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Reproductive Health Commodity Security
             (2007 – 2011)

                Government of Nepal
          Ministry of Health and Population
           Department of Health Services
                      July 2006

                                       Table of Content
Table of content
Executive Summary

   1. Introduction
        1.1 Background
        1.2 Health Services Delivery System in Nepal
             1.2.1 Reproductive Health Services

   2. Reproductive Health Commodity Security
       2.1 What it is
       2.2 Rationale for National RHCS Strategy
       2.3 Objectives of National RHCS Strategy
       2.4 Process of developing National RHCS Strategy

   3. Situation, Issues and strategy
        3.1. Context
        3.2. Client Utilization
        3.3. Commodities
        3.4. Commitment
        3.5. Capital
        3.6. Capacity
        3.7. Coordination

   4. Strategic Action Plans

  1. Members of Working Group
  2. Forecasting of RH Commodities
        2.1 FP commodities: quantity and cost
        2.2 Other Essential Commodities: Quantity and cost


ACDP     Annual Commodity Distribution Program
ANC      Antenatal Care
ARI      Acute Respiratory Infection
ARV      Anti Retroviral
ASL      Authorized Stock Level
BNMT     Britain Nepal Medical Trust
CDD      Control of Diarrheal Diseases
CDP      Community Drug Program
CHD      Child Health Division
CIDA     Canadian International Development Agency
CPR      Contraceptives Prevalence Rate
CRS      Contraceptive Retail Sale
CCSWG    Consensus Contraceptives Security Working Group
DC       District Clinic
DDA      Department of Drug Administration
DDC      District Development Committee
DFID     Development Fund for International Development
DHO      District Health Office
DHS      Demographic and Health Surveys
DoHS     Department of Health Services
EDP      External Donor Partners
EHCS     Essential Health Service Package
EPI      Expanded Program on Immunization
EOP      Emergency Order Point
EU       European Union
FCHV     Female Community Health Volunteer
FHD      Family Health Division
FNCCI    Federation of Nepalese
FP       Family Planning
FP/MCH   Family Planning and Maternal Child Health
FPAN     Family Planning Association of Nepal
GMP      Good Manufacturing Practice
GO       Governmental Organization
GoN      Government of Nepal
GTZ      German Technical Cooperation
HC       Health Center
HEJAN    Health Journalists Association of Nepal
HF       Health Faculty
HMIS     Health Management Information System
HP       Health Post
ICP      Inventory Control Procedure
ICPD     International Conference on Population and Development
IEC      Information Education and Communication

INGO      International Non Governmental Organization
IPPF      International Planned Parenthood Federation
ISO       International Standard Organization
IUD       Intra Uterine Device
JSI       John Snow Inc.
KfW       Kreditanstalt fur Wideraufbau
LHI       Local Health Institutions
LMD       Logistics Management Division
LMIS      Logistics Management Information System
LSIP      Logistics System Improvement Plan
MCHW      Maternal Child Health Worker
MD        Management Division
MDGs      Millennium Development Goals
MoHP      Ministry of Health and Population
MSI       Marie Stopes International
NCASC     National Center for AIDS and STD Control
NCPS      Nepal Contraceptive Prevalence Survey
NDHS      Nepal Demographic Health Survey
NFFS      Nepal Fertility and Family Planning
NFHP      Nepal Family Health Program
NGO       Non Governmental Organization
NGOCC     Non Governmental Organization Coordination Council
NHEICC    National Health Education, Information and Communication Center
NHSP-IP   Nepal Health Sector Program-Implementation Plan
ORS       Oral Re-hydration Solution
PHC       Primary Health Care
PHCC      Primary Health Care Center
PoA       Programme of Action
PRSP      Poverty Reduction Strategy Paper
PSI       Population Services International
RH        Reproductive Health
RH/FP     Reproductive Health/Family Planning
RHCC      Reproductive Health Coordination Committee
RHCS      Reproductive Health Commodity Security
RHD       Regional Health Directorate
RM        Regional Medical Store
SHP       Sub Health Post
SLTHP     Second Long Term Health Plan
SM        Social Marketing
SoI       Statement of Intension
SPARHCS   Strategic Pathway to Reproductive Health Commodity Security
SSMP      Support to Safe Motherhood Programme
STI       Sexually Transmitted Infection
SWAp      Sector-wide Approach
TBA       Traditional Birth Attendant
UNAIDS    Joint United Nations Program on AIDS
UNHCR     United Nations High Commissioner for Refugees
UNFPA     United Nations Funds for Population Activities
UNICEF    United Nations Children's Fund
USAID     United Nations Agency for International Development

VCDP   Vulnerable Community Development Plan
VDC    Village Development Committee
VHW    Village Health Worker
WB     World Bank
WHO    World Health Organization


           Dr. ……………


          Dr. Mahendra B. Bista
          Director General

This document is jointly prepared by Logistics Management Division and Family Health
Division of Department of Health Services with financial and technical supports of United
Nations Population Fund (UNFPA) and technical support of United States Agency for
International Development (USAID). A large number of stakeholders actively involved in
reproductive health programs participated by providing technical supports as well as inputs to the
document at various stages of strategy development. A small working group with representatives
from key partners and stakeholders was formed to draft this document.

The technical part of the document is based on the modules of the SPARHCS model, a model
jointly developed by UNFPA, USAID, and various international technical agencies including
John Snow, Inc. and JHU/CCP.

Thanks to UNFPA for being an active member of contraceptive security working group, and
conducting RHCS workshop in Sri Lanka and Bangkok which led to development of this
strategy document. UNFPA‟s support in procurement of contraceptives and support in
conducting national Annual Commodity (Contraceptive) Distribution Program for Logistics
Management Division is equally appreciated. Thanks to Dr. Jayanti Man Tuladhar, UNFPA
CST Adviser on RH/FP Management Information System and Logistics of Bangkok for his
technical assistance in guiding the process of developing the strategy and actual preparation of
this strategy document.

Thanks to USAID for a technical support provided through Nepal Family Health Program
(NFHP) in conducting contraceptive security forecast endeavors in Nepal since 1998. We also
like to extend our thanks for their technical assistance in national integrated health logistics and
support for Logistics Management Information System for the Logistics Management Division.

Thanks to SSMP of DFID for their contribution as working group members in the development
of this document. Thanks to DFID and KfW providing support to the development of this
strategy at various stages.

Thanks to FPAN and Social Marketing Company (CRS) for being a important stakeholder in the
Family Planning and Reproductive Health program of MOH and their inputs and participation in
the development of this document.

Thanks to Dr. Janardan Lamichhane for sharing his Draft paper entitled „RHCS in Nepal (June
2006)‟, which was very helpful as a background document especially in doing situation analysis,
an important section of the strategy document. We would like thank all the members of the
working group for their hard work in preparing this important document and to all who have
provided inputs to the draft document. Dr. Kalpana Tiwari, Coordinator/Consultant of UNFPA
contributed to the document by consolidating and compilation of information from the working
groups meeting and Stakeholders‟ workshop on RHCS Strategy.

_____________________                                  ____________________

Dr. Peeyoosh K. „Rajendra‟          Dr. Mahendra K. Chhetri
Director                            Director
      Family Health Division              Logistics Management Division

                                     Executive Summary
National Reproductive Health Commodity (RHCS) Strategy has been prepared in a participatory
manner involving a wide range of stakeholders. The goal of RHCS is to ensure a secure supply
and choice of quality contraceptives and other reproductive health commodities to meet every
person‟s needs at the right time and in the right place. RHCS exists when people are able to
reliably choose, obtain, and use the contraceptives, and other essential reproductive health
supplies they want. Hence, the ultimate aim or goal of RHCS centers on meeting the clients‟

Nepal is signatory to the ICPD which aims to achieve universal access to reproductive health by
2015. National Reproductive Health Strategy of Nepal recognized that RH is a crucial part of
overall health and is central to human development. Reproductive Health, within the context of
Primary Health Care, identifies 8 different components which include family planning with
emphasize on preventing unwanted pregnancies, safe motherhood, care of new born, prevention
and management of STDs, HIV and AIDS and others.

As in many developing countries, Nepal is facing crunch in meeting much needed resources for
essential reproductive health commodities including contraceptives. In family planning alone,
there is a funding gap of US$ 23 million for the period 2006 – 2011 both in public and private

RHCS is a long-term goal, requiring a multi-sectoral approach and continuous commitment; it
needs to be addressed in coordinated manner capitalizing partnerships on comparative
advantages to mobilize resources and strengthen national capacity. Strategic planning as
embodied in the RHCS strategy will help prioritize and succeed its aim.

National RHCS Strategy‟s long term goal is to create positive environment to meet ICPD‟s goal
of universal access to reproductive health by 2015. The strategy has 8 specific objectives for the
period 2007 – 2011.

Nepal has several policies, documents, and service delivery guidelines related to population and
reproductive health; all of which are supportive to certain elements of RHCS explicitly or
implicitly. More needs to done in areas of policy and acts/regulation and structural framework to
strengthen policy environment for RHCS.

There are several barriers to access reproductive health services coupled with the utilization
problem. Unmet need for family planning is still high. Disparity between rural and urban and
between different geographic regions in the use of contraceptive methods and maternal health
services is quiet alarming. Unmet need and disparity in service utilization should be addressed
through improving availability and accessibility of services, equity, reducing barriers to care,
improving quality of care and market segmentation for public and private sectors.

