the global community. In other words, commitments can be leveraged to support global and national RH goals / strategies at each of the commitments ‘life-cycle’. The summary findings are presented below, with country examples in the main report: EXECUTIVE SUMMARY Motivation Countries generally make commitments to reaffirm their existing RH/ family planning (FP) goals and strategies. Countries value commitments to facilitate change, accelerate progress to address unmet needs/ gaps, and attract additional financial/ technical assistance from partners. The global community views commitments as a platform for collective action, a signal of national will as the basis for more funding, and as a social contract to hold committers accountable. Implementation A majority of stakeholders interviewed for this study commented on the implementation of commitments made under the more recent initiatives of FP2020, Ouagadougou Partnership and UNCoLSC. Their view was that most countries are yet to begin or are just beginning to implement these commitments. A lot of the countries’ focus is currently in developing tools for implementation, such as action plans and strategies. For earlier commitments, such as those made under the Every Woman, Every Child initiative, several countries are reported to be in the process of implementation, with some expecting to fully achieve their commitments by 2015. The main enablers for successful implementation include strong political leadership, partner (including civil society) support, clarity of commitment, and consultative processes. Resource constraints, limited technical skills, changes in leadership, and lack of sub-national level engagement are some of the early implementation challenges encountered. Formulation The formulation of commitments is shaped by many factors and is a process of negotiation amongst stakeholders involved. The content of a commitment is mainly influenced by, and drawn from, existing RH/FP plans and strategies in country, and also draws on global priorities/strategies (such as the Millennium Development Goals (MDGs)) and previous commitments. For the most part, national processes to develop commitments involve multiple stakeholders, typically led by the Ministry of Health (MoH), and are generally consultative and informed by RH needs/ gaps and related data analysis in the country. Results/impact It was unanimously agreed by stakeholders interviewed on this study that commitments have the potential to influence/effect change in countries, although it is premature to assess impact given implementation is just beginning on several recent commitments. However, lack of M&E and accountability mechanisms is a big gap. To address this, some tools to track and monitor results are now being developed/rolled out at the country and initiative level. 5 ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS DRAFT Potential RHSC strategy/roles at country level In the context of RHSC’s commitments initiative, its draft 2015-25 Strategy,2 and our analysis of the “commitment life-stages” on this study, we have suggested five possible roles for RHSC to engage on commitments at the national level with the objective to improve access to and use of affordable, quality RH supplies. These inter-related roles - advocacy, knowledge hub, technical support, accountability mechanism, and resource mobilisation support - are presented below. Advocacy: given its ‘convening power’, ability to ‘broker partnerships’ from a ‘neutral’ platform and ‘respected name’, RHSC is well-positioned to advocate to countries for better formulation, implementation and monitoring of RH supplies commitments. Activities to deliver this role include: (i) influencing governments (and implementing partners) to include and promote RH supplies when they formulate and/ or implement commitments and ensuring RH supply security remains prominent in the post-2015, SDG agenda; (ii) generating consensus on RH supplies issues and ensure that the voices of all partners are captured in the commitment process; (iii) facilitating the identification and training of “FP Champions” to promote RH supplies in countries; (iv) incorporating national experiences/ outcomes on commitments to contribute to a growing global evidence base to inform effective advocacy and action; and (v) supporting better linkages and two-way communication between national and global actors/processes on RH supplies commitments. Knowledge hub: A key lesson of our study is that countries are keen to learn from each other, both in terms of how best to formulate commitments and to implement them successfully. In this context and given RHSC’s ‘brain trust’ lever of change, it could support: (i) developing “How to” or “Best practice” guides, including success stories, across the commitments life-cycle (building on the existing www. supplypromises.org platform); (ii) educating and creating awareness amongst countries on new commitment events/ initiatives and shining the spotlight on RH supplies; (iii) organising workshops/meetings to unite countries with common objectives and challenges, and share lessons learnt; and (iv) disseminating the knowledge gathered using a range of traditional and more dynamic communication media and forums. Technical support: RHSC can leverage its multi-sectoral membership base and its ‘convening power’ to support governments in their commitments work. This could entail: (i) working with the government and other country-level partners to identify the policy, financial and programmatic implications of commitments; (ii) supporting the development of actionable strategies and plans to execute the commitments, and address any barriers to implementation; and (iii) undertaking capacity building and tapping a range of technical skills required (including at the global level) to bring about change in country as well as monitor results. Accountability mechanism: Our study highlights a clear need for more robust progress tracking, reporting and monitoring tools for commitments. Working with other partners, RHSC could provide an effective and ‘neutral’ platform to report on progress across all commitments related to RH supplies. This could include activities such as: (i) tracking and reporting on a periodic basis on progress/impact on the implementation of RH supplies commitments across countries; (ii) supporting countries in developing and operationalising tools to collect and report on data/progress on commitments; and (iii) strengthening civil society organisation (CSO) accountability mechanisms at the national and sub-national level. Resource mobilisation support: Fund-raising is a critical part of the commitments process. Given its wide membership and ‘flexible resource base’, RHSC could support countries to: (i) identify funding gaps for commitments and develop resource mobilisation strategies; (ii) link up national stakeholders and global funding agencies for RH supplies; and (iii) monitor use of funds and report on progress/ results. EXECUTIVE SUMMARY 2 The Strategy identifies four ‘pillars’ (availability, quality, equity and choice) and six ‘levers of change’ (neutrality, convening power, brain trust, brokering partnerships, flexible resource base, and respected name) to achieve RHSC’s vision and mission. DRAFT Whilst the above suggested activities for RHSC engagement will be centred around RH supplies commitments, they are also likely to support broader national RH/FP strategies and plans that have formed the basis of and/or have evolved from commitments. RHSC’s specific engagement strategy in each country will depend on the local context and needs. Further, some of the proposed roles for national-level engagement may not be new to RHSC and would build on their and other partners’ work to date. By closely coordinating its efforts at the global, regional and national levels, RHSC can play a vital role in ensuring the centrality of RH commodity security in the post-2015 RMNCH policies and strategies. This will help sustain the momentum created by existing and new commitments, and galvanise their fulfilment. EXECUTIVE SUMMARY 6ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS 7 ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS DRAFT Introduction The Reproductive Health Supplies Coalition (RHSC), with support from Cambridge Economic Policy Associates (CEPA), has developed a compendium of commitments on reproductive health (RH) supplies (the “Commitments Compendium”; available at www.supplypromises.org) and analysed the dynamics surrounding RH supplies commitments. The work was delivered in two phases, as described below. Phase 1 Phase 1 of our assignment supported RHSC in the development of the online Compendium to facilitate access to all commitments made under these eight initiatives and the supporting documentation (e.g. country plans). Across the eight initiatives, 394 commitments were reviewed. Of these, our analysis identified 176 commitments that included an explicit or implicit reference to RH supplies.5 Following our manual verification, 137 commitments were identified to be truly related to RH supplies6 and have been analysed and included in the Compendium. Given that RH supplies commitments had not previously been systematically collated or presented, the Compendium seeks to enable national and global stakeholders to access these commitments easily and to enhance their visibility and usefulness from both a policy and implementation perspective . Importantly, although the eight initiatives tend to be seen as ‘standalone’, most of them are closely interlinked and The Compendium covers commitments made by governments and other institutions3 under the following eight key initiatives: Maputo Plan of Action (2006); the Muskoka Initiative on Maternal, Newborn and Child Health (2010); Every Woman, Every Child (EWEC) (2010); the HANDtoHAND (H2H) Campaign (2010); the Ouagadougou Partnership (2011); the UN Commission on Life-Saving Commodities (UNCoLSC) (2012); Family Planning 2020 (FP2020) (2012); and the International Conference on Population and Development (ICPD) Beyond 2014 (1994/ 2012-14).4 8 key initatives commitments under the more recent initiatives build on previous ones: › FP2020 commitments “contribute to the UN Secretary General’s Global Strategy for Women’s and Children’s Health (Global Strategy), EWEC, and fall within its accountability framework”;7 › The Ouagadougou Partnership and FP2020 have the same aspirations8—although FP2020 is global whilst Ouagadougou Partnership is regional—and eight of the nine Ouagadougou Partnership countries having signed up to FP2020;9 and 2 The Strategy identifies four ‘pillars’ (availability, quality, equity and choice) and six ‘levers of change’ (neutrality, convening power, brain trust, brokering partnerships, flexible resource base, and respected name) to achieve RHSC’s vision and mission. 