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FigureAbout one fifth of married women aged 35 years <strong>and</strong> older<strong>and</strong> over one quarter of those with three or more surviv<strong>in</strong>gchildren rely on <strong>the</strong> pill. Rely<strong>in</strong>g on <strong>the</strong> pill ra<strong>the</strong>r thanaccept<strong>in</strong>g longer-act<strong>in</strong>g <strong>and</strong> permanent methods poses amajor problem for <strong>the</strong> efficiency of <strong>the</strong> programme.Under <strong>the</strong> Mayer Hashi Project, funded by USAID, <strong>the</strong>goal is to achieve 5 million voluntary sterilization clientsover <strong>the</strong> four-year project period (May 2009 to September2013). The target is unlikely to be achieved because of<strong>the</strong> lack of prerequisite conditions, such as shortage oftra<strong>in</strong>ed providers. The achievements <strong>in</strong> longer-act<strong>in</strong>g <strong>and</strong>permanent methods are below <strong>the</strong> targets (GOB, 2008a),<strong>and</strong> this has been fur<strong>the</strong>r confirmed by <strong>the</strong> concernedDGFP officials. The Mayer Hashi Project is implementedby EngenderHealth <strong>in</strong> collaboration with DGFP.Figure 3 shows <strong>the</strong> trend <strong>in</strong> longer-act<strong>in</strong>g <strong>and</strong> permanentmethod performance <strong>in</strong> <strong>the</strong> national programme. Thetotal number of voluntary sterilization cases <strong>in</strong>creasedfrom about 70,000 for <strong>the</strong> period from October 2002to September 2003 to about 300,000 dur<strong>in</strong>g <strong>the</strong> periodOctober 2009 to September 2010; however, <strong>the</strong> numbersdecl<strong>in</strong>ed dur<strong>in</strong>g <strong>the</strong> periods October 2005 to September2006 <strong>and</strong> October 2001 to September 2008. The numberof IUD acceptors <strong>in</strong>creased from fewer than 200,000 dur<strong>in</strong>g<strong>the</strong> period October 2002 to September 2003 to around350,000 dur<strong>in</strong>g <strong>the</strong> period October 2008 to September2009, but <strong>the</strong>n decl<strong>in</strong>ed to around 200,000 dur<strong>in</strong>g <strong>the</strong>period October 2009 to September 2010. The number ofimplant acceptors <strong>in</strong>creased from over 50,000 dur<strong>in</strong>g <strong>the</strong>period October 2002 to September 2003 to over 200,000dur<strong>in</strong>g <strong>the</strong> period October 2008 to September 2009, but<strong>the</strong>n decl<strong>in</strong>ed to 50,000 from October 2008. The decl<strong>in</strong>e<strong>in</strong> <strong>the</strong> use of <strong>the</strong> different longer-act<strong>in</strong>g <strong>and</strong> permanentmethods between October 2002 <strong>and</strong> September 2010 islargely due to such methods be<strong>in</strong>g out of stock <strong>and</strong> to <strong>the</strong>shortage of tra<strong>in</strong>ed providers, equipment, <strong>in</strong>frastructure<strong>and</strong> f<strong>in</strong>ance. Fur<strong>the</strong>r, <strong>the</strong> dem<strong>and</strong> for longer-act<strong>in</strong>g <strong>and</strong>permanent methods is affected by <strong>the</strong> poor quality ofservices <strong>in</strong> <strong>the</strong> public sector <strong>and</strong> lack of promotional efforts.Overall, <strong>the</strong> quality of health <strong>and</strong> FP services cont<strong>in</strong>ues tobe low, <strong>and</strong> this disproportionately hurts <strong>the</strong> poor (WorldBank, 2010).High discont<strong>in</strong>uation rate:A key concern for FP programmes overly-dependent ontemporary modern methods is <strong>the</strong> rate of discont<strong>in</strong>uation<strong>and</strong> <strong>the</strong> clients’ reasons for discont<strong>in</strong>uation. Over half(56.5%) of <strong>the</strong> users stopped us<strong>in</strong>g a method with<strong>in</strong> 12months of start<strong>in</strong>g its use <strong>in</strong> 2007, up from 48 per cent <strong>in</strong>1993/94 (see Table 1). The discont<strong>in</strong>uation rate was