Clients of reproductive health services including family planning are heavily depended on the
public sector. As a result, the public sector is taking major burden in meeting commodities
requirement. Female condom is still not offered as a choice of contraceptives. It is also not

offered to sex workers for preventing STDs including HIV. Commodities particularly
contraceptives are available through only donors‟ financial supports until recently. The
government of Nepal started making contribution to procuring contraceptives from 1996 and still
the amount is insignificant to the quantities that are required for the country. Commodity issues
need to be addressed especially to decrease donor dependency and move away from free
distribution to those who can afford to pay. NGOs, private sectors and communities should be
brought into the programs with their specific roles to cater rural disadvantaged underserved

Commitment is the key to RHCS. Although various government‟s plans and policies reflect
support to the related programs, its real long-term commitment is lacking from government,
donors, NGOs and private sector to RHCS. This is reflected by the fact that no one has come
forward to meeting the shortfalls of essential reproductive health commodities including
contraceptives for the period 2006 – 2010. These need to be addressed urgently through
advocacy to policy makers, senior government planners, donors, NGOs, private sectors and civil
societies. In order to address an issue of sustaining programs, donors also need to give sufficient
time for the government with donors‟ exist strategies.

National capacity building will strive to enable country programmes to improve their ability to
forecast requirements, develop the necessary financing, carry out efficient procurement and
deliver the products to users where and when they are needed. The current integrated logistics
management of LMD/DOHS should be expanded to include HIV/AIDS commodities. Current
forecasting methodology should be revisited to reflect the government‟s goals and target and
develop national capacity of central and district personnel. There is a need to streamline the
procurement procedures and develop national capacity in the area of procurement planning. The
need to improve warehousing, distribution and transportation systems should be a line with the
increasing demand for more supplies.

Needless to mention, coordination mechanism is to be strengthened and established with new
forum. A high level RHCS coordination group is indeed a priority to increase coordination
between various government agencies, donors, NGOs, civil societies and private sectors.

1.     Introduction


Nepal is a small landlocked country situated in between India and china. It spreads over 147181
square kilometers in area and its population, according to the 2001 census is approximately 23.2
million with average per capita income of $ 244. During the decade 1991-2001, annual
population growth rate (National) remained about 2.24 percent.

The International Conference on Population and Development (ICPD)‟s focus on population-and
development-related efforts, such as increasing access to reproductive health services, promoting
gender equality, and nurturing a better understanding of the linkages between population
dynamics, development and poverty, is a prerequisite to the achievement of the larger
development goals of the Millennium Development Goals (MDGs), such as eradicating poverty
and hunger. ICPD Programme of Action (PoA) sets the target of reaching universal access to
reproductive health by 2015. The government of Nepal is signatory to both the ICPD and
Millennium Development (MD).

While the MDGs do not contain any specific goal or target on reproductive health, they do
contain specific targets related to components of reproductive health, including maternal health,
HIV/AIDS and gender equality.

1.2 Health Service Delivery system in Nepal

Ministry of Health and Population (MoHP) underwent major structural change in 1987 in line
with decentralization policy of the government. This structural change in MoHP led to the
establishment of Regional Health Directorates (RHD) in each of the five development regions of
the country.

Department of Health Services (DoHS) was re-established in 1993 with the responsibility of
implementing, monitoring, and supervising preventive, promotional, rehabilitative, and curative
health programs through its Divisions and Centers, Regional Health Directorate (RHDs), and
District Health Offices (DHO). The Divisions and Centers are responsible for:

          Target setting for the specific programs in consultation with RHDs and DHOs
          Preparation of operational plans and programs
          Supporting health facilities (HFs)
          At the regional level RHDs are responsible for planning, programming, training, and

Policymaking and formulation of annual, five-year, and long-term planning along with donor
coordination is a responsibility of MoHP. DoHS provide inputs for policymaking and plan
formulation. Curative services are provided through central hospitals, regional, zonal and district
hospitals, and primary health centers (PHCs), health posts (HPs), and through sub health posts
(SHPs) below district levels.

District Health Offices are responsible for preventive, promotional, and curative services.
Ayurvedic dispensaries deliver health services in Ayurvedic Sector. Homeopathic and Unani
medical services are delivered through central hospitals and dispensaries located in Kathmandu.

1.2.1 Reproductive health services

Reproductive health services are provided throughout the country under the directives of DOHS
which has the responsibility of delivering preventive and curative health services including
promotional activities. The sub health post (SHP) is the first contact point for the basic health
care and referral services. But, in actual practice SHPs are the referral centers of Traditional
Birth Attendant (TBA) and Female Community Health Volunteer (FCHV), as well as
community-based activities such as PHC outreach and EPI clinics. Each level above SHPs is a
referral point in hierarchical networks. This referral hierarchical network is designed in a way to
ensure basic health services, and minor treatment is accessible and affordable to the people.
Logistical, financial, supervisory, and technical supports are provided to lower level from one
level above.

The institution involved in the delivery of basic health services in Nepal during 2001/02 included
79 hospitals, 178 Primary Health Centers (PHC) / Health Centers (HCs), 705 Health Posts (HPs),
and 3,132 Sub-Health Posts (SHPs). In particular it appears that the contribution of Maternal
Child Workers (MCHWs) and Village Health Workers (VHWs) at the Sub-Health Posts level is
having a significant impact on the overall improvement in health coverage. Additionally, 15,603
Traditional Birth Attendants (TBA), 48, 047 Female Community Health Volunteers (FCHW),
and 15,364 Primary Health Care Outreach sites were also involved in service provision or
referring client services.

                                                    Box 1

           Priority issues for Reproductive Health
                Family planning
                Safe motherhood
                Child health (newborn care)
                Prevention and management of complications of abortion
                Reproductive Tract Infection/Sexually Transmitted Disease/Human Immuno-
                   Deficiency Virus/Acquired Immuno Deficiency Syndrome
                Prevention and management of sub fertility
                Problems of elderly women (i.e. uterine, cervical and breast cancer treatment
                   at tertiary level or in the private sector

Integrated package of reproductive of health services includes, among others, family planning,
safe motherhood, prevention & management of complications of abortion and RTI/STD and
infertility (see box 1 for the full list). Each of these interventions is implemented through the
health institutions mentioned above. Activities under each intervention, however, limit to the
capacity of personnel and physical facilities. For detail, please see National Reproductive Health
Strategy. Family Health Division of DoHS is responsible in implementing RH strategies and
programs. Logistics Management Division of DoHS is responsible for procurement,
warehousing, and distribution of reproductive health commodities including supplies and

Nepal's National Reproductive Health Strategy is well inline with the policies adopted in
National Health Policy (1991) and Second Long Term Health Plan (1997-2017) which aims at
reducing infant, child and maternal morbidity and mortality and reducing total fertility rate. The
Nepal RH Strategy is adopted for an effective and efficient provision of quality Reproductive
Health services in Nepal. The following strategies have been embraced:

         Implement the 'Integrated Reproductive Health Package' at all level of health institutions
          as well at the community level based on standardized and clinical protocols and
          operational guidelines.
         Enhance integration of Reproductive Health activities carried out by different divisions of
          Ministry of Health and Population and Population.
         Advocacy of the concept of Reproductive Health including environment of collaboration
          of all sectors
         Review and develop IEC materials to support all level of interventions
         Review and update the existing training curricula of various health workers
         Ensure effective management systems by strengthening and revitalizing existing
          committees at all levels
         Construct/upgrade appropriate service delivery and training facilities at all levels
         Institutional strengthening through structured planning, monitoring/supervision and
          performance review
         Develop an appropriate RH program for adolescents
         Support for national experts/consultants
         Promote inter-sectoral and multi-sectoral coordination

2. Reproductive Health Commodity Security

2.1       What it is

Reproductive Health Commodity Security (RHCS) is defined as ensuring a secure supply and
choice of quality contraceptives and other RH commodities to meet every person‟s needs at the
right time and in the right place. RHCS exists when people are able to reliably choose, obtain,
and use the contraceptives, condoms, and other essential reproductive health supplies they want.
Hence, the ultimate aim or goal of RHCS centers on meeting the clients‟ needs.

Attention to RHCS first began when projections were shown to have shortfalls in financial
requirements to meet the need. Many countries feel serious challenges to meet people‟s rising

demand for contraceptives and other essential reproductive health supplies, especially due to
limited in-country and donor resources combined with weak infrastructure. Every country faces
challenges to meet the ICPD goal of achieving universal access to reproductive health by 2015 if
RHCS does not exist.

UNFPA predicts that shortfalls in contraceptive assistance could have serious consequences in
terms of maternal and child health (see box 2).

                                                    Box 2

       For every US$1 million shortfall in contraceptive commodity assistance:

           •   Increase in the number of unintended pregnancies: 360,000
           •   Additional induced abortions: 150,000
           •   Additional maternal deaths: 800
           •   Additional infant deaths: 11,000
           •   Additional deaths of children under 5: 14,000

Therefore, the consequences of failing to achieve our reproductive health commodity security
aims are painful to contemplate. Since RHCS is a long-term goal, requiring a multi-sectoral
approach and continuous commitment, it needs to be addressed in coordinated manner
capitalizing partnerships on comparative advantages to mobilize resources and strengthen
national capacity. Strategic planning as embodied in the RHCS strategy will help prioritize and
succeed its aim.