3 These include academic and research institutions, foundations, global partnerships, health care professional organisations, multilateral organisations, NGOs, and the private sector. 4 These initiatives are the key recent pledging initiatives and platforms on maternal health since 2006. 5 We have categorised commitments as: (i) explicit RH supplies commitments, which call out RH supplies specifically; and (ii) implicit RH supplies commitments, which relate to broader RH and family planning interventions, services and programmes and which in order to be delivered effectively, require RH supplies or commodities as a key input. 6 As described in the Methodology chapter, we manually excluded the commitments related to: (i) false positives, e.g. pill referring to pillar; (ii) HIV/AIDS commodities; (iii) the broader realm of RH commodities, e.g. HPV vaccine. 7 FP2020, Building the Foundation of a Global Movement, http://www.familyplanning2020.org/reaching-the-goal/reaching-the-goal 8 The objective of the Ouagadougou Partnership is “to reach at least one million new users of family planning methods in nine countries by 2015”. http:// partenariatouaga.org/le-partenariat/ INTRODUCTION 8ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS DRAFT › The UNCoLSC is part of the EWEC movement and aims to contribute to EWEC’s overall goal.10 Further, although some initiatives use the terminology of being a “movement” and operate in different ways (e.g. some provide direct funding, others provide technical support, a few provide coordinating structures), they share the overall objective of eliciting commitments to further Reproductive, Maternal, Newborn and Child Health (RMNCH) goals. Phase 2 Building on the detailed review of commitments undertaken during the development of the Compendium, RHSC commissioned CEPA to undertake a qualitative study that seeks to: (i) clarify the processes and rationale behind countries making and advancing on commitments, and shed light on their value within the development context; and (ii) serve as the basis for development of the Coalition’s commitments strategy in terms of its role and engagement with stakeholders at the country level. Phase 2 therefore delves deeper into the dynamics surrounding the commitment processes in selected countries. This report presents our findings and conclusions, drawing on our analysis in both phases of work. We have sought to take a holistic approach to understanding the notion and value of RH supplies commitments at each stage of their ‘life-cycle’: (i) motivation; (ii) formulation; (iii) implementation; and (iv) results/impact (refer Figure 1.1). Our main finding is that commitments can be a powerful development tool for both the countries making commitments and the global community. At the country level, commitments serve as a ‘visible’ pledge to address key RH supplies needs/gaps, a call to action around national RH/FP strategies and plans, a signal of political will that could help mobilise greater resources, and a mechanism to strengthen accountability of the government to improved RH supplies. Further, the country-level involvement of a range of stakeholders that is mobilised around a commitment can be leveraged to deliver more effective action and impact in terms of RH supply security. At the global level, commitments catalyse collective action around a specific issue and serve as an accountability tool to monitor progress/results. 9 Furthermore, as noted in an FP2020 document: FP2020 intends to complement the work of the Ouagadougou Partnership to reverse the historically low levels of investment and uptake in FP services in West Africa. FP2020 has already taken tangible steps to align with the Ouagadougou Partnership. A representative of the Ouagadougou Partnership sits on the Country Engagement Working Group, and FP2020 also participates in Ouagadougou Partnership meetings. FP2020 accepts country plans developed through the Ouagadougou Partnership. See FP2020 http://www.familyplanning2020.org/images/content/ documents/FP2020_Global_QA_Series_Issue_Three_Final.pdf 10 UNCoLSC (2012) Commissioner’s Report, September 2012, http://www.everywomaneverychild.org/images/UN_Commission_Report_September_2012_Final. pdf Figure 1.1: Commitments life-cycle INTRODUCTION 9 ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS DRAFT Methodology As noted, the assignment was delivered in two phases: › Phase 1 was a desk-based quantitative analysis of patterns and trends in the RH supplies commitment texts across the eight initiatives on the nature and content of commitments. It included some initial consultations to draw lessons on the nature of the commitment process. › Phase 2 involved consulting with a broader range of commitments related stakeholders, attending the 2014 General Membership Meeting in Mexico, and conducting further, focussed desk research. The consultations were supported by structured interview guides, with tailored questions for individual stakeholders, as appropriate. We consulted with a range of stakeholders involved in the commitment process at the national, regional and global levels:11 › Country stakeholders: Guided by RHSC, we selected four countries for a detailed review of their commitment process: the Democratic Republic of Congo (DRC), Myanmar, Nigeria and Uganda.12 In these countries, we consulted with a mix of government representatives, and/ or civil society, and/or country-based partners who had been closely involved in the commitment process and/or are accountable for their implementation. We use the term “country” in this report to refer primarily to government representatives, but also at times to a broader range of national stakeholders such as CSOs or FP partners. › Regional/ global stakeholders: These include stakeholders involved in launching commitment initiatives, those supporting countries in developing commitment implementation tools and tracking/monitoring of commitments; and key donors/experts in the RH supplies domain. Limitations Key limitations of the study are as follows: › Consultee bias: Given the qualitative nature of the study, stakeholder consultations provided a key source of information. We sought to consult with various global and national stakeholders, including governments, donors, civil society, and other RH partners. However, there is bound to be some consultee bias and not all findings might be generalisable. We have tried to mitigate the impact of this by objectively triangulating views across interviews, to ensure that our findings are relevant in the broader context of commitments. › Focus on recent initiatives: A majority of those we interviewed in the preparation of this report had been involved with the FP2020 commitments (and the Ouagadougou Partnership and UNCoLSC to a lesser extent), rather than earlier commitments such as for the Maputo Plan of Action or EWEC initiative. Therefore, our findings are heavily weighted towards the commitments experience of these more recent initiatives. Nevertheless, we have tried to draw our broader commitments analysis in Phase 1 of work, and where relevant, we reference these in the report. › Selected country coverage: We engaged primarily with countries that have made commitments and with the stakeholders involved in the commitment process. Even within these, the scope of Phase 2 of our study involved a detailed review of four countries. Hence, consultations yielded limited information on why some countries do not make commitments or why countries who have made commitments do not fulfil them. We have tried to develop some prognosis on these, based on our wider research and analysis. › Limited published information on the commitment processes: There is almost no documentation available in formal or grey literature on the processes around the formulation of commitments – which is the core of this study. We have therefore had to rely heavily on stakeholder perspectives and their institutional memories regarding the often intricate and political processes around the making of commitments. › Stage of commitment fulfilment: We understand from our interviews on this study that most countries are just beginning to implement the more recent commitments and are in the process of developing tools and action plans for the same. It is, therefore, too early to measure results/ impact. In light of this, the extent of information and analysis on the ‘implementation’ and ‘results/ impact’ stages of the commitment process is more limited than the earlier two stages. INTRODUCTION 11 The text italicised and enclosed in quotation marks in the sections below draws on quotes from stakeholder interviews. 12 The countries were selected based on the following criteria: (i) mix of geographies; (ii) mix of commitments made in 2012 and in 2013; and (iii) countries where RHSC has local partners/ networks or experience. 10ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS DRAFTMOTIVATION FOR COMMITMENTS 13 UN Department of Economic and Social Affairs Population Division (2014) “2014 Update for the MDG Database: Contraceptive Prevalence”. Available from http://www.un.org/en/development/desa/population/theme/family-planning/index.shtml, only South Sudan, Guinea, Somalia and Chad have lower mCPR than DRC Motivation for commitments This section explores the rationale behind why countries make commitments, and reasons why the global communitys seek them. Our main finding is that countries generally make commitments to reaffirm their existing RH/ FP goals and strategies . Countries value commitments to facilitate change, accelerate progress to address unmet needs/ gaps, and attract additional financial/ technical assistance from partners. The global community views commitments as a platform for collective action, a signal of national will as the basis for more funding, and as a social contract to hold committers accountable. What motivates a country to make a commitment and for what purpose(s)? A commitment is not made “in a vacuum”; rather countries leverage commitments to reaffirm their existing RH/ FP goals and strategies. In this context, countries make commitments for three main reasons: › in recognition of gaps and needs in country and as a means to address them; › as a public statement/ testimonial to be a part of the global discourse/ consensus on a specific issue; and › as an instrument to attract funding and/ or technical assistance. We explore each of these motivations in turn below, quoting country examples. Recognition of gaps and needs Countries have made commitments to reinforce an unmet need and accelerate progress to address gaps in specific areas. Commitments are viewed by countries as “transformational” and (as mentioned by a donor) are often built by “. (an) implicit expectation that things will change because of that commitment”. In some countries, commitments are closely linked to existing national plans/ strategies, and prioritise the most pressing needs within these. This motivation is evident in several country commitments, as evidenced below: › Uganda’s FP2020 commitment was made following the recognition that “family planning services and the contraceptive prevalence rate are low in Uganda. So we have to commit ourselves to make sure [we can improve this]”. › DRC’s FP2020 commitment was also strongly linked to a desire to increase FP prevalence–DRC has one of the lowest modern method contraceptive prevalence rates (mCPR) in the world13–and to reduce the exceptionally high maternal mortality rate. In their words, “the country needed to do something, we needed to make FP a priority”. The commitment was also conceived to help achieve the newly developed National Strategic Plan for Family Planning (2014-2020). › Nigeria’s high maternal and under-5 mortality rates underpinned the government’s commitment to FP2020 and making FP a key intervention to decrease both indicators. Commitments also tend to be aligned with previous international and/or regional commitments and goals – such as the MDGs and the Abuja declaration – and reaffirm a country’s existing pledges and accelerate progress on achievements made. As noted by a country consultee, “a 11 ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS DRAFT commitment is a trigger of momentum on an already laid out regional or international declaration, reaffirming that the country will implement/ enforce certain rights”. Public statement to be a part of global discourse or consensus Countries sometimes commit to be a part of the global discourse or consensus on a specific issue and be seen as contributing to a global goal such as the FP2020 goal of providing access to voluntary FP to 120m women and girls by 2020. This may be viewed as an external dimension of a commitment, whereby countries seek visibility to “demonstrate to the world, to other countries, to the donor community, that they are committed to family planning”. The process of participating in high-profile events with a global audience offers countries the opportunity to make public statements and to “go on record” regarding their commitments. There is often an expectation of external financing support underlying such a public testimonial, but, equally, the committing country creates a ‘social contract’ with both the global community and its own population (see below). Instrument to attract funding and/or technical support Countries also make commitments to leverage additional resources, both financial and technical, although this motivation is, at times, implicit. In relation to FP2020, almost all countries consulted mentioned the potential to mobilise greater financial support as an underlying motivation to make a commitment. By demonstrating political will to address an issue, “countries are more likely to be in a position to attract more support from donors. There is always a link between financial, technical and visibility returns and commitments”. Therefore, clarity and transparency at the commitment initiative on the availability of funding to support countries’ commitments influence the process of formulating commitments and their nature and content. Some global stakeholders commented that “if countries see (that) money is on the table, then they are willing to make bolder commitments, as they see it as an opportunity to capture available funding”. For example, there was a lack of clarity around FP2020 as a funding mechanism both before and during the London Summit event. This resulted from the fact that a number of donors had pledged financial commitments, which alluded to “a pot of money” behind the initiative, which countries believed they would have access to by making commitments. But not all countries make commitments… However, not all countries make commitments to an initiative. There may be a number of reasons for this, including: › Lack of awareness of the initiative, and its rationale and benefits to the country. In this regard, country partners and stakeholders can play a key role in advocating for and improving awareness of global and regional commitment events. › Misaligned priorities between the country and the initiative, i.e. FP/ RH is not yet on the country’s agenda and/or is perceived as a controversial issue in the country. › Inability of a country to make multi-year financial commitments (for example, FP2020 requires commitments to 2020), due to the nature of national congressional cycles and parliamentary approval processes. › Competing priorities in country, such as changes in government or instability/ conflict. › Commitment “fatigue” resulting from a “generation of commitment making” over the past two decades. A pertinent example is Latin America and the Caribbean (LAC), a region which had limited participation in FP2020, with only Colombia present at the London Summit and no country in the region having made a commitment since. This raises the question of whether global initiatives really are “global”. Latin American countries’ failure to sign up to FP2020 can be related to several factors, as below: › Only four countries from the LAC region are amongst FP2020’s 69 focus countries,14 as such a large part of this region is not covered under FP2020’s overall goal. At the London Summit, 15 member organisations of the LAC Forum produced a factsheet to highlight the “tyranny of averages” in the region - the tendency for macro-level growth and prosperity to mask social and economic disparities at sub-national levels.15 This factsheet was circulated on the day of the Summit to donors and accompanied by a dedicated social media campaign. 14 Haiti, Honduras, Nicaragua and Bolivia 15 ForoLAC (2012) “The paradox of development: Economic growth, the burden of inequity and its impact on sexual and reproductive health in the LAC region”; available at: http://www.rhsupplies.org/uploads/tx_tspagefileshortcut/en.pdf MOTIVATION FOR COMMITMENTS 12ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS DRAFT 16 Brown, W. et al. (2014) Developing the “120 by 20” Goal for the Global FP2020 Initiative, Studies in Family Planning, 45: 73-84. › There is limited in-country presence of international partners (e.g. UK DFID, USAID, UNFPA), who typically play a key ‘linking’ role between global initiatives and countries to advocate for commitments. Where there is international partner presence, most › There has been an absence of country-to-country “spillover effect”, whereby a country in the region sees others participating in such an event and wants to be part of the movement. However, Colombia is now planning to host a regional conference linked to FP2020 in 2015. The motivation for the conference appears to be mainly linked to the funding opportunities that a commitment is seen to provide, as well as a means to give visibility to the remaining challenges in the region. However, we understand that to date, funding has not been forthcoming for this event . MOTIVATION FOR COMMITMENTS Why does the global community seek commitments? A commitment initiative is typically constructed as a platform to shine the spotlight on a specific need or issue. Commitments are viewed as a means to turn national priorities into globally recognised pledges, which can signal to donors and the wider community the areas of greatest need in countries. However, initiatives operate differently on how they “elicit” countries to participate in the commitment event, although there tends to be a certain degree of “orchestration” from the organisers/ donors to solicit commitments. For example, the 69 countries invited to FP2020 constituted the 120 million additional users of modern contraceptive methods by 2020 in the world’s poorest countries. The donors and organisers of the initiative then played a key role in systematically following up with the invited countries to ensure that they participate and actually make commitments. As noted by a stakeholder involved in the process, “All [69 countries] were invited through various channels, e.g. UK DFID reached out to its network of priority countries, USAID and UNFPA also contacted them through their networks […] and in the end the ones that we got, were the ones we expected”. Catalyst for collective action Commitments provide a global platform for dialogue and consensus on a prioritised issue, with the intent to trigger and accelerate positive action and results in countries. Commitments have a uniting and catalytic dimension, in that they can bring together national stakeholders and donors/ partners around a specific cause, typically manifested in the theme of the commitment event. A country consultee noted that “the value of commitments is to bring the government into the game”. In this sense, commitments represent a pledge to collective global action. As reflected in the literature, the FP2020’s goal of ‘120 by 20’ provided “world leaders with a clear, measurable goal as a rallying point for collective action on the parts of governments, donors and implementing organisations”.16 This was echoed by several stakeholders interviewed; as noted by a donor: “commitments are a moment in time when things come together; […] all the people who are like minded come together and share together – virtually or physically – for a common purpose”. Signal of national will to support increased funding As donors and multilateral agencies are moving towards strengthening of domestic financing models for improved health, country-level commitments – especially where governments make budget commitments – highlight the political will to invest in FP. As commented by a donor agency, › an opportunity to catalyse collective action around a specific agenda or issue; › a signal of national will and basis for increased financing; and › a social contract or an accountability tool. In this context, the