Core Package Final Report: A Policy Approach to Contraceptive Security in Romania, 2000-2003

Publication date: 2004

[image: image1.emf][image: image2.png] POLICY Project CORE PACKAGE FINAL REPORT: A Policy Approach to Contraceptive Security in Romania, 2000–2003 POLICY Project March 2004 [image: image3.jpg][image: image4.png][image: image5.emf] A Policy Approach to Contraceptive Security in Romania, 2000–2003 POLICY Project March 2004 [image: image6.png] [image: image7.jpg]The POLICY Project is funded by the U.S. Agency for International Development (USAID) under Contract No. HRN-C-00-00-00006-00. POLICY is implemented by the Futures Group in collaboration with the Centre for Development and Population Activities (CEDPA) and Research Triangle Institute (RTI). The views expressed in this paper do not necessarily reflect those of USAID. [image: image8.jpg]Contents Abstract iv Abbreviations v Introduction 1 Analytical Framework 2 Romania’s Contraceptive Security Policy Initiative: Context, Policy Issue, and Stakeholders 3 Policy Implementation Problems and the POLICY Project’s Response 9 Contraceptive Security Policy Changes that POLICY Helped Achieve 14 Summary 29 POLICY’s Impact and Future Perspectives 30 Notes 32 References 34 [image: image9.jpg] Abstract In August 2000, the Romanian government approved—for the first time ever—public sector funding for contraceptives and the provision of free commodities to vulnerable population sectors. These policies, however, were broad, and implementation problems soon emerged, particularly the access of the poor to free contraceptives. The USAID-funded POLICY Project assisted the government in identifying and addressing barriers to implementing Romania’s landmark contraceptive security policies. POLICY’s assistance in conducting research, forming advocacy networks, and data-based advocacy and policy dialogue contributed to four policy changes that occurred between September 2001 and March 2003: increased government budgetary allocation for free distribution of contraceptives; coverage of generic contraceptive formularies by the health insurance system; public sector funding of nongovernmental organizations involved in public health programs such as family planning and reproductive health information campaigns; and simplified certification requirements for the poor to access free contraceptives. Initial assessment of the impact of these policy changes shows that free contraceptives and more method choices are now available in various urban and rural clinics. Pharmacies are also filling contraceptive prescriptions and have been reimbursed by the social health insurance system, although pharmacists are purportedly wary of slow reimbursements. How much the country can achieve in the area of contraceptive security has yet to be determined. In the meantime, the Romanian experience provides a policy model for contraceptive security that entitlement-oriented societies can consider. Abbreviations [image: image10.jpg] ARAS Anti-AIDS Association in Romania CAs Cooperating agencies CDC Centers for Disease Control and Prevention DHA District Health Authorities DHIH District Health Insurance House FP Family planning GOR Government of Romania GP General practitioner IEC Information, education, and communication IOMC Institute of Mother and Child IUD Intrauterine device JSI John Snow International MCH Maternal and child health MOH Ministry of Health MOHF Ministry of Health and Family NGO Nongovernmental organization NHIH National Health Insurance House NLW National League of Women Ob-Gyn Obstetrician-Gynecologist PSI Population Services International RH Reproductive health RRHS Romania Reproductive Health Survey SECS Society for Education on Contraception and Sexuality SES Socioeconomic status STI Sexually transmitted infection UNFPA United Nations Population Fund USAID U.S. Agency for International Development [image: image11.jpg] I. Introduction Contraceptive security, defined as a condition when all women and men who need and want contraceptives can obtain them (Sine and Sharma, 2002), is a new concept in Romania. Nonetheless, in August 2000, the government approved—for the first time ever—policies that included a budget line item for contraceptives and the provision of free commodities to vulnerable population sectors. The August 2000 policies were broad, and implementation problems soon emerged. In response, the USAID-funded POLICY Project (POLICY) provided a focused package of technical assistance (TA) that lasted from March 2001 to December 2002 to help the government of Romania (GOR) to target those most in need and improve family planning equity. POLICY assistance contributed to four GOR policy decisions that occurred between 2001 and 2003: Increased Ministry of Health and Family (MOHF) resources for free contraceptives in 2001 and 2002 Generic contraceptive formularies covered by social health insurance (2002) Norms for government funding of nongovernmental organizations (NGOs) involved in public health programs, including providing free contraceptives to the poor (approved in 2003) Self-certification of poverty status as documentary proof for access to free contraceptives (2003) These policy changes are significant and also interrelated. After the public health budget laws for 2001 and 2002 approved line items for contraceptives, the health ministry increased allocations over the original budget line item for the procurement of commodities to be distributed free to target groups, including the economically disadvantaged. Previously hampered by onerous certification requirements, the poor could now obtain free contraceptives simply by signing a document certifying their inability to pay. To improve access to contraceptives and also help reduce public sector burden, generic formularies of contraceptive pills and injectables were now included in the list of drugs compensated by health insurance (which primarily benefits wage earners and their families). Finally, after meeting with NGO networks committed to informing the poor about the importance of accessible and quality family planning and reproductive health (FP/RH) information and services, including free contraceptives, the government approved operational policies that would allow public sector funds to go to NGOs involved in public health initiatives. This paper documents POLICY’s role in achieving these recent policy decisions. A framework for policy development is first provided, followed by an overview of the FP/RH context and contraceptive security policy process in Romania. The main body of the paper focuses on each of the four policy decisions and the technical assistance provided by POLICY that helped achieve such policy actions. In summary, the paper presents a policy approach to contraceptive security using a strategy that emphasized research, multisectoral advocacy, and policy dialogue that led to several interrelated policy decisions that occurred during a relatively short time period (September 2001 to March 2003). II. Analytical Framework Effective policy development and change must consider each of the following components and how they influence each other: Context, which includes the socioeconomic, historical, political, and policy environment, refers to the environment in which a problem or process occurs, and what influences a country’s development priorities and the means to attain them; Issue, which refers to a problem that requires a policy action; Stakeholders, including primary decision makers and other formal policymaking bodies, as well as individuals and institutions that influence the policy process or represent those affected by the problem or policy decisions; and Process, which, in its entirety, encompasses problem identification and issue-framing, agenda-setting, decision making, implementation, program development, funding, and evaluation. Context affects who can be involved in identifying problems and proposing policy solutions, which decisions are made, the amount of resources generated and how they are allocated, and the extent to which policies are implemented. Context is also affected by development challenges and policies, and by changes in political leadership and power structures. How a problem is identified is then brought to the attention of decision makers, and the policy solutions selected are shaped by the types of stakeholders that are involved in the process. Formal decision makers as well as nonpolicy stakeholders are influenced by their respective sociopolitical backgrounds at both the macro and micro (or institutional) levels. The policy process is influenced by individuals and organizations that occupy varied positions in power structures and that have their own values and expectations regarding the issue at hand. Over time and with wider diffusion of democratic initiatives, processes have become more open to the intervention of nontraditional policy actors, thereby influencing decisions and changing the policy environment itself. These four components of policy development are discussed more fully in the following sections that describe the events and actions that led to the four recent GOR decisions affecting contraceptive security in Romania. Section III describes Romania’s FP/RH context, contraceptive security as the main policy issue, and the key stakeholders. Section IV briefly discusses initial efforts and problems in implementing the August 2000 policies and describes POLICY’s response and overall strategy. This section focuses on two starting points of this strategy: identification of barriers to the implementation of the August 2000 contraceptive security policies and advocacy network development. Section V gives a brief overview of the policy process in Romania, then focuses on each of the four GOR policy changes that occurred in 2001 through 2003 to help remove key barriers, the specific processes that led to these changes, and the roles played by key stakeholders in such policy changes. Section VI provides the summary and Section VII discusses POLICY’s impact and the implications for Romania in the future, with relevance to countries of similar sociopolitical backgrounds. III. Romania’s Contraceptive Security Policy Initiative: Context, Policy Issue, and Stakeholders Socioeconomic and FP/RH Context. Although Romania’s 1989 revolution ended decades of dictatorship and an inefficient socialist system, the transition to a market economy and democracy has been difficult. The economy contracted in the 1990s, although positive growth started in 2000. Gross national income per capita approached $1,700 in 2001 compared with approximately $2,000 for low/middle income countries in Europe and Central Asia (World Bank, 2003). Poverty in Romania, estimated at more than 40 percent, is particularly high among households with many children, rural households, households headed by farmers, the unemployed, those with low education and income, recipients of social pensions, and ethnic minorities (National Institute of Statistics, 2000). Romania’s total population of about 22 million is declining mainly because of a long-term decline in fertility rates achieved through abortion. While oppressive national policies that banned abortion and contraception were immediately repealed after the 1989 revolution, the population continued to rely on abortion as the primary method of controlling fertility, given the lack of access to modern contraception. In the early 1990s, less than 10 percent of all women ages 15–44 used modern contraception (IOMC and CDC, 1995); and, on average, the total lifetime abortion rate per woman was 3.4. Complications from abortion led to maternal mortality levels ranking among the highest in Europe (Ghetau, 1997). Beginning in 1992, international donors helped pressure the government to establish family planning clinics. The 1999 Romania Reproductive Health Survey (RRHS) showed that nearly one-half (48%) of all women ages 15–44 used some sort of family planning method (Table 1), with traditional methods accounting for 25 percent, and modern methods accounting for the other 23 percent. Low fertility preferences combined with continued reliance on ineffective traditional methods explain why Romania’s abortion rates (the 1999 RRHS lifetime total abortion rate per woman was 2.2) and maternal mortality levels remain high. Table 1. Reproductive Health Indicators, Romania 1999 Indicator Reference Population Contraceptive use among women ages 15–44 All women (%) Women in union (%) Currently using 48 64 Modern 23 30 Traditional 25 34 Not currently using 52 36 Currently using modern methods 23 30 Condom 8 9 Pill 6 8 IUD 5 7 Other modern methods 4 6 Modern use by residence Women in union (%) Urban 35 Rural 21 Modern use by SES of women in union High SES 39 Middle SES 33 Low SES 18 Method sources among women in union Public sector clinic 32 Private/NGO clinic 8 Pharmacy/store 51 Other 8 Women ages 15–44 in union who want no more children 58 All women (%) Total fertility rate (children per woman) 1.3 Ideal family size (children per woman) 2.0 All women (%) Women in union (%) Unmet need Not using, but with high risk of an unintended pregnancy 5 6 Unmet need for a modern FP method 29 39 Source: 1999 Romania Reproductive Health Survey, Final Report (CDC et al., 2001) Contraceptive Security as a Broad Policy Issue. Despite the urgency of improving access to FP/RH services, the government did not issue any national FP/RH policy until after 1998. However, more than 200 family planning clinics provided family planning information and services. Mostly found in urban areas, these clinics were mainly staffed by general practitioners (GPs) with six months of training in modern contraceptive technology. Recent interrelated developments—health sector reform, the 1997 approval of the health insurance law, and decentralization—provided opportunities for FP/RH policy changes. As health sector reform proceeded and the government attempted to operationalize health insurance in 1998, POLICY supported multisectoral policy dialogue on which FP/RH services would be covered by health insurance. Once key FP/RH services were identified, POLICY supported the Coalition for Reproductive Health in Romania (Coalition) in conducting advocacy events in three USAID priority judets (districts) to promote the support of the public and national and local leaders for health insurance coverage of FP/RH services, access to these services in rural areas (through primary care family doctors), and continuity of the family planning clinics. As a result, the government approved the following policies: Inclusion of selected FP/RH services in the health insurance basic benefits package (Government Order 312/1999; see also Health Insurance Methodological Norms); MOH state budget funding of FP clinics in 1998 and 1999; and National Health Insurance House (NHIH) designation of “competency” for doctors in FP clinics to enable the NHIH to assume payment of the salaries of family planning staff in 2000. In 1999, as policy and program initiatives focused on improving access to services, the FP/RH community in Romania became concerned about depleting stocks of public sector contraceptives that were purchased under an expiring health loan. In response, POLICY supported policy dialogue and advocacy for government procurement of contraceptives. Becoming more receptive to FP/RH issues, the MOH originally planned to procure contraceptives for all women using contraception. Government-wide budget cutbacks in 2000, however, shrunk allocations for health programs. POLICY-supported advocates and project staff met with the MOH on the need to focus limited government resources for contraceptives to the most vulnerable sectors of the population. A window for advocacy also came about through the Romania Consultative Team for the POLICY-supported Europe and Eurasia Conference on RH financing that was held in Austria in June 2000. The team consisted of senior officials of the Ministry of Health and Family (MOHF), NHIH, Ministry of Finance, Society for Education on Contraception and Sexuality (SECS, the primary family planning NGO), and the Institute of Mother and Child (IOMC, an independent evaluation agency attached to the MOHF), with USAID, UNFPA, and POLICY staff assisting. Team meetings to assess reproductive health finance data to prepare the country assessment for the Austria conference became venues for advocacy on FP/RH issues, including public sector funding of contraceptives. In August 2000, the Prime Minister and the ministers of Finance and Health signed Government Order 730/2000 on Funding for National Health Programs, which specifically highlighted maternal and child health (MCH) protection, through the provision of a line item for contraceptives to be procured and distributed based on the following broad guidelines: Central procurement and distribution of free contraceptives to the disadvantaged (i.e., students, the unemployed, those with low or no income, and those receiving social assistance [Art. 3, 1]); Establishment of revolving funds for local purchase and the sale of contraceptives to nontargeted sectors of the population, with proceeds to build up local revolving funds (Art. 3, 2); and Distribution of public sector contraceptives by family doctors in rural areas without family planning clinics (Art. 3, 3). Because of the August 2000 policies, the Romanian government made contraceptive funding a priority for the first time by specifying a line item for commodities in the state budget. Efforts to improve access by targeting free commodities to the disadvantaged were also groundbreaking, considering common expectations of entitlement. Thus, in a clear departure from the past when there was unclear support for family planning among political leaders, access to contraceptive commodities was becoming recognized as a national policy issue. Policy Stakeholders. Figure 1 shows a graphic representation of individuals and organizations that played key roles in Romania’s recent contraceptive security initiatives. National government institutions included the MOHF, which was headed by Minister Daniela Bartos from 2001 to 2003. In addition, the MOHF had pivotal policy champions for contraceptive security: Dr. Mihai Horga, head of the Directorate for Family and Social Assistance, and Eugenia Erhan, who headed the General Directorate of the Budget. Besides the MOHF, the Commission of Obstetrics-Gynecology (Ob–Gyn) of the College of Physicians and the NHIH are two other national institutions with FP/RH decision-making roles. High-level representatives of the three organizations constitute the Committee on Transparency. Under health reform and social health insurance, this committee reviews health sector policy and funding. Other public sector officials who were also involved in policy dialogue on contraceptive security came from Parliament, the Ministry of Finance, and the IOMC. Figure 1. Stakeholders that Played Key Roles in Romania’s Contraceptive Policy Initiatives from 2001 to 2003 National nongovernmental groups that worked for contraceptive security policy changes were primarily members of the Coalition, composed of mostly Bucharest-based NGOs, such as SECS and Youth for Youth, and women’s groups, such as the National League of Women (NLW). There were also provider associations with interest in contraceptive-related issues: the Ob–Gyn Society, the Association of Family Doctors, and the Family Planning Association (made up primarily of GPs in family planning clinics). At the judet level, key stakeholders in the public sector are district health authorities (DHAs), which are the technical counterparts of the MOHF at the local level (although under decentralization DHAs are part of the district government structure); and district health insurance houses (DHIHs), which are the local branches of the NHIH. Each DHA has technical oversight of providers within the district, including FP clinics and family doctors. Within the nongovernmental sector, local affiliates and members of the Coalition spearheaded the formation of local FP/RH advocacy networks. Some of the most prominent judet NGOs were actually the local affiliates of SECS, the Anti-AIDS Association in Romania (ARAS), Youth for Youth, and the NLW. International organizations also played key roles: UNFPA, USAID/Romania, and the staff of two USAID projects implemented in Romania: the Integrated RH Project 2001–2005 (led by John Snow International, or JSI) and POLICY. Other USAID cooperating agencies (CAs) that should be mentioned are the Centers for Disease Control and Prevention (CDC), the Population Council, and Population Services International (PSI). IV. Policy Implementation Problems and the POLICY Project’s Response Policy Implementation Problems. Upon approval of the August 2000 policies, stakeholders who supported reproductive health initiatives were elated that the government made it a matter of policy to commit state resources to purchase contraceptives and target distribution to the most needy. However, stakeholders, including international organizations and Romanian NGOs, also expressed apprehension about health system capabilities to implement the new initiative. Problems soon emerged as local governments and clinics attempted to put the August 2000 policies into practice. Field reports indicated that certain sectors of the population, specifically rural residents and the poor, were unaware of the availability of free contraceptives. The efficiency of procurement and distribution was also questioned. National and local institutions that were designated to assess contraceptive needs and undertake procurement needed appropriate training and resources; however, the clamor from the family planning clinics for contraceptive supplies pressured authorities to purchase contraceptives as soon as possible. Targeting was another challenge. With entitlements as the norm during the previous socialist system, local government officials, clinic managers, and providers were unfamiliar with the rationale and practice of targeting resources to a specific sector of the population. Lack of data hampered policy implementation. Supplies sent to local clinics did not match local demand. Procurement and distribution took place despite the absence of information about the size and the contraceptive needs and behavior of the most vulnerable groups across and within judets. There was also inadequate information about existing supplies. The MOHF needed to determine the effectiveness and efficiency of its new contraceptive initiative and to undertake necessary changes while it was still early in the process, but it did not have the resources to undertake the assessment. In response, POLICY proposed a package of technical assistance to help the MOHF identify and eliminate barriers to the implementation of the August 2000 policies. The MOHF and USAID immediately approved POLICY’s proposal due to its timeliness. The POLICY strategy involved the following interrelated components: Policy research to identify barriers to the implementation of contraceptive security policies; Policy dialogue to discuss research findings and develop recommendations for policy action; Assistance to the MOHF in policy change initiatives related to contraceptive security; and Network formation and advocacy to promote policies aimed at access to affordable commodities and client-responsive operational policies to ensure contraceptive security. Initial Activities under the POLICY Assistance Package. The POLICY package began with two activities: policy research to identify barriers to the implementation of August 2000 policies and assistance to local NGOs in three judets to form civil society-based networks that would help advocate for FP/RH