2.2    Rationale for National RHCS Strategy

The prospects for RHCS are depended upon the contextual context of every country. Policies and
regulations that exist in a country affect the availability of RH supplies and ultimate making
difference in meeting clients‟ needs for reproductive services and commodities. It also has affect
direct bearing due to factors such as social and economic conditions, political and religions
practices and competing priorities within the country. Commitment of the government and
partners of RHCS together with leadership and focused advocacy demonstrated by supportive
policies make needed resource available (capital) for commodities, work in coordinated manner
and develop the necessary national capacity. Since the focus of RHCS is clients who are the
ultimate beneficiaries of RHCS, the utilization of services is central to demand for RH

All these elements - Client Utilization; Commodities; Commitments; Capital; Capacity;
Coordination; and Context – are to be addressed in ensuring RHCS through the development of a
new or strengthen an existing reproductive health commodity security. At present, there is no
RHCS Strategy in Nepal to address all those issues or elements of RHCS.

  2.3      Objectives of National RHCS Strategy

  An objective of the National RHCS Strategy for 2007 – 2011 is to address all elements of RHCS
  in a holistic manner and streamlined activities to meet ICPD‟s goal of universal access to
  reproductive health. The National RHCS Strategy has the following specific objectives relating
  to each element:

 I.     Context: Promote/create favorable policy environment by cataloguing present policies and
        suggesting new ones
  II.   Client Utilization and Demand: Address the unmet need of RH services and commodities
        and increase accessibility
 III.   Commodities: Identify/finalize RH commodities, diversify portfolio of donors and increase
        GON‟s commitment
IV.     Commitment: Improve and formalize collaborative commitments on RHCS from within
        public, donors and private sector
 V.     Capital: Consolidate 5 years running budgetary requirement for RH commodities/program
        and ensure funding commitments from public, donors, and private sector
VI.     Capacity: Build capacity of stakeholders including district level for RHCS management
        towards achieving 6 “Rights” of logistics management
VII.    Coordination: Strengthen/establish formal functional coordination groups with defined roles
        and responsibilities

  2.4      Process of developing National RHCS Strategy

  This National Reproductive Health Commodity Security (RHCS) Strategy is an outcome of hard
  work done by a Working Group set up by the DoHS, MoHP and many partners and stakeholders.
  This working group comprised of technical staff of government, donors, NGOs, INGOs and
  others involved in reproductive health program in the country (see Annex 1). Contributions were
  made at various stages of the development of the draft document.

                                                 Box 3
         Important events leading to National RHCS:

               •    Development of LSIP and its implementation - 1994
               •    International Conference on Population and Development (ICPD), Cairo 1994
               •    Annual Contraceptives Security Forecast for 5 years– MoHP since 1998 leading
                    to key MCH commodities forecast
               •    Contraceptive Security Assessment using SPARHCS Framework, 2003
               •    Reproductive Health Commodities Security Workshop, Colombo, Sri Lanka -
                    April 2005
               •    Strategic Pathway to Reproductive Health Commodity Security (SPARHCS)
                    Workshop, Bangkok Thailand June, 2006

There were a number of important events that led to the development of the National RHCS
Strategy. These events (listed in the box below) culminated leading to RH commodity
Security from Contraceptive Security in Nepal due to the existence of strong collaboration
among MOHP, FHD, LMD, USAID, UNFPA, DFID, KFW, World Bank and number of other
key stake holders like FPAN and Social Marketing.

The last event – the SPARHCS workshop in Bangkok organized by UNFPA CST Bangkok –
made 4 Nepali Team members (two from DoHS, one each from NFHP and UNFPA) familiar to
the process of developing RHCS strategy using SPARHCS tool. An application of this tool helps
countries to develop and implement strategies to secure essential reproductive health supplies. It
is meant to bring together a wide range of stakeholders to initiate at the country level aiming to
reach the goal of RHCS.

In the Bangkok workshop, the Nepali team achieved in understanding the process of –
customization of SPARHCS, application of SPARHCS to identify issues and gaps through
situation analysis; and development of strategic action plans.

With the initiation of the Nepali Team and UNFPA Nepal, the process of developing National
RHCS Strategy moved forward with creation of Working Group by the DoHS to draft Strategic
Action Plans. UNFPA CST Adviser of Bangkok and Senior Logistics Expert of NHFP reviewed
and refined the draft Strategic Action Plans developed by the Working Group.

The Draft Strategic Action Plans were shared in a one-day workshop which was attended by a
wide range of partners and stakeholders (government, donors, NGOs, INGOS, Private sectors
and Civil Societies). In this stakeholders‟ workshop, participants made inputs giving comments
and suggestions to the draft. At the same time, major partners (USAID, KfW, DFID, WHO, and
UNFPA) together with government representatives reiterated their commitments to RHCS. The
suggestions were incorporated by the Working Group.

Hence, this document has been prepared in the participatory manner with the involvement of a
wide range of stakeholders. Situation Analysis helped in identifying issues and gaps which were
the basis for the development of key strategic activities.

3.       Situation Analysis, Issues and Strategies
3.1      Context

Nepal has several population and reproductive health related policies, documents, and service
delivery guidelines in place. Some of these include:

     National Health Policy (1991)
     National Population Policy
     Poverty Reduction Strategy Paper (PRSP: 2002-2007)
     Second Long Term Health Plan (1997 – 2017)
     National Safe Motherhood Plan (2002 - 2017)
     National Reproductive Health Strategy (2004)

   Health Sector Strategy: An Agenda for Reform (2004)
   Nepal Health Sector Program – Implementation Plan (2004-09)
   Vulnerable Community Development Plan for Nepal Health Sector Program Implementation
    Plan (2004/5 – 2008/9)

Most of these documents appear to be supportive of family planning and reproductive health,
particularly in reducing stock out of commodities for essential health care services. Though there
is adequate support for commodities from government and donors, there is a lack of long term
commitment to commodity security. This is evident from the resources available for
contraceptives, indicating funding gap of US$10.5 million for the period 2008 – 2010 in the
public sector alone. The funding gap will remain until there is a strong, long term commitment
and sustainable partnership between public, donor, private sector and NGOs.

Concerning HIV/AIDS, these policy documents do not explicitly mention of securing adequate
supplies of condoms and other commodities. However, there is a forum to include this topic
through biannual meeting on family planning and HIV/AIDS to discuss on the commodities
needs. This forum is attended by donors, NGOs, marketing groups at the DoHS. There is
definitely not sufficient participation to provide adequate attention to address the issues of
commodity security. This is to be addressed through frequent interactions to increase
coordination and understanding between various agencies concerned.

Contraceptives such as condom, injectables, oral pills and other RH commodities are included in
Essential Drug List (EDL). There is no barrier as such in terms of age and parity to access
contraceptives by clients. No prescription is required to purchase contraceptives (condom, pills,
and injectables) in market (i.e. pharmacies). It is to be noted that pharmacies do need to obtain
certificate which they get after undergoing training conducted by DDA. Spousal consent is not
needed to obtain permanent method. However, contraceptives except condoms have to be
dispensed by the trained health workers in service outlets. There are service protocols and
guidelines available and service providers do obtain pre and in-service training.

For the private sector to operate in the country, the government does provide positive
environment. Contraceptives can be advertised their products (condoms and others). While
importing contraceptives and vaccines there is no tax, some items can be brought to the country
with minimum tax (1%). They do need to obtain a license before importing the products.
Private sectors including NGOs are free to fix the prices and there is no government‟s policy
restriction in distribution of these products.

Nepal government gives high priority to social sector. The recently announced budget for
2006/07 allocates 16 per cent (Rs. 23 billion) for education, while only 6 per cent (Rs. 9.2
billion) of total budget for health.

Community Drug Programme (CDP) that operates in 44 districts (full coverage in 14 districts
and partial coverage in 30 districts) applies certain fees for essential drugs except contraceptives.
However, NGOs who received contraceptive from public sector do charge certain fee for service.

The Poverty Reduction Strategy Paper (PRSP) explicitly mentioned of an important of issue
availabilities of commodities. Nepal Health Sector Program – IP aims to reduce stock outs of
essential health care services commodities 0% by 2009. The second Long Term Health Plan
recognizes importance of alternative financing mechanisms to bring non-governmental funds by
increasing the public-private mix in financing and providing Essential Health Care Services
(EHCS), which include reproductive health as one of the main interventions with specific targets.
Several policy options under logistics have been identified to improve commodity security in the
country. Family Planning and Safer Motherhood which are parts of reproductive health have
been identified as program components to address social inclusion on health services under the
Vulnerable Community Development Plan (VCDP) for the period 2004/5- 2008/9.

Health Sector Strategy document has also identified a need to bring private sector and NGOs to
play complementary role in improving procurement and distribution of drugs, supplies and
equipment. This issue has been clearly mentioned under National Reproductive Health Strategy
with specific role of collaborating partners. The strengthening of this collaboration should be
further explored for sustainable commodity security.

Issues to be addressed under context or policy environment for the strategic actions (for detail
see section 4) are as follows:

      Policy and Acts/Regulations
      Structural framework

Proposed key strategies are:

      Review of existing policies, identify areas of improvement and recommendations through
       meetings, workshops and seminars to ensure commodity security issues addressed
      Integrate RHCS in the explicitly all national health policy documents in line with
       securing total health commodities for all EHCS
      Plan and conduct advocacy activities to increase awareness among politicians, national
       and local leaders, policy makers, and senior officials on the need to have favorable
       policies for private sectors, NGOs and civil societies and communities to improve
       commodity security;
      Create health policy forum;
      Develop implementation plans in support of population and RH related national policies
       and enhance commodity security in the respective plans and programs; and
      Formulation of maintenance policy and plan for RH equipments and physical facilities.

