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National Reproductive Health Commodity Security Strategy and Operational Plan 2008-2012
Republic of Liberia UNITED NATIONS Ministry of Health & Social Welfare POPULATION FUND (UNFPA) [image: image6.png] [image: image2.png] National Reproductive Health Commodity Security Strategy and Operational Plan 2008 – 2012 In support of the Road Map for Accelerating the Reduction of Maternal and Newborn Morbidity and Mortality in Liberia October 2007 [image: image3.jpg][image: image1] EUROPÉAN COMMISSION Abstract Reproductive health commodity security (RHCS) promotes the idea that every person should be able to choose, obtain, and use quality contraceptives and/or other RH products every time he or she desires. The goal is thus to make sure that supply corresponds to demand. Liberia is engaged through its RH programs to ensure the availability of RH products to correspond with demand. With the financial support of the European Commission through the Joint ACP/UNFPA/EC Programme for ACP countries most in need of achieving reproductive health commodity security, the UNFPA Liberia country office and the Ministry of Health & Social Welfare of Liberia prepared this report with assistance from a team of consultants lead by John Snow, Inc./Logistics Services (JSI/LS). This analysis of the RHCS situation and the corresponding strategy and operational plan will help to strengthen interest in improving RHCS and to build consensus between the various stakeholders on the priorities to be taken into account to ensure RHCS for the RH commodities identified. TABLE OF CONTENTS 2List of Acronyms 4Preface 5Acknowledgements 6Introduction 6Goal 6Purpose 6Specific Objectives 7Vital RH Commodities 7Budget Summary 8Methodology 8Assumptions 10RHCS Strategy 10Context 121. Policy Environment 142. Finance 163. Coordination 174. Service Delivery 195. Client Use & Demand 206. Supply Chain 23Monitoring & Evaluation 24Operational Plan 37References 38Appendix 1 38List of stakeholders involved in developing the RHCS Strategy and Plan List of Acronyms ANC antenatal care ARV anti-retroviral ATP ability to pay BCC behavior change communication BPHS Basic Package of Health Services CBD community-based distribution CHAL Christian Health Association of Liberia CHO county health officer CHT county health team CHW community health worker COC combined oral contraceptive CPR contraceptive prevalence rate DHS Demographic and Health Survey EML essential medicines list EPI Expanded Programme on Immunization EU European Union FEFO first-to-expire, first-out FHD Family Heath Division FP family planning FPAL Family Planning Association of Liberia GFATM Global Fund to Fight AIDS, Tuberculosis & Malaria GOL Government of Liberia HIV/AIDS human immunodeficiency virus/acquired immune deficiency syndrome HMIS health information management system HSCC Health Sector Coordinating Committee ICB international competitive bidding IDA International Dispensary Association IEC information, education, and communication INGO international nongovernmental organization IPPF International Planned Parenthood Federation iPRS Interim Poverty Reduction Strategy IPT intermittent preventive treatment (for malaria) IUD intrauterine device JSI John Snow, Inc. LDHS Liberian Demographic and Health Survey LMIS logistics management information system M&E monitoring and evaluation MMR maternal mortality ratio MNH maternal and newborn health MOF Ministry of Finance MOHSW Ministry of Health & Social Welfare MOS months of stock MOU memorandum of understanding NCSS National Contraceptive Security Strategy NDS National Drug Services NGO nongovernmental organization NHPD National Health Promotion Division OFM Office of Financial Management POP progestin only pills PR Principal Recipient RHCS reproductive health commodity security RHTC Reproductive Health Technical Committee SDP service delivery point SOP standards of practice SPARHCS Strategic Pathway to Reproductive Health Commodity Security STG standard treatment guideline STI sexually transmitted infection TB tuberculosis TFR total fertility rate TOR terms of reference UNDP United Nations Development Program UNFPA United Nations Population Fund USAID United States Agency for International Development WHO World Health Organization Preface (To be written by MOHSW) AcknowledgementS (To be REVISED by MOHSW) This strategy and operational plan is the result of collaboration and support from many people and institutions. Dr. Bernice Dahn, Deputy Minister and Chief Medical Officer at the Ministry of Health & Social Welfare (MOHSW), initiated the strategy development in collaboration with Rose Gakuba, UNFPA Resident Representative in Liberia, and Dr. James Duworko of the U.S. Agency for International Development (USAID). Jennifer Antilla, Paul Dowling, Meba Kagone, and Christopher Wright from the USAID-funded DELIVER Project and John Snow, Incorporated provided technical assistance in the development and finalization of this document. Special thanks are due to the European Commission who provided the financing for this mission through the joint ACP/UNFPA/EC programme for ACP countries most in need of achieving reproductive health commodity security. Appreciation goes to Dr. Dahn and Ms. Gakuba for their enthusiastic support for the data collection, analysis, and consultative process that informed this strategy and operational plan, and for making their staff and colleagues, offices, vehicles, and other resources available to support this work. Gratitude is also due to the many international and national stakeholders who gave freely of their time to meet to help develop this strategy and operational plan. They provided valuable insightful and candid perspectives. See Appendix 1 for a complete list of stakeholders involved. We hope the stakeholders will recognize their contributions in the following pages. Introduction Reproductive health commodity security exists when every person is able to choose, obtain, and use quality contraceptives and other reproductive health commodities whenever she or he needs them. Reproductive Health Commodity Security (RHCS) is experienced one client at a time. It is absent when a woman goes to a clinic for a Depo Provera injection and it is out of stock, or when a woman in labor experiences eclampsia and dies because the midwife has no supply of magnesium sulfate at hand. [image: image4.png]Many factors affect RHCS, from the socio-economic context of the country, to the policy environment for RH services, to the availability of funds to procure commodities, to the capacity of the health system to procure, store, and distribute them effectively to the people when and where they are needed. People need to know about RH services and contraceptive options and to seek them, which requires information. Service providers need the skills to deliver quality care. Ultimately, quality health care delivery at the client level depends on three interrelated elements—trained providers, quality drugs and other commodities, and effective information. Furthermore, these three pillars of health delivery must be closely coordinated at every level to ensure they are in place at the facility level. They must also be supported by favorable policies and adequate financing. Goal The goal of this National Reproductive Health Commodity Security Strategy is to ensure that every woman and man in Liberia is able to choose, obtain, and use quality contraceptives and other vital reproductive health commodities whenever she or he needs them. Purpose The purpose of this National Reproductive Health Commodity Security Strategy and Operational Plan is to identify critical needs and specify the interventions required to ensure continuous availability of contraceptives and vital RH medicines at all health service delivery and commodity distribution points. It is designed to complement the Road Map for Accelerating the Reduction of Maternal and Newborn Morbidity and Mortality in Liberia and to support other national health strategies and plans, including: National Health Policy (2007 – 2011) National Health Plan (2007 – 2011) Road Map for the Implementation of the Basic Package of Health Services Specific Objectives This strategy presents six specific objectives that, if achieved, will significantly improve reproductive health commodity security. The five-year operational plan identifies strategies and priority activities for achieving the following specific objectives: The policy environment at the national, county, and local levels sustains and supports the objectives of this strategy. There is sustainable and equitable financing for the delivery of contraceptive and reproductive health products and services and related health promotion services. Strong coordination and partnership exists at all levels, and between all stakeholders and sectors, for the delivery of RH/FP services. Providers have the skills and materials necessary to satisfy client needs and demand. Clients have the information required to access the RH services and supplies they need. An effective and efficient supply chain exists for contraceptives and essential RH commodities that ensures the availability of products to all people who need them throughout the country. Vital RH Commodities For the purpose of this strategy, the following commodities have been designated as vital to reducing maternal and newborn mortality and morbidity in Liberia. This list was agreed by the Reproductive Health Technical Committee and was adapted from a recommended list of vital and priority RH drugs developed by the United Nations Population Fund (UNFPA) and the World Health Organization (WHO). Vital Drugs Contraceptives Magnesium Sulfate Combined oral contraceptive (COC) pills Oxytocin Progestrine only (POP) pills Ergometrine Injectable hormonal contraceptive Iron/Folate Intrauterine device (IUD) Amoxicillin Emergency contraceptive pills Azithromycin Male condoms Clotrimazole Female condoms Metronidazole Benzathine Benzylpenicillin Cefixime Erythromycin Budget Summary The budget summary below provides estimated costs to implement the activities over the five years of the plan. These costs do not include routine operational costs for facilities, equipment, or salaries for civil servants, but they do include the costs of partner interventions and technical assistance. Detailed work plans will need to be developed on an annual basis. The disaggregated cost of contraceptives is presented in a separate table in the Finance section of the RHCS Strategy. Budget by Component Component Cost (US$) Policy Environment $78,000 Finance (technical assistance/management only) $221,000 Finance (contraceptives, three-year total) $2,293,000 Coordination $155,000 Service Delivery $273,000 Client Use and Demand $226,000 Supply Chain $411,000 Total $3,657,000 Methodology The process of developing this National Reproductive Health Commodity Security Strategy began in March/April 2006, following a logistics system assessment conducted by consultants from the USAID-funded DELIVER project. An awareness raising workshop was conducted to increase decision makers' knowledge of contraceptive security and its role in reducing maternal mortality. This resulted in a decision to conduct an assessment of the contraceptive security situation in Liberia. In February 2007, the Family Health Division (FHD) of the Ministry of Health and Social Welfare (MOHSW) in collaboration with three consultants from the DELIVER Project conducted the assessment, which resulted in a draft National Contraceptive Security Strategy. The assessment used the Strategic Pathway to Reproductive Health Commodity Security (SPARHCS) tool adapted to the Liberian situation. SPARHCS is a diagnostic guide consisting of a range of questions and tables designed to gather information on reproductive health commodity security by focusing on six different components influencing RHCS: coordination and partnership, commitment and policies, capital/finance, service delivery, client use and demand, and supply chain. The scope of the tool can be adapted to a wide range of health commodities, depending on the situation. The primary objectives of the initial assessment of contraceptive security were to: Identify strengths and weaknesses in each of six areas influencing commodity security, Reach consensus on priority issues, Use the assessment findings to begin the development of a strategic plan. The assessment team collected information by reviewing available strategies, policies, and plans, conducting focus group discussions with key stakeholders, visiting health facilities in five counties (Montserrado, Grand Cape Mount, Bomi, Grand Bassa, and River Cess), and interviewing key informants from the various stakeholders located in Monrovia. Based on the results of this assessment, the team identified and presented key strengths and weaknesses