issues, including contraceptive security. Both activities started immediately because of their time requirements and implications on subsequent activities under the package. Research results would be used in multisectoral dialogue and advocacy to develop recommendations for policy action. The networks would select issues for advocacy from the key barriers and recommendations that were to be identified during the multisectoral consultation. Determining Barriers to Policy Implementation. Three policy studies were conducted to provide answers to the following questions: How were contraceptive budgetary needs determined? Compared with government funds allocated for contraceptive procurement, how much was actually used to procure supplies for free distribution vis-à-vis local sale? Were central and local procurement proceeding efficiently? What were the contraceptive needs and sources across socioeconomic groups of the population? How was targeting actually done in the clinic setting? Who was getting the free commodities? Were the free commodities sufficient to meet the needs of target groups? The first study aimed to provide an overview of the government financing structure and the laws, regulations, and procedures for central and local procurement by government entities, particularly of contraceptives. The study also attempted to put together, for the first time, data from local governments on the actual amounts and value of free contraceptives that judets received from central procurement and from local purchases. The second study, conducted by Romanian counterparts and POLICY staff, used the 1999 RRHS to segment the female population in the childbearing ages according to their socioeconomic characteristics, contraceptive use, and method source. Because this analysis was a critical component of POLICY’s assistance, proposed market segments were discussed with the MOHF and other key stakeholders who provided suggestions that were incorporated into the analysis. The third study, also undertaken by Romanian consultants and POLICY staff, assessed the implementation of the August 2000 policies. Data came from national and local records; interviews with national decision makers, local FP/RH managers, and clinic providers in four judets (Constanta, Iasi, Cluj, and Targu Mures); and exit interviews of clients in the clinics. Local NGO members of the RH Coalition conducted the latter. The assessment focused on the period from August 2000 to July 2001. Mobilizing Stakeholders by Building RH Advocacy Networks. While data gathering proceeded, POLICY also assisted local NGOs and community groups in three USAID-priority judets (Cluj, Constanta, and Iasi) to form RH advocacy networks. Local NGO members of the Coalition brought together interested groups and individuals to present the new contraceptive security policies, the importance of advocacy networks, the network development process, and POLICY’s TA. Through POLICY grants, groups in each judet formed their network as they formulated network-building plans; formed committees to oversee implementation of plans; met regularly to allow members to work together as a team and coalesce; purchased computers, printers, and/or fax machines to improve communication systems; elected judet advocacy coordinators to facilitate network-building, with the coordinators meeting regularly on network development initiatives and progress; developed mission statements, communication trees, organizational structures, and collaboration protocols; developed individual network identities by selecting their individual network’s names and designing corresponding logos and brochures; and elected coordinating councils for internal management decisions. By September 2001, formal RH advocacy networks were established, first in Constanta, then in Iasi and Cluj. Based in the three largest judets in the country, these multisectoral networks drew from various sectors of civil society: NGOs involved in FP/RH/AIDS, women’s groups, youth associations, human rights groups, faith-based organizations, ethnic minority alliances, community organizations, provider associations, and individuals from local government agencies and the media. POLICY supported technical briefings by local experts to strengthen network members’ understanding of technical issues related to FP/RH and contraceptive security. The project also provided advocacy training to help the networks prepare for their advocacy campaigns. Policy Dialogue on Research Results. On October 15–16, 2001, the MOHF and POLICY hosted the Roundtable on Contraceptive Security Policies in Sinaia, Romania. Participants included MOHF officials, members of the Committee of Ob–Gyns of the National College of Physicians, FP coordinators of judet health authorities, representatives of FP clinics and family doctors, coordinators and members of the three judet networks recently formed by POLICY, members of the Coalition, representatives of NGOs from two other judets, a parliamentarian, representatives of pharmaceutical companies, and key staff of USAID and CAs, such as JSI and PSI. During the roundtable, participants used the findings of the three studies to identify barriers to policy implementation and recommended policy actions to reduce barriers to contraceptive security. In summary, the following describes the most salient findings of the three studies. There was higher modern contraceptive use among high-income women, with more than 25 percent obtaining their contraceptives from government clinics. Thus, public funds were disproportionately paying for the supplies of those who could afford to pay. The low-income women, constituting the bottom 40 percent of the income distribution, tended to use traditional methods, had high unmet need, and had a greater number of abortions. Only about 10 percent used modern family planning methods, notably pills. Government resources for contraceptive procurement in 2000 and 2001 were inadequate. In the ideal situation, oral contraceptives procured centrally from August 2000 to July 2001 would have been sufficient for only 15 percent of low-income pill users. Among the target groups, few low-income women in the areas studied received free contraceptives compared with students. Underlying reasons for this imbalance included inadequate resources, differential access to information regarding free contraceptives, and difficulties in obtaining poverty certification. Central and local procurement focused on pills and relatively expensive brands of contraceptives. Even with the limited funds available, purchasing cheaper brands would have significantly increased supplies, and potentially reached more target groups. Rural access to subsidized commodities was practically nonexistent. Subsidized commodities were not provided to family doctors, who as primary-care providers are often the only source of healthcare in rural areas. While roundtable participants proposed many recommendations to remove financial and operational barriers, they gave priority to the following to improve access and equity: Increase resources for contraceptives by including contraceptives in the list of drugs covered by health insurance, and increasing government allocations for contraceptive procurement and ensuring more efficient procurement (e.g., purchasing cheaper brands and expanding the method mix). Concentrate public sector resources on commodities for free distribution. Improve the knowledge of low-income groups of the free contraceptive program and improve access to such commodities by simplifying the process. Self-declaration of poverty status should be permitted. Allow family doctors to distribute free contraceptives (by providing doctors with training on family planning and ensuring their access to supplies). Involve the nongovernmental sector in FP/RH program implementation. NGOs, for example, can help mobilize the support of local leaders and community members for FP/RH, inform low-income women about the availability of free contraceptives and how they can be accessed, and help monitor and evaluate public health programs. V. Contraceptive Security Policy Changes that POLICY Helped Achieve Policy Process. Policymaking in Romania consists of the legislative process, in which constitutional acts, laws, and statutory authorizations—such as annual state budgets—are passed by Parliament; and the regulatory or operational process in which government decisions (hotarare) and orders (ordine) are developed by specific ministries and approved by the executive branch to implement legislative acts and statutes. All approved statutes, laws, decisions, and orders must be published in the Official Gazette (Monitorul Oficial) prior to effective dates. The following processes focus on government orders and regulations related to contraceptive security that occurred in Romania during the period from 2001 to 2003 and the roles played by POLICY and its counterparts. The POLICY assistance package achieved several results; however, this report focuses on the following high-level policy and financing changes and the processes that led to these results: Increased government resources for free contraceptives in 2001 (Government Decision 216/2001) and 2002 (Government Decision 41/2002) Inclusion of generic contraceptive formularies in the list of drugs covered by social health insurance (Government Order 72/44, approved in February 2002) Norms and criteria for public sector funding of NGOs involved in public health programs that include improved access to contraceptives (Government Decision 97, approved in January 2003) Self-certification of poverty status permitted as documentary requirement to access free contraceptives (Government Order 248/149, approved in March 2003) Because the policy process is dynamic and nonlinear, factors that helped bring each result about cannot be presented in strict chronological fashion. Nor can all aspects of the entire policy process be fully documented because not all is known about how individual decision makers regarded specific issues and made final decisions. To the fullest extent possible, the following discussion provides the main pathways to each policy change and identifies the main actors and their roles that resulted in recent policy actions related to contraceptive security. Increased Government Resources for Free Contraceptives in 2001 and 2002 The MOHF increased the financial allocation for contraceptives twice during the entire time that the POLICY assistance package was implemented. The first increase occurred in September 2001 when the MOHF used unspent funds to augment the outlay for free contraceptives for the year. The second involved the 2002 budget cycle. a. Increased Government Resources in 2001 After the government approved the state budget for 2001 (Law 216/2001), the MOHF allocated about 3.4 billion lei for free contraceptive procurement for the year. The MOHF also released local Program 12 funds to all judets, which used a little more than 4 billion lei for local contraceptive procurement by the third quarter of 2001. Excluding management costs, the original allocation for central and local contraceptive procurement for 2001 was 7 billion lei. In September 2001, however, the MOHF added 4 billion lei to Program 12, primarily to procure contraceptives for free distribution. Augmentations were taken from MOHF savings and unspent central funds for national health programs. MOHF sources cited POLICY assistance as contributing to its decision to increase the budget for contraceptives from the original allocation of 7 billion lei (equivalent to $240,000) to 11 billion lei (equivalent to more than $370,000) in 2001. Although the core package was still in its first months of operation, POLICY helped this result occur by (1) providing the MOHF access to initial research findings and soliciting inputs in ongoing policy studies, and (2) assisting networks in advocating to local decision makers who then put pressure on the MOHF. MOHF Use of Initial POLICY Findings. Even as the POLICY assistance package began, MOHF decision makers expressed great interest in how the August 2000 policies were being implemented. Between March and September 2001, local and U.S.