For detailed Strategic Action Plans, please Section 4.

3.2 Client Utilization and Demand
3.2.1. Service availability and utilization

The National Reproductive Health Strategy aims to provide integrated reproductive health
services through five different levels: family/decision makers level; community level; sub-health
post (SHP)/health post (HP) level; primary health care center level; and district level.
Reproductive health services of selected components of family planning, safe motherhood,
prevention and management of complications of abortion, prevention and management of
RTI/STD/HIV/AIDS, adolescent RH and problems of elderly and reproductive cancer are
available from SHPs/HPs which are referral points for family decision makers and community
where they conduct mostly IEC activities.

Though SHPs/HPs are widely distributed throughout the country at community and village levels
ensuring equitable distribution of health facilities and services, there is a problem of accessing
essential RH services due to difficult terrains and insufficient transportation services. The major
shortcomings in the public sector therefore in terms of service access and utilization include
inadequate number of facilities, lack of service providers and sufficient quantity of commodities.

The 2001 Nepal Demographic and Health Survey (DHS) found that there are some
improvements in the utilization of some selected reproductive health services. The DHS found
that the majority of pregnant mothers (51 percent) did not receive antenatal care (ANC) services.
Data also suggested that there was substantial differential in utilization of health services. For
example, rural mothers are less likely to receive ANC services than their urban counterparts (18
percent in rural and 53 percent in urban). Ninety one percent of deliveries occurred at home in
rural areas while only 54 percent in urban. If one looks at unmet need for family planning,
percentage of currently married women with unmet need is double in rural areas in comparison
to urban.

3.2.2. Contraceptive use and trend

Contraceptive prevalence rate (CPR) has reached at almost 40 percent in 2001. The most
preferred method according to the 2001 DHS is female sterilization followed by injectable
contraceptives and male sterilization. In the beginning of the family planning programme, male
sterilization was the most popular and it soon overpowered by female sterilization which is still
the most preferred method.

Over 25 years, CPR has increased from 2.9 percent (1976) to 38.5 percent (2001). While the use
of female sterilization increased by four percentage points over 10 years, the use of injectable
contraceptives is substantial (7 percentage points). Other methods such as condoms, IUDs and
Norplant increased slightly during the same period (Table 1).

Table 1:             Contraceptive method use from 1976 – 2001 by method
Method                    1976 NFS      1981 NCPS       1986 NFFS       1991 NFFS      1996 NFHS        2001 NDHS

Any modern method            2.9            7.6             15.1           24.1            28.8             38.9

Female sterilization         0.1            2.6               6.8          12.1            13.3             16.5

Male sterilization           1.9            3.2               6.2           7.5              6               7

Pill                         0.5            1.2               0.9           1.1             1.5             1.8

Injectables                   0             0.1               0.5           2.3              5              9.3

Condom                       0.3            0.4               0.6           0.6             2.1             3.2

Norplant                       -              -                -            0.3             0.5             0.7

IUD                          0.1            0.1               0.1           0.2             0.3             0.4
Sources: Various sample surveys (Nepal World Fertility Survey, 1976, Nepal Contraceptive
Prevalence Survey 1981, Nepal Fertility and Family Planning Survey 1986, and Nepal
Demographic and Health Surveys 1991, 1996, and 2001) conducted since 1976.

The hindrance to the increased use of contraceptive could be related to lack of information
among women who did not intend to use in future. The DHS reported of findings that fear of side
effects was reasons for not using the contraceptive (21 percent). Most men (71 percent) cited
fertility-related reasons for not using in future. This suggests that the programmes emphasize on
providing quality services improving quality of care coupled with advocacy, information and
education activities to reduce fears and misconceptions about specific contraceptive methods.
Programmes that emphasize counseling, informed choice and a comprehensive range of methods
would help increase the contraceptive use and reduce unmet need. In this respect, introduction of
new contraceptives (female condoms) and expansion of currently available methods should be

3.2.3 Unmet need for contraception:

There is significantly high unmet need for FP services. The 2001 DHS indicates there are 28
percent of currently married women with unmet need1 (11 percent for spacing and 14 percent for
limiting) in the country. Unmet need is twice as high among women in rural areas as among
women in urban areas. Although there is a slight decline in unmet need for family planning,
demand does not equate with demand met until now. While only 4 percent of currently married
had met their spacing need for family planning, more than 35 percent met their limiting need.
The percentages of currently married women whose demand satisfied are quiet disproportionate
between urban (80 percent) and rural (56 percent) and between ecological region (49 percent in
mountain, 55 percent in hill and 63 percent in terai).

 It is likely that unmet might have increased after 2001 as shown by the survey done in 2006 in selected areas of the
country (see Figure 1).

                Figure 1: The gap between preferences and actual fertility springs
                from what demographers label the "unmet need for contraception"

                               Unmet Need for Contraceptives 1996-2006

                35                   31.4
                30                                                27.8

                25                                                                       21.2
                20            17.1                         16.4
                15                                 11.4
                              1996                        2001                           2006

                                            For Spacing    For Lim iting   Total

                          Source: NDHS 2001, NFHP Mid Term-Survey 2006

In summary, dimensions of access and utilization of family planning services include difficult
terrain, over reliance on certain methods, lack of human resources, shortage of commodity funds,
quality of care, social and religious barriers and provider competency (Table 2).

              Table 2: Barriers to access and utilization of FP Services

          Access                                Utilization
              Difficult            geographic       Lack                        of
                 condition                              information/knowledge of FP
              Over reliance on seasonal                options
                 camps (sterilization) and           Socio/cultural on exercising
                 injectables                            choice
              Shortage         of      trained      Service provider attitudes and
                 personnels     and    skewed           skills
                 distribution                        Cost of services
              Looming            gap        in
                 contraceptive financing
              Civil conflict

Issues to be addressed under Client utilization and Demand for the strategic actions (for detail
see section 4) are as follows:

      Availability and accessibility of services
      Equity (social, geographic and economic inclusion)
      Health seeking behavior
      Barriers to care

      Quality of care
      Market segmentation

Proposed key strategies are:

      Conduct studies: market segmentation; user-profile and reasons for non-use and quality
       of care
      Social inclusion monitoring in HMIS
      Design and pilot studies on social inclusion
      Design and implement programmes to remove barriers and increase contraceptive choice
      Feasibility study for testing RH commodity (condoms and other selected commodities)

3.3 Commodities

Major sources of RH commodities are public, NGO (Family Planning Association of Nepal),
social marketing and commercial sector. Public sector and NGO provide Pills, Condoms,
Injectables, Implant, IUDs and permanent methods. On the other hand, social marketing offers
Pills, Condoms and Injectables. Among different commodities four brands of commodities are
subsidized by social marketing. Although these agencies are dependant on reliable financing
mechanism to keep programs in full supply, rationing has not occurred till date in commodity
distribution. Distribution of RH commodities including FP supplies has been streamlined within
the government framework with minimal wastage of supplies due to expiration of the products.
Existing supply chain is not limiting the program expansion.

Table 3: Type of contraceptives distributed (percentage distribution) to current users by most
recent source of method, 2001

Source                   Pill        IUD       Injectables     Implants    Condom Total
Government               55.3        64.3      86.0            51.5        46.0        79.4
NGOs                     7.6         11.0      5.1             42.3        4.2         7.7
Private medical (SM)     30.1        18.5      7.7             6.2         38.1        7.3
Other (shop, etc.)       2.6         0.0       0.4             0.0         8.3         0.9
Other                    4.5         4.5       0.8             0.0         3.4         3.9
Total                    100.0       100.0     100.0           100.0       100.0       100.0
Note: Figures for IUD are based on unweighted cases as reported in the DHS report. Total may
not add up to 100 due rounding and „Don‟t know‟ cases.
Source: Nepal Demography and Health Survey 2001.

As it can be seen from data presented in Table 3, users are heavily depended upon the
government sector. The DHS reported that the share of the public sector remained constant over
the last five years. Eight percent of users get methods from the nongovernment sector, mostly
from the Family Planning Association of Nepal (FPAN), and 7 percent get their methods from
the private medical store, mostly pharmacies which sell social marketing products.

The female condom was piloted in the outskirt of Lalitpur district by a nongoverment
organization in 2001. There is enough evidence that female condom is on demand by sex
workers to protect themselves from STI and HIV. As sex worker clients in general object to
using male condom, sex workers are exposed to the risk of infection, it is important to address
this issue by including female condoms in the Essential Drugs List (EDL). EDL also does at
present include IUDs. There is still lack of comprehensive RH commodities in Nepal. While
developing RD commodities list, essential equipment for reproductive health services should be
included as per the WHO guidance.

Quality of these RH commodities including FP supplies is maintained throughout the supply
chain. All commodities needed to be registered with Department of Drug Administration (DDA)
which requires certificate of origin and WHO certification for each product for its registration.
Quality assurance of these commodities are also maintained through pre shipment inspection at
manufacturing sites and provision of replacement of products from the manufacturer if found
sub-standard at the time of post shipment inspection.