at a meeting of decision makers, consisting primarily of members of the RH technical committee. Having reviewed the findings, this group prioritized key issues and developed a five-year National Contraceptive Security Strategy (NCSS) to address them. In September 2007, the NCSS remained in draft form and the MOHSW elected to collaborate with two consultants from John Snow, Inc. working with UNFPA to update and expand the NCSS to include other RH commodities, such as priority medicines and supplements for antenatal care, emergency obstetric care, and the treatment of sexually transmitted infections. To this end, the consultants reviewed updated versions of national policies, plans, roadmaps, assessment findings, and standard treatment guidelines (for a complete list, see References section). The consultants also met with those organizations and stakeholders involved in developing the NCSS in February 2007 to 1) determine what progress, if any, had been made in implementing the activities outlined in the NCSS, and 2) identify any key areas related to the provision of reproductive health services and supplies that were not addressed in the draft NCSS. In collaboration with the MOHSW/FHD and UNFPA, the results of the document review and these meetings were compared to the strengths and weaknesses identified in February 2007. A comprehensive and updated list of strengths and weaknesses was presented to technical working group consisting of key stakeholders for validation. These working groups then revised existing objectives of the NCSS to reflect the expanded scope of the strategy and altered situation, and developed new objectives, strategies, and activities to address emerging areas for action. The result of this process is the following National RHCS Strategy and Operational Plan: 2008 – 2012. Assumptions The RHCS Strategy and Operational Plan has been written with the following assumptions: Civil stability will continue and strengthen, resulting in normalization of governance, the economy, and society at large. The transition from humanitarian and crisis assistance to development assistance will be successful. Development partners will continue to provide generous financial support and technical assistance over the next five-year period. The number of health sector workers will increase and the quality of their skills will improve in accordance with the National Health Plan. Road conditions will improve for all primary national transportation corridors. Health facilities will be renovated or rebuilt in accordance with the National Health Plan. RHCS Strategy The rationale for the Liberian Reproductive Health Commodity Security Strategy is to set a direction for improved access to vital RH commodities, including contraceptives. It spans a period of five years: January 2008 through December 2012. The strategy addresses six interdependent components that affect the availability of contraceptives and vital RH drugs at health service delivery points: Policy Environment Finance Coordination Service Delivery Client Use & Demand Supply Chain All six of these components work together within the specific country context of Liberia to affect RH commodity security. This strategy is designed to address agreed upon weaknesses by building on the strengths identified during the assessment and operational planning phase, establishing specific objectives and strategies for achieving them. It includes a five-year operational plan that serves as a road map for ensuring that every woman and man in Liberia is able to choose, obtain, and use quality contraceptives and other vital reproductive health commodities whenever she or he needs them. Context Before the war, Liberia enjoyed relative prosperity among the ECOWAS countries with a GDP of US$1,269 in 1980. After the war, this fell to US$163 in 2005, leading to widespread poverty. Seventy-five percent of the population earns less than US$1 a day. The population, dispersed in internal camps, is now returning to their locations of origin—or in many cases moving to Monrovia—to face the challenges of rebuilding their lives. Roads are in very bad condition and many bridges have been destroyed, preventing rapid communication and provision of urgently needed goods and services, including vital drugs and emergency health care. The poor condition of the roads has drastically reduced the capacity of existing transport resources, wreaking havoc on vehicles and increasing the cost of maintenance. The electrical grid was largely destroyed by the war. Electrical power is dependent on small diesel generators and a limited number of facility-based solar units. However, security is increasing in rural areas. In 2005, a democratic government was elected. The people of Liberia expect from the newly elected government a great deal of improvement in their lives. As of 2007, Liberia is still transitioning from emergency assistance to recovery, reconstruction and development. The challenges facing the country during this transition period stem from the withdrawal or scaling back operations of humanitarian organizations that have been assisting the Liberian people since the war. Their programmed withdrawal will create a huge gap that must be filled by the government of Liberia (GOL). An alternative form of external assistance is urgently needed for an extended period since the government alone is not in a strong position to meet the needs of the people. The years of conflict severely disrupted the delivery of health care in Liberia. Reconstruction of facilities and revitalization of services has begun, but significant challenges remain to strengthening the physical infrastructure, human resources, and institutional capacity to provide basic services to the population. Until very recently, there has been a lack of data on the health situation, with only piece-meal surveys for particular conditions. Malaria, acute respiratory infections, diarrhea, tuberculosis, sexually transmitted infections (STIs), worms, skin diseases, malnutrition and anemia are the most common causes of morbidity and mortality. Malaria accounts for over 40 percent of out-patient attendance and up to 18 percent of inpatient deaths. Diarrheal diseases are the second leading causes of morbidity and mortality (National Health Policy). Preliminary data from the Liberian Demographic and Health Survey (LDHS) indicates that maternal mortality is much higher, at 994 deaths per 100,000 births, than previously estimated in the interim Poverty Reduction Strategy (580/100,000). However, the LDHS offers some reason for optimism, too. HIV prevalence is only 1.2 percent, while the previous estimates suggested a prevalence of around 5.2 percent. Infant mortality remains high at 72 deaths per 1,000 live births, but is considerably lower than the 1999-2000 LDHS rate of 117 and the iPRS estimate of 157. Contraceptive prevalence has increased slightly from 10 percent of currently married women in 1999-2000 to 11.2 percent in 2007, but the use of modern methods has increased from 8.1 to 10.2 percent during the same period. Data on unmet need for contraception is not yet available from the 2007 LDHS, but in 1999-2000 it was 13.6 percent. Total fertility has declined from 6.2 children per woman of reproductive age in 1999-2000 to 5.2 in 2007. Disruptions of health services by conflict have greatly affected access to health services. Data are unreliable but the interim Poverty Reduction Strategy (iPRS) reports that only 41 percent of the population has access to health services. Significant displacement of the population occurred during the conflict and whole areas have been depopulated with many moving to the Monrovia area. A census is planned for later in 2007, though many estimate that between one-third and one-half of the population of around 3.2 million now resides in Monrovia. The Liberian health care system is comprised of three levels of care: primary, secondary and tertiary. The primary level of care consists of health clinics in rural and urban areas. The secondary level of care consists of district health centers and county hospitals, primarily in urban areas. The tertiary level of care is represented by the JFK Medical Center in Monrovia, which is autonomous and managed by its hospital administration department under the supervision of a board of directors. The health care system has endured all the socio-economic hardship caused by the war and will face major challenges in the future. During the emergency period, health care continued to be delivered by humanitarian organizations throughout the country. Health care delivery currently remains heavily dependent on donor funded vertical programs and international nongovernmental organizations (INGOs). In most cases, INGOs and faith-based organizations such as churches associated with the Christian Health Association of Liberia (CHAL) have replaced the government in managing health services. Disease prevention and control programs exist for malaria, TB, and HIV/AIDS, while a variety of INGOs support service delivery through public sector facilities, mainly in the most war affected areas. Local NGOs, which were very active in the prewar era, have witnessed their operations shrink considerably. For example, FPAL, the main provider of family planning services in the country, offered FP services in over 120—mostly GOL owned—clinics. The number now has dropped to three FPAL-owned facilities. In the public sector, the MOH Rapid Assessment conducted in 2006 has shown that out of 521 existing health facilities, 300 are assisted by INGOs in a humanitarian mode, 132 are nonfunctional, and 89 are facilities functioning without INGO assistance. Among the functioning facilities, 46 percent have no water supply and 88 percent have no vehicle for emergency evacuation. Health manpower in the public sector consists of approximately 4,000 full-time and 1,000 part-time staff. A significant proportion of these health professionals lack the skills and experience necessary to manage the facilities and deliver services efficiently. In general, staff has very low morale due to poor compensation packages and inadequate conditions to perform their duties. INGOs pay significantly more and offer better working conditions than the GOL. As INGOs scale back their activities and switch from emergency relief to development, there is a danger that service delivery will weaken in these areas as the government is not yet prepared to take over from the humanitarian NGOs. The GOL and the MOHSW have launched an ambitious plan to improve the health care system. The National Health Policy presents a comprehensive strategy to addressing the county's dire health situation. At its center is the introduction of a Basic Package of Health Services (BPHS) at the primary care level, and comprising services such as maternal and newborn health; child health; adolescent, sexual, and reproductive health; disease prevention, control, and management; and essential emergency treatment. The National Health Plan lays out critical interventions in infrastructure, human resources, management support, resource mobilization, monitoring and evaluation, and coordination required to improve access to quality health services for the people of Liberia. In addition, the Family Health Division (FHD) of the MOHSW has developed the Road Map for Accelerating the Reduction of Maternal and Newborn Morbidity and Mortality in Liberia (MNH Road Map), which addresses safe motherhood and reproductive health, including family planning. This RHCS strategy and operational plan complements the MNH Road Map by filling in gaps and providing additional strategies and priority activities to achieving the goal of the MNH Road Map. Taken together, the RHCS strategy and the MNH Roadmap represent a comprehensive approach to ensuring the availability of quality services, supplies, and information needed to improve reproductive health and reduce maternal and newborn mortality. 