-based POLICY staff met several times with Dr. Mihai Horga, director of the MOHF Directorate for Family and Social Assistance, to discuss findings from the clinic and client interviews and the draft results of the contraceptive market segmentation analysis. Initial findings showed limited supplies of free commodities in the clinics that were visited, including those in urban areas. Early clinic visits also indicated that poor people had little access to free supplies. POLICY also reported to the MOHF on related policy and financing concerns that emerged from meetings with USAID, JSI, SECS, UNFPA, and NGOs of the Coalition. As former head of a research organization, Horga expressed appreciation for POLICY’s efforts to identify problems and barriers in implementing the new government initiatives, most of which were policies developed with his leadership. Meetings with Horga also helped POLICY determine additional data needs in the ongoing policy studies. POLICY staff also met with Eugenia Erhan, director of the Department of Budget and Finance, to discuss draft market segments and existing policies affecting the public sector and health insurance financing in the context of decentralization. Alin Stanescu (POLICY long-term advisor) met several times with Erhan to discuss basic FP/RH issues and recount field visits that revealed limited supplies of free contraceptives—even in urban areas and family planning centers—and local providers’ concerns about the potential impact of limited contraceptives on abortion rates and maternal health. Erhan then received requests for additional contraceptive supplies from district health authorities and family planning clinics that POLICY visited. As Erhan stated after the October 2001 roundtable during an MOHF–POLICY meeting: In 2001, the MOHF increased the budget for contraceptives because of POLICY advocacy, information, and discussion regarding the importance of contraception. Networks Immediately Started to Promote Local Support for Contraceptive Security Issues. In the course of network building between May and September 2001, NGO members contacted various groups and individuals, including officials from local governments and health departments, to join their networks or attend network activities. Besides organizing small events and meetings to which government officials were invited, network members also attended events sponsored by local government or community leaders. These events provided opportunities for network members to speak out about the importance of access to FP/RH services and contraceptives for the most disadvantaged. Central officials of the MOHF reported that many judet authorities, including those approached by NGO members, did contact the MOHF to request additional supplies of free contraceptives. These requests put pressure on central authorities to increase the 2001 allocation for free commodities. Thus, by September 2001, when the MOHF was deciding where to allocate unspent central funds, the ministry gave priority to more successful programs such as family planning because of high demand among the population. b. Increased Government Resources in 2002 The Government Decision on Program Funds of the Ministry of Health and Family and Social Health Insurance (Law 2002, Official Gazette No. 66/30, January 2002) approved an MOHF budget line item for central procurement of contraceptives for free distribution to specified vulnerable sectors of the population. As specified in this 2002 law, these sectors are the unemployed, students, individuals in families that receive social assistance, individuals who have no income, women with permanent residence in rural areas, and women who undergo elective abortions in a public health unit (Article 6). The MOHF then allocated 10 billion lei for 2002 (equivalent to $333,000) for free contraceptives. By the fourth quarter of 2002, however, the total MOHF outlay for free contraceptives reached 14 billion lei. While earlier allocations were intended for judets across country, the 2002 outlay for contraceptives was to be primarily provided to 23 judets. Based on agreements with the MOHF, UNFPA- and USAID-donated contraceptives would be provided free to targeted populations in the 18 priority or partner judets of the two donors. In turn, the MOHF would fund and procure contraceptives for target sectors of the population in the remaining 23 of the 41 judets in the country, plus Bucharest. UNFPA, USAID, and JSI played key roles in facilitating the donations. POLICY contributed to increased resources for public sector contraceptives in 2002 in two ways: use of POLICY-generated data and advocacy by networks and champions assisted by POLICY. Use of POLICY-Generated Data by MOHF Decision Makers and Partners. Horga attributed the MOHF decision to increase resources for contraceptives in 2002 to various FP/RH actors and their use of data from the POLICY-supported studies: It was all teamwork. On one hand, the MOHF needed to set up the family planning system with the assistance of USAID. Through JSI, family doctors are being trained by the Center for Post-graduate Training. Training on the MIS forms was provided to ensure a working system for monitoring and evaluation. The Director of Public Health and the Center for Health Promotion coordinated the IEC campaign for free contraceptives. The MOHF used POLICY’s research papers and worked with JSI in estimating the number of contraceptives needed. (Interview with Horga, October 2002) POLICY data led to informed contraceptive security discussions among the major stakeholders, which ultimately led to informed decisions. The key role of the data was pointed out by UNFPA National Program Officer Doina Bologa (former head of the old MOH’s Family Planning and Sex Education Unit, which has since been renamed the Directorate for Family and Social Assistance under Horga). Bologa could not attend the roundtable held in October 2001, but learned of the results of the three POLICY-supported studies from Horga. During a POLICY–UNFPA meeting following the roundtable, Bologa summed up POLICY’s role: While various organizations and individuals reported problems in the implementation of the new (August 2000) policies, it was through POLICY that data on implementation was gathered, analyzed, and presented in an organized manner, thus providing the government and donors with important information for policy and strategy decisions. Data from the market segmentation study (Sharma et al., 2002) and the policy implementation assessment (Dayaratna et al., 2001) were used by the IEC Working Group of the RH Committee composed of the MOHF, JSI, donors led by USAID and UNFPA, other USAID CAs, NGO representatives of SECS, Youth for Youth, and the Romania Association Against AIDS (ARAS). The JSI memorandum written by Irina Dinca (JSI IEC coordinator) to organize the IEC campaign with the MOHF cited statistics from the two studies. Also, USAID/Romania’s Senior Reproductive Health Advisor Susan Monaghan used the report on public sector financing (Erhan, 2001) in a USAID document on health sector reform (relayed by Monaghan during a February 2002 telephone conference with the author). MOHF key informants also informed POLICY that data from the three POLICY studies were used to refocus central procurement on cheaper brands and other contraceptive methods other than pills. Moreover, as Horga previously outlined, the MOHF used findings from the POLICY studies and JSI estimates of contraceptive logistics requirements in planning and budgeting for procurement of public sector commodities. These estimates were in turn used as a rationale for USAID’s commodity assistance to Romania (approximately $1 million) to augment donations from the UNFPA global contraceptive procurement program. Finally, the findings of the POLICY studies and recommendations from the roundtable, particularly those intended to make procurement more efficient, were used by the MOHF—along with key partners such as JSI, SECS, USAID, and UNFPA—in developing the National Reproductive Health Program Strategy, with contraceptive distribution as a major component. Policy Champions and Networks Advocated to Key MOHF Decision Makers. USAID’s Monaghan cited the roles of local and international organizations and individuals who advocated for government funding of contraceptives, but singled out Horga as the critical policy champion. As Monaghan emphasized: Horga was the pivotal catalyst who personally advocated to the Minister (Dr. Daniela Bartos) to increase resources for contraceptives in the MOHF budget. Then the Minister made it happen. (Interview with Monaghan, October 2002) Policy champions other than Horga helped facilitate MOHF decision making to elicit increased government funding for contraceptives in 2002. Erhan, MOHF director of the Department of Budget and Finance, also reported to the MOHF minister and other ministry leaders about requests from judets for additional free contraceptive supplies. POLICY advisor Stanescu also used his various meetings with the MOHF as opportunities to talk to government decision makers about the importance of ensuring funding for contraceptives in 2002. Two leaders of NGOs with judet affiliates also advocated to the MOHF to increase government resources for contraceptives: Borbola Koo (SECS executive director) and Smeranda Ionescu (president of the NLW). Both organizations have been active members of the Coalition since 1996. Koo cited POLICY’s contribution to the 2002 MOHF decision to increase funds for contraceptives through the project’s assistance to champions and NGOs: POLICY played a very important role…by exposing important decision makers to a new way of thinking, for program management to be committed to RH, not just to publicly state but also to take the practical step, like to make the budget allocation…POLICY also prepared NGOs, made NGOs realize that they are playing a very important role. While SECS is now becoming a professional organization, it is important to keep grassroots NGOs involved, to consult with NGOs, and to keep the relationship. (Interview with Koo, October 2002) Ionescu supported increased MOHF funding for contraceptives by being involved in local as well as national advocacy. Ionesco actively supported the advocacy efforts of the Constanta network because the head of the NLW Constanta Chapter, Maria Frangetti, was elected advocacy coordinator of the judet’s advocacy network in 2001. Ionescu attended the February 2002 advocacy workshop that POLICY staff facilitated to help the Constanta network develop a strategy to advocate for contraceptive security and related RH concerns. Recently reelected to Parliament, Ionescu advocated to fellow parliamentarian, MOHF Minister Bartos, about government funding for contraceptives. Ionescu also reported speaking to the following parliamentarians about the need to increase state funding for contraceptives to be targeted to the most vulnerable sectors of the population: Senator Liviu Mayor (member of the Commission for Equal Opportunities and head of the Commission for European Affairs Integration of which Ionescu is Deputy), Florin Georgescu (head of the Budget Commission), and Deputy Constanta Popa (member of the Health Commission, and a former member of the Coalition). These various advocacy efforts helped broaden political support for government funding of contraceptives. Inclusion of Generic Contraceptive Formularies in the List of Drugs Covered by Health Insurance In early 2002, the MOHF and NHIH approved the list of drugs that would be compensated