Almost all contraceptives needed to be imported as there are no local manufacturers for these
commodities and no import duties are applied to RH supplies. Although the registration
procedures and import mechanism are transparent and well understood to private sector,
procurement process by public sector is lengthy. The draft Logistics Management Strategy study
report of 2003 recommends that center negotiates the rate and quality control for the
procurement for districts.

DFID (through UNFPA), KFW (through GoN), USAID (for Social Marketing and FPAN)
remain the major donors for these commodities. Over the last ten years (1996 to 2006), donors
have been providing fund for contraceptives in incremental manner (US$ 2.6 million in 1996 to
US$5.4 million in 2006). On the other hand, the government of Nepal has started funding for
contraceptives from 2001/2002 fiscal year with US$99,000. The government allocation reached
at US$140,000 in 2006/7 fiscal year, with the government pool fund, the total fund committed is
around US$1.82 million support for contraceptives (US$0.14 million from government and
US$1.67 million the government pool) fund. Though, the government has been increasing its
contribution to contraceptive commodities until now, there is no commitment for contraceptives
from 2007/08 onward. Detailed on funding status is discussed under “Capital” section.

Strengthening of social marketing with proper market segmentation can play a crucial role in self
reliance. Potential of commercial sector is yet to be tapped to manufacture selected commodities

Issues to be addressed under Commodity for the strategic actions (for detail see section 4) are as
     Identification and list of RH commodities including equipment
     Funding/in-kind sources of RH commodities
     Effective and efficient decentralized procurement
     Donor funding

Proposed key strategies are:

      Expert group to finalize the list of RH commodities
      Design and pilot cost recovery models for contraceptives
      Incorporate RH commodities in CDP as pilot project
      Evaluation of existing situation on female condoms to establish distribution mechanism
       for sex workers
      Pilot financing schemes for RH commodities to reduce burden on public sector
      Advocate government and donor to increase funding for RH commodities and equipment
      Development of procurement standard and procedures

3.4 Commitments
As stated earlier in “Context” section, there is a supportive policy and regulatory environment,
increasing the government‟s allocation of fund for RH commodities. Still, there are some
questions that can be asked about political commitment from different sectors (government,
private and donors). It is important to keep in mind that commitment to RHCS is not the same as
commitment to family planning/reproductive health. Rather, it is about the policy level
embracing the need to make and keep supplies available to clients, both women and men.

MoHP's commitment to RHCS has been reflected in the national health sector reform program
and RHCS is a priority program under RH in Family Health Division of DOHS. This
commitment has been further strengthened as the Directors at FHD and LMD are the key
leaders/champions for reproductive health commodity security. This leadership initiates an effort
to achieve RHCS through a coordination committee among all stakeholders, biannual meeting
with donors and MoHP divisions, and FPAN for long term forecasting of contraceptives needs
besides pipeline monitoring.

Senior government officials are motivated to support RHCS as this program has been identified
as a priority program and better health care services is linked with poverty reduction plan of the
country. Government's commitment is also reflected in its budget allocation for contraceptives
and other reproductive health supplies, which has increased overtime. However, the long
commitment to secure RH commodities is still lacking within government, among donors and
private and civil society.

Besides government commitment, a number of private sector/NGO leaders such as FPAN, Social
marketing, Health Media, other line agencies like DDA are active partners in RH and to some
extent in contraceptive security. In order to ensure commodity security, political leaders, policy
makers, leaders of different groups such as donors, NGOs and local leaders must be advocated
on the importance of commodity for quality RH services. Local level forces such as FCHVs,
Mothers Group, VDCs, district level RH coordination committee (RHCC) can be mobilized for
advocating RHCS to civil societies. Media advocacy has started and covered all five regions. It
is more of a contraceptive security, but now it is moving to RH commodity security in holistic

Commodities availability is also included in poverty reduction Strategy Paper (PRSP). Impact of
national health sector reform and decentralization is yet to come. The public burden of RH
commodities financing is to be shifted in gradual manner towards NGOs and social marketing.

Issues to be addressed under Commitment for the strategic actions (for detail see section 4) are as
     Lack of long term commitments
     Communication in public and private sector
     Inadequate advocacy
     Insufficient involvement/participation of NGOs, social marketing and private health
        institution in RHCS

Proposed key strategic are:

      Advocacy workshops for parliamentarians (health committee) on the importance of
      Media sensitization workshop for public awareness for under-served, people, poor and
       socially deprived people (social inclusion) and increase in demand for services and
      Conduct retrospective study on donor‟s planning process adopted in support of
       commodities in view of making donors prospective plan to avoid abrupt decision to
       withdraw support
      Favorable policy environment for NGOs and social marketing to be created to expand
       coverage beyond urban areas to capture socially deprived and underserved people and
       those who can pay for the services

3.5 Capital
Until 2000/2001 fiscal year, contraceptive needs had been fully met with donors‟ funding (Table
4). The government of Nepal started sharing the cost of contraceptives from 2001/2002 fiscal. It
has increased from US$99,000 in 2001/2002 to US$14,000 in 2006/7. Total fund committed for
2006/07 is US$1, 877,000 for contraceptives. It is likely that there will be a shortfall of US$11
million during 2007/08 – 2009/10 unless donors come forward to meet the gap. The government
and NGOs (FPAN) are expected to come with US$820,000.

The main target of the public resources is mainly for poor community and free for all in seeking
FP services. FP delivery services are free to 25 districts based on low human development index.

Cost recovery system does exist for FP commodities. Although user fee system for essential
drugs is in place under Community Drug Program it does not include the user charge system for
FP and RH commodities. FPAN runs a cost recovery program in some districts as pilot project
for FP commodities by selling the FP commodities provided by GoN.

Table 4: Contraceptives Funding – Nepal (in US $)

           Source                  1996         2001         2006         2007
Government                            0.00         0.00     126,000     1,877,000    520,000
DONOR (Public Sector)
UNFPA                              829,048             0            0            0         0
USAID                              757,944     285,000              0            0         0
DFID                                      0   1,640,000    2,700,000             0         0
KfW                                       0   1,446,000     760,000              0         0
DONOR (FPAN and Social Marketing)
USAID (FPAN)                       400,000             0            0            0         0
IPPF (FPAN)                               0    317,000      100,000      100,000     300,000
KfW (FPAN)                                0    219,000      355,000              0         0
USAID (social marketing)           594,000    1,000,000    1,000,000             0         0
KfW (social marketing)                    0     78,000      355,000              0         0
TOTAL FUNDING                    2,580,992    4,985,000    5,396,000    1,977,000    820,000
Sources: LMD, DoHS
* Expected figures

NGOs such as FPAN, MSI and some local NGOs charges nominal fees for services under social
marketing program for which they receive contraceptive supplies from public sector.
Information has been regularly feed in through the LMIS pipeline report, HMIS for CDP
revolving fund and semi/ annual consensus forecast report.

Contraceptives are provided free of charge through the public sector outlets (hospitals, health
center, health post, sub-health posts, outreach clinic and mobile camp and FCHVs. However, FP
commodities like pills, injectables, Cu-T, Norplant and condom can also be purchased by client
in private clinics/ outlet/NGO clinics and pharmacies. Majority of urban populations can afford
to pay for the FP commodities but these groups getting free supplies through public sectors.

There are selected groups who are piloting health insurance scheme in few health facilities of
Lalitpur, Morang and Nawalparasi districts. The preliminary results of these initiatives are
encouraging. These schemes does not include RH particularly FP services. Lessons learned from
such schemes might be impeccable for family planning and other reproductive health services
and commodities.

Community Drug Program which runs in 44 districts (full coverage in 14 districts and partial
coverage in 30 districts) has alternative financing mechanisms. Similarly, Community Health
Insurance piloted in a few health facilities of 4 districts also has alternative financing

Based on current forecast of contraceptive needs from 2006 to 2010, the current funding gap is
estimated to be around US$10.5 million 2008 – 2010 in public sector, while the total gap would
be around US$23.7 million for the same period for all sectors (public, social marketing and
NGOs). At present, social marketing is totally dependent on donors, while NGOs are dependent
on government and donors. It is encouraging to see that GON/MOH increases the funding
through „pool fund‟; but the donor commitment is yet to be received from 2008 onward.

                  Figure 1: Total funding needed and committed as of July 2006
                                        for contraceptives
                                      Contraceptive Funding (2006-2010)






                                    2006       2007         2008     2009       2010

                                                   Needed     Committed

               At the National level, a total of 23.7 million US$ shortfall for the period 2006-2010

The funding gap shown above (Figure 2) for contraceptives in future could help alleviate the
problem to some extent of some initiatives and new initiatives could be replicated/implemented
with the purpose of sustaining the program. Also attempt should be made to implement what
Health Sector Strategy (2004) aims for (1) making local bodies responsible and capable of
managing health facilities in a participative, accountable and transparent way with effective
support from MOHP and its sector partners and (2) public health sector to develop a new major
role in working with private sector and NGOs.