global community seeks commitments as: 13 ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS DRAFT this creates momentum for (additional) funding by providing donors with a “business case” as to why they should support certain countries over others . Social contract/ accountability tool A commitment pledged at an international forum demonstrates the political backing of the country to its FP/ RH goals; and the global community views this as a mechanism to hold the government and other national stakeholders accountable to results and ‘public scrutiny’ on performance. The visibility generated as a result of the commitment often translates into governments being held to account by civil society and through parliamentary oversight in their respective countries. Where a commitment is backed by external funding or technical assistance, it is generally accompanied by more formal/ rigorous reporting and performance monitoring mechanisms. This resonates with the noted characteristic of commitments as a “social contract” that binds commitment makers to both the global community and their country in terms of following through on their pledges. MOTIVATION FOR COMMITMENTS 14ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS DRAFTFORMULATION OF COMMITMENTS Formulation of commitments This section delves deeper into the making and content of a commitment – what objectives, activities and targets are chosen to be included in the commitment text and the processes followed in country to develop the commitment. Our key finding is that the content of a commitment is mainly influenced by and drawn from existing RH/ FP plans and strategies in country, and typically using multi-stakeholder, consultative processes. How do countries decide on the content of commitments? The overall theme/ focus of a commitment event influences the nature of the commitments it secures. Understandably, theme-based initiatives – such as FP2020 or the HANDtoHAND Campaign – elicit commitments with direct references to RH and RH supplies, as compared to broader initiatives (e.g. EWEC, Muskoka). For example, Benin makes a general reference to RH in its EWEC commitment - “ensure access to full package of reproductive health interventions”, but a direct reference to RH supplies in its FP2020 commitment - “ensure the availability and accessibility of contraceptive products throughout the country. By 2015, Benin will ensure that modern methods of contraceptives are available without cost”. However, the specific commitment text is primarily guided by three main factors: › existing country strategies and plans; › global priorities such as the MDGs; and › previous commitments. These are discussed below in turn. Existing country strategies and plans The content of commitments is largely based on a country’s existing priorities, as documented in its strategies and plans. Our consultations did not raise any evidence of a commitment promising completely new objectives that are not already expressed in a national RH/ FP strategy/ plan; rather it helped reconfirm and state more publicly these priorities. As noted by a committing government official, “The London Summit was not operating in a vacuum. Without exception, all [commitments] came out of existing plans and strategies”. Commitments are often a sharper version of the national strategy, with the commitment making processes helping countries to prioritise the most urgent needs and gaps that will support them in achieving their ultimate goals. “Commitments state state things the country is already doing or wants to accelerate. We shouldn’t fool ourselves that people came to these events to commit things they had not already thought about”. As such, country commitments draw heavily on the contents of their FP/ RH country strategies and plans; for example: › DRC’s FP2020 commitment, made in 2013 at the Third International Conference on Family Planning in Addis Ababa, is largely drawn from its National Strategic Plan on Family Planning (2014-20), which was then in the final stages of development. The two primary objectives of the Strategic Plan - (i) increase estimated contraceptive coverage to at least 19% by 2020; and (ii) assure access to and utilisation of modern contraceptive methods for 2.1m Congolese women by 2020 - are replicated in the ‘concrete actions’ committed to by the Government as part of the FP2020 commitment.17 Further, both the Strategic Plan and commitment cover the period 2014-20. Indeed, one country stakeholder described the DRC commitment as launching the National Strategic Plan on Family Planning, rather than making a new commitment to FP. 17 http://www.familyplanning2020.org/resources/remarks/215-country-statement-for-the-democratic-republic-of-the-congo-s-commitment-to-family- planning-2020 15 ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS DRAFT › Tanzania’s FP2020 commitment is based on its 2010 national Costed Implementation Plan (CIP) for Family Planning and Reproductive Health – indeed, five of the focus areas in the commitment were taken directly from the 2010 CIP.18 More specifically, countries which refer to RH supplies in their commitments had already identified RH commodity security to be a priority in their national strategies, i.e. country stakeholders “were already aware of the issue of RH supplies”. Of all the commitments studied by us, India is the only country to have explicitly referenced a specific RH product/ methods (within the paradigm of ‘choice’). India’s FP2020 commitment states “The centre-piece of its strategy on family planning will be a shift from limiting to spacing methods, and an expansion of choice of methods, especially IUDs (Intrauterine devices)”. The Indian Government’s commitment to RH commodities is highlighted in a USAID report, which takes a sample of 20 countries across Africa, Latin America and Europe/Asia and calculates the sources of funding for public-sector contraceptive supplies.19 India is one of only five countries where contraceptive supplies are fully funded by the government, rather than external sources, and the only country surveyed that has a Contraceptive Security Committee run exclusively by the Ministry of Health (MoH) rather than technical partners. Uganda is another example where the national policy environment has been strengthened to be supportive of RH supply security.20 Uganda already had specific references to RH supply security in its Poverty Eradication Plan (2004/5 – 2007/8) and as one of the six focus areas of its Health Sector Strategic Plan III (2010/11 - 2014/15). The pledging of its FP2020 commitment by President Musoveni and the presence of key FP champions in country further supported the prioritisation of RH supplies. Global priorities The content of commitments is also guided by global priorities such as the MDGs, with the commitment being seen as a driver of change that can define actionable steps to achieve these goals. “Commitments are a way to .achieve the MDGs.” Some country examples are: › Myanmar’s FP2020 commitment was developed “in such a way that through FP2020, we will not only meet MDGs 4 and 5, but also ensure sustainable development beyond 2015, which will also achieve the country’s National Plan”. › Nigeria’s FP2020 commitment, which pledges to increase the annual RH commodity budget, was guided by “the MDG perspective; those indicators were far from the actual goals and if we really wanted to get there, we needed a lot of effort to improve RH issues; this was a big consideration on what to put the money towards”. › The MDGs guided the Zambian government in developing their FP2020 commitments, which were seen “to meet the challenge of the unfinished business of the MDGs; to accelerate achievements already made”. This is shown in the Zambia FP Country Plan, which states it was developed in line with the FP2020 commitment and that the overall goal is to “contribute to the reduction of maternal mortality and morbidity through scaling up the provision of quality integrated family planning services in Zambia in line with the MDGs”.21 FORMULATION OF COMMITMENTS 18 Tanzania’s commitment available at: http://supplypromises.org/united-republic-tanzania-2/. Tanzania’s 2010 CIP available at http://www.fhi360.org/sites/ default/files/media/documents/national-fp-costed-implementation-plan-tanzania-main-text.pdf. The five areas of focus are: (i) ensure contraceptive commodities security; (ii) capacity building; (iii) advocacy and demand creation; (iv) improve service delivery systems; and (iv) improve management, measurement, and evaluation. 19 USAID DELIVER Project, Task Order 4. (2012) “Measuring Contraceptive Security Indicators in 2011” Arlington, Va: USAID DELIVER Project, Task Order 4, available at http://deliver.jsi.com/dlvr_content/resources/allpubs/guidelines/MeasCSIndi_2011.pdf 20 Chattoe-Brown, A. and Bitunda, A. (2006) “Reproductive Health Commodity Security: Uganda Case Study”, UK DFID Health Resource Centre, available at http://www.heart-resources.org/wp-content/uploads/2012/10/Reproductive-Health-Commodity-Security-Uganda.pdf 21 Republic of Zambia (2013) “Family Planning Services: Integrated Family Planning Scale-up Plan 2013-2020” 16ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS DRAFTFORMULATION OF COMMITMENTS Previous commitments Commitments can also re-affirm a country’s previous pledge(s), indicating continuity and coherence across commitments made over time on a specific issue. In its FP2020 commitment, Mauritania refers to its commitment to the Ouagadougou Partnership22 - “Building upon its existing commitment to the Ouagadougou partnership, Mauritania commits to the principles and objectives of FP2020 and will work to mobilise the resources necessary to meet these objectives”. We understand that these two initiatives have been well-coordinated, and build on their synergies at the national level. For example, the two initiatives have sent a co-signed letter to all seven Ministries of Health of the Ouagadougou Partnership countries to inform them that the two initiatives work together. Cameroon, Guinea-Bissau and Togo make reference in their EWEC commitment to regional initiatives such as the Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA), and Lesotho and Sierra Leone reaffirm their target to meet the Abuja Declaration in FP2020.23 What processes/ actors are involved in developing commitments? For the most part, national processes to develop commitments are led by the MoH; often involve a wide range of actors; are described as consultative; and