by health insurance, including two generic formularies of contraceptives (Government Order 72/44, Official Gazette, No. 126/18, February 2002). These generic formularies—ethinylestradiolum, progesteronum, and estrogen—are used for oral pills and injectables. Based on provisions of the health insurance law, the health insurance fund would reimburse pharmacists 65 percent of duly listed prescriptions issued by medical providers of the health insurance system. While Romania’s social health insurance system aims for universal coverage, the system is primarily employer/employee funded, and the direct beneficiaries of such coverage are wage earners and their dependents. While the increase in state funding for contraceptives was described as the outcome of various organizations working together, Monaghan attributed health insurance coverage of contraceptives primarily to Horga. Horga singled out POLICY’s role before and during the TA package: POLICY…helped us argue for generic contraceptive formularies to be included in the list of drugs compensated by 65 percent under the health insurance fund. (Communication from Horga to Harry Cross, Director, POLICY Project, January 2003) Earlier Groundwork by POLICY. POLICY explored health insurance funding for contraceptives as early as 1999 during meetings of the MOH’s Policy Barriers Working Group, chaired by Alin Stanescu, both IOMC deputy director and a POLICY long-term advisor. The Policy Barriers Working Group was part of an informal RH committee that Bologa created while still head of the FP/MCH office of the MOH. The committee was composed of representatives of local and international organizations working with the national FP/RH health program. After stakeholders warned of a looming crisis regarding contraceptive supplies in the public sector, Stanescu invited representatives of the NHIH and the College of Physicians to attend the working group’s meetings to discuss various options, including NHIH funding for commodities. One mechanism that was explored was the idea of listing contraceptives among the drugs compensated by health insurance; another idea was for NHIH to provide a sizable advance to the MOHF or local health authorities to procure contraceptives. At that time, representatives of the NHIH and College of Physicians advised the working group to more fully explore state funding given the rapidly diminishing stocks of contraceptive supplies. State funding was also viewed as more feasible because of various policy and operational barriers to health insurance funding for contraceptive supplies. NHIH decision makers would more likely consider family planning a preventive intervention, and thus a responsibility of the health ministry as prescribed in the health insurance law. It was suggested that the viability of the health insurance drug fund should be assessed first, considering numerous other drugs proposed for health insurance funding. It was also argued that the use of prescribed contraceptives could not be easily determined, making verification difficult. Overall, it was deemed premature to include contraceptives in the compensated drug list in 1999. POLICY, however, kept the issue alive through policy research and dialogue while supporting policy champions in advocating for state budget funding for contraceptives. The project commissioned a paper exploring the potential of funding family planning through health insurance (see Lazarescu, 2002). The issue was also raised during preparatory meetings of the Romania Consultative Team at the Europe/Eurasia Conference on RH financing. The report of the consultative team, presented in June 2000 in Austria (Marinescu and Cakir, 2000), showed that in 1998, public subsidies exceeded private funding in the reproductive health sector, except for family planning, where the reverse was true. The discrepancy in family planning was due to the high prices people paid for contraceptives. Changing Sociopolitical Context. Changes in political leadership in late 2000 and early 2001 helped the MOH place the issue of health insurance funding for contraceptives on the formal agenda of NHIH decision makers. Dr. Bartos was appointed Minister of Health by a broad coalition government, thereby promising the ministry more political support and stability after years of frequent leadership changes. A known reproductive health supporter, Bartos was also a member of the Coalition, and a frequent participant of POLICY-supported forums and technical updates. The MOH underwent reorganization and was renamed the MOHF. The former Family Planning and Sex Education Unit was vested with greater authority and broader responsibilities and renamed the Directorate for Family and Social Assistance, headed by Dr. Horga. Years of economic stagnation, resulting high poverty, and negative impacts on the family were among the reasons cited in renaming the health ministry, which was in the midst of implementing health reform. Overall, Romania’s FP/RH policymakers and institutions were changing as the broader sociopolitical context shifted. These changes helped bring to the fore the issue of health insurance coverage for contraceptives. POLICY helped bring attention to this issue through policy research, dialogue, and advocacy. Use of Policy Analysis in Issue Identification and Agenda Setting. In July 2001, as the MOHF prepared its recommendations of which drugs should be covered by health insurance, Dr. Horga met with Minister Bartos about adding contraceptives to the list because of increased demand and the potential savings by preventing abortions or related complications, which rank among the main reasons for hospital admissions. Encouraged by the minister’s support, Horga requested POLICY assistance in preparing the cost justification of the proposal. Horga and POLICY staff, led by Stanescu, used initial results of POLICY studies—particularly information on the size and contraceptive behavior of specific market segments, the market prices of specific contraceptives procured locally by judet health authorities, and corresponding retail prices in commercial pharmacies—to estimate the cost to the health insurance system of including one or two low-priced brands of commonly used contraceptive methods. Dr. Horga immediately incorporated the estimates into a memorandum for Minister Bartos. After internal discussion within the MOHF, Minister Bartos signed and forwarded the memorandum to the Committee on Transparency. Composed of MOHF board members, senior officials of NHIH, and the College of Physicians (see Figure 1), this committee reviews all proposals for health insurance funding, which become government orders if approved. Policy Dialogue among Decision Makers. Months passed without any final decision on the compensated list. Health insurance funding of contraceptives was again proposed during the MOHF–POLICY October 2001 Contraceptive Security Roundtable, as part of a set of recommendations advanced by participants who expressed concern about limited public sector supplies, and subsidies benefiting primarily those who can afford to pay. In response, Dr. Horga publicly informed roundtable participants that his office was already working with POLICY on health insurance coverage and that the MOHF had already proposed the inclusion of contraceptives in the compensated drug list, which, if approved, would make generic contraceptives available to all who are insured. Horga also assured everyone that roundtable recommendations would be forwarded to MOHF and NHIH decision makers. Advocacy by Champions and Networks. Because of lobbying by numerous individuals and groups favoring various other drugs, the contents of the proposed health insurance compensated drug list changed often. There were, however, individuals within the health sector itself who were championing the inclusion of contraceptives in the much-coveted list. Toward the end of 2001, Horga reviewed the latest version of the drug list and noted that contraceptives were no longer included. Once informed about this development, the minister spoke with NHIH decision makers about putting contraceptives back on the list. As Dr. Horga summed up: POLICY technical assistance through the Core Package on contraceptive security…helped us argue for generic contraceptive formularies to be included in the list of drugs compensated by 65 percent under the health insurance fund. (Horga’s communication to Harry Cross, Director, POLICY Project, December 2002) Other MOHF officials, such as Erhan, also supported the minister’s advocacy efforts. During joint meetings of the MOHF and the NHIH concerning budget plans of both agencies, Erhan discussed with the NHIH Deputy Director of the Budget the need to improve access to contraceptives through inclusion on the list of compensated drugs. There was also constant advocacy from the nongovernmental sector. Representatives of the three judet networks and POLICY staff regularly contacted Horga for follow-up on progress regarding health insurance coverage of contraceptives. Led by advocacy coordinators, the Constanta and Iasi networks also met with local government officials, other NGOs, community leaders, and community groups to mobilize popular support for increased access to FP/RH services and commodities through health insurance and the state budget. The networks also used various opportunities to advocate to judet insurance houses for coverage of contraceptives under the drug fund. The advocacy coordinator of the Cluj Network, Lia Rugan, who hosts a national television talk show on social issues, reported that one session of her talk show focused on the need for government-subsidized contraceptives, including coverage through health insurance. Government Norms and Criteria for Public Sector Funding of NGOs Involved in Public Health Programs, Including the Contraceptive Program In February 2003, the government approved norms and criteria for NGOs to receive government funds to implement national public health initiatives. Government funding of NGOs involved in public sector development initiatives was earlier approved in Government Order 54/2000; however, no operational policies were issued, and the policy was never implemented. This is a common problem (see Cross et al., 2001). It was only during the MOHF–POLICY roundtable of October 2001 that representatives of the RH Coalition and three judet networks were informed about Government Order 54/2000. The order was discussed after concerns were raised about the need to mobilize communities to help inform the poor about the free contraceptive program and their right to have access to such resources. There was also a need to advocate to local leaders and providers for access to FP/RH services and commodities. Network representatives expressed interest in working with the government on these initiatives, especially given the existence of local affiliates in communities all over Romania. POLICY technical assistance that led to this result was primarily directed to the judet networks. Project support included capacity building on contraceptive security and advocacy, and small grants for advocacy and policy dialogue. Network Capacity Building and Use of Data. After the roundtable, POLICY assistance to the networks included meetings with Romanian experts involved in the project’s three policy studies. These meetings aimed to enhance network members’ understanding of various issues related to the government financing system, contraceptive security, market segmentation, and targeting. The experts also updated network members on related or proposed policy actions following the roundtable. POLICY also supported workshops to help the networks identify issues for advocacy and correspondingly develop strategies for each network’s advocacy campaign. During the advocacy workshop that was facilitated by POLICY in February 2002, network members