Issues to be addressed under Capital for the strategic actions (for detail see section 4) are as
     Current and future funding gap
     Donor dependency
     Funding mechanism
     Burden to public sector

Proposed key strategic are:
    Advocate for increased budget allocation for RH commodities

      Local level advocacy to mobilize local health budget for RH commodities
      Advocate to link with micro-credit programs
      Encourage private sector to initiate health insurance schemes
      Review RH financing policy and integrate RH commodities into CDP with aim of
       running SM with CDP
      Enhance existing collaborative support with DDC, VDC, HMC, Civil society for RH
      Document innovative programs (good practices)

3.6 Capacity

Supplies are best managed only when the principle of six ”Rights” are applied in logistics
management. The Six “Rights” are:

                              The Right goods
                            in the Right quantities
                            in the Right condition

                                  delivered …

                              to the Right place
                              at the Right time
                              for the Right Cost

Logistics management often fails when the program is not able to fulfill one or more of the six
“Rights”. Capacity to properly handle these six “Rights” relate to different elements of supply
management – service delivery; ability to provide right products; forecasting and procurement;
inventory management (warehousing, distribution and transportation), information system and
monitoring. Each one of these will be discussed briefly below.

3.6.1 Service Provider Skills

In rural areas, clients access services from midwives, nurses, community-based delivers,
pharmacists, drug store clerks and so on. Generally, clients seek services from private clinics and
hospitals, even to nearest city when health problem is complicated. On other hand, urban clients
go to private or public clinics of OB/GYNs and general practitioners to seek, but this population
is small in comparison to rural.

The service providers do have different level of skills but not adequate. Service providers
training curricula includes include counseling for informed choice, taking into account gender
norms, logistics/reordering, and appropriate technical skills (e.g., IUD or implant insertion and
removal). Based on the skill of service providers, contraceptives and other RH supplies are
provided to the service outlets to ensure standards of care maintained.

There is no provider bias against particular client groups or methods rather some communities
prefer specific type of contraceptives. Some clients directly go for permanent methods rather than

Supervisors check the quality of the providers‟ work and provide on-the-job training to improve
their skills in counseling including attention to gender issues, storage, ordering; record-keeping,
etc. this generally happens in Safe motherhood districts.

3.6.2 Logistics Management

Both push and pull systems do exist in the logistic management system. The distribution system
from Center to Districts is push and from health facilities (HFs) to District is Pull. There are four
distribution levels i.e. Central to Regional, Regional to District and from district to health
facilities such as HC, HP, SHP.

There is a maximum/minimum inventory control system in place at different level. Authorized
Stock Level (ASL) and Emergency Order Point (EOP) is maintained at lowest service delivery
sites i.e. SHPs. At district, ASL and EOP is maintained for 10 months and 3 months
respectively, while at HFs level, ASL and EOP are 5 months and 1 months respectively. At
regional level, 3 to 4 months of buffer stock is maintained.

Almost 50% of the district has new storerooms, so the good storage facility is needed in rest of
the 50%. There is no significant loss of product through damage and theft at any level.

Transportation facilities are not adequate to deliver commodities from districts to health facilities
but it is satisfactory from center to region and to district level. However, transportation is
challenging from district to HFs level in some geographically difficult districts.

The distribution schedule at all level is available and working well. LMIS is working and
functioning well for timely and accurate data on stock on hand, consumption and wastage.
However, the use of LMIS data at the district level is not optimal. There is a need for
strengthening LMIS through electronic means for faster reporting and corrective action. Staff
salary of LMIS unit of LMD, DoHS is at present fully paid by donor agency.

There are guidelines in placed for inventory management and handling of supplies to have
minimum wastage of supplies due to damage and expiry of products.

For the public sector, the contraceptive logistics system does not stand alone. It is integrated with
seven programs (Child Health, ARI, EPI, Malaria and Kalazar, Tuberculosis, Leprosy and FP). If
donor resources diminish, it can not be sustained and LMIS will be paralyzed.

The distribution infrastructure is improving and its demand is likely to increase. Geographical
and unstable political situation limit the availability of supplies at service delivery points. The
distribution system accommodated most of the commodities for existing programs. It is
important to accommodate HIV/AIDS related commodities together other health supplies in
future. At present, it is perhaps better to handle separately because of limited number of sites

which provide services to HIV/AIDS clients. However, it is good to start LMIS part of
HIV/AIDS supplies into the National LMIS.

3.6.3 Forecasting
The forecasting of the program commodities for five years particularly the commodities such as
contraceptives, iron, oxytocin, ORS, Vitamin A, and Cotrim's are done routinely. Forecasting is
done using LMIS and HMIS data. The forecast is updated every year. DoHS‟s divisions FHD
and LMD lead the forecasting activities including fictionalizations of Consensus Contraceptive
Forecasting Working Group with the technical assistance from donor agencies like
NFHP/USAID, UNFPA. Forecasting data have been used for resource generation and to ensure
contraceptive security for the country. There is still room for improvement in forecasting
methodology to capture changing demography with the government program‟s goal and target
and reduce over estimation of estimated need arises from HMIS data. Capacity to forecast needs
to be developed at central and district to support the government‟s decentralization policy.

3.6.4 Procurement
LMD is responsible for procurement of contraceptives and other RH and essential drug
commodities. Technical assistance is sought from KfW for the procurement for KfW funded
health commodities. DFID funded procurement is done by UNFPA. There is coordination
between logistics and procurement staff when needed. District level training has been started in
some selected district using the standard procurement training manual.

Dispensed data are used in procurement planning. Appropriate product is procured to prevent
stock outs. Frequent coordination meeting is held with donors for effective procurements. There
have been no donor-related disruptions in supply to programs so far indicating that the
procurement plan is working well.

For the government, the procurement standard procedure is followed in order of - issuing
tenders, evaluating bids, and monitoring supplier performance. Though the process is
transparent, the actual procurement gets delayed very often due to long bureaucratic process. The
bidding procedures comply with international bidding procedures of funding agencies. Lead time
is around six months.

Although there is a delay in procurement, the quality assurance in procurement is maintained by
following WHO standards, pre and post shipment inspections including following the lab test

There is a scope for efficiency for cost saving by centralizing procurement process. It will
reduce the price of product. At the moment, district is paying more prices for same drugs than
the central level procurement. Capacity building in the area of procurement planning will help
the implementation of decentralization programme of the government.

3.6.5 Monitoring and Evaluation

LMIS and HMIS data are routinely used in planning RHCS commodities. There is good support
from policy level and HMIS and LMIS is included in Health Sector Reform Plan and Long term

Health Plan and routine feedback system exists. Findings of annual performance review
meetings have been source of information for policy makers. Similarly trimester review meetings
are held at district level. Population level data are collected through DHS in every 5 years and
census is done every 10 years.

Issues to be addressed under Capital for the strategic actions (for detail see section 4) are as

         Warehousing and Storage
         Inventory Management/ Forecasting
         Distribution and Transportation
         Logistics Management Information system
         Procurement
         Up-gradation of competency among health service providers

Proposed key strategies are:
    Advocacy on higher level to make the LMIS unit sustainable
    Review and expand scope of LMIS to include other RH components including
      HIV/AIDS; increase use of LMIS data
    Scale-up „Pull‟ system of essential RH commodities in additional 12 districts per year
    Conduct feasibility study to establish plants to manufacturer FP Injectables and condoms.
    Include RHCS in the DoHS website
    Enhance capacity of central/districts in RHCS activities like forecasting, procurement at
      district level for logistics personnel and service providers
    Construct district stores in remaining 35 districts
    Strengthen supervision and monitoring of logistics system

3.7       Coordination

Reproductive health commodity security is based upon collaboration and joint action planning.
Coordination is required at multiple levels and different stakeholders, among donors
(internationally and in-country), different players within the government, and across all sectors
involved in Reproductive Health Commodity Security. Needless to say effective coordination
helps avoid duplication of efforts and information sharing amongst the parties involved.

There are several stakeholders in the field of RHCS. These include several government agencies
donors (DFID, USAID, KfW), international agencies (UNFPA, UNHCR, World Bank, UNICEF,
WHO); and private sector (Pharmacies, Private Service Providers, FNCCI) and Health Journalist

There are number of committees where stakeholders from variety of FP and RH areas meet to
discuss the status, on-going implementation and future planning in the area of Reproductive
Health and HIV/AIDS. At present, there is no RHCS Coordinating Committee which overseas
commodity security for RH including family planning and HIV/AIDS. RH Committee at present
does not review/ monitor commodity issues of RH services including HIV/AIDS.

One of the regular and directly related to RHCS is the Consensus Contraceptive Security
Working Group (CCSWG) which is participated by a wider group of stakeholders including
donors, National Planning Commission and Ministry of Finance. An initiative has been
underway to transform this group into RHCS Committee to discuss, plan and implement all
elements of RHCS including forecasting and financing. This proposed committee should be of
high level and overseas all RH services including FP and HIV/AIDS regarding commodity
security. It will continue to lead by Ministry of Health. Selected stakeholders were involved in
developing the terms of reference for the proposed committee.

Though the existing group demonstrates that there is strong willingness to strengthen
coordination between and among donors, within government agencies, coordination between
government and civil society organizations need to be strengthened. Within the MOHP also,
there is a need to address strengthening of coordination between Family Health Division (RH
Committee), Logistics Management Division (CCSWG) and National Center for AIDS/HIV and
STD Control (HIV/AIDS Committee). There is a HIV/AIDS Logistics Committee within MOH
having separate distribution management.

While External Development Partners (EDPs) committee is in operation to discuss there
program, however formal dissemination of information of EDP‟s meetings to other stakeholder
is not in practice.