1. Policy Environment Current Situation The current policy environment is very supportive of RHCS. Several policies are being developed, others have already been adopted which call for support to reproductive health and family planning services and availability of contraceptives. For example, the health policy and health plan make provisions for reproductive health, and family planning is mentioned in the basic health package in two areas: safe motherhood and adolescent sexual and reproductive health. The health plan also stresses the importance of access to essential drugs and of distributing contraceptives at SDPs. Likewise, the drug policy makes mention on several occasions of actions in favor of family planning products. It recommends that there will be no tax on condoms and IUDs and authorizes the private sector to procure contraceptives. Additionally, the 2001 Reproductive Health Policy advocates for availability of contraceptive and a strong supply chain to ensure availability of FP products at SDPs. Finally, the National HIV/AIDS strategy explicitly mentions provision of FP services to all as part of its overall strategy. However, many of these policies and strategies remain in draft form and must be adopted by the GOL. They then must be incorporated into road maps and operational plans to ensure they are implemented appropriately. In addition, standard treatment guidelines (STGs) for RH services must be reviewed and updated, and protocols for family planning services must be drafted and form the basis of subsequent training curricula. All STGs and protocols should include elements addressing youth and male involvement. Finally, the private sector—including pharmacies, medical stores, and private service providers such as CHAL, FPAL and other NGOs and INGOs—remain largely free of regulation or oversight. Although CHAL and FPAL are significant providers of services, their role as partners in attaining national health goals is poorly defined, and this hampers their ability to collaborate with the MOHSW and to access contraceptives and other supplies from the NDS and county depots. Specific Objective 1 The policy environment at the national, county, and local levels sustains and supports the objectives of this strategy. Strategy 1.1: Adapt the existing RH policy, particularly the FP component to the current situation. A reproductive health policy was developed in 2001 and contains provisions for family planning. During discussions with key informants and through the site visits, the need for clear and detailed policy in family planning was clearly expressed. Therefore, the RHTC should review the existing policy and recommend revisions, which should then be submitted to the Health Sector Steering Committee for approval and adoption. The new policy should be operationalized by incorporating additional strategies and actions into the MNH Road Map and the BPHS Road Map. Strategy 1.2: Define the procedures for selecting the methods and the brands of contraceptives approved for the country. The current contraceptive method mix is limited to short-term methods, with IUDs available in only a few facilities. In addition, there is a multiplicity of brands of pills currently available, which complicates supply management and causes confusion among clients who are asked to switch between equivalent brands based on availability rather than informed choice. The RHTC should review the current method mix and incorporate strategies to expand access to long-term methods into the MNH Road Map. In addition, it should review which COC and POP brands should be procured (by donors and/or by NDS) and advise on brand selection as part of annual procurement planning for contraceptives. Strategy 1.3: Define the scope and role of FPAL and CHAL in providing FP services, specifically in collaboration with the public sector. Prior to the conflict, a local NGO, FPAL, was a key provider of FP services with over 120 health facilities. The number of health facilities that they manage has fallen to three, primarily in the Monrovia area. In the interim, CHAL has become a major provider of RH/FP services. This specific objective builds on the existing reputations and past performance of these partners to enable them to better respond to the increased demand for services and assist the MOHSW in providing RH/FP services in the public sector. The MOHSW should review past collaboration mechanisms and enter into memorandums of understanding (MOU) or other contractual mechanisms with FPAL, CHAL, and any other donor-supported partner working in health care delivery. Strategy 1.4: Ensure that the commercial sector provides safe and affordable quality FP products and services to clients. Medicine stores selling contraceptives are required to be licensed and registered; however, many do not meet these criteria and continue to sell hormonal contraceptives. Furthermore, training for pharmacy dispensers is nonexistent. The Pharmacy Bureau or other appropriate regulatory authority should improve monitoring of pharmacies and medical stores and ensure they are staffed by adequately trained pharmacy dispensers. Strategy 1.5: Increase access to contraceptives in the private sector through the introduction of social marketing for contraceptives including condoms for prevention of STIs. Several public sector brands of pills and condoms were found for sale in the commercial sector, pointing to possible leakage. Although undesirable, this does mean increased access for clients. Implementing a social marketing program for pills and condoms will both increase access in the private sector and curtail existing leaks. RHTC should review social marketing best practices in other countries, and develop proposals for the Health Sector Steering Committee to consider and, if required, to take to the parliament for appropriate legislation. 2. Finance Current Situation Without adequate funding and sound financial management, clients are unlikely to receive quality health care consisting of services, supplies, and information. In the current setting, funding the BPHS and managing donor contributions are significant challenges for the MOHSW. Within the MOHSW, an Office of Financial Management has been established to manage financial issues related to decentralization, implementing national plans and policies, the BPHS in particular, and mobilize resources to that end. In terms of funding basic supply chain activities, NDS's operational costs are partially covered through a subsidy from the MOHSW. As services expand and the need for essential drugs and contraceptives increase, the demand on NDS's infrastructure and their procurements will grow. The European Commission has recently conducted an extensive assessment of NDS and its role in relation to the MOHSW; they plan on addressing the issues identified through their assessment, including the financing of NDS's operations. Financing of essential drug is not sustainable without long-term donor commitment. The GOL has recently provided funding for "regular" essential drug procurement; NDS does do restricted tendering in some instances through suppliers like Mission Pharma and IDA. However, the dispersement of GOL funds to NDS limits NDS's ability to procure bulk quantities and gain economies of scale, and GOL funding only covers a fraction of national essential drug needs. Many drugs are financed through a variety of mechanisms and funders, mainly the GFATM, which fund drugs for HIV/AIDS, other sexually transmitted infections (STIs), opportunistic infections, and malaria. Contraceptives are being funded mainly by USAID at this time. USAID currently supply male condoms, Depo-Provera, Lo-Femenal (combined pill), Ovrette (progesterone only pill) and IUDs. UNFPA was a major financer in the past and still supports procurement of female condoms, reproductive health kits, and smaller quantities of pills (Microgynon and Microlut). The Global Fund to Fight AIDS, Tuberculosis & Malaria (GFATM) has previously financed male condoms and intends to finance both male and female condoms in the future. The GOL currently does not support procurement of contraceptives, and will likely rely on donors for most of its contraceptive requirements for a number of years (see table below for three-year forecast of contraceptive requirements). Many INGOs complement public sector supplies with various commodities, for example, the International Planned Parenthood Federation (IPPF) provides small quantities of a range of products to FPAL. Official policy for the next two years states that all essential drugs are to be provided free of charge to clients in public sector facilities; however, this may prove difficult to implement in public facilities functioning without NGO support and where staff often try to charge fees. FPAL and CHAL facilities charge for products but prices are generally low. Prices at commercial pharmacies and medicines stores are also low; this is possible since most of the products sold are leaked from the public sector. Given the lack of purchasing power, these prices, although low, are probably still beyond the reach of most of the population. There is no significant third party financing of contraceptives or other RH drugs. Contraceptive Requirements 2008 – 2010 (October 2007 Forecast) Method 2008 2009 2010 Quantity Cost Quantity Cost Quantity Cost Male Condoms 8,234,000 $315,362 9,881,000 $ 378,442 10,375,000 $ 397,362 Female condoms -- -- 48,000 $ 30,384 48,000 $ 30,384 Depo Provera 195,000 $207,675 215,000 $ 228,975 236,000 $ 251,340 Ovrette (POP) 105,000 $ 25,515 110,000 $ 26,730 116,000 $ 28,188 Lo-Femenal (COC) 464,000 $112,752 487,000 $ 118,341 511,000 $ 124,173 IUD 3,000 $ 4,902 3,500 $ 5,719 4,000 $ 6,536 Total $666,206 $ 788,591 $ 837,983 Note: This is a three-year forecast of need, but procurement plans must be adjusted to take into account existing stock balances. Specific Objective 2 There is sustainable and equitable financing for the delivery of contraceptive and reproductive health products and services and related health promotion services. Strategy 2.1: Obtain direct GOL support for reproductive health commodity procurement. The MOHSW has already demonstrated its commitment to making essential drugs available by proposing a budget and allocating some funds for essential drug procurement through the Pharmacy Division. However, the GOL continues to depend on donors to provide contraceptives and other health commodities, such as vaccines, anti-malarial drugs, anti-tuberculosis drugs, HIV test kits, ARV drugs, and other commodities included in UNFPA's emergency kits. The GOL should develop a financial sustainability plan for contraceptives and other vital RH drugs to better prepare for withdrawal of humanitarian NGOs as well as possible future withdrawal or scale back of current major donors of contraceptives. FHD and the RHTC should advocate for a budget line item for contraceptive procurement, and for the allocation and disbursement of funds for that purpose. In addition, RHTC should ensure that contraceptives and other vital RH drugs are included in the EML list of vital drugs to ensure they are given priority in NDS procurement decisions. Strategy 2.2: Mobilize donor commitment and specify procurement plans for funding contraceptives and other vital RH drugs at least one year in advance. Key contraceptive donors have not made any formal commitment to ensure that the contraceptives required are procured at the right time. Similarly, other donors have not communicated their future intentions regarding commodity procurement to the MOHSW or NDS. Normally when donors do make commitments they are short-term for a period of one year at most. This makes planning difficult. For example, key contraceptive donors have not made any formal commitment to ensure that the contraceptives required are procured at the right time. The MOHSW would benefit from knowing the extent of donor commitment in advance of their budget cycle, enabling them to identify and respond to funding gaps for any essential health commodity. The MOHSW should formally discuss with donors to secure their commitment to purchase all contraceptives for a clearly determined period of time. RHTC should produce annual three-year forecasts of contraceptive requirements and annual three-year quantifications of other vital RH drugs in order to determine budget requirements and mobilize donor resources to fill gaps. Forecasts and quantifications should be updated semi-annually, and MOHSW should convene donor meetings to review these forecasts and to adjust procurement plans as needed. Strategy 2.3: Ensure adequate funding is available for NDS to procure full supplies of all vital drugs on the EML. Currently, the NDS uses its own processes for determining which drugs to purchase based on its available funding. Without guidance from the MOHSW, NDS must decide what drugs to ration when inadequate funds limit its ability to order sufficient quantities to meet annual drug needs. Currently, NDS is stocked out of both magnesium sulfate and Oxytocin, both of which are vital drugs for emergency obstetric care. Although the cause of this stockout is hard to determine, NDS has no guidance about which drug stocks to monitor most closely. The GOL, after determining and designating vital drugs among those listed in the EML, should adequately fund vital drugs to ensure full supply, and direct NDS to ensure these vital drugs are given priority in fund allocation and procurement decisions. Strategy 2.4: Obtain adequate and sustainable funding for health promotion activities. The budget for implementing the BPHS includes line items for addressing the need for trained service providers as well as the commodity supply chain. However, no such line item exists for health promotion activities related to the roll out of the BPHS. A four-year budget estimate for health promotion activities should be developed and included in the National Health Plan budget. In addition, NHPD staff should participate in all coordination mechanisms. Strategy 2.5: Remove financial barriers to fully supplying health commodities, particularly essential and vital RH commodities and contraceptives, at the county level. To defray operational costs, NDS currently charges storage fees to donors using their storage space. In the past, users had been charged fees for services and drugs; however, this policy has been suspended for a period of two years, leaving counties to rely on the budget provided them by the central level to cover drug costs. Counties have been assured that the central level will step in if their funds for drugs are insufficient; however, this introduces a situation in which counties may choose to either charge users fees or purchase more vital and essential, curative health commodities over preventative commodities, such as contraceptives. Therefore, the GOL must ensure that decentralized financial management systems adequately fund the operational costs of storing and distributing all commodities, regardless of source. 