selected their advocacy issue as the development of an operational policy to implement MOH Order 54/2000. At the networks’ request, Erhan attended a network meeting to explain MOH Order 54/2000. Although the policy existed, the order could not be put into practice because implemen-tation guidelines had not been developed, particularly the criteria to select NGOs and release funds. The judet networks agreed to work together to draft a set of criteria for the MOHF’s approval. On behalf of the entire advocacy network in each of the three judets, an NGO member obtained a small grant from POLICY to fund each network’s advocacy campaign. The Constanta Network immediately hosted a workshop in May 2002 for representatives of the three networks to draft their proposed criteria for MOH Order 54/2000. To prepare for this meeting, network members made inquiries to government agencies on existing mechanisms for funding NGOs to serve as examples during the workshop. Copies of policies and documents from other ministries were also obtained by the NGOs for reference in drafting their proposals. Subsequent meetings involved advocacy coordinators organizing internal network meetings within each judet to discuss proposed norms and criteria. The Iasi and Cluj networks also hosted meetings in their respective judets to allow representatives of the three networks to work together to review existing norms and criteria for NGO involvement in nonhealth development programs of the public sector. As a result of these meetings, the three networks drafted a set of criteria for NGOs eligible for MOHF funding, along with norms for applications, review, fund releases, and implementation. Preparations took several months. Once the networks were ready, the advocacy coordinators contacted Horga for a meeting on the networks’ proposal. Judet Networks Advocated to the MOHF. On July 1, 2002, network representatives traveled to Bucharest to meet with Horga to present the networks’ consolidated proposal. The networks’ presentation demonstrated their diligence. Networks had prepared the following items: (1) criteria to determine NGO eligibility to apply for MOHF funding; (2) norms for applications, reviews, fund releases, and implementation, along with an application format and assessment checklist; (3) expected results and a plan for continuing activities beyond MOHF funding; and (4) a draft public-private partnership agreement. During the meeting, network representatives cited findings from POLICY research that indicated that many poor clients did not know of or were not informed about the new program in which they could access free contraceptives. The network representatives also highlighted members’ capabilities, geographic reach, commitment to FP/RH, and their goal to help build healthy communities. The meeting ended with Horga and the networks agreeing to work together to gain approval for implementation of MOH Order 54/2000. During other meetings and workshops in which national government officials participated (for example, MOH-sponsored meetings and USAID- or JSI-funded workshops), network members reiterated their strong interest in helping the government implement public health initiatives. Using data to emphasize FP/RH problems (including data generated by POLICY), network members again cited their existing community work and potential for informing poor women about new FP/RH initiatives. The networks showed how they could address area-specific concerns, such as adolescent health, STIs/HIV/AIDS, or violence against women. Active network members and their proposals made national and local officials recall the extremely successful POLICY-supported women’s health events in various judets and Bucharest that were organized by the Coalition in 1998, 1999, and 2000. These events included youth discos to promote sexual responsibility, women’s health fairs and forums in cities, and caravans sent to rural areas to solicit the support of community leaders and the public for national government approval of policy recommendations, such as health insurance coverage of and increased government allocations for FP/RH services. To broaden support for their proposal, the networks also organized small advocacy events in their respective localities. Judet government officials, health providers, civil society groups who were not members of the network, and other community groups were invited to town meetings where they were briefed on the RH networks’ advocacy goals and objectives, their current focus on contraceptive security, MOH Order 54/2000, and the proposed norms and criteria submitted to the MOHF for NGO involvement in FP/RH programs of the government. The networks also provided examples of the types of assistance they could provide and encouraged other NGOs to identify some activities they could undertake in partnership with the government. Policy Dialogue between the MOHF and Networks. One major concern expressed during the October 2001 roundtable involved the need to mobilize rural and low-income communities to help inform the poor about the existence of free contraceptives and to advocate to local leaders and providers for access to FP/RH services and commodities. Network representatives expressed keen interest in working with the government for these initiatives, especially given the existence of local affiliates in communities all over Romania. After the July 1, 2002, meeting, Horga invited a representative of the networks to work with the government team to finalize the criteria for Order 54/2000 and draft a government decision approving public sector funding of NGOs to promote public health concerns and for public–private partnerships in public health activities. MOHF leaders reacted positively to the networks’ proposed norms and criteria because they illustrated the networks’ initiative and capabilities. The networks were surprised because Horga proposed that 10 percent of the MOHF budget for family and social assistance programs be allocated to fund public partnerships with NGOs. Afterward, Horga invited network representatives at the MOHF to present their proposal to MOHF decision makers. Network members reported to POLICY that Horga himself helped network representatives explain their proposed norms and criteria to the senior MOHF officials who attended the meeting. The draft order was approved internally by the MOHF, then endorsed by NHIH, the Ministry for European Integration, and other ministries that have their own health insurance schemes (e.g., the Ministry of Transportation, Ministry of Public Works, and local public administra-tions). This process is required in the health sector before any policy can be officially approved for implementation. Network members who monitored the process reported receiving positive comments about the proposal from health sector leaders because of the public–private partnerships it fostered. Self-Certification of Poverty as Documentary Requirement to Access Free Contraceptives Government Order No. 248, approved March 24, 2003 (published in Official Gazette on April 9, 2003), provided guidelines on the funding, control, and reporting of health subprograms financed by the MOHF and social health insurance budget (MOHF and NHIH Presidential Order No. 85/65/2002). The operational policy included the following provision: Contraceptives procured through bidding at the national level from Family and Child Health Program funds are distributed without payment, in the prefigured conditions of Art. 6, paragraph (1) of Government Decision No. 41/2002. The documents required as proof of eligibility for free contraceptives are student and unemployment cards, certification from the local council, and also declarations on [one’s] own responsibility, according to the case (Annex, 7). POLICY helped achieve the aforementioned government action through project-supported research, capacity building (to help networks and champions more fully understand the key issues), policy dialogue, and advocacy. Research on the Poverty Certification Process. According to existing financial accountability guidelines, a client must provide officially recognized documentation proving eligibility before receiving government-subsidized services or supplies. In 2000 and 2001, eligible categories included students, the unemployed, people with low or no income, and families receiving social protection allowances. The POLICY study on the implementation of the August 2000 policies reported that service providers were likely to provide free contraceptives to students with valid school or university identification cards. In contrast, clients claiming eligibility, but bearing no proof of poverty status, could not be given free contraceptives. Policy research raised basic issues related to contraceptive security: market segmentation, targeting, and equity. It was clear during the roundtable, however, that network members and champions needed to delve into the results of the studies more extensively. POLICY-supported technical meetings allowed Romanian experts and network members to discuss research results and data on key issues. In addition, POLICY staff traveled with network members to visit clinics in peripheral areas of the Constanta judet to learn more about the service delivery setting. In these areas, female clients who used contraceptives were asked about their sources and the costs of contraceptive supplies. Network members learned that many of the clients were poor; however, they often had to go to local pharmacies and pay two or three times the cost of popular contraceptives. Limited access to free contraceptives struck a chord among network members, considering their long espousal of access to FP/RH. After the October 2001 roundtable, POLICY and Frontiers (Population Council) staff discussed the possibility of conducting a pilot study to identify and eliminate operational barriers to effective targeting in Romania. As a preliminary step to assess if the research was warranted, advocacy coordinators of the various networks were asked to gather information on the certification process in early 2002. Network volunteers went to the offices of mayors in urban and rural areas to inquire about obtaining certification for free contraceptives. Volunteers reported that obtaining poverty certification was tedious and unclear. In one area, a network informant spent hours in line—first to be appraised by an office assistant before lining up again at the mayor’s office to submit the request for certification. Income tax declarations, employment certifications, or asset statements were requested. Some network members said that they would have to get these papers from their homes or apply to appropriate authorities to obtain these documents. In addition, those in rural areas needed to submit certification about land ownership and whether the land was unused or unproductive. In addition, a local government worker would have to visit the claimant’s home or land to determine whether the certification was warranted. Documents used for government purposes also needed to be notarized—another lengthy step—before a mayor’s signature could be provided. Volunteers also reported that additional requirements were requested in some clinics, such as signatures of village council members. It was also reported that local officials often explained that while they had heard about the health program regarding free contraceptives, they were waiting for guidelines on how they could issue the certification. Overall, certifications bearing the signature of the mayor and the stamp of the local government were difficult to obtain. Network members realized that the process of obtaining poverty certification was onerous and time-consuming. POLICY sent the consolidated field report of network members to Dr. Horga for reference. Advocacy and Policy Dialogue to Simplify Poverty Certification. The