Issues to be addressed in coordination for the strategic actions (for detail see section 4) are as

      Coordination within public sector and among programs
      Coordination between Public and Private sectors
      Coordination among donors
      Coordination between government and donors

Proposed key strategies are as follows:

              Formation of high level RHCS Coordinating Committee within MOHP to
               overseas all RH services including FP and HIV/AIDS;
              Identification of focal person to strengthen coordination mechanism in MOHP;
              Preparation of operation plan jointly under the leadership of MOHP as decided by
               the High level RHCS Coordinating Committee;
              Review RHCS issues at national and regional RH review meetings;
              Advocate to build public – private partnership; and
              Redesign EDPs meetings to look at in integrated approach (RH with HIV/AIDS);

4.      Strategic Action Plans

Objective: Promote/create favorable policy environment by cataloguing present policies and
suggesting new ones

Issues addressed:         1. Policy and Acts/Regulations
                          2. Structural framework

Coordinating agency: Logistics Management Division and Family Health Division

Assumption:       Political commitment will grow.            Time Period: 5 years
                 Donor support will continue and enhance
                 Increased involvement of social marketing and private sector

        Strategic Activity           Implementing    Estimated    Timing        Output         Outcome
                                       Agency          Budget                 Indicators      indicators
 1. Review exiting policies          LMD      and   $ 10,000     Nov 2007   Meeting held,   Revised
 (including safer motherhood         FHD                                    List of area    policies    in
 policy, alternative financing                                              requiring       place
 policy (CDP)), identify area of                                            further
 improvement                   and                                          attention
 recommendations          through                                           prepared
 meeting, workshop seminar
 2. Integrate RHCS in the            LMD      and   $10,000      2007       Policy          New policy in
 explicitly all national health      FHD                                    document        operation
 policy documents in line with                                              prepared
 securing        total      health
 commodities for all EHCS
 3. Plan and conduct advocacy        FHD, LMD       $15,000      2007-11    RHCS issues     Increased
 activities to increase awareness                                           included in     awareness
 among politicians, national and                                            policy, plan    and
 local leaders, policy makers, and                                          and programs    involvement
 senior officials on the need to
 have favorable policies for
 private sectors, NGOs and civil
 societies and communities to
 improve commodity security
 4. Create health policy forum to    MOHP, NPC      $5,000       2007       Forum           Suggestion
 provide inputs on policy                                                   formed          on
 development matters                                                                        development
                                                                                            of      policy
 5. Develop implementation plans     FHD, LMD       $10,000      2007-11    Implementati    Improved
 in support of population and RH                                            on       plan   RHCS in the
 related national policies and                                              developed       country
 enhance commodity security in                                              and
 the respective      plans    and                                           implemented
 6. Discussion and formulation of
 maintenance policy and plan for

RH equipment and physical


Objective: Address the unmet need of RH services and commodities and increase accessibility

Issues addressed:           1. Availability and accessibility of services
                            2. Equity (social, geographic and economic inclusion)
                            3. Health seeking behavior
                            4. Barriers to care
                            5. Quality of care
                            6. Market segmentation

Coordinating agency: Logistics Management Division and Family Health Division

Assumption: Required financial and human resources available                         Time Period: 5 years
            Political commitment increases

       Strategic Activity          Implementing     Estimated   Timing         Output              Outcome
                                     Agency           Budget                  Indicators          indicators
1.    Conduct market              FHD/LMD          $ 20,000     2007      Market               Strategy to
      segmentation study in                                               segmentation         reach excluded
      three ecological belt in                                            study conducted      people
      five regions                                                                             developed
2.    Conduct user profile        FHD              $ 20,000     2007      User profile         Strategy to
      analysis; livelihood                                                analysis             reach excluded
      analysis; conduct further                                           conducted            people
      analysis of DHS data to                                                                  developed
      understand the reason for
      non-use of contraception
      among women who want
      to space or limit
3.    Study on quality of care    FHD              $ 10,000     2007      Study report         Quality of RH
      of available RH services                                                                 care improved
4.    Social inclusion            HMIS unit, MD    $ 2,000      2007      HMIS tools           Greater
      monitoring included in                                              revised to include   utilization of
      HMIS                                                                social inclusion     RH services by
5.    Design and pilot special    FHD              $ 10,000     2007-08   Special RHCS         Greater
      RHCS program for                                                    program designed     utilization of
      social inclusion                                                    and piloted          RH services by
6.    Program design and          FHD/I/NGO/loc    $20,000      2007-11   Carried activities   Greater
      initiate activities to      al communities                          to remove            utilization of
      remove barriers to care                                             barriers             RH services by
      (for example.,                                                                           all including
      emergency transport,                                                                     socially
      fund, cost sharing and                                                                   excluded
      providers incentive)

7.    Review and update RH        NHEICC/FHD/C     $ 5,000      2007-08   RH IEC/BCC           Audience

      Strategic Activity          Implementing   Estimated   Timing          Output             Outcome
                                    Agency        Budget                   Indicators          indicators
     IEC, BCC package based      HD                                    materials based     specific RH
     on audience                                                       on audience         IEC, BCC
     segmentation                                                      segmentation        materials
                                                                       reviewed and        developed and
                                                                       updated             used
8.   Conduct focused BCC         NHEICC/FHD/C    $ 50,000    2008-11   Focused BCC         Greater
     (behaviour change           HD                                    activities on       utilization of
     communication)                                                    revised RH          RH services by
     activities on revised RH                                          package             all including
     package                                                           conducted           socially
9.   Conduct feasibility study   DDA             $ 10,000    2007      Feasibility study   Lead to
     to establish quality                                              to establish        establishment of
     control laboratory for                                            quality control     quality control
     testing RH commodity                                              laboratory for      laboratory
     like condom and other                                             testing RH
     selected commodities                                              commodity


Objective: Identify/finalize RH commodities, diversify portfolio of donors and increase GON‟s
Issues addressed:     1. Identification and list of RH Commodities including equipment
                      2. Funding/in-kind sources of RH commodities
                      3. Effective and efficient decentralized procurement (where applicable) of
                              RH commodities (central, district)
                      4. Donor funding

Coordinating agency: Family Health Division and Logistics Management Division

Assumption: Internal resources mobilized
            Donor support will continue                                   Time Period: 5 years
   Strategic Activity         Implementing        Estimated     Timing         Output          Outcome
                                 Agency             Budget                   Indicators       indicators
1. Make a expert group      FHD, LMD             $ 4,000      2007         Expert group     Finalized list of
committee to finalize the                                                  formed           RH
list of RH commodities                                                                      commodities
including key equipment
2. Design and pilot         FHD, LMD, NGOs       $ 10,000     2008         Implemented      Revised cost
models for cost recovery                                                   pilot program    recovery
for contraceptives                                                                          policies in
3. Incorporating RH         LMD, FHD             $ 15,000     2007/8       Number of        Revised CDP
commodities (FP and SM)                                                    commodities      Strategy
in Community Drugs                                                         and amount       (Focused on
program, starting by                                                       spent for RH     Population
piloting in 3 district                                                     commodities in   perspective
                                                                           the piloted      Plan)
4. Evaluation of existing   NCASC, LMD,          $ 10,000     2007/8       Female           Control of
situation female condoms,   CRS, FPAN                                      condoms          spreading
establish distribution                                                     distrbution      HIV/AIDS and
mechanism of female                                                        mechanism        other STIs
condoms among sex                                                          established
5. Piloting Financing       LMD, CRS, FPAN,      $ 30,000     2007/9       Implementation   Access to
scheme for RH based on      MoLD, Marketing                                of pilot         quality RH
market segmentation         institution of GoN                             program in       services for
study in 3 districts of 3                                                  districts        different
ecological belt                                                                             segments of
6. Advocacy on increase     FHD, LMD             $5,000       2007 – 11    Increased        Adequate
MOH and donor funding                                                      commitment of    supply of RH
on RH commodities                                                          RH               commodities
                                                                           commodities      for clients at
                                                                           from MOH and     community
                                                                           donors           level
7. Development of           LMD                  $3,000       2007 – 08    Development      All level

procurement standard and         of procurement   follows the
procedures to be followed        standards        procurement
by all levels                                     standards

Objective: Improve and formalize collaborative commitments on RHCS from within public,
donors and private sector

Issues addressed:           1. Lack of long term commitments
                            2. Communication in public and private sector
                            3. Inadequate advocacy
                            4. Insufficient involvement/participation of NGOs, social marketing and
                                    private health institution in RHCS

Coordinating agency: Logistics Management Division and Family Health Division

Assumptions: Political environment will continue to be favorable.                 Time Period: 5 years
             Donor support will continue

       Strategic Activity           Implementing    Estimated   Timing       Output             Outcome
                                      Agency          Budget                Indicators         indicators
1. Advocacy workshop for            FHD, LMD       $ 4,000      2007/09   Workshop held     Increase funding
parliamentarians (health                                                                    from MOH for
committee) on the importance of                                                             RH and FP
RHCS                                                                                        commodities
2. Media sensitization workshop     FHD, LMD       $ 20,000     2007/9    Workshop held     Increase the
for public awareness for under-                                                             demand from
served, people, poor and socially                                                           people and
deprived people (social                                                                     commitment
inclusion) and increase in                                                                  from MOHP
demand for services and
3. Identification of underserved    LMD, FHD,      $ 25000      2007/8    Underserved       Underserved
population in every district        MoLD, MD,                             population        population
supported by EDPs in respective     EDPs                                  identified        access to RH
district                                                                                    services will be
(major agenda of PRSP so                                                                    increased
should be done in coordination
with MoLD/DDC)
4. Conduct retrospective study      UNFPA/GON      $10,000      2007      Study conducted   Donor‟s long
on donor‟s planning process                                                                 term plan
adopted in support of
commodities in view of making
donors prospective plan to avoid
abrupt decision to withdraw
5. Favorable policy environment     MOHP           $5,000       2007/08   Policy            Wider coverage
for NGOs and social marketing                                             recommendation    by NGOs and
to be created to expand coverage                                                            social marketing.
beyond urban areas to capture                                                               Reduced burden
socially deprived and                                                                       in public sector.
underserved people and those
who can pay for the services