3. Coordination Current Situation For RHCS to be achieved, coordination is essential at multiple levels. At the national level, the government must coordinate among many different MOHSW programs to ensure that all elements of the BPHS are closely coordinated, and that the MNH Road Map and RHCS strategy is integrated into comprehensive national strategies and action plans for service provider training, supply chain strengthening, and health promotion. In addition, the government must mobilize donor resources while preventing redundancies in donor programs, filling gaps, and ensuring that the government, not development partners, is driving the pace and the direction of implementation. Coordination is also essential at the county level. The county health and social welfare teams are the nexus of this coordination, but service delivery NGOs and faith-based organizations such as FPAL and CHAL must also be included at the county level on a routine bases to improve local coordination and collaboration. This is particularly true when NGOs and CHAL facilities access medicines, contraceptives, and other supplies through the county depots. Community mobilization campaigns are another area where coordination among county stakeholders is vital. At present, this degree of coordination does not exist. Vertical programs, with the support of specific donors and INGOs, are developing their own plans for training, and the training coordinator in the MOHSW is being urged to roll-out provider training on elements of the BPHS without having a comprehensive training strategy or roll-out plan. The Health Sector Coordinating Committee (HSCC) chaired by the Minister of Health & Social Welfare has begun the arduous task of coordinating all health activities at the national level and focusing partners on supporting the BPHS. In addition, the Reproductive Health Technical Committee (RHTC) has been established and is meeting with some regularity, but the productivity and scope of the committee is not as great as it could be. The RHTC needs to be strengthened so that it is productive and provides clear value to all stakeholders. Its relationship to the HSCC must be defined, as well as its role in coordinating with coordinating bodies for the roll-out of the BPHS. The RHTC also needs clear definition of membership—for instance, the National Drug Service (NDS), the Pharmacy Bureau, and the National Health Promotion Division (NHPD) of the MOHSW are not currently represented on the committee. Furthermore, attendance by stakeholder representatives is inconsistent, and many of the personnel attending the RHTC meetings lack the technical expertise or decision-making authority to fully contribute to the RHTC's work. At the county level, County Coordination Meetings have been introduced as a way to ensure that all GOL agencies, including the County Health Team (CHT) members, are meeting with outside stakeholders such as local representatives of INGOs, NGOs, and CHAL. However, this mechanism needs significant strengthening to ensure it functions as a routine implementation, coordinating, and problem-solving forum and not simply as an opportunity for presenting reports. Specific Objective 3 Strong coordination and partnership exists at all levels, and between all stakeholders and sectors, for the delivery of RH/FP services. Strategy 3.1: Strengthen existing mechanisms at the central level between the MOHSW and partners. The MOHSW has created two coordination mechanisms, the HSCC and the RHTC, to effectively use resources, increase communication among partners, and facilitate implementation of its activities. To strengthen the RHTC, the terms of references (TOR) of the committee should be reviewed and refined to clarify roles and responsibilities of the committee, of member agencies, and of subcommittees. The TOR should define membership of the RHTC stakeholders and level of decision-making authority of the stakeholder representatives. It should also establish routine participation of one-two CHT representatives on the RHTC. In addition, a budget line item for RH coordination should be included in the FHD budget that includes cost of CHT participation (travel and per diem costs) in RHTC meetings. Strategy 3.2: Strengthen the leadership capacity of the RHTC to ensure subcommittees are functional, stakeholders are attending and contributing as needed, and there is regular communication with the Health Sector Coordinating Committee on critical policy, financing, and resource mobilization issues. The RHTC currently lacks strong leadership and commitment by stakeholder representatives, resulting in low productivity and results, and creating a cycle of declining involvement and lowered expectations. The leadership capacity of RHTC must be strengthened through linkages and mentoring opportunities with high-functioning equivalent committees in neighboring countries. An RHCS Coordinator should be appointed and placed in the FHD to provide support to the RHTC and to monitor progress of RHCS activities. Strategy 3.3: Coordinate all activities related to RH/FP service provision, supply chain, and health promotion, including training in these skills. At both the national and the county levels, coordination must focus first of foremost on the routine elements of providing reproductive health and family planning services. At the national level, official subcommittees of the RHTC should be established in the TOR for service provision, supply chain, health promotion, and training. The RHTC TOR should also define the institutional membership of the subcommittees and the competency of stakeholder representatives. Finally, the subcommittees should be constituted and operationalized, with routine reporting to the RHTC on subcommittee tasks. Strategy 3.4: Establish and/or strengthen RH coordinating mechanisms at the county level. As part of the GOL's efforts to decentralize services, county coordinating mechanisms are being introduced in the 15 counties, under the chairmanship of the county administrator. However, county personnel need significant support and assistance to make these mechanisms productive for routine coordination of health activities such as provider training, health promotion campaigns, and access to supplies by private sector partners like FPAL and CHAL. To encourage the adoption of productive coordination practices for RH and family planning (FP) activities, the MOHSW should establish semi-annual meetings of the 15 county RH supervisors for regular RH/FP program monitoring and experience sharing on operational issues and challenges. Among other benefits, these meetings would encourage the RH supervisors to make RH/FP issues a routine agenda item at regular County Coordination Meetings. 4. Service Delivery Current Situation Providing clients with quality health care requires service providers capable of meeting clients' needs. Skilled service providers in Liberia are currently lacking since many fled the country during the war and have not returned. The strength of Liberia's current capacity for service delivery lies primarily in the commitment of the MOHSW as well as several international and local NGOs to continue to provide services and train providers during this transitional period. The extensive support for improving capacity among service providers in recent policies, plans, and roadmaps, specifically the National Health Policy, the National Health Plan, the Roadmap for Implementing the Basic Package of Health Services, and the MNH Road Map, is also significant. This commitment indicates a high level of awareness that capacity is extremely limited and yet will play a crucial role in the successful roll out of the BPHS. In addition, the MOHSW has created a position to coordinate the training required to improve existing service providers' skills in the five areas addressed in the BPHS. A person has been hired to fill this role, and she has a good understanding of the task at hand as well as the planning and coordination it requires, however additional support is needed to approach a task of this size. Specific Objective 4 Providers have the skills and materials necessary to satisfy client needs and demand. Strategy 4.1: Develop a national training strategy for service providers that includes reproductive health and family planning services. Many of the existing plans and roadmaps, particularly the MNH Road Map, focus on developing curricula, training trainers, and rolling out the training to the health facility level. Despite these strengths, the absence of a national training strategy and plan is noticeable and critical. The MOHSW, donors, and NGO plans to train trainers and service providers are not fully coordinated and are being implemented on an ad hoc, non-standardized basis. A national training strategy and plan must be developed not only to coordinate training sessions on different topic areas, but to standardize training curricula, assess training needs, and make provisions to ensure that services continue to be offered to clients when primary service providers are participating in sessions. Strategy 4.2: Develop and disseminate STGs for RH/FP to providers at all levels of the health system. Curricula for the BPHS will need to be based on standard treatment guidelines (STG) for reproductive health conditions, such as antenatal and emergency obstetrical care, as well as standards of practice (SOP) for services, such as family planning. Currently, many providers reported dispensing progestin only pills (POP) not only to lactating mothers but also to adolescents and younger women starting modern contraception for the first time. Generally, POP pills are indicated for nursing mothers only, with combined oral contraceptives (COC) as the pill of choice for all others unless there are particular medical reasons for not doing so. Protocols for contraceptives should be developed, and STGs should be developed for antenatal and emergency obstetric care. STGs for malaria control, intermittent preventive treatment (IPT) for pregnant women, and STIs have been recently revised. Strategy 4.3: Expand the provision of RH services through community health workers (CHW). Two other areas are mentioned in brief in the MNH Road Map: service provision, particularly for reproductive health and family planning services, by community health workers (CHWs), and coordinating efforts to supervise providers. These areas deserve additional attention given their potential not only to maintain provider skills once they have been trained, but to reach populations who cannot easily access health facilities. Strategy 4.4: Strengthen the existing system of supportive supervision at all levels. Current service providers do not receive regular supervisory visits. The transportation situation is such that any supervisory visits are conducted sporadically and then jointly to conserve resources. As with training, the number of skills that will need to be monitored through supportive supervision visits, including logistics and health promotion/counseling skills, must be incorporated into the existing supervisory checklists. Regular visits should be budgeted for and scheduled for all CHTs to monitor ongoing activities, identify potential problems as well as provide on-the-job training and thus refine capacity. Supervisory checklists should be reviewed and revised to ensure that FP protocols, RH STGs, and logistics and health promotion issues are routinely monitored during supervisory visits. 5. Client Use & Demand Current Situation Current use of reproductive health services from trained health providers is modest, in part due to lack of access. Nonetheless, in the 2007 LDHS, 79 percent of pregnant women reported attending at least one antenatal care (ANC) visit. Rural women, particularly in the North Central region of the country, reported lower attendance than urban women, reflecting the problem of access to services and information. Only 46 percent of births were attended by a trained health professional, and 37 percent of women delivered in a health facility. Only 39 percent of children have received the full range of vaccinations (BCG, measles, and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth)). Contraceptive use is still very low, at 11.2 percent, although it has risen slightly and the share of modern method CPR has increased to 10.2 percent. But short-term methods—particularly pills and injections—remain the most popular methods (3.8 and 4.1 percent respectively) while CPR for long-term methods such as IUDs (0.2 percent) and female sterilization (0.6 percent) is very low. This is probably due to the lack of access to trained providers for these methods, as well as a general absence of information about the benefits of long-term methods for women who have achieved their ideal family size. Lack of access to health services is a significant factor in the current situation. However, the lack of information is also an important constraint that must be addressed. Health promotion is one of the three essential pillars in delivering quality health care (the others being trained service providers and adequate supplies of vital health commodities). Health promotion delivers information and motivation that encourage health seeking behaviors, such as antenatal care, family planning, and immunizations. It is essential for family planning clients to make informed choices about their contraceptive methods. However, health promotion is entirely absent in both the MNH road map and the BPHS road map. In fact, the budget in the National Health Plan has no line item for health promotion activities. But without information, education, and communication (IEC) materials, and behavior change communication (BCC) and community mobilization campaigns, people will not know about the services available under the BPHS and will not have the information or motivation needed to increase healthy behaviors that reduce maternal and infant mortality, lower the total fertility rate, and improve disease control and prevention. A comprehensive health promotion strategy is needed for all services offered under the BPHS, with sufficient financial and human resources to implement campaigns for each of the service areas in the package. Such a strategy should include a social marketing branding campaign with a service logo that identifies facilities that offer the full range of BPHS services from fully trained and certified providers. Achieving specific continuing education requirements for the providers should be a criterion for maintaining and renewing this brand, and successful renewal should be tied to provider bonuses or other financial incentives. Specific Objective 5 Clients have the information required to access the RH services and supplies they need. Strategy 5.1: Ensure that RH/FP IEC/BCC activities are integrated with the national roll-out of provider training and commodity supply. The NHPD is developing a BPHS health promotion strategy, and it will include reproductive health and family planning IEC/BCC activities. However, the capacity of the NHPD to implement such a strategy is very limited. Furthermore, health promotion activities will likely require training, so it is essential to integrate IEC/BCC/health promotion skills into a national BPHS training strategy and plan. The health promotion strategy should include a materials dissemination plan that ensures all facilities are stocked with appropriate health promotion display posters/charters and consumable materials. There should be a catalog of display and consumable information materials for each level of facility. NHPD, in collaboration with other BPHS stakeholders, should determine the quantities of display and consumable materials for each level of facility and the gross number required for full supply of all facilities. A routine supply chain for consumable information materials should be established and integrated into drug LMIS reporting and requisition vouchers. A monitoring system is required to ensure supervisors conduct routine checks of display and consumable information materials at the facility level. Strategy 5.2: Increase health seeking behaviors among women of reproductive age (WRA) to 70 percent (strategic indicator: percent of pregnant women attending four ANC visits). The MNH Road Map seeks to ensure the availability and accessibility to quality services to at least 70 percent of pregnant women and children by 2015. Although data is still unavailable from the LDHS, the number of women making four antenatal care visits to health clinics is assumed to be significantly lower than 70 percent, and CPR is very low. Therefore, efforts are needed to increase health seeking behavior by women of reproductive age, with pregnant women as the representative group. Programs that target WRA should develop an integrated promotion strategy and campaigns. Because donor-support INGOs have gained significant experience in conducting these coordinated campaigns in parts of Liberia, these past experiences/best practices should be shared with all stakeholders working in RH/FP and safe motherhood. Strategy 5.3: Promote access to, and use of, neglected methods: IUD, female condom, emergency contraceptive, voluntary surgical contraception (male and female). Contraceptives currently available to clients are limited to temporary methods (hormonal pills, condoms, and injectables). Access to IUDs and male/female sterilization is hampered by the absence of a trained cadre of providers as well as space and equipment. Similarly, emergency contraceptives are available and offered by a very limited number of NGOs and medicine stores. A sizeable stock of female condoms is available in country, but awareness among the population is extremely low. Increasing the awareness of and access to these neglected methods will expand the range of methods from which clients can choose based on their need. In addition to health facility staff, community health workers need to be trained and given IEC materials to conduct direct marketing of benefits of neglected methods to the community. All IEC materials should include the full range of contraceptive methods. Strategy 5.4: Specifically target adolescents on the benefits and importance of family planning. The strategy is worth mentioning, since it is a vital element of any effective RHCS strategy. However, it is adequately addressed in both the National Health Plan (area 3) and the MNH Road Map (section 3.6.7). 6. Supply Chain Current Situation Significant support for an effective and efficient supply chain has been generated at the national level. The National Health Policy, National Health Plan, the Roadmap for Implementing the Basic Package of Health Services, and the MNH Road Map all refer to the need to provide facilities with commodities. In addition, the counties, NGOs, and the National Drug Service have institutional memories of a time when the system functioned in a satisfactory manner, particularly when compared with the existing state of the supply chain. In the post-conflict setting today, the weak capacity of the public sector supply chain creates a vacuum in which vertical supply chains, driven by program and donor interests, emerge to provide commodities to facilities. An effective and efficient logistics system is comprised of several important components, including a logistics management information system (LMIS) and inventory control procedures. Well thought out inventory control procedures help facilities issuing and distributing commodities to maintain adequate stock levels and avoid both stock outs, stockpiling and, consequently, significant expiries. Based on these procedures, the LMIS collects accurate and timely data, which can be used to make better decisions regarding ordering and distributing commodities among the different levels of the system. Currently, the system is very weak. Reporting through the LMIS is very irregular and, when done, the data is often incomplete or inaccurate. Inventory control procedures are not followed or are inadequate, resulting in frequent stockouts of many vital commodities. Storage conditions are poor, and transport for health commodity distribution is extremely limited or, where it exists, is not integrated, but serves a single vertical program. Specific Objective 6 An effective and efficient supply chain exists for contraceptives and essential RH commodities that ensures the availability of products to all people who need them throughout the country. Supply Chain Capacity Strategy 6.1: Develop a functional and integrated logistics system for all essential drugs, including contraceptives and reproductive health commodities. At the central level, NDS has established maximum and minimum inventory control levels and procedures, however, these seem to have fallen out of practice in the context of the limited funds NDS has for procurement purposes and the donor driven procurement practices of other programs, such as GFATM and UNFPA. At the county and facility level, order quantities are arrived at via guesswork based on estimates of future demand with no reference to order intervals or maximum or minimum stock levels. Each vertical system currently operating in Liberia has its own system for reporting and managing stock levels. This is reflected in NDS's ACCESS-based tool for managing their stock. Within this inventory management system, each program has a separate database for commodities financed by various donors. The MOHSW's basic reporting system consists of forms and reports; this system does not routinely collect all types of logistics data needed and the system is not fully functional. The FHD forms and reports on service statistics collect supply received, supply issued, balance on hand, and some consumption information for contraceptives by way of new clients and revisits, but fails to collect data on losses and adjustments. The Monthly Reproductive Health MCH/Family Planning Report, currently undergoing revision, also collects information on antenatal visits, IPT, and PMTCT, vaccination, and vitamin A dispensed. The Requisition and Issue Form, available at the FHD, only includes quantity requested, quantity approved, and quantity issued for contraceptives. Strategy 6.2: Strengthen the integration of contraceptives into the NDS supply chain. Vertical systems, such as those for contraceptives as well as HIV/AIDS, TB, and antimalarial drugs currently in place, are frequently used at the request of donors interested in maintaining oversight. By integrating contraceptives into a comprehensive NDS supply chain, resources can be consolidated and effectively used to manage all commodities. Strategy 6.3: Ensure all personnel with logistics functions have the capacity and support to perform them. Clear job descriptions that are well communicated to all players in the supply chain to help those with logistics system responsibilities understand their roles in assuring RH commodity supply. The current tasks and responsibilities of those involved in the contraceptive and essential drug supply chain, particularly at the county level, are not well defined or understood by personnel. Ordering and collecting contraceptives has previously been the responsibilities of the RH Supervisor at the county level. Recent efforts to make distribution more efficient have led the FHD to ask the county health officers (CHO) to submit orders and pick up contraceptives when doing the same task for other essential drugs. However, this effort has not been well received by all CHOs, leading to contraceptive orders being left behind and increasing the potential for contraceptive stock outs. At the central level, this has meant that, once order requests are made, several different MOHSW divisions become involved in the request approval process, introducing another obstacle to NDS's ability to fill orders and distribute commodities on schedule. Strategy 6.4: Determine the vital reproductive health commodities to be procured at full supply levels. As recently as February 2007, the Essential Medicines List did not include contraceptives, instead referring to the Family Health Department (FHD) for more information. In the intervening months, the Pharmacy Division revised the EML and the new list, released in August 2007, now includes contraceptives. However, the current EML does not give any indication of priority, in terms of vital or essential, among the various drugs. In a situation where resources are limited and forecasted drug requirements are rarely procured in full