incorporate supporting data analysis. These points are discussed below, as well as the role of technical partners and the influence of commitments made by other countries. The ultimate decision on a commitment’s content is typically made by senior leaders/ political officers, often Heads of State. The factors that influence their final decision are therefore often political and difficult to report on. Collaborative multi-stakeholder process Most countries consulted described a variety of health and non-health stakeholders being involved in formulating commitments. The autonomy and cooperative process in developing the content of commitments are highly valued by country stakeholders. › In Nigeria, the FP2020 commitment process was initiated by the federal MoH and involved the Ministry of Finance, donors (e.g. UK DFID and USAID), implementing partners (e.g. UNFPA and World Health Organization (WHO)), and CSOs. For UNCoLSC, the government is reported to have led a wide stakeholder discussion, including workshops to seek everyone’s input on the indicators and targets; “it wasn’t their own [the government] making alone”. › In DRC, a committee that had been set up following the 2009 national FP conference developed the FP2020 commitment. It consisted of Ministry officials, FP practitioners, NGOs, CSOs, donors, and religious organisations. Commitments require political buy-in, which implies that senior political leaders are often involved. “In Uganda, the inclusion of Parliamentarians in the development of the FP2020 commitment was a key factor in increasing funding for FP.” “We invited Parliament, as we wanted them to commit and increase their funding for family planning”. Additionally, this process was described by several Ugandan stakeholders as collaborative, with tasks for each member assigned based on their comparative advantage, and priorities being discussed consultatively until agreement was reached: “everyone contributed to the commitment; whoever was in the meeting”. A similar consultative process was followed in the Ouagadougou Partnership countries, which used a “participatory, inclusive and decentralised process” to develop the country plans, led by a steering committee consisting of government officials, CSOs, private sector and technical partners (e.g. UNFPA). The following box reviews the process of the Ouagadougou Partnership. 22 The Ouagadougou Partnership includes nine francophone West African countries (Bénin, Burkina Faso, Guinea, Ivory Coast, Mali, Niger, Mauritania, Sénégal, and Togo) as well as a range of international donors and partners. 23 “The Government of Lesotho is committed to meeting the Abuja Declaration Target of 15% expenditure for health, compared to the current 14% expenditure” (EWEC, 2011); and “Sierra Leone commits to increasing its annual health budget from 8% to 12% by 2013 and gradually thereafter until the Abuja target of 15% is met.” (FP2020, 2012). 17 ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS DRAFT Launched in February 2011 at the “Population, Development, and Family Planning in West Africa: An Urgency for Action”, the Ouagadougou Partnership brought together governmental and non- governmental representatives from eight francophone West African countries - Benin, Burkina Faso, Guinea, Mali, Mauritania, Niger, Senegal, and Togo - with Ivory Coast joining the initiative later. The conference was sponsored by several governments and donors and saw the participation of multilateral organisations such as UNFPA, WHO, and UNICEF as well as private organisations which provided logistical support and technical expertise.24 The process and timelines for the development of the Ouagadougou Partnership are presented below:25 SEPTEMBER 2011 At the Saly Conference, the Ouagadougou Partnership donors considered the possibility of funding the development of country action plans and between September and December 2011, preliminary FP plans were developed. MARCH 2012 At a conference in Paris, the donors defined a common vision for the Partnership, including key activities and operating model, followed by a period of refinement of the country plans to include priority activities and detailed costing, undertaken through a “participatory, inclusive and decentralised process”. JULY 2012 There was high visibility of Ouagadougou Partnership countries at the London Summit, with Burkina Faso, Senegal and Niger making formal commitments towards FP. OCTOBER 2012 The Partnership was formalised with the launch of the Coordinating Unit at IntraHealth International in Senegal. NOVEMBER 2012 The first country plan (Senegal) was officially launched. Other plans have followed in 2012-13 (Niger, Burkina Faso, Mauritania), and others are in the process of being finalised.26 Ouagadougou Partnership Focus on data analysis and evidence base All our interviewees on this study viewed the multi- stakeholder consultative discussions as a catalyst for data analysis and re-assessment of RH gaps/ needs in country - which had not happened to such an extent prior to formulating the commitment. These analyses helped in the formulation of commitments. Although the preparatory work for structuring commitments varies by country, a number of our interviews emphasised the reviews, needs assessment and gap analyses undertaken as part of their commitment- making process. There was a clear desire to develop evidence-based commitments with realistic targets that reflect country priorities and are credible on the global stage. › Developing Nigeria’s FP2020 commitment included a review of key government documents and policies, data from the Nigeria Demographic and Health Survey (DHS), National RAPID projections, and commodity forecasting. This is reflected in the statement “we needed to include what could be justified by available evidence”. The data- 24 Ouagadougou Partnership “Family Planning: Francophone West Africa on the move – A call to Action”. 25 Ouagadougou Partnership, http://advancefamilyplanning.org/sites/default/files/resources/1_ATodd_USAID_13Mar13.pdf 26 Ouagadougou Partnership, Action Plans, available at http://partenariatouaga.org/nos-actions/ FORMULATION OF COMMITMENTS 18ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS DRAFT driven process resulted in the development of an unpublished position paper “Status of Family Planning in Nigeria”, which influenced its FP2020 commitment.27 › Myanmar’s philosophy in developing its FP2020 commitment was “whatever we promise, it is essential that we keep to it”. The first step of the process was for the MoH to collate and analyse maternal mortality and newborn health data to demonstrate that the burden of mortality and morbidity was unacceptably high. › Uganda used information from the DHS and national budgets to demonstrate the unmet needs and insufficient funding/ investment in FP. Role of technical partners Technical partners, such as Advance Family Planning (AFP), Clinton Health Access Initiative (CHAI), and International Planned Parenthood Federation (IPPF), support the formulation of commitments on two fronts: › Given their linkage to and close understanding of the initiative, providing technical assistance to countries in the development of their commitment: › In DRC, AFP played a key introductory role to FP2020 that ensured country stakeholders become aware of the commitment process and options for DRC to commit to the initiative. AFP also provided key technical input and assisted the DRC government in drafting its FP2020 commitment. › In Nigeria, CHAI helped the federal MoH to strengthen their coordination across RH partners by undertaking a partner landscaping exercise of partner activities, key gaps and needs, and where the UNCoLSC catalytic funding could be allocated. CHAI also assisted in developing implementation strategies to roll out the FP2020 commitment. › Sharing “best practice” across countries. Countries acknowledge the importance of learning about the experiences of their peers in the formulation of commitments. Such lessons could be taught in a more systematic manner to feed into formulating new commitments or fulfilling existing one. In fact one of the countries we studied mentioned being influenced by references to FP supplies in their research of other commitments. Our interviews on this study suggested that such sharing of lessons across countries in formulating new commitments and/or fulfilling existing commitments can be undertaken in a more systematic manner. Finalisation of commitment text Given the visibility of commitments at the global and national level, as well as the political backing they demonstrate, their content is approved by senior politicians/leaders who typically participate in the commitment event and make their country’s pledge. National processes and actors involved in developing commitments recognise the political context and priorities in which commitments need to be developed. For example, in drafting DRC’s FP2020 commitment, members of the working group drew inspiration from President Kabila’s 2011 re-election speech, in which he committed to making DRC an emerging market country by 2030.28 The group framed the commitment within these economic development terms, in order to “make the President comfortable”. Once the commitment text is developed and submitted to the concerned authority for approval, the process of finalising it is inevitably less consultative, as it is guided by several political considerations. Uganda’s draft commitment submitted to the President contained 11 statements, but the final version presented by the President as a speech at FP2020 contained only four. None of those interviewed on this study were privy to the motivations of the President’s office in selecting the four statements. We also learnt that DRC’s FP2020 commitment was tweaked right up until a few hours before its announcement in Addis, with the budget figure as well as some text such as “country-wide” being removed to make the commitment more realistic. “The final commitment was a decision by top officials, not involving other parties”. 27 As referred to in Dickerson, D & Ahmed, AA (2013) “Advocacy for Family Planning: Understanding the budget process in Two Nigerian States – Cross River and Zamfara”, Washington, DC, Health Policy Project, Futures Group. Available at: http://www.healthpolicyproject.com/pubs/104_ AAHPPNigeriaStatesBudgetAdvocacyFINAL.pdf 28 http://www.congoplanete.com/news/3311/joseph-kabila-candidat-election-presidentielle-novembre-rd-congo.jsp FORMULATION OF COMMITMENTS 19 ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS DRAFTIMPLEMENTATION OF COMMITMENTS Implementation of commitments This section analyses the country processes and tools for implementation of commitments. The majority of stakeholders consulted for this study commented on the implementation of commitments made under the more recent initiatives of FP2020, Ouagadougou Partnership and UNCoLSC. Their view is that countries who have committed to these initiatives are currently developing tools to support implementation and there is not yet much evidence of operationalising commitments. For earlier commitments such as those made under EWEC, several countries are reported to be in the process of implementation. The Partnership for Maternal, Newborn and Child Health (PMNCH) 2013 Report highlighted that: “Many stakeholders have made significant progress in implementing their commitments and some data are beginning to emerge concerning the Global Strategy’s goals of preventing 33 million unintended pregnancies and reaching 43 million new users in 49 countries in 2015”.29 Our key finding is that most commitments made under the recent initiatives of FP2020, Ouagadougou Partnership and UNCoLSC are still to be implemented, although there is some evidence that commitments made under the Global Strategy/ EWEC are being implemented. A lot of the countries’ focus is currently in developing tools for implementation, such as action plans and strategies. Some of the implementation challenges faced are changes in political leadership, lack of sub-national level engagement, resource constraints, and limited technical skills. What are the country processes and tools for implementation of commitments? Countries manage the implementation of commitments through different approaches. The main approaches followed are: › developing commitment-specific action plans; and › using broader national RH strategies/ plans such as Costed Implementation Plans (CIP) – some of which may pre-date the commitment. The extent of implementation guidance to countries by each commitment initiative also varies: whilst some have provided limited direction (e.g. at FP2020, there was “no explicit conversation.about how countries would do it”), others – such as the UNCoLSC and the Ouagadougou Partnership – have established more structured processes to support countries in implementation . 29 PMNCH (2013) The PMNCH 2013 Report: Analysing progress on commitments to the Global Strategy for Women’s and Children’s Health, World Health Organisation (p. 49) “UNCoLSC and the Ouagadougou Partnership have established more structured processes to support countries in implementation.” 20ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS DRAFTIMPLEMENTATION OF COMMITMENTS Commitment-specific action plans One of the approaches to implementing commitments has been for countries to develop specific plans detailing actions, timelines, roles and responsibilities of various stakeholders concerned. This is evidenced in the following commitments: Following the joint UNCoLSC conference in October 2012 in Abuja, the eight Pathfinding countries of the initiative – DRC, Ethiopia, Malawi, Nigeria, Senegal, Sierra Leone, Tanzania and Uganda – developed detailed country implementation plans outlining specific activities and costs to action their commitment. These were developed through a consultative stakeholder process with UN agencies, key implementing partners and contracted consultants, and based on national strategies and frameworks. This was followed by an RMNCH landscape assessment in each of the eight countries to identify key gaps that need to be addressed, as part of the final plan. We however understand that the quality of these plans varies across the countries. › Following its commitment to the FP2020 Summit in 2012, Zambia developed its Scale-Up Plan for 2013-20.30 This Plan was developed with assistance from FHI360 and Marie Stopes International (MSI), and includes a CIP, a range of M&E tools, and preliminary annual objectives. › Nigeria committed to UNCoLSC in 2012; and released a Country Implementation Plan in August 2013, which outlined strategies to improve the supply chain and availability of RMNCH life-saving commodities. The acknowledgement section of the Plan states that it “was developed through a highly participatory, consultative, collaborative and interactive process”.31 National strategies/ plans Since commitments are primarily based on a country’s RH priorities, some countries use existing national strategies and plans as the basis of implementation. For example: › Nigeria’s implementation of its FP2020 commitment is guided by its National Strategy on MDGs 4 and 5, the national CIP, and the MDG Acceleration Framework. › DRC’s National Strategic Plan for Family Planning (2014-20) forms the backbone of the country’s FP2020 commitment. An Implementation Plan32 has been developed for the National Strategic Plan and each objective includes detailed sub-objectives and expected outcomes. Implementation has just started - the government has transferred the allocated funding for the purchase of contraceptives to a dedicated account in line with the Plan and as per its commitment. The relationship between commitments and national RH strategies is a two-way process: “Whilst some countries use existing RH strategies as the basis for implementing commitments, in other countries, commitments have supported the development of new RH strategies and policies” For example, under its UNCoLSC commitment, Nigeria set up three committees to improve access to key commodities: (i) RH and maternal health commodities committee; (ii) child health commodities committee; and (iii) neonatal health commodities committee. Each committee has a focal point to lead on the different commodities and includes federal government representatives, UNFPA, and other partners. Each committee had to develop plans/ strategies to strengthen commodity security at the national level. Thus, Nigeria’s UNCoLSC commitment was a “driver of strategy and implementation at country level”. Many countries have developed (or are developing) national CIPs to meet their RH/ FP goals and strategies, upon which the FP2020 and Ouagadougou Partnership commitments are based. “A CIP details the programme activities necessary to meet national FP goals and the costs associated with the activities, providing clear programme-level information on the resources a country must raise domestically and from partners”.33 For example, the action plans developed by the Ouagadougou Partnership countries are based on their existing/ refined CIPs.34 30 Republic of Zambia (2013) “Family Planning Services: Integrated Family Planning Scale-up Plan 2013-2020” 31 Federal Republic of Nigeria (2013) “Country Implementation Plan for United Nations Commission on Life-Saving Commodities for Women and Children” 32 Democratic Republic of Congo (2014) Implementation of the National Strategic Plan for Family Planning: Results to achieve in 2014 33 Zlatunich, N. (2013) “Costed Implementation plans for family planning”, Health Policy Project Brief. 34 The Partnership supports countries in the development of action plans that also serve as a tool for advocacy and resource mobilisation. 21 ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS DRAFT What are the enablers for successful implementation of commitments? Our consultations have highlighted the following enablers for the successful execution of commitments: › Multi-stakeholder consultative processes: Such a process ensures the buy-in and ownership of all stakeholders, which helps in coordinated implementation and stronger accountability for results. For example, in developing their FP2020 commitment action plans in September 2012, Uganda received inputs from all stakeholders that would be involved in implementation.35 › Strong political leadership: Generating momentum for implementation of commitments requires political champions and political will at the national and sub- national levels. Political support is generally forthcoming when commitments are pledged publically at high-profile/ international events. As echoed by a country-level consultee, “If the government does not own the agenda, if there is no political commitment, then it is extremely difficult to implement”. Further, Parliamentarians have a unique role to play in enabling the implementation of commitments. As noted in the literature: “elected officials who hold political authority, particularly members of Parliament (MPs), are uniquely positioned to support the MoH stewardship of family planning by promoting and approving funding for FP policies and programmes”. › Partner support: The support of engaged partners and donors assists countries in implementation: international partners can provide technical assistance and global perspectives and lessons for implementation, and local partners (such as CSOs) can provide hands-on support in implementation. Although the implementation process is nationally owned, global stakeholders and technical partners often work closely with, and assist, countries in the post-commitment phase in addressing key gaps. For example, DRC is supported by AFP and Tulane University in the implementation and monitoring of its FP2020 commitment through a Gates Institute grant. › Active civil society: In addition to supporting implementation, CSOs and other non-state actors at the national and sub-national level play a ‘watchdog’ role in advocating for, and monitoring, implementation, as well as holding the government accountable for results. As noted by a country consultee: “it is critical for civil society to know what commitments have been made so that they can follow up with government on implementation”. › Coordinating mechanisms of some initiatives: Supporting structures of some initiatives such as the FP2020 Secretariat at the UN Foundation, the Ouagadougou Partnership Secretariat at IntraHealth International in Senegal, the UNCoLSC Secretariat at UNICEF, and the H2H Campaign at RHSC are key coordinating mechanisms to support the implementation of commitments. Although each of these structures operates differently, they support countries in the implementation of commitments as well as in follow-up and tracking and monitoring progress on commitments. In general, they are nodal agencies that “keep the momentum going” on an initiative. › Clarity of commitment: Where the commitment text follows the SMART36 principle, it supports smooth implementation. A consultee stated that “specificity and concrete indicators make for successful commitment”. In this regard, FP2020 states that commitments must be long-term, sustainable and measurable.37 However, our analysis of commitments in Phase 1 of work suggests that not all of them are SMART. IMPLEMENTATION OF COMMITMENTS 35 Elizabeth Leahy Madsen, Health Policy Project, Futures Group (2014), “Stewardship for FP2020 Goals, The Role of Parliamentarians.) 