Objective: Consolidate 5 years running budgetary requirement for RH commodities/program
and ensure funding commitments from public, donors, and private sector

Issues addressed:           1. Current and future funding gap
                            2. Donor dependency
                            3. Funding mechanism/Household funding (purchasing capacity,
                            willingness to pay)
                            4. Burden to public sector (social marketing, NGO, and private
                            sector to less the burden in public sector)

Coordinating agency: Logistics Management Division and Family Health Division

Assumption:         Political environment remains to be favorable                         Time Period: 5 years
                    Donor support will continue
         Strategic Activity               Implementi    Estimate   Timing        Output               Outcome
                                           ng Agency   d Budget                 Indicators           indicators
                                                         (US$ )
1. Advocate for budget allocation         MOHP/DoH     $6,000      annual    Workshop held        GoN budget for
(ministry, parliament, donors forum,      S                                                       RHCS increased
women pressure group, media
mobilization, RH as political agenda)
2. Local level advocacy to mobilize       FHD,         $30,000     1/VDC/    Advocacy             Increased
local health budget for RH                DHO/PHCC                 year      Meeting held         allocation       to
commodities                               /HP/SHP,                                                RHCS.
- Sensitize health management             HMC
committee,       community       based
organization      (mothers      group,
FCHVs) to explore local resources
including civil society for RHCS
3. Advocate to link RHCS with             FHD          $4,000      2007-     Commodities as       Household
micro-credit programs                                              2011      part of micro-       budget spared for
                                                                             credit program       RHCS
4. Review RH financing policy             LMD/FHD      $1,000      2007      Area of policy       Favorable policy
(private, public sector) and integrate                                       improvement
RH commodities into CDP. CDP and                                             determined
SM program should run hand in hand
5. Encourage private sector to initiate   MoHP         $10,000     2007-     Private   Sector     Insurance
health insurance scheme, increase                                  2011      involvement          scheme piloted
share of social marketing, NGOs,
private sector hospitals in RHCS
6. Enhance existing collaborative         DHO/DDC      $15,000     annuall   Shared       need    increased
support DDC, VDC, HMC, civil                                       y         collaboration        collaborative
society etc. for RH services                                                                      support
7. Document innovative programs           FHD, LMD     $3,000      2007-09   Program              Clients buying
(good practices) to encourage clients                                        replicated           more          RH
to pay various programs and                                                                       commodities
dissemination for replication


Objective: Build capacity of stakeholders including district level for RHCS management
          towards achieving 6 “Rights” of logistics management

Issues addressed:           1. Warehousing and Storage
                            2. Inventory Management/ Forecasting
                            3. Distribution and Transportation
                            4. Logistics Management Information system
                            5. Procurement; effective and timely decision-making by minimizing
                              discretionary measures
                            6. Up-gradation of competency among health service providers

Coordinating agency: Logistics Management Division and Family Health Division

Assumption:         MOHP fill-up vacant positions                                   Time Period: 5 years
                   Donor support will continue

           Strategic Activity      Implementing    Estimated    Timing         Output              Outcome
                                     Agency          Budget                   Indicators          indicators
1. Advocacy on higher level to     LMD, FHD       $ 2,000      2007-08    Approve policy       LMIS         unit
make     the   LMIS       unit                                            for creation of      incorporated in
sustainable                                                               staff position for   LMD's
                                                                          LMIS unit            organogram
2. Review and expand scope         LMD, FHD,      $ 5,000      2006/      Revised LMIS         Revised LMIS in
of LMIS to include other RH        MD and other                2007       tools developed      place
components             including   stakeholders
HIV/AIDS; increase use of
LMIS data
3. Scale-up „Pull‟ system of       LMD, FHD       $ 70,000     December   Capacity             Year         round
essential RH commodities in                                    2007       developed and        availability     of
additional 12 districts per year                                          Pull       system    RH commodities
                                                                          introduced      12   in the service
                                                                          districts            delivery sites
4. Conduct feasibility study to    LMD, FHD       $ 7,000      2007-08    Feasibility study    Potential       for
establish      plants        to                                           report               Private or public
manufacturer FP Injectables                                                                    investment       to
and condoms.                                                                                   establish plants
                                                                                               for     injectables
5. Include RHCS in the DoHS        HMIS/MD,       $ 2,000      2007       RHCS included        Wider
website                            LMD                                    in DoHS website      dissemination of
6. Enhance capacity of             NHTC, LMD,     $ 20,000     2007-      RHCS capacity        Improved       RH
central/districts in RHCS          FHD                         2011       in all districts     logistic
activities like forecasting,                                              enhanced             management
procurement at district level                                                                  system

           Strategic Activity      Implementing    Estimated     Timing       Output               Outcome
                                     Agency          Budget                  Indicators           indicators
- basic and refresher logistics                   $ 30,000
management training, pull
system training)
- Organize inter country
exchange visits to observe best                   $ 125,000
practices,              training
- integrate RHCS in existing                      $25,000
training curricula of health
service providers
7. Construct district stores in    LMD/USAID-     $ 1,750,000   2007-11   35 district stores   Improved
remaining 35 districts             JSI/KfW                                constructed          storage facility
8. Strengthen supervision and      LMD/FHD/R      $ 15,000      2007-11   Supervision visit    Logistic
monitoring of logistics system     HDs/DHOs                               undertaken           management
                                                                          Monitoring           system improved
                                                                          review meeting


Objective: Strengthen/establish formal functional coordination groups with defined roles and

Issues addressed:            1. Within public sector (including central - district level)
                             2. Public and Private sector/NGO
                             3. Among Donors
                             4. Government and Donors

Coordinating agency: MOHP

Assumption: Increased GON‟s commitment                              Time Period: 5 years
            Increased Donor Support

       Strategic Activity           Implementing        Estimated      Timing       Output          Outcome
                                       Agency            Budget                    Indicators      indicators
1. Formation of RHCS                MOHP            $ 2000           2007         Committee       Improved
committee at MOHP                                                                 formed          coordination
                                                                                                  in MOHP
2. Identification of focal person   MoHP/DoHS       -                2007         Focal Person    coordination
for strengthening coordination                                                    named           process
mechanism in MOHP.                                                                                moved
3. Prepare operation plan jointly   Health Sector   $ 10,000         2007-011     Integrated      Consensus on
under leadership of MOHP            Reform Unit,                                  Plan            work plan
                                    FHD/LMD                                       developed       build
4. Public Sector:                   Health Sector   $ 10,000         First week   Meeting held    Issues
Increase advocacy to concern        Reform Unit,                     of           Minutes         discussed
 ministries by Department                                            November     prepared and    Action to be
(annual inter ministerial meeting                                                 acted upon.     taken
under chairmanship of Secretary                                                                   identified
of Health)
5. Organize Advocacy                DoHS, LMD,      $ 20,000         Semi-        Workshop        Public Private
Workshop on building public –                                        annual       Organized.      partnership
private partnership (FNCCI,                                                       Report          strengthened
Pharmaceutical companies,                                                         prepared and
private hospitals association and                                                 circulated
medical colleges)
6. Include RHCS review in           MD/LMD/FH       $ 25,000         2007-11      RHCS            Action to be
national and regional review        D                                             program         taken
meetings                                                                          reviewed        identified
7. Routine EDPs meetings             GTZ, USAID,    -                Monthly       coordination   Communicati
(monthly) and dissemination of      DFID, KfW,                                    meeting held    on improved.
information-role clarity            UNFPA and                                     coordination    Issues
                                    others                                        issues          clarified.
                                                                                  discussed       consensus

                                     Annex 1:
Members of Working Group for Drafting the RHCS Strategy and Action Plan

      1. Dr. Mahendra K. Chhetri, Director, LMD
      2. Dr. Peeyoosh K. „Rajendra‟, Director, FHD
      3. Ms. Sumitra Shrestha, Public Health Administrator, LMD
      4. Mr. Pangday Yonzone, Program Specialist, USAID
      5. Dr. Ganga Shakya, Advisor, SSMP/DFID
      6. Mr. Ajit S. Pradhan, M&E Advisor, SSMP/DFID
      7. Mr. Ram Bhandari, Consultant, MEH Consultant/KfW
      8. Mr. Subhash Shrestha, Coordinator, FPAN
      9. Ms. Indira Chitrakar, Area Manager, CRS
      10. Mr. Heem S. Shakya, Sr. Program Officer/deputy team leader, Logistics,
      11. Mr. Bhogendra Dotel, Public Health Administrator, FHD
      12. Mr. Sher Bahadur Chaudhary, Public Health Expert, UNFPA
      13. Dr. Janardhan Lamichane, Team Leader Logistics/Sr. Policy Specialist, NFHP/JSI-

Resource person:
        Dr. Jayanti M. Tuladhar, CST UNFPA, Bangkok
      Dr. Kalpana Tiwari, UNFPA

Annex 2: