Stewardship for FP2020 Goals: MOH Role in Improving FP Policy Implementation

Publication date: 2014

HEALTH POL ICY P R O J E C T STEWARDSHIP FOR FP2020 GOALS MOH ROLE IN IMPROVING FP POLICY IMPLEMENTATION August 2014 Ministries of health are largely responsible for achieving the commitments that their national governments have made as part of the FP2020 initiative, which aims to enable 120 million more women and girls to use contraceptives by 2020. Despite having approved family planning (FP) policies, many countries face significant challenges in implementing them. As stewards, ministries of health are responsible for fostering effective policy implementation. Yet, putting policies into practice is challenging, and policy implementation is often weak. Moving from policy to action is “…a dynamic, iterative process that unfolds differently in different contexts” (HPI, 2010b, p. 3). It comprises four broad stages: problem identification, policy formulation, policy implementation, and policy monitoring (HPI, 2010b). Navigating the process successfully requires skillful stewardship in managing elements such as data analysis and use, resource mobilization, and action planning. Many factors can hinder policy implementation. Policy barriers such as incomplete, inadequate, outdated, or conflicting policies result in a lack of direction on how to implement policy among government officials, partners, Brief Alyson Lipsky, Rebecca Mbuya-Brown Health Policy Project, Futures Group Brief Series: Supporting MOH Stewardship for FP2020 As stewards, ministries of health are responsible for “the careful and responsible management of the well- being of the population” (WHO, 2000). However, the ministries’ ability to meet FP2020 goals depends on the strength of their stewardship functions, including overseeing the policy and regulatory environment, building partnerships with and generating support from other actors and across sectors, and fostering policy implementation. This series of three briefs provides guidance on the key roles of both ministries of health and parliamentarians in supporting stewardship for FP2020. The briefs address: ƒ The role of the MOH in strengthening family planning policy implementation ƒ The role of parliamentarians in securing funding for FP ƒ The role of the MOH in strengthening linkages with the private sector to achieve FP2020 goals 2 August 2014 and providers. Inadequate resources and tracking of resource use can result in unfunded mandates. Health system challenges, such as human resource shortages, poor infrastructure, and inadequate coordination, often make service delivery difficult, if not impossible. Operational barriers, such as poor referral mechanisms and logistics, can limit a policy’s effectiveness. FP policy implementation is particularly vulnerable to socio-cultural, economic, and political issues, such as gender inequality and religious opposition (HPI, 2010b). These challenges may be magnified in decentralized contexts because authority and responsibility are shifted to local levels, where capacity, coordination, and accountability may be weak.1 The USAID-funded Health Policy Project (HPP) has identified three ways that ministries of health can address substantial barriers to policy implementation and strengthen their ability to manage their countries’ FP2020 efforts. These are ƒ Fostering multisectoral coordination and partnership building ƒ Developing costed implementation plans ƒ Engaging in policy monitoring Fostering Multisectoral Coordination and Partnership Building The MOH can take a leadership role in coordinating a broad range of stakeholders, both within and outside government, to ensure successful development and implementation of FP policies and programs. Those responsible for FP policy and implementation can coordinate with external actors and notify the minister of health and other high-level policymakers within the ministry to solicit their help with initial outreach to external partners (see Table 1). They can also coordinate FP policies and programs with other MOH departments, such as finance, reproductive health, and maternal and child health, soliciting feedback to create joint ownership. Table 1 outlines some key stakeholders for MOH coordination, how those stakeholders can support FP efforts, and potential ways to coordinate with them. MOH staff can be dedicated to developing sustainable relationships with partners. For FP, the MOH can institutionalize relationships by leading discrete efforts such as FP technical working groups (FP TWGs) and contraceptive security (CS) committees. In many countries, FP TWGs have played an important part in achieving FP progress (USAID/Africa et al., 2012). Composed of government, donor, and (in most countries) civil society representatives, FP TWGs help guide countries’ overall FP approaches, facilitate policy development, monitor the implementation and impact of policies and programs, and coordinate actors’ efforts to avoid fragmentation or duplication. Experiences in Ethiopia, Rwanda, and Malawi demonstrate that with strong MOH leadership and a functioning secretariat, FP TWGs can effectively engage other government agencies; create a collaborative atmosphere among diverse partners; use strategic, evidence- based advocacy to build support and mobilize resources; and monitor progress (USAID/Africa et al., 2012). Contraceptive security—“when people are able to choose, obtain and use high-quality contraceptives and condoms whenever they want them” (Pandit and Bornbusch, 2004, p. 1)—is key to the successful implementation of FP policies and programs. In Latin America and the Caribbean, CS committees have played an important role in advancing FP. To ensure a stable supply of contraceptives, CS committees’ work may include policy analysis, developing strategies, advocating for policy change and increased political commitment, analyzing FP markets and demand, forecasting the need for contraceptives, and improving logistics systems (HPI, 2008; Betancourt, 2007). MOH leadership is vital to CS committees’ success. In Paraguay, the MOH’s leadership contributed to the national CS committee’s success in eliminating the country’s reliance on donor support to purchase contraceptives. The MOH provided a vision and objectives for the committee, developed joint ownership of CS, and kept diverse members on task. In 2011, Paraguay purchased all of its contraceptives without donor support. The CS Committee, established in 2003, was recognized as a key factor in achieving this milestone (HPP, 2012). Developing Costed Implementation Plans Costed implementation plans (CIPs) for FP can provide countries with a road map for achieving FP2020 goals and strengthen implementation of FP strategies and policies by clearly defining the actions and resources necessary to put those plans into practice. By estimating the potential demographic and health impacts of FP programs, as well as the budgetary requirements for FP program implementation, CIPs can help secure political commitment and resources to achieve FP2020 goals. The consultative process of developing CIPs can help build consensus and strengthen coordination among donors, government and private sector2 stakeholders. CIPs can also be used to monitor policy implementation and progress. To date, 13 countries have launched detailed CIPs for FP—Benin, Burkina Faso, Côte d’Ivoire, Democratic Republic of the Congo, Guinea, Kenya, Mali, Mauritania, Niger, Senegal, Tanzania, Togo, and Zambia (Zlatunich, 3 MOH Role in Improving FP Policy Implementation 2013; Nichole Zlatunich, pers. comm.). Zambia’s CIP has contributed to several advances in FP programming, including new sex education curricula with a roll-out timeline, additional government staff to support the FP program, and a new reproductive health commodities budget line in the 2014 national budget that was approximately double the previous year’s amount. The MOH can initiate and facilitate CIP development— securing financial and technical assistance as necessary, and supporting the formation of a Technical Support Team (TST) to guide the consultative CIP development process. Once a CIP is developed, the MOH should lead monitoring of implementation through national multisectoral coordination bodies, such as an FP TWG (Zlatunich, 2013).3 Policy Monitoring Policy monitoring allows the MOH to track policy implementation and effectiveness in the complex policy landscape, which comprises many stakeholders, agencies, and various types of providers (Bhuyan et al., 2010; HPI, 2010a). Policy monitoring can identify barriers to implementation and factors to improve effectiveness, such as promoting accountability and fostering equity and quality (Bhuyan et al., 2010). Assessing the mechanisms, resources, and relationships that move FP from policy to action enables the MOH to adapt its implementation strategies or undertake policy change to reflect realities on the ground (Bhuyan et al., 2010). Policy monitoring and its impact can be strengthened by: ƒ Assembling a coalition of stakeholders from diverse sectors to define success and monitor select indicators of FP policy implementation through an established mechanism, such as the FP TWG, or workshops. Table 1. Key Stakeholders* for MOH Coordination for Family Planning Key Stakeholders Purpose of Coordination Ways to Coordinate Other ministries and government agencies ƒ Build multisectoral support for family planning ƒ Ensure consistency in FP policies and programs across other ministries such as ministries of education, labor, and finance ƒ Hold participatory workshops and presentations ƒ Include other line ministries in working groups, such as FP TWGs and commodity security committees ƒ Participate in other sectors’ working groups Local government officials and leaders ƒ Ensure FP goals and policies are implemented at all levels of government by strengthening data collection, analysis, and use; forge partnerships; and foster collaboration ƒ Acknowledge and raise awareness of common health systems challenges ƒ Develop broad-based support for FP ƒ Ensure the quality of FP services at subnational levels ƒ Convene intergovernmental health forums to acknowledge common health systems challenges ƒ Participate in FP policymaking and build partnerships with civil society through existing governance structures such as FP TWGs ƒ Develop the capacity of local government ƒ Participate in subnational performance monitoring and supervision of FP programs Donor agencies ƒ Mobilize technical and financial support ƒ Align donor support with country goals and strategies ƒ Participate in planning meetings and working groups ƒ Develop a national FP policy and Costed Implementation Plan ƒ Require regular reporting about all activities ƒ Provide guidance and direction on what activities are needed throughout the country * See separate briefs on working with parliamentarians and the private sector: Leahy Madsen, E. 2014. Stewardship for FP2020: The Role of Parliamentarians. Washington, DC: Futures Group, Health Policy Project. Lipsky, A., and J. Gribble. 2014. Stewardship for FP2020: Working with the Private Sector. Washington, DC: Futures Group, Health Policy Project. August 2014 4 The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010. It is implemented by Futures Group, in collaboration with Plan International USA, Futures Institute, Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and the White Ribbon Alliance for Safe Motherhood (WRA). The information provided in this document is not official U.S. Government information and does not necessarily represent the views or positions of the U.S. Agency for International Development. Contact Us Health Policy Project 1331 Pennsylvania Ave NW, Suite 600 Washington, DC 20004 www.healthpolicyproject.com policyinfo@futuresgroup.com ƒ Defining indicators and including them in basic reporting mechanisms; strengthening the documentation of data collection methods, data collected, and data analysis; and regularly reviewing data internally with stakeholders. ƒ Conducting a policy implementation assessment to provide information on how policies are being implemented, and how to improve their effectiveness.4 ƒ Preparing succinct recommendations for policymakers. Sensitivity to the political risks associated with reporting little or no progress—ensuring proper documentation, unbiased reporting, and broad stakeholder engagement—can help mitigate these risks. ƒ Providing training in policy monitoring. In 2002, Uttarakhand became the first state in India to enact its own Health and Population Policy, and in 2008, the state leaders chose to assess the policy’s implementation with support from the USAID | Health Policy Initiative. The assessment included a situation analysis, a policy review and implementation assessment, and a high-level policy dialogue. It revealed that substantial progress was being made, but large disparities in health status and service access were hindering additional gains in key health indicators. It also revealed that women’s FP choices were limited, preventing Uttarakhand from achieving replacement-level fertility. The state leaders developed an addendum to the policy that provided additional support for identified strengths, and addressed specific barriers by focusing on educating men and women, providing them with a variety of FP methods to generate demand, and encouraging choice and informed consent (HPI, 2010a). Conclusion Ministries of health face significant challenges in implementing family planning policies, including political, financial, operational, and socio-cultural barriers. To achieve FP2020 goals, ministries will need to assert their role as stewards, and leverage other partners to keep their countries on track. Fostering multisectoral coordination, developing costed implementation plans, and monitoring policy implementation are concrete ways to effectively address key policy barriers for FP2020. Notes 1. See the Health Policy Project’s The Effects of Decentralization on Family Planning: A Framework for Analysis (2014) for a tool to support MOH understanding of FP decentralization. 2. The private sector is defined as both the commercial and nonprofit sectors. 3. See the Health Policy Project’s Costed Implementation Plans for Family Planning (2013) for further information on a 10-step collaborative process for developing a CIP. 4. The Policy Implementation Assessment Tool—PIAT—developed by the USAID | Health Policy Initiative could be used to conduct such an assessment. Available at: http://www.healthpolicyinitiative.com/policyimplementation/index.html. References Betancourt, V. 2007. Contraceptive Security Committees: Their Role in Latin America and the Caribbean. Washington, DC: Futures Group, Health Policy Initiative, Task Order 1. Bhuyan, A., A. Jorgensen, and S. Sharma. 2010. Taking the Pulse of Policy: The Policy Implementation Assessment Tool. Washington, DC: Futures Group, Health Policy Initiative, Task Order 1. Bloom, D., and M. Chu. 2012. “Health Economics Private Enterprise for Public Health.” Global Investor 2(1): 14–16. Health Policy Initiative (HPI). 2010a. Informing Equitable Health Policy Reform: Policy Implementation Assessment Inspire Action in Uttarakhand, India. Washington, DC: Futures Group, Health Policy Initiative, Task Order 1. Health Policy Initiative. 2010b. The Art of Moving from Policy to Action: Lessons Learned from the USAID | Health Policy Initiative (2005–2010). Washington, DC: Futures Group, Health Policy Initiative, Task Order 1. Health Policy Initiative. 2008. Safeguarding Contraceptive Security in Latin America and the Caribbean. Washington, DC: Futures Group, Health Policy Initiative, Task Order 1. Health Policy Project (HPP). 2012. Promoting Country Ownership through Latin American Contraceptive Security Committees: Paraguay Case Study. Washington, DC: Futures Group, Health Policy Project. Health Policy Project. 2014. The Effects of Decentralization on Family Planning: A Framework for Analysis. Washington, DC: Futures Group, Health Policy Project. Judice, N., and E. Snyder. 2013. Framework for Monitoring and Evaluating Efforts to Reposition Family Planning. Chapel Hill, NC: MEASURE Evaluation. Lagomarsino, G., S. Nachuk, and S.S. Kundra. 2009. Public Stewardship of Private Providers in Mixed Healthy Systems: Synthesis Report from the Rockefeller Foundation-Sponsored Initiative on the Role of the Private Sector in Health Systems. Washington, DC: Results for Development Institute. Pandit, T., and A. Bornbusch. 2004. Contraceptive Security Ready Lessons: Overview. Washington, DC: USAID, Contraceptive Security Team. Sharma, S., and V. Dayaratna. 2005. “Creating Conditions for Greater Private Sector Participation in Achieving Contraceptive Security.” Health Policy 71(3): 347–357. USAID/Africa Bureau, USAID/Population and Reproductive Health, Ethiopia Federal Ministry of Health, and Rwanda Ministry of Health. 2012. Three Successful Sub-Saharan Africa Family Planning Programs: Lessons for Meeting the MDGs. Washington, DC: USAID/Africa Bureau. World Health Organization. 2000. The World Health Report 2000: Health Systems: Improving Performance. Geneva: World Health Organization. Zlatunich, N. 2013. 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