36 SMART stands for Specific, Measurable, Assignable, Realistic and Time-related. 37 http://www.familyplanning2020.org/reaching-the-goal/making-a-commitment-to-fp2020 22ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS DRAFT What challenges are faced by countries in implementation of commitments? Notwithstanding the majority view of our interviewees on the study that most countries are yet to begin or are just beginning to implement the more recent commitments, some of the challenges that have been raised for countries in the ‘early stages of implementation’ include: › Changes in political leadership: Given that commitments are long-term pledges, it is likely that governments will change over the implementation period. At times, a commitment is no longer seen as a priority by a new administration and dropped from the national agenda. To ensure continued political will, it is therefore crucial that implementation, action plans and national strategies ‘embed’ a commitment in the country’s health systems and garner the support of different stakeholders in the country and the international community. › Sub-national level engagement: Implementation of a commitment requires support at the local or sub-national level, where the activities need to be carried out. As stated by the stakeholders interviewed, there is often limited awareness of commitments made (including by governments) at the sub-national level, and at times, lack of resources to implement them. This leads to low buy-in and limited engagement of local stakeholders . › Resource constraints: Competing budget priorities for limited resources are one of the biggest barriers to implementing commitments. There is often a mismatch between available resources and activities described in the action plans, which hinders and/or delays implementation. › Limited technical skills: At times, despite the best of political intentions, commitments are not implemented on account of limited technical expertise available in country in terms of planning, financing and executing the commitments. Fulfilling supply commitments requires skills in developing pragmatic implementation plans and strategies as well as programmatic experience to action them and monitor progress. IMPLEMENTATION OF COMMITMENTS 23 ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS DRAFT Results/impact of commitments Nearly all respondents were cautious about referring to the impact of commitments, with it either being too early to assess this and/ or recognising the difficulties in attribution. However, there was almost unanimous agreement that commitments are a valuable development tool and have the potential to effect change in countries in the future. Given that it is too early to examine the impact of commitments, this section focuses on national monitoring and accountability mechanisms and tools to track commitments, including examples from initiatives outside of this study. It then presents some initial illustrations of results based on our consultation feedback. Our key finding is that commitments have the potential to influence/ effect change at the country level, but it is premature to assess impact. Although accountability mechanisms have been recognised as a gap, some tools to track and monitor results are being developed both at the country and commitment initiative level. What are the monitoring and accountability mechanisms for commitments? Commitment tracking and reporting have been identified as areas of weakness across initiatives; monitoring of progress is mostly being conducted on an ad-hoc basis. At the country level, the monitoring aspect of commitments is typically not addressed during the formulation process, as many commitments face the challenge of not being quantifiable. No country was identified as having a proven and effective monitoring mechanism in place. This seems to suggest that commitments are often made without agreement of what constitutes “success”, making it difficult to measure and report on results. Some consultee feedback in this area are “although there is an M&E framework attached to the implementation plan, monitoring tends to be disconnected” and “making commitments is not enough; these must be accompanied by monitoring systems that can ensure accountability to the regional and global initiatives”. That said, there are some ongoing efforts to strengthen data collection and analysis, and develop tools to facilitate tracking of progress at both the country and initiative level, as described below. We also provide selected examples of other initiatives (not covered by our study) that track progress and results. Country-level tools › Uganda: Since April 2014, Uganda has been piloting a Commitments Motion Tracker to monitor its EWEC, UNCoLSC and FP2020 commitments. This tool provides a framework to guide activities required for implementation, and notes progress through a 4-step approach. Although still in its infancy, the tool shows promise, particularly in its consolidated approach to tracking all country commitments rather than focusing on a specific initiative. Additionally, the tool ensures that a wide range of stakeholders are involved, and frames progress in terms of “success” rather than “activities not achieved”. RESULTS/ IMPACT OF COMMITMENTS 38 http://familyplanning-drc.net/index.php 24ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS DRAFT › DRC: A consolidated monitoring approach is also being proposed in DRC by AFP/ Tulane University, which is currently developing an accountability tool to track the progress of DRC’s FP2020 commitment. This will soon be available on their dedicated FP website,38 and aims to recognise achievements in relation to their commitments. › Zambia: Youth Vision Zambia, a CSO, started tracking the national RH budget immediately after the FP2020 Summit, where Zambia’s commitment included budget targets. The first step of this process was for the CSO to fully understand the national budget process, and then track the budget being allocated to RH commodities. This understanding has led to the CSO’s ability to influence budget policy, negotiate budget allocations, and track that allocations are disbursed and spent on what they were intended for. As noted by a stakeholder in Zambia, “tracking a commitment alone is not enough”; there needs to be strong advocacy to bring about change. Initiative-level tools At the initiative level, tracking of commitments is based on data provided by countries supported by targeted initiatives that seek to complement routine surveillance. Annual reports published by some initiatives seek to provide an incentive for data collection and timely reporting of progress by countries. They also help to maintain focus and attention on the commitments and ensure that they are supported by investments and funding: › Partnership in Action Reports: Produced by FP2020 on an annual basis, this report tracks progress of the commitments pledged to FP2020 from countries and organisations in both the Global North and Global South. It also includes key findings for each of the FP2020 core indicators.39 › Track20 project: FP2020 has also developed the Track20 project to monitor progress of its commitments.40 Launched in 2013, this is a five-year project implemented by Futures Institute, which supports national efforts to collect, analyse and use data to track progress in FP and develop effective programme strategies and plans. Track20 works with governments to transform current practices that rely heavily on national households surveys conducted every five years or so, to a system in which data collected by the government are used to produce annual estimates on a range of key FP indicators. Activities undertaken by Track20 include: (i) national level M&E officer recruitment; (ii) expansion of UN Population Division model for estimating FP indicators; (iii) annual data consensus-building workshop; (iv) creation and implementation of FP M&E tools and materials; (v) country expenditure tracking; and (vi) documentation and dissemination of country progress and lessons learnt. › PMA2020: this is another FP2020 initiative.41 Implemented by the Bill and Melinda Gates Institute for Population and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health, PMA2020 is a data collection surveillance approach that uses an innovative mobile-Assisted Data and Dissemination System (mADDS) to enable countries to obtain key household and facility- level FP data on an annual basis, thereby providing supporting data to the DHS. The project is implemented by country-based organisations such as universities and research institutions, thus building local capacity in data collection and analysis. Other initiative-level monitoring tools We also outline below a few monitoring and accountability mechanisms used for initiatives outside the scope of this study that may provide useful lessons: › PMNCH Reports on Commitments to the Global Strategy. Since the launch of the Global Strategy in 2010, PMNCH has produced Commitment Reports on an annual basis aimed to: (i) facilitate reporting, auditing and communication of new and existing commitments and their implementation; and (ii) analyse the nature and impact of commitments by describing how implementation of commitments address the gaps identified in the Global Strategy and contribute to achieving MDGs 4 and 5.42 RESULTS/ IMPACT OF COMMITMENTS 39 he ten core indicators are: (i) Modern Method Contraceptive Prevalence Rate (mCPR); (ii) total number of contraceptive users by method; (iii) % of women whose demand for contraception is satisfied; (iv) % of women with unmet need for contraception; (v) annual expenditure on family planning from government domestic budget; (vi) couple-year of protection (CYP); (vii) number of unintended pregnancies; (viii) number of unintended pregnancies averted due to contraceptive use; (ix) number of maternal deaths averted due to contraceptive use; and (x) number of unsafe abortions averted due to contraceptive use. 40 http://www.track20.org/pages/about 41 http://www.pma2020.org 42 PMNCH Reports 2011,2012,2013, and 2014. 43 www.alma2015.org 25 ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS DRAFT › African Leaders Malaria Alliance43 uses a scorecard mechanism to monitor progress across countries and awards prizes for success. Leaders benchmark results and investments against other countries. Countries such as Ethiopia and Nigeria are now using this mechanism to expand into Maternal and Child Health (MCH). › Open Health Initiative is a similar initiative in East Africa to benchmark investments and results for RMNCH, specifically to forward the UN Commission on Information and Accountability (CoIA) agenda. They are currently working to add incentives of small grants to this model. RESULTS/ IMPACT OF COMMITMENTS Since 2004, DRC has committed to reposition FP. However, it was only after the government’s FP2020 commitment and finalisation of the National Family Planning Strategy that the Ministry of Finance began budgeting for FP. In 2013, the government created a dedicated bank account and transferred US$1m into it for procurement of contraceptives. The government’s commitment to funding, as well as the creation of a clear FP strategy and commitment, have led to donors being more willing to invest in DRC’s FP objectives. In Myanmar, FP has historically been a highly sensitive topic. The country’s FP2020 commitment made in Addis and simultaneously publicly announced in Naypyidaw, has provided a “licence [for international organisations] to talk about FP openly”. Nigeria’s signing up to FP2020 in 2012 is considered as a driver of FP commodities being provided free of charge in the country. This policy change “would have been difficult without the commitment; it would not have happened”. What are some early examples of results? Although it is premature to assess the results/ impact of recent commitments, some stakeholders interviewed presented examples of positive change as a result of commitments (we have not been able to independently verify this): 26ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS DRAFTANNEX 1: BIBLIOGRAPHY Annex 1: Bibliography › Annie Chen, Nichole Zlatunich, Modibo Maigo, Donald Dickerson (2013), “Strategic Budgeting Process for Setting up of Family Planning; Costed Implementation Plans (CIPs) for Family Planning” › Brown, W. et al. (2014), “Developing the “120 by 20” Goal for the Global FP2020 Initiative, Studies in Family Planning, 45: 73-84” › Chattoe-Brown, A. and Bitunda, A., (2006) “Reproductive Health Commodity Security: Uganda Case Study”, UK DFID Health Resource Centre” available at http://www.heart-resources.org/wp-content/uploads/2012/10/Reproductive-Health-Commodity- Security-Uganda.pdf › Democratic Republic of Congo (2013), “Implementation Plan: Results to Achieve in 2014” available at http:// advancefamilyplanning.org/sites/default/files/resources/DRC%20FP_Results%20to%20achieve%20in%202014.pdf › Dickenson, D & Ahmed, AA (2013), “Advocacy for Family Planning: Understanding the Budget Process in Two Nigerian States – Cross River and Zamfara:, Washington Health Policy Project, Futures Group. Available at: http://www.healthpolicyproject. com/pubs/104_AAHPPNigeriaStatesBudgetAdvocacyFINAL.pdf › Elizabeth Leahy Madsen, Health Policy Project, Futures Group (2014), “Stewardship for FP2020 Goals, The Role of Parliamentarians” › Federal Republic of Nigeria (2013), “Country Implementation Plan for United Nations Commission on Life Saving Commodities for Women and Children” › FHI360 (2014) Costed Implementation Plans: Guidance and Lessons Learnt, available at http://www.fhi360.org/sites/default/ files/media/documents/costed-implementation-plans-guidance-lessons-learned.pdf › ForoLAC (2012), “The paradox of development: Economic growth, the burden of inequity and its impact on sexual and reproductive health in the LAC region”. Available at: http://www.rhsupplies.org/uploads/tx_tspagefileshortcut/en.pdf › FP2020, Building the Foundation of a Global Movement, http://www.familyplanning2020.org/reaching-the-goal/reaching-the- goal › Janowitz, B and Bratt, J (1994) “Methods for costing family planning services” UNFPA and FHI. Available at: http://www. popcouncil.org/uploads/pdfs/frontiers/Capacity_Bldg/unpf0050.pdf › John Hopkins Bloomberg School of Public Health, AFP Family Planning (2013), “Develop a Strategy. AFP SMART: A Guide to Quick Wins – Build Consensus, Focus Efforts, Achieve Change” › Nichole Zlatunich, Health Policy Project (2013), “Costed Implementation Plan for Family Planning” › Ouagadougou Partnership “Family Planning: Francophone West Africa on the move – A call to Action” › Ouagadougou Partnership, http://advancefamilyplanning.org/sites/default/files/resources/1_ATodd_USAID_13Mar13.pdf › Ouagadougou Partnership, Action Plans, available at http://partenariatouaga.org/nos-actions/ › PMNCH (2013) The PMNCH 2013 Report: Analysing progress on commitments to the Global Strategy for Women’s and Children’s Health, World Health Organisation. › RHSC Annual Report (2014) http://www.rhsupplies.org/fileadmin/user_upload/Annual_Report/RHSC_Annual_Report_2014. pdf 27 ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS DRAFT › RHSC Strategy 2015-2025, Draft. › Republic of Zambia (2013), “Family Planning Services: Integrated Family Planning Scale-up Plan 2013-2020” › UNCoLSC (2012) Commissioner’s Report, September 2012, http://www.everywomaneverychild.org/images/UN_Commission_ Report_September_2012_Final.pdf › UN Department of Economic and Social Affairs Population Division (2014), “2014 Update for the MDG Database: Contraceptive Prevalence”, available at http://www.un.org/en/development/desa/population/theme/family-planning/index.shtml › USAID DELIVER Project, Task Order 4. (2012) “Measuring Contraceptive Security Indicators in 2011” Arlington, Va: USAID DELIVER Project, Task Order 4”, available at http://deliver.jsi.com/dlvr_content/resources/allpubs/guidelines/ MeasCSIndi_2011.pdf › Zlatunich, N. (2013) “Costed Implementation Plans for family planning”, Health Policy Project Brief, available at http://www. healthpolicyproject.com/pubs/253_CostedImplementationPlanBrief.pdf › http://www.congoplanet.com/news/1881/joseph-kabila-speech-reelection-pictch-dr-congo-november-election.jsp › http://www.familyplanning2020.org/reaching-the-goal/making-a-commitment-to-fp2020 › http://familyplanning-drc.net/index.php › http://partenariatouaga.org/le-partenariat/ › http://www.track20.org/pages/about › http://www.pma2020.org › www.alma2015.org ANNEX 1: BIBLIOGRAPHY 28ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS DRAFT Annex 2: Stakeholders interviewed This annex presents a list of stakeholders consulted for this work. Table A2.1 sets out the consultations undertaken in Phase 2 of the assignment (over the period August – October 2014, by telephone and in-person at the Mexico meeting); and Table A2.2 sets out the consultations conducted in Phase 1 (over the period November 2013 – May 2014). A majority of the stakeholders interviewed are national level stakeholders, with others being global (such as commitment event organisers, donors, and FP partners). ANNEX 2: STAKEHOLDERS INTERVIEWED Name Position ad Organization Dr. Collins Tusingirwe Chief of RH Services, Ministry of Health, Uganda Dr. Jotham Musinguzi African Regional Director, Partners in Population and Development (PPD), Uganda Patrick Mugirwa Programme Officer, PPD, Uganda Dr. Moses Muwonge Director, SAMASHA, Uganda Dr. Arsene Binanga Tulane International LLC & President of CTMP, DRC Dr. Kayode Afolabi Director of Reproductive Health, Federal MoH Nigeria Anita Okenwu CHAI, Nigeria Dr. Wale Adeleye National Coordinator, Civil Society for Family Planning in Nigeria (CiSFP), Nigeria Aliyu Ahmed Advocacy & Accountability Advisor, CiSFP, Nigeria Edford Mutuma Planned Parenthood Association of Zambia Amos Mwale Executive Director, Youth Vision Zambia Halima Sharif Country Director, AFP, Tanzania Dr. Thein Thein Htay Deputy Health Minister, Myanmar Julia Bunting Program and Technology Director, International Planned Parenthood Federation (IPPF) Chris Gee Advocacy Officer, IPPF Jessica Schwartzman Senior Manager, Donor Outreach and Engagement , FP2020 Paul Pronyk Senior Programme Specialist, RMNCH, Strategy and Coordination Team, UNICEF Dr. Kechi Ogbuagu Coordinator, Global Programme to Enhance Reproductive Health Security, UNFPA (retired) Shara Renee Ticku Global Family Planning Team, CHAI Jay Gribble Deputy Project Director, Futures Group Fatimata Sy Director, Ouagadougou Partnership Badara Seye Regional Advisor, SECONAF Beth Fredrick Executive Director, Advance Family Planning (AFP) Alison Bodenheimer Programme Officer, Francophone Africa, AFP Lene Lothe Senior Advisor, NORAD Dr. Jane Bertrand School of Public Health and Tropical Medicine, Tulane University Sono Aibe Senior Advisor for Strategic Initiatives, Pathfinder Dr. John Skibiak Director, RHSC Lou Compernolle Global Commitments Officer, RHSC Gloria Castany Regional Coordinator, RHSC Table A 2.1: List of stakeholders interviewed (Phase II) 29 ANALYSIS OF THE DYNAMICS SURROUNDING REPRODUCTIVE HEALTH SUPPLIES COMMITMENTS DRAFT Name Position ad Organization Mabou Benin Bola Leonie Ministry of Health, RH commodity security, DRC Nana Amma Oforiwaa Sam Planned Parenthood Association of Ghana (PPAG), Ghana Aliyu Aminu Ahmed Health Policy Project, Nigeria Poonam Muttreja Population Foundation of India Carlos Guitierrez Prisma, Peru Ndeye Fatouma Ndiaye Direction de la Sante de Reproduction et Survie de l’Enfant, Senegal Halima Shariff Advance Family Planning, Tanzania Dr. Moses Muwonge Director, SAMASHA (Uganda) Mark Riling, Linda Cahaelen USAID, USA Win Brown Bill and Melinda Gates Foundation (FP2020) Koen Kruytbosh, Paul Schaper Merck, MSD Frank Roijmans Independent expert Table A.2: List of stakeholders interviewed (Phase I) ANNEX 2: STAKEHOLDERS INTERVIEWED The Reproductive Health Supplies Coalition The Coalition is a global partnership of public, private, and non-governmental organizations dedicated to ensuring that everyone in low- and middle-income countries can access and use affordable, high-quality supplies for their better reproductive health. It brings together agencies and groups with critical roles in providing contraceptives and other reproductive health supplies. These include multilateral and bilateral organizations, private foundations, governments, civil society, and private sector representatives. Rue Marie-Thérèse 21 1000 Brussels Belgium Tel: +32 2 210 0222 Fax: +32 2 219 3363 E-mail: secretariat@rhsupplies.org

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