question of who should receive free contraceptives was one of the most widely discussed topics during the October 2001 roundtable. While there was general agreement that the poor should be given high priority, a few participants argued that universal access and equality should be the goal of the contraceptive security initiative. Thus, it was determined that free contraceptives should be given to all women who want to practice family planning, with no one being discriminated against, including wealthy women. Even more controversial was whether free contraceptives should be made available to students, regardless of family income, or whether the poor should be accorded the highest priority. Some stakeholders argued that students are highly vulnerable segments of the population because they experience the most abortions and do not have jobs. Thus, students and the poor should be given equal priority. However, data from reproductive health surveys and health information systems show that women ages 20–34 or those who have many children were more likely to have abortions. While underreporting of abortion exists and is posited to be more likely among students, it was also argued that because abortion is already legal and covered by social health insurance, which mandates coverage of all students, underreporting may not be as high as suspected. In several forums, SECS Executive Director Koo also raised the point that in many urban areas, students whose families could afford cars were driving to family planning clinics to pick up free contraceptive supplies. As a result, the supply of free commodities often ran out, leaving little or nothing for the more deserving poor. The concern was also valid because SECS, the leading family planning service delivery NGO in the country, has been trying to carve out a niche for its clinics in selected urban areas. Students have been a major clientele of SECS, the Romanian IPPF affiliate, which provides family planning services, including the sale of low-priced contraceptives procured by IPPF. Thus, the availability of free commodities in government-subsidized clinics could crowd out the fledgling NGO sector. POLICY often pointed out how the contraceptive market is segmented, and that given limited resources, the government must respond to the needs of the poor and simultaneously stimulate private sector participation and expansion. Over time, reproductive health policy champions and network members became more supportive of the proposal to revise the documentary requirement for the poor to access free contraceptives. Another boost occurred when Erhan stressed in forums with the networks and in meetings with MOHF managers that self-declaration of economic status is permitted by law. As Erhan explained during POLICY-supported forums, documentation is required for auditing purposes to prove that a government-funded service was indeed received by a deserving individual. Certification can be a simple document that a woman signs, containing a pledge stating that she certifies that she is poor and does not have the funds to buy contraceptives. Simplifying the process improves access to subsidized commodities among the most vulnerable sectors of society. Considering the enthusiasm with which key stakeholders advocated for self-certification, Horga promised to study the proposal. For months, as more data on limited access among the poor emerged, and as more advocacy efforts took place, Horga himself advocated to other MOHF officials to support self-certification. He also met with the Ministry of Finance on the proposal. Eventually, Horga garnered the support of both the MOHF and the Ministry of Finance. Government Order No. 248 approved self-certification of poverty status as valid documentary proof of eligibility. To operationalize the order, the MOHF issued an accompanying document entitled “Technical Norms of the MOHF’s National Program for Child and Family Health” (February 2003) to stress that self-declaration suffices and does not need to be notarized. VI. Summary The Romanian experience shows that the process of policy reform on contraceptive security is not contained in one neat, complete box. Certain policy actions were made soon after the problem was identified, while other policy modifications required more time and advocacy. However, the four key policy and financing changes detailed previously in this report occurred within a period of 19 months (September 2001 to March 2003). In sum, the Romanian experience highlights the important roles that champions and networks played in promoting the issue of contraceptive security and influencing the policy process. The foregoing also shows that these key stakeholders became empowered as the sociopolitical context changed, as policymakers who were committed to FP/RH issues opened the policymaking process. Certain aspects of technical assistance from POLICY proved important in influencing the contraceptive security policy reform process in Romania: policy research, capacity building, and multisectoral advocacy and policy dialogue. Policy research and stakeholder mobilization served as the primary starting points to further advocacy and policy dialogue. POLICY-generated data enlightened champions to develop what Porter (1995) called “scientifically defensible” arguments. Policy learning among nontraditional policy stakeholders is also important (Sabatier and Jenkins-Smith, 1993). NGO-led networks also needed to learn more about contraceptive security issues, related policies, and policymaking. Policy analysis is not merely a problem-solving function; it is “a tool of the democratic process” (Shulock, 1999), as it contributes to citizens’ understanding of issues and the policy process. NGO-led multisectoral networks certainly provided the heart and passion for FP/RH issues, including contraceptive security. Networks also expanded to include more groups, and thus helped build wider ownership for issues related to contraceptive security and consensus toward difficult and challenging policy actions such as giving the most vulnerable segments of society priority access to contraceptive subsidies. NGO networks often made the early push in Romania; however, once dynamic policy champions from the public sector became convinced of the importance of an issue, such champions provided the necessary commitment to see the process through the final hurdle in official decision making. The four policy results occurred somewhat sequentially, probably because earlier successes became building blocks for subsequent, related policy changes. Several key actors were involved in achieving all four results. Successive results certainly became more achievable as policy champions and networks made the issue of limited contraceptive financing and access more prominent and understandable to decision makers and other stakeholders. Public sector policy champions grew to appreciate the role played by NGOs in providing champions with the constituency and backing needed to espouse issues of national significance. It is hoped that continuing dialogue between public and private sector entities on the issue of contraceptive security will contribute to improved policies and implementation in the coming years. VII. POLICY’s Impact and Future Perspectives POLICY helped change the policy environment for contraceptive security in Romania through the approval of four groundbreaking policies, including those aimed at increasing government resources for contraceptives and focusing subsidized commodities on the most vulnerable sectors of the population. As Horga wrote in January 2003: POLICY assisted the Ministry in…the decision to fund and target free contraceptives to disadvantaged groups and helped us allocate additional funds for contraceptives in 2001 and 2002…POLICY technical assistance also helped us argue for generic contraceptive formularies to be included in the list of drugs compensated under the health insurance fund. (Communication sent to Harry Cross, Director, POLICY Project, February 2003) USAID’s Monaghan asserted that the main contribution of the POLICY assistance package in Romania was in helping people understand certain concepts, particularly “targeting” and market systems: In time [as the donated contraceptives run out], Romanians will have to think of targeting. Continuity will have to be faced; targeting will have to be done. [Right now] Romanians are still concerned about entitlement and universal access to contraceptives, but eventually will have to face living with targeting. (Communication sent to Harry Cross, February 2003) POLICY assistance in Romania ended in late 2002. But did the POLICY assistance package really make a difference in people’s lives? Has policy change improved access to contraceptives? Are the supplies of public sector-funded contraceptives reaching more clinics and people? Has the health insurance system reimbursed pharmacies for dispensing pills and injectables duly prescribed by health insurance providers? These questions can be partly answered by members of NGO networks, who at POLICY’s request visited family planning clinics, family doctors, and pharmacies in various urban and rural areas in and around their judets in December 2002. Network members reported that free contraceptives were available; and in some areas method choices other than pills were offered. Some pharmacies also filled prescriptions for contraceptive supplies and have been reimbursed by health insurance; however, pharmacists are wary of long delays in drug reimbursements made by the health insurance system. Romania still faces several policy and implementation challenges. The government must ensure resources for contraceptives each year into the future. When USAID- and UNFPA-donated commodities in late 2001 increased, the government added two more priority groups for free contraceptives in 2002: women residing in rural areas and those who have had an abortion in a public health unit (Government Decision 41, Art. 6, January 17, 2002). However, USAID has phased out contraceptive donations in countries with even more difficult economic circumstances than Romania. The availability of donations in the interim buys Romania time to develop a long-term contraceptive security plan and to prepare for donor phase-out. In the long run, limited government resources and the potential of the nongovernmental sector must be recognized, and the government has to reassess the large number of target groups to determine which groups are most in need—which requires hard choices. The Romanian experience provides lessons and models that can be considered in future policy initiatives in the country and in other social contexts as well, particularly in entitlement-oriented socioeconomic settings. Notes References Altman, J.A. and E. Petkus. 1994. “Toward a Stakeholder-based Policy Process: An Application of the Social Marketing Perspective to Environmental Policy Development.” Policy Sciences 27: 37–51. Brinkerhoff, D. and B. Crosby. 2002. Managing Policy Reform: Concepts and Tools for Decision-Makers in Developing and Transitioning Countries. Bloomfield, CT: Kumarian Press. Bryson, J. and B. Crosby. 1992. Leadership for the Common Good: Tackling Public Problems in a Shared-Power World. San Francisco: Jossey-Bass Publishers. Caplan, N. et al. 1975. The Uses of Social Science Knowledge in Policy Decisions at the National Level. Ann Arbor: Institute for Social Research. Centers for Disease Control and Prevention (CDC), Romanian Association of Public Health and Health Management, and National Commission of Statistics. 2001. Romania Reproductive Health Survey: 1999. Bucharest: Institute of Mother and Child Care. Cross, H. 2000. Presentation at POLICY Project Technical Development Week. Washington, DC: Futures Group, POLICY Project. Cross, H., K. Hardee, and N. Jewell. 