supply, indicating the essential drugs that are vital, essential, and necessary has the potential to guide NDS's plans for procurement as well as donor support as necessary. Forecasting/Supply Planning and Procurement Strategy 6.5: Build in-country capacity to prepare reliable contraceptive forecasts and reproductive health drug quantifications. Having a reliable supply of contraceptives and essential RH commodities available requires accurate forecasting. Thus far, contraceptive forecasts have been prepared by outside consultants at the ad hoc request of the donors procuring them. As a result, in-country capacity and experience in contraceptive forecasting is limited. NDS has a procurement team consisting of four members with some experience in quantification of essential drugs that can be built on. To ensure regular and reliable forecasts for all essential drugs and contraceptives, the MOHSW should take concrete actions to build its internal capacity for forecasting. Strategy 6.6: Develop in-country capacity to procure contraceptives. Through the Pharmacy Division's budget, NDS received limited funding to procure essential drugs. As a result, they have developed some capacity to estimate drug requirements, plan procurements, and restricted tendering from a list of pre-approved suppliers. Since contraceptives were not included on the EML until recently and because they are managed vertically by UNFPA, NDS has no experience in procuring contraceptives and does not have market knowledge of contraceptive suppliers. Gaining this experience is critical for the sustainability of the family planning program in Liberia. Strategy 6.7: Coordinate essential drug quantification, including forecasts for contraceptives and other RH commodities, and supply planning among the MOHSW and donors. Various donors and programs, primarily GFATM and USAID, have their own capacity to conduct quantification exercises for the commodities they provide. This process of developing separate forecasts for program specific commodities creates a situation where procurement of critical commodities may be overlooked or other commodities may be procured by one or more programs in excess of the combined need, wasting precious financial resources. To decrease the risk of both stocking out or overstocking, an inclusive process that coordinates both drug estimates as well as identifies funding gaps should be introduced. Storage and Transportation Strategy 6.8: Improve transportation capacity to support supply distribution. During the conflict, NGOs providing services established their own systems for supplying their facilities with health commodities and other goods. As NDS reestablished itself post conflict, some NGOs directly purchased essential drugs from NDS and received contraceptives free of charge from the UNFPA warehouse. NDS has limited transportation capacity (one one-ton truck and two pickups), thus NGOs use their own vehicles to distribute commodities to their facilities. In an effort to avoid further disruption of humanitarian INGOs withdrawing their services, the government now encourages remaining NGOs to obtain their essential drugs and contraceptives from the county health departments. Although NDS periodically uses their vehicles to distribute essential drugs, their schedule is sporadic and disrupted by an unpredictable order approval process. In response, counties collect contraceptives and essential drugs themselves when they arrive at the central level to submit their requests. Strategy 6.9: Ensure storage capacity at all levels that is adequate in terms of security and space and guarantees product quality and sufficient quantity to meet downstream needs. At the county level, depots constructed by the GFATM are located in nine counties and are meant to meet the storage needs of all fifteen counties, introducing some contention among counties without a depot. County depot staff include a Focal Person, hired by the County Health Team with NDS providing their incentive, and a Depot Assistant, who is paid through Round Six Global Fund and trained by NDS to manage the depot. Although these depots were meant to store only GFATM commodities, counties have been using them to store other health commodities as well. The exception is contraceptives, for which the RH Supervisors are responsible and are therefore frequently kept in the RH Supervisor's office where storage conditions are poor. Among the depots, storage conditions vary. Some have racks and are climate controlled, but these features are not standardized among all of the depots. County health departments are also concerned that the storage space may not be adequate, particularly in light of high-volume commodities, such as bed nets and condoms. At the central level, NDS's storage complex is comprised of several large buildings. Plans to relocate the warehouse to an area outside of Monrovia have been made; however, funding has only allowed implementation of these plans as far as the purchase of land. As with NDS's inventory management system, commodities from different donors for their vertical program are stored separately. For instance, UNFPA rents space from NDS for storing contraceptives. The GFATM also has a specific area, including a cold room, of the NDS warehouse for their commodities. Strategy 6.10: Strengthen the system and procedures for handling expired and/or damaged products at all levels. Clients expect to receive high quality, potent commodities when they receive them from health facilities. When expired or damaged commodities are not disposed of properly, there is a risk that they will find their way into clients' hands. Despite the existence of procedures for expired stock, they are not being fully or properly followed. Currently, facilities and counties are instructed to keep their expired or damaged stock until NDS is able to collect and dispose of them properly. Although most facilities are rumored to have incinerators, it is unlikely that they are being used, particularly in light of the collection procedure followed by NDS. At the central level, the incinerator is no longer functional. While NDS has plans to construct a new incinerator on land outside of Monrovia, financing has not yet been secured. Monitoring & Evaluation The RHCS Operational Plan includes indicators for each priority activity listed. The RH Technical Committee, with support from UNFPA, is responsible for monitoring progress of the operational plan during monthly meetings, and for ensuring funded activities are implemented within the indicated timeline, or that appropriate adjustments to the operational plan are made when activities are delayed. The RHTC, through the Health Sector Coordinating Committee, should advocate for funding from development partners for all unfunded activities. The cause of funded activity delays must be analyzed and addressed by the RHTC. Finally, strategies should be assessed semi-annually to determine their effectiveness in achieving the specific objectives presented in this strategy. Operational Plan 1. Policy Environment Specific Objective: The policy environment at the national, county, and local levels sustains and supports the objectives of this strategy. Strategy Activity Timeline Target Lead Agent(s) Objectively Verifiable Indicator Means of Verification Cost 2008 2009 2010 2011 2012 1.1 Adapt the existing RH Policy, particularly the FP component to the current situation. 1.1.1 Review the existing RH Policy and recommend revisions. HSCC RHTC Recommendations are developed for the RH Policy List of recommendations for revision $6,000 1.1.2 Approve and adopt revised RH Policy GOL HSCC RH Policy is adopted by the GOL New RH Policy $4,000 1.1.3 Operationalize new RH policy by incorporating additional strategies and actions into the MNH Road Map and the BPHS Road Map. MOSHW RHTC FHD Existing strategies include updates from RH Policy Revised strategies $2,000 1.2 Define the procedures for selecting the methods and the brands of contraceptives approved for the country. 1.2.1 Review the current method mix and incorporate strategies to expand access to long-term methods into the MNH Road Map. FHD RHTC MNH Roadmap includes strategies reflecting new position of the RHTC on method mix MNH Roadmap, RHTC meeting minutes $10,000 1.2.2 Review which COC and POP brands should be procured (by donors and/or by NDS) and advise on brand selection as part of annual procurement planning for contraceptives. HSCC NDS UNFPA USAID RHTC FHD Annual procurement plans for contraceptives reflect the consensus on brands Annual procurement plans $9,000 1.3 Define the scope and role of FPAL and CHAL in providing FP services, specifically in collaboration with the public sector. 1.3.1 Review past collaboration mechanisms and enter into memorandums of understanding (MOU) or other contractual mechanisms with FPAL, CHAL, and any other donor-supported partner working in health care delivery. FPAL CHAL Other INGOs RHTC MOHSW HSSP Contractual mechanisms clearly communicate the terms of collaboration between FPAL, CHAL, and the MOHSW Signed contractual mechanisms $2,000 1.4 Ensure that the commercial sector provides safe and affordable quality FP products and services to clients. 1.4.1 Improve monitoring of pharmacies and medical stores and ensure they are staffed by adequately trained pharmacy dispensers. Pharmacies Medical stores RHTC Pharmacy Bureau Increased quality of service by the commercial sector Number of monitoring visits made $15,000 1.5 Increase access to contraceptives in the private sector through the introduction of social marketing for contraceptives including condoms for prevention of STIs. 1.5.1 Review social marketing best practices in other countries. UNFPA RHTC Data collected on social marketing in other countries List of best practices $20,000 Develop proposals for the Health Sector Steering Committee to consider and, if required, to take to the parliament for appropriate legislation. HSSP Parliament RHTC HSCC is briefed on social marketing Proposal for the HSCC $10,000 2. Finance Specific Objective: There is sustainable and equitable financing for the delivery of contraceptive and reproductive health products and services and related health promotion services. Strategy Activity Timeline Target Lead Agent(s) Objectively Verifiable Indicator Means of Verification Cost 2008 2009 2010 2011 2012 2.1 Obtain direct GOL support for reproductive health commodity procurement. 2.1.1 Develop a financial sustainability plan for contraceptives and other vital RH drugs to prepare for withdrawal of humanitarian NGOs as well as possible future withdrawal or scale back of current major donors of contraceptives. MOF Donors MOHSW FHD RHTC $10,000 2.1.2 Advocate for a budget line item for contraceptive procurement, and for the allocation and disbursement of funds for that purpose. MOF MOHSW/OFM MOHSW FHD RHTC $10,000 2.2 Mobilize donor commitment and specify procurement plans for funding contraceptives and other vital RH drugs at least one year in advance. 2.2.1 Conduct annual funding gap analyses based on estimated requirements. Forecasting/ Supply Planning Committee Forecasting/ Supply Planning Committee Funding gaps for estimated drug requirements identified Funding Gap Analysis $50,000 2.2.2 Schedule and hold semi-annual Forecasting/Supply Planning meetings with donors to present supply plans and gap analysis results. GOL Donors Forecasting/ Supply Planning Committee GOL and donors have information on current funding gaps for procuring drug estimates Semi-annual Forecasting/ Supply Planning meeting notes $125,000 2.2.4 Advocate for donor commitment regularly. Donors Forecasting/ Supply Planning Committee Supply Plan includes donor commitments Supply plan $7,000 2.3 Ensure adequate funding is available for NDS to procure full supplies of all vital drugs on the EML. 2.3.1 Adequately fund vital drugs (as determined in EML) to ensure full supply. MOF Donors MOHSW HSCC Vital drugs are fully funded based on requirement estimations Number of stock outs To be determined by forecasts 2.3.2 Issue policy directing NDS to ensure vital drugs are given priority in fund allocation and procurement decisions. NDS MOHSW Pharmacy Bureau FHD Policy giving vital drugs priority in fund allocation and procurement decisions Fund allocations and procurement documentation $2,000 2.4 Obtain adequate and sustainable funding for health promotion activities. 2.4 1Estimate the 4 year costs of activities HSCC MOHSW NHPD Costs of health promotion activities determined Health promotion budget $5,000 2.4.2 Include a health promotion line in the National Health Plan budget for campaigns, materials, and technical assistance HSSP MOF OFM MOHSW NHPD NHPD has a line item in the National Health Plan budget National Health Plan budget $1,000 2.4.3 Health promotion is represented at all coordination meetings RHTC Other Coord Mechanism NHPD NHPD regularly attends coordination meetings Meeting minutes $1,000 2.5 Remove financial barriers to fully supplying health commodities, particularly essential and vital RH commodities and contraceptives, at the county level. 2.5.1 Participate in the design of decentralized financial management systems to ensure adequate funding of the operational costs of storing and distributing all health commodities, regardless of source. MOF OFM FHD OFM NDS Operational costs of storing and distributing costs are adequately funded Financial Management System $10,000 3. Coordination Specific Objective: Strong coordination and partnership exists at all levels, and between all stakeholders and sectors, for the delivery of RH/FP services. Strategy Activity Timeline Target Lead Agent(s) Objectively Verifiable Indicator Means of Verification Cost 2008 2009 2010 2011 2012 3.1 Strengthen existing mechanisms at the central level between the MOHSW and partners. 3.1.1 Review and refine the RHTC terms of references to define stakeholder membership on the RHTC and its subcommittees, and level of decision-making authority of the stakeholder representatives. It should also establish routine participation of one-two CHT representatives on the RHTC. Donors NGOs INGOs CHTs FHD RHTC Clear terms of reference for the RHTC, including county representation RHTC TOR $6,000 3.1.2 Include a budget line item for RH coordination in the FHD budget that includes cost of CHT participation (travel and per diem costs) in RHTC meetings. OFM FHD CHT participation in RHTC meetings is included in RHTC budget RHTC budget line item for county travel and per diem $1,500 3.2 Strengthen the leadership capacity of RHTC to ensure subcommittees are functional, stakeholders are attending and contributing as needed, and there is regular communication with Health Sector Coordinating Committee on critical policy, financing, and resource mobilization issues. 3.2.1 Hire and place a full-time RHCS Coordinator at the FHD to support the RHTC and monitor RHCS activities. MOHSW UNFPA FHD RHCS Coordinator hired and placed in the FHD RHCS Coordinator placed in FHD $24,000 3.2.2 Identified leaders, including county representatives, of the RHTC conduct a study tour with Ghana's RHTC to identify key steps to Ghana's success, see how Ghana's committee functions, review Ghana's TOR, etc. RHTC MOHSW FHD RHTC leadership RHTC Leaders submit a report summarizing the strengths, weaknesses, and best practices identified in Ghana and present their findings to the RHTC Trip Report RHTC meeting minutes $57,000 3.2.3 Ongoing communication with Ghana's RHTC as "sister organization." RHTC RHTC Leadership Results of communication shared with greater RHTC RHTC meeting minutes $10,000 3.2.3 Conduct advocacy training for RHTC to improve RHTC member capacity level RHTC MOHSW FHD RHTC leadership Completion of the advocacy training Certificate of completion $30,000 3.3 Coordinate all activities related to RH/FP service provision, supply chain, and health promotion, including training in these skills. 3.3.1 Establish subcommittees of the RHTC in the TORs for service provision, supply chain, health promotion, and training. The RHTC TOR should define the institutional membership of the subcommittees and the competency of stakeholder representatives. Donors NGOs INGOs CHTs FHD RHTC MOHSW At least four subcommittees have TORs Sub-committee TORs $3,000 3.3.2 Constitute and operationalize the subcommittees with routine reporting to the RHTC on subcommittee tasks. RHTC subcommittees RHTC Sub-committees begin meeting and complete tasks RHTC and sub-committee notes $500 3.4 Establish and/or strengthen RH coordinating mechanisms at the county level. 3.4.1 Establish semi-annual meetings of the 15 county RH supervisors for regular RH/FP program monitoring and experience sharing on operational issues and challenges. UNFPA MOHSW FHD CHTs County RH supervisors meet regularly RH supervisor meeting schedule and notes $8,000 3.4.2 Provide support to County RH supervisors to make RH/FP issues a routine agenda item at regular County Coordination Meetings. UNFPA MOHSW FHD RH/FP issues are discussed at County Coordination Meetings County Coordination meeting notes $15,000 4. Service Delivery Capacity Specific Objective: Providers have the skills and materials necessary to satisfy client needs and demand. Strategy Activity Timeline Target Lead Agent(s) Objectively Verifiable Indicator Means of Verification Cost 2008 2009 2010 2011 2012 4.1 Develop a national training strategy for service providers that includes reproductive health and family planning services. 4.1.1 Determine training needs of existing service providers. Nationwide MOHSW Training Coordinator Service providers' training needs have been identified and categorized Training Needs Assessment Report $37,000 4.1.2 Evaluate existing curricula relevant to the BPHS. Nationwide MOHSW Training Coordinator Curricula meeting the needs and standards of the BPHS identified List of existing curricula to be used in National Training $10,000 4.1.3 Develop curricula to address any areas of the BPHS not included in existing curricula. Nationwide MOHSW Training Coordinator Additional curricula for the BPHS developed to standard Curricula $125,000 4.1.4 Develop a national BPHS training strategy that includes a means for continuous provision of services. Nationwide MOHSW Training Coordinator National Strategy outlines the approach to standardized training in the BPHS National Training Strategy $10,000 4.1.5 Develop a master plan and schedule for all components of service provider training. Nationwide MOHSW Training Coordinator Master plan and schedule for BPHS training includes all relevant components Master Training Plan and Schedule $10,000 4.2 Develop and disseminate STGs for RH/FP to providers at all levels of the health system. 4.2.1 Review existing STGs/SOPs. Nationwide MOHSW FHD STGs/SOPs are updated to reflect changes in practice, treatment, and the EDL Updated STGs/SOPs $10,000 4.2.2 Develop STGs for antenatal care, emergency obstetric care, and SOPs for contraceptives. Nationwide MOHSW FHD New STGs and SOPs are fully developed and reflect current practices and treatments STGs for Antenatal Care, STGs for Emergency Obstetric Care, and SOPs for Contraception $45,000 4.2.3 Integrate into a comprehensive STG/SOP document and disseminate to providers. Nationwide MOHSW FHD Service providers have a comprehensive STG/SOP document Comprehensive RH/FP Standards for Treatment and Practice $10,000 4.3 Expand the provision of RH services through Community Health Workers (CHW)s. 4.3.1 National meeting to share experience from MOHSW, Africare and FPAL programs. Central and County MOHSW (FHD) Africare FPAL Increased awareness of the lessons learned and best practices for CHW programs Meeting notes $1,000 4.3.2 Develop a standard job description for CHWs. Community MOHSW FHD Africare FPAL CHWs have a clear understanding of their responsibilities Job description $1,500 4.4 Strengthen the existing system of supportive supervision at all levels. 4.4.1 Strengthen/clarify the supervision component in the MNH Roadmap and other national plans. MHH Roadmap MOHSW FHD WHO RHTC MNH Roadmap includes a strategy focused on improving supportive supervision Supportive Supervision strategy and activities in MNH Roadmap $1,000 4.4.2 Review existing supervisory checklists and identify gaps. Central County MOHSW CHT NGOs? All skills and tasks are identified for inclusion on position specific supervisory checklists List of skills and tasks for each position $8,000 4.4.3 Produce and disseminate a comprehensive supervisory checklist. Service Providers and Supervisors MOHSW CHT Position specific supervisory checklists include technical, health promotion, and logistics skills Comprehensive Supervisory Checklist for each position $5,000 5. Client Use & Demand Specific Objective: Clients have the information required the access the RH services and supplies they need. Strategy Activity Timeline Target Lead Agent(s) Objectively Verifiable Indicator Means of Verification Cost 2008 2009 2010 2011 2012 5.1 Ensure that RH/FP IEC/BCC activities are integrated with the national roll-out of provider training and commodity supply. 5.1.1 Integrate IEC/BCC/health promotion skills into a national BPHS training strategy and plan. MOHSW BPHS Coord. Committee NHPD Training Coordinator National Training Strategy includes a component on health promotion skills National Training Strategy $3,000 5.1.2 Develop a catalogue of display and consumable information materials for each level of facility. MOHSW FPAL CHAL CHTs NHPD Display and consumable information materials available for each facility Catalogue of display and consumable information materials $3,000 5.1.3 Determine the quantities of display and consumable materials for each level of facility and the gross number required for full supply of all facilities. MOHSW FPAL CHAL CHTs MOHSW NHPD RHTC BPHS Coord Com Order quantities of display and consumable materials known by level and nationally Order invoice $3,000 5.1.4 Develop a materials dissemination plan in the health promotion strategy that ensures all facilities are stocked with appropriate health promotion display posters/charters and consumable materials. Health Facilities NHPD MOHSW RHTC Materials dissemination plan is developed for all facilities Materials dissemination plan $5,000 5.1.5 Establish a routine supply chain for consumable information materials and integrate it into drug LMIS reporting and requisition vouchers. CHTs Health Facilities NHPD NDS Routine supply chain for IEC materials integrated into integrated LMIS Integrated LMIS forms $7,000 5.1.6 Incorporate IEC materials in the supervisors checklist to monitor display and consumable information materials at the facility level. MOHSW CHTs NHPD HR IEC materials are routinely monitored Supervisory Checklist $3,000 5.2 Increase health seeking behaviors among women of reproductive age (WRA) to 70 percent (strategic indicator: percent of pregnant women attending four ANC visits). 5.2.1 Coordinate health promotion targeting WRA through integrated promotion strategies and campaigns. MOHSW INGOs FPAL CHAL RHTC NHPD Promotion strategies and campaigns target WRA are developed Promotion strategy and campaigns $25,000 5.2.2 Share past experiences/best practices of donor-support INGOs in conducting coordinated campaigns in parts of Liberia with all stakeholders working in RH/FP and safe motherhood. MOHSW FPAL CHAL RHTC NHPD Best practices for coordinated campaigns are identified and share among partners Meeting minutes $2,000 5.3 Promote access to, and use of, neglected methods: IUD, female condom, emergency contraceptive, voluntary surgical contraception (male and female). 5.3.1 Train health facility staff and community health workers to conduct direct marketing of benefits of neglected methods to the community. Providers CHWs RHTC NHPD Training Coordinator Health facility staff complete training on conducting direct marketing on benefits of neglected methods Certificate of completion $75,000 5.3.2 Develop and provide CHWs IEC materials that include the full range of contraceptive methods. CHWs RHTC NHPD CHWs have materials to promote informed choice Supervisory checklist $100,000 5.4 Specifically target adolescents on the benefits and importance of family planning. See National Health Plan (area 3) and the MNH Road Map (section 3.6.7). 6. Supply Chain Specific Objective: An effective and efficient supply chain for contraceptives and essential RH commodities that ensures the availability of products to all people who need them throughout the country. Strategy Activity Timeline Target Lead Agent(s) Objectively Verifiable Indicator Means of Verification Cost 2008 2009 2010 2011 2012 6.1 Develop a functional and integrated logistics system for all essential drugs, including contraceptives and reproductive health commodities. 6.1.1 Determine what range of commodities will be included in the integrated system. NDS MOHSW NDS MOHSW USAID UNFPA UNICEF GFATM FPAL CHAL List of commodities included in the integrated system LMIS forms (Stock cards, Request and Issue Vouchers) $4,500 6.1.2 Evaluate the current inventory control system procedures to determine its capacity to manage stock levels of the expanded range of commodities included in the integrated system. NDS MOHSW health facilities NDS MOHSW Recommendations for ICS for integrated system shared at Integrated System Design Workshop Minutes from Integrated Logistics System Design Workshop $35,000 6.1.3 Conduct an integrated system redesign workshop, with vertical programs' involvement. NDS MOHSW NDS MOHSW UNFPA USAID GFATM FPAL CHAL Integrated Logistics System Integrated Logistics System SOPs $40,000 6.1.4 Redesign standardized LMIS forms to support new integrated supply chain system. NDS MOHSW NDS MOHSW UNFPA USAID GFATM FPAL CHAL New forms include essential logistics data for selected commodities in the integrated logistics system LMIS forms $6,500 6.2 Strengthen the integration of contraceptives into the NDS supply chain. 