2001. “Reforming Operational Policies: A Pathway to Improving Reproductive Health Programs.” POLICY Occasional Paper, No. 7. Washington, DC: Futures Group, POLICY Project. Dayaratna, V., I. Zosa-Feranil, A. Stanescu, L. Marcu, and C. Butu. (revised) 2002. “Barriers to Implementing Contraceptive Security Policies in Romania.” Prepared for the October 2001 Roundtable on Contraceptive Security in Romania. Bucharest: Ministry of Health and POLICY Project. Erhan, E. 2001. “Public Sector Funding of Contraceptives in Romania.” Prepared for the 2001 Roundtable on Contraceptive Security in Romania. Bucharest: Ministry of Health and POLICY Project. Ghetau, V. 1997. “Maternal Mortality and Abortion in Romania: 1989–1996.” Unpublished commissioned paper. Bucharest: UNFPA/Romania. Government of Romania, National Health Insurance House. Order 143/13 and College of Physicians Order 792/13. 1999. “Methodological Norms to Apply the Health Insurance Framework Contract for 1999.” Official Monitor, September 7, 1999. Government of Romania. 2000. “Order for the Approved Structure, Indicators and Funds Referring to Financing of National Public Health Programs for 2000” (Order No. 730 issued August 2000). Official Monitor I: 422. Hardee, K., I. Zosa-Feranil, J. Boezwinkle, B. Clark, and A. Eckman. Forthcoming 2004. The Policy Circle. Working Paper Series, No. 11. Washington, DC: Futures Group, POLICY Project. Hill, K., C. Abou Zahr, and T. Wardlaw. 2001. Estimates of Maternal Mortality for 1995. Bulletin of the World Health Organization 79 (3): 182–193. Ingraham, P. 1987. “Toward More Systematic Consideration of Policy Design.” Policy Studies Journal 15: 4. Institute for Mother and Child Care, and Centers for Disease Control and Prevention. 1995. Romania Reproductive Health Survey: 1993. Lazarescu, D. 2001. “Reproductive Health Financing Issues in Romania: An Update.” Unpublished commissioned paper. Bucharest: POLICY Project. Marinescu, L., and V. Cakir. 2000. “Financing Reproductive Health in Romania.” Paper prepared for the June 2000 Europe and Eurasia Conference on Reproductive Health Financing. Bucharest: POLICY Project. Ministry of Health. 1998. Romania’s Reproductive Health Promotion Program Operational Plan, 1998–2003. Bucharest: Ministry of Health. National Institute of Statistics. 2000. Romania Statistical Yearbook 2000. Bucharest. POLICY Project. 1999. Networking for Policy Change: An Advocacy Training Manual. Washington, DC: Futures Group, POLICY Project. Porter, R. 1995. Knowledge Utilization and the Process of Policy Formulation: Toward a Framework for Africa. Washington, DC: Academy for Educational Development, SARA Project. Sabatier, P. and H. Jenkins-Smith. 1993. Policy Change and Learning: An Advocacy Coalition Approach. Boulder: Westview Press. Sharma, S., W. Winfrey, and M. Marin. 2002. “A Family Planning Market Segmentation Analysis: A First Step in Operationalizing Contraceptive Security Policies in Romania.” Paper prepared for the 2001 Roundtable on Contraceptive Security in Romania. Bucharest: Ministry of Health and POLICY Project. Shulock, N. 1999. “The Paradox of Policy Analysis: If It Is Not Used, Why Do We Produce so Much of It?” Journal of Policy Analysis and Management 18 (2): 226–244. Sine, J. and S. Sharma. 2002. “Policy Aspects of Achieving Contraceptive Security.” Policy Issues in Planning and Finance, No. 1. Washington, DC: Futures Group, POLICY Project. Stover, J. and A. Johnston. 1999. “The Art of Policy Formation: Experiences from Africa in Developing National HIV/AIDS Policies.” POLICY Occasional Paper, No. 3. Washington, DC: Futures Group, POLICY Project. Thomas, J. and M. Grindle. 1994. “Political Leadership and Policy Characteristics in Population Policy Reform.” Population and Development Review 20 (supplement): 51–70. Walt, G. and L. Gilson. 1994. “Reforming the Health Sector in Developing Countries: The Central Role of Policy Analysis.” Health Policy and Planning 9 (4): 353–370. Weiss, C. 1977. Research for Policy’s Sake: The Enlightened Function of Social Research.” Policy Analysis 3 (Fall): 531–545. World Bank. 2003. World Development Report, 2003. Washington, DC: World Bank. Romanian Consultative Team members during the E&E RH Finance Conference in June 2000, including representatives of the Ministry of Health, Ministry of Finance, National Health Insurance House, Institute of Public Health and Management, SECS, POLICY, USAID, and UNFPA. Team members prepared the country assessment showing the need for improved FP financing that led to government approval in August 2000 of the country’s first-ever policy for a Ministry of Health budget line item for contraceptive procurement and distribution of free supplies to vulnerable sectors of the population. “It was all teamwork.” Dr. Mihai Horga, head of the Directorate for Family and Social Assistance “…the MOHF increased the budget for contraceptives because of POLICY advocacy, information, and discussion…” Eugenia Erhan, director of the Department of Budget and Finance The Iasi RH advocacy network convened a meeting in October 2002 to inform NGOs and local groups about the need for civil society involvement in RH issues, including contraceptive security. Network representatives also used the occasion to broaden support for their advocacy campaign targeted to the MOHF to allocate funds for NGOs to help inform community leaders and members about the government's RH initiatives. Participants of the October 2001Contraceptive Security Roundtable included representatives of the MOHF, Ministry of Finance, the Committee of Ob-Gyns of the College of Physicians, USAID, parliamentarians, the national RH Coalition, district public health authorities, local networks, and NGOs. Eugenia Erhan with coalition members at the MOHF-POLICY Contraceptive Security Roundtable “POLICY played a very important role…by exposing important decision makers to a new way of thinking…” Borbola Koo, executive director of SECS Local advocacy coordinator Maria Frangetti during a development meeting for the Constanta advocacy network. � EMBED PowerPoint.Slide.8 ��� � Policy refers to any formal government statement, including officially approved laws, national policies and plans, operational policies, and resource allocation decisions. National policies provide the general framework, rationale, objectives, and/or direction regarding an area of concern. In contrast, operational policies are the rules, regulations, guidelines, plans, budgets, procedures, and norms needed to translate laws and national policies into programs and services (Cross, 2000). Some pronouncements of high-level government officials, standard norms of practice, or traditional procedures, although unwritten, are also considered policies. � In 2000, the Ministry of Health (MOH) was renamed the Ministry of Health and Family (MOHF). The name change came about after the ministry was reorganized at the start of Dr. Daniela Bartos’ tenure. Dr. Bartos emphasized family health and welfare, and correspondingly, the FP/MCH office, formerly known as the Family Planning and Sex Education Unit, was upgraded after the reorganization and renamed the Directorate for Family and Social Assistance. For this paper, MOH or MOHF is used depending on the time reference. 3 Walt and Gilson (1994) described policymaking as consisting of four key components: context, content, actors, and process. POLICY (1999) used the broad term “stakeholders” to refer to all key actors of the policy process: those who influence and are influenced by policies. Hardee et al. (2004) proposed a policy circle framework to analyze all aspects of policymaking, including the problem, people/places involved in policymaking, the process of policymaking, the price tag or cost of the policy, the paper representing the policy document, the program to implement the policy, and performance to achieve policy goals and objectives. 4 Eleven family planning centers and 230 family planning clinics were established from 1991 to 1994 with international donor assistance. About 211 were still operational in late 2001. 5 Please refer to Hill et al. (2001) for adjusted international maternal mortality ratios. 6 The mean ideal family size for men was also two. Ideal family size was ascertained during the 1999 Reproductive Health Survey (CDC et al. 2001) by asking respondents the ideal number of children for a young family in Romania. 7 Romania’s Reproductive Health Promotion Program Operational Plan, 1998–2003 (MOH, 1998) cited the existence of “a policy in evidence by programs undertaken rather than a formal document produced.” 8 USAID’s three priority judets were Cluj, Constanta, and Iasi. Advocacy events included caravans, forums, and fairs to promote health insurance coverage of FP/RH services and access in rural areas. 9 Under Romania’s social health insurance law, primary care workers, specialists, and hospitals are paid by the health insurance system. Family planning clinic staff, mostly GPs, do not fall into these categories. The designation of “competence” by the health insurance system recognized the special skills of family planning staff without categorizing them among medical specialists. As a result, health insurance funds could be used to pay family planning clinic staff. 10 SECS is also one of JSI’s subcontractors in implementing USAID’s Integrated Reproductive Health Project. 11 Please refer to the country assessment report, entitled “Financing Reproductive Health in Romania,” that was drafted by Luiza Marinescu and Volkan Cakir (2000). 12 The fall of the Soviet Union and budgetary constraints thereafter severely handicapped the health information system. 13 “Core” refers to funds from USAID/Washington in contrast to field funding from USAID missions in a given country. The criteria for core packages include cutting-edge orientation, potential to achieve results in a relatively short period, and applicability to other countries. 14 An average exchange rate of 29,160 Romania lei to U.S. $1 was used in January to July 2001. In September 2001, the exchange rate was 30,000 lei to U.S. $1. 15 The policy also provides the international standard codes of the generic drug formularies. 16 Logistics requirements for health insurance funding of contraceptives was explored more extensively by the MSH FPMD Project in 1999. 17 The figure of 10 percent was also discussed by Horga with Laurentiu Stan, JSI’s program officer, for the Integrated Reproductive Health Project, 2001–2005. 18 Horga and colleagues from WHO and IPAS conducted a study that showed that in some areas in Romania abortion rates were 50 percent higher than reported. 19 In the basic health insurance law (approved by Parliament in 1997), Law 145, Article 6 defines persons under 26 years of age enrolled in a teaching/training institution as automatically insured, regardless of payment of insurance contributions. 20 Please refer to Brinkerhoff and Crosby (2002), Bryson and Crosby (1992), Porter (1995), and Stover and Johnston (2000) for more extensive discussions on the policy process. 21 Refer to Caplan et al., (1975) and Weiss (1977) on the “enlightenment function” of policy research. 22 Refer to Altman and Petkus (1994) for a social marketing approach to policy change. 23 Thomas and Grindle (1994) discussed the importance of building ownership for FP/RH given the controversy it often engenders. PAGE ii _1144664882.ppt District Health Insurance House Judet (district) authority District Health Authority Hospitals FP clinics Family doctors Other Directorates National Health Insurance House College of Physicians Committee on Transparency Ministry of Health and Family (Minister Daniela Bartos) Secretary of State for Medical Assistance General Directorate for Public Health General Directorate of the Budget (Eugenia Erhan) Directorate for Family and Social Assistance (Mihai Horga) Other departments

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