6.2.1 Ensure contraceptives store staff are integrated into NDS' management structure. NDS NDS UNFPA Contraceptive store staff included in NDS' organization chart NDS organization chart $3,000 Advocate for the inclusion of contraceptives in the integrated logistics system. NDS MOHSW FHD UNFPA Contraceptives included on the list of commodities handled by the ILS LMIS forms (stock cards, request and issues vouchers, daily registers) $700 6.3 Ensure all personnel with logistics functions have the capacity and support to perform them. 6.3.1 Provide job descriptions that clearly define the different roles and responsibilities of personnel with logistics responsibilities. NDS MOHSW NDS MOHSW FPAL CHAL Roles and responsibilities for all logistics activities at all levels of the system are clear and communicated Job descriptions $6,500 6.3.2 Integrate logistics supervision and monitoring into supportive supervision plans. NDS MOHSW NDS MOHSW Supportive supervision checklists include logistics tasks and visits are conducted jointly Supervision checklist and county supervision schedules $3,000 6.3.3 Integrate plans to train personnel in logistics into the national training strategy. MOHSW Training Coordinator NDS MOHSW Roll out of logistics training is included in National Training Strategy and Plan National Training Strategy and Plan/Schedule $3,000 6.4 Determine the vital reproductive health commodities to be procured at full supply levels. 6.4.1 Designate contraceptive & priority RH drugs as vital on the EDL. Pharmacy Division Pharmacy Division NDS Essential drugs are categorized as vital, essential, and necessary Addendum to EDL $6,500 6.4.2 Require and fund NDS to procure vital drugs at full supply levels. NDS NDS MOHSW Reduced number of stock outs of vital drugs Physical inventory, stock cards $1000 (not including commodity costs) 6.5 Build in-country capacity to prepare reliable contraceptive forecasts and reproductive health drug quantifications. 6.5.1 Establish regular forecasting exercises. MOHSW Forecasting/Supply Planning Committee Forecasts reflect national stock situation and client demand Updated forecasts for essential drugs and contraceptives $1,000 6.5.2 Advocate for inclusion of developing in-country capacity as part of the forecasting exercises. MOHSW NDS Forecasting/Supply Planning Sub –Committees In country representation on Forecasting/Supply Planning Committee and Sub-Committees Forecasting/Supply Planning Committee and Sub-Committees Roster $700 6.5.3 Train Forecasting/Supply Planning Committee in at least two contraceptive forecasting and drug quantification methods. Central Level Forecasting/Supply Planning Committee and Sub –Committees Reconciliation of two forecasts for contraceptives and essential drugs, respectively Forecast Justifications $40,000 6.6 Develop in country capacity to procure contraceptives. 6.6.1 NDS to review procurement systems and suppliers for major contraceptive procurement agencies: USAID, UNFPA. NDS NDS USAID UNFPA Contraceptive orders placed by NDS Contraceptive Procurement Tables; RHI $1,000 6.7 Coordinate essential drug quantification, including forecasts for contraceptives and other RH commodities, and supply planning among the MOHSW and donors. 6.7.1 Form a Forecasting/Supply Planning Committee, including representatives of NDS, Pharmacy, Donors, MOHSW. Central Level NDS MOHSW Pharmacy Division Donors Members to participate in the Forecasting/Supply Planning Committee identified Forecasting/Supply Planning Committee Roster $1,500 6.7.2 Form sub-committees that forecast for key program commodities (i.e.: RH, malaria, HIV/AIDS, etc), each including representatives from NDS, Pharmacy Division, appropriate program managers, and appropriate MOHSW division. Central Level NDS MOHSW Pharmacy Division Program Managers At least three sub-committees in place (RH, Malaria, HIV/AIDS) and members identified Forecasting/Supply Planning Committee organizational chart and sub-committee rosters $1,500 6.7.3 Develop TOR for the Forecasting/Supply Planning Committee and its sub-committees that includes preparing forecasts, reviewing forecasts, conducting gap analyses, ensuring funding for forecasts, and procuring commodities. Forecasting/Supply Planning Committee NDS MOHSW Pharmacy Division Donors Forecasting/Supply Planning Committee TORs clearly define the roles and responsibilities of the committee and its sub-committees. TOR for Forecasting/Supply Planning Committee $3,000 6.7.4 Sub-committees schedule and hold regular forecasting exercises, at least once every six months. Forecasting/ Supply Planning Sub-committees Forecasting/Supply Planning Sub- committee Regular forecasting exercises are conducted Forecasting schedule and meeting notes $100,000 6.8 Improve transportation capacity to support supply distribution and supervision. 6.8.1 Define transportation requirements at all levels. Nationwide NDS MOHSW CHT Transportation requirements are clearly identified List of transportation requirements $3,000 6.8.2 Map health commodity distribution routes. Nationwide NDS MOHSW CHT FPAL CHAL All routes to health facilities requiring commodities and current road conditions identified Distribution route map, including a legend indicating road condition $30,000 6.8.3 Develop a comprehensive distribution schedule. Nationwide NDS MOHSW CHT Agreed upon distribution schedule for all facilities Integrated Logistics System SOPs $7,000 6.8.4 Budget for maintenance, driver, fuel. Nationwide NDS MOHSW CHT Line items for vehicle maintenance, driver, and fuel NDS and county budgets N/A 6.8.5 Synchronize MOHSW order approvals for vertical programs with NDS essential drug distribution schedule. MOHSW NDS MOHSW MOHSW signatories follow NDS' essential drug distribution system Requisition Form $700 6.9 Ensure storage capacity that is adequate in terms of security and space and guarantees product quality and sufficient quantity to meet downstream needs. 6.9.1 Calculate the existing storage space at the central and county levels. Central County NDS CHT Storage capacity of all warehouses and depots on record Posted capacity parameters at warehouses and depots $30,000 6.9.2 Design racking systems in line with storage capacity at county depots. County NDS CHT Appropriate racking system for each depot identified County depot racking system plan $10,000 6.9.3 Procure and construct racking systems at county depots. County NDS CHT County depots have racking system Depot Supervision Visit Contingent upon results of design 6.9.4 Post storage guidelines in each warehouse, depot, and health facility. Nationwide NDS CHT Facilities Storage guidelines posted in each storage facility/area nationwide Supervision checklist $500 6.10 Strengthen the system and procedures for handling expired and/or damaged products at all levels. 6.10.1 Review current procedures; amend if necessary. Nationwide NDS Updated procedures for handling expire/damaged product are available National Procedures for Expired/Damaged Products $2,000 6.10.2 Review capacity to handle expired/damaged products at all levels. Nationwide NDS CHT Evaluation of all health facilities' capacity to handle expired/damaged products Evaluation report $20,000 6.10.3 Disseminate procedures. Nationwide NDS CHT Health facilities National Procedures for Expired/Damaged Products are available at each facility Supervision checklist $5,000 6.10.4 Logistics training includes component on handling expired/damaged products. MOHSW Training Strategy/ Plan NDS MOHSW Training Coordinator Integrated Logistics System curricula includes a session on handling expired/damaged products Integrated Logistics System curricula $1,500 6.10.5 Advocate for funding for construction of proper waste management facility at central level. NDS MOHSW NDS MOHSW Donors Funding available to construct central level waste management facility Request for Bids released for Waste Management Facility $2,000 References Global Fund to Fight AIDS, Tuberculosis and Malaria, Liberia Round Six Proposal Hare, L., Hart, C. Scribner, S., Shepherd, C., Pandit, T. (ed.) and Bornbusch A. (ed.). 2004. SPARHCS Strategic Pathway to Reproductive Health Commodity Security: A Tool for Assessment, Planning and Implementation. Baltimore, MD: Information and Knowledge for Optimal Health Project/Center for Communication Programs, John Hopkins Bloomberg School of Public Health. International Monetary Fund. 2007. Liberia Interim Poverty Reduction Strategy Paper. IMF. Kagone, Meba, Paul Dowling, Jennifer Antilla, Ruth Cooper. 2007. Liberia: A Contraceptive Security Assessment. Washington DC: JSI/DELIVER for the U.S. Agency for International Development. Measure DHS. 2007. Liberia Demographic and Health Survey 2007 Preliminary Report. Calverton MD: Macro International. Merlin Liberia. 2006. Knowledge, Attitudes and Practice Survey in Grand Gedeh County, Liberia. Monrovia: Merlin. Merlin Liberia. 2006. Knowledge, Attitudes and Practice Survey in Maryland County, Liberia. Monrovia: Merlin. Ministry of Health and Social Welfare. Undated. Reproductive Health IEC and Advocacy Strategy. Monrovia: Ministry of Health and Social Welfare and UNFPA. Ministry of Health and Social Welfare. 2000. Reproductive Health Policy for the Republic of Liberia. Monrovia: Ministry of Health and Social Welfare. Ministry of Health and Social Welfare. 2001. National Drug Policy. Monrovia: Ministry of Health and Social Welfare. Ministry of Health and Social Welfare. 2006. Rapid Assessment of the Health Situation in Liberia. Monrovia: Ministry of Health and Social Welfare. Ministry of Health and Social Welfare. 2007. Essential Medicines List for the Republic of Liberia. Monrovia: Ministry of Health and Social Welfare. Ministry of Health and Social Welfare. 2007. National Contractive Security Strategy (2007-2011) (March 2007 draft). Monrovia: Ministry of Health and Social Welfare. Ministry of Health and Social Welfare. 2007. National Health Policy (June 2007 draft). Monrovia: Ministry of Health and Social Welfare. Ministry of Health and Social Welfare. 2007. National Health Plan (2007- 2011) (August 2007 draft). Monrovia: Ministry of Health and Social Welfare. Ministry of Health and Social Welfare. 2007. Road Map for Accelerating the Reduction of Maternal and Newborn Morbidity and Mortality in Liberia (August 2007 draft). Monrovia: Ministry of Health and Social Welfare. Ministry of Health and Social Welfare. 2007. Roadmap for the Implementation of the Basic Package of Health Services (July 2007 draft). Monrovia: Ministry of Health and Social Welfare. Ministry of Planning and Economic Affairs. 2000. Liberia Demographic and Health Survey: 1999/2000. Monrovia: Ministry of Planning and Economic Affairs and UNFPA. Appendix 1 List of stakeholders involved in developing the RHCS Strategy and Plan Name Title Affiliation Dr. Walter Gwenigale Minister MOHSW Dr. Bernice Dahn Deputy Minister/Chief Medical Officer MOHSW Health Service Department Betty Kalloh Assistant Director MOHSW Family Health Division Ruth Cooper RH Focal Point MOHSW Family Health Division Dr. Sodey Lake Training Coordinator MOHSW Department of Health Service Dee-zoe Lake NGO Coordinator MOHSW Planning, Research & Development Department Jacob Hughes Resource Mobilization & Fund Manager MOHSW Office of Financial Management Chris Dagadu Director MOHSW National Health Promotion Division J.K. Ofori BCC Advisor MOHSW National Health Promotion Division Mr. Duredoh F. George Pharmacist MOHSW Pharmacy Division Dr. Linda Birch County Health Officer Bomi County Health Team Tommy Gulley Managing Director National Drug Service Beyan Johnson Operations Officer National Drug Service David Logan Coordinator Liberia Coordinating Mechanism Ellen B George Williams Executive Director CHAL Miatta Kiawu Executive Director FPAL Dr. J. Kota Kesselly Program Manager FPAL Mercy Travers Logistics Assistant FPAL Sylvanus Dangan Medical Laboratory Tech. FPAL Claudette Bailey Chief of Party Africare Luke Bawo Africare Christopher McDermott Health Team Leader USAID Mae Podesta Country Representative Clinton Foundation Eugene Nyarko Representative WHO Dr. Julie Conneh-Duworko Family Health & Population Advisor WHO Rose Gakuba Resident Representative UNFPA Jacob Lawuobahsumo National Program Officer, RH UNFPA Dr. Geetor Saydee Director & Professor Institute for Population Studies, University of Liberia Jennifer Antilla Technical Advisor John Snow, Inc. Christopher Wright Senior Technical Advisor John Snow, Inc. � EMBED Word.Picture.8 ��� � For a full situational assessment for each component see Liberia: Contraceptive Security Assessment Report (Kagone et al.) PAGE [image: image5.emf]_1245441550.doc [image: image1.png]