highestamong condom users (76%), followed by those practis<strong>in</strong>gwithdrawal (67%), us<strong>in</strong>g <strong>the</strong> pill (54%), <strong>in</strong>jectables (53%)<strong>and</strong> IUD (33%). Most users drop out because of methodfailure, side effects, health reasons, or because <strong>the</strong>y want tobecome pregnant. Dropp<strong>in</strong>g out on account of side effects<strong>and</strong> method failure <strong>in</strong>dicates that FP services are of lowquality. Such a high drop-out rate implies huge systemlosses for <strong>the</strong> programme.Ris<strong>in</strong>g unmet need <strong>and</strong> high future<strong>in</strong>tention to use family plann<strong>in</strong>gRis<strong>in</strong>g unmet need for contraception:Unmet need for contraception <strong>in</strong>creased from 11 per cent<strong>in</strong> 2004 to 17 per cent <strong>in</strong> 2007 (see Table 1). Fur<strong>the</strong>r, ifthose us<strong>in</strong>g traditional methods of FP (8% <strong>in</strong> 2007)Figure3Trend of National LA/PM Performance (October 2002 - September 2010)400000350000300000250000200000150000100000500000Tubectomy Vasectomy Total VSC IUD ImplantOct-02 to Sep-0335003407567575918370755972Oct-03 to Sep-04624994719110969019866984977Oct-04 to Sep-058490159222144123210878107137Oct-05 to Sep-06684325672012515225390451386Oct-06 to Sep-071066089839520500319659911164Oct-07 to Sep-0810251587559190074269112211069Oct-08 to Sep-0912471612646225117833612653896Oct-09 to Sep-1012814315612828427121920949683114
are considered, unmet need for effective methods ofcontraception was 25 per cent <strong>in</strong> 2007. Unmet need has<strong>in</strong>creased across all age groups, all educational groups, <strong>in</strong>both rural <strong>and</strong> urban areas, <strong>and</strong> <strong>in</strong> all geographic regionsof <strong>the</strong> country. Unmet need is highest <strong>in</strong> Sylhet division(26%), <strong>and</strong> lowest <strong>in</strong> Khulna <strong>and</strong> Rajshahi divisions (12%).Unmet need is higher among limiters (11%) than spacers(7%). The <strong>in</strong>crease <strong>in</strong> unmet need reflects problems withfieldworker home visitations, <strong>the</strong> supply of FP methods<strong>and</strong> services, <strong>and</strong>/or an actual <strong>in</strong>crease <strong>in</strong> <strong>the</strong> dem<strong>and</strong> forFP.High future <strong>in</strong>tention to use: A large majority (70%)of <strong>the</strong> non-users <strong>in</strong> <strong>the</strong> 2007 BDHS reported that <strong>the</strong>ywanted to use FP <strong>in</strong> <strong>the</strong> future (see Table 1). The highproportion of non-users who <strong>in</strong>tended to practise FP <strong>in</strong><strong>the</strong> future created both a challenge <strong>and</strong> an opportunity for<strong>the</strong> programme to be able to provide <strong>the</strong>m with access togood-quality FP services.Gaps <strong>in</strong> contraceptive securityThe term “commodity security” is used to describe a situationwhere every person will<strong>in</strong>g to practise FP is able to choose,obta<strong>in</strong> <strong>and</strong> use good-quality FP methods at <strong>the</strong> right time<strong>and</strong> <strong>in</strong> <strong>the</strong> right place. The “six rights” pr<strong>in</strong>ciples are: rightcommodities, right quantities, right conditions, right place,right time <strong>and</strong> right prices (GOB, 2010c). Contraceptivesecurity exists when <strong>the</strong> follow<strong>in</strong>g four conditions are metby <strong>the</strong> programme: (a) <strong>the</strong> programme has <strong>the</strong> ability toaccurately estimate its contraceptive requirements; (b) ithas or has coord<strong>in</strong>ated <strong>the</strong> necessary fund<strong>in</strong>g to procurecontraceptives; (c) it has <strong>the</strong> technical capacity to procurecontraceptives on a timely basis; <strong>and</strong> (d) it is able to ensure<strong>the</strong> availability of contraceptives <strong>and</strong> <strong>the</strong>ir reliable deliveryto <strong>the</strong> end-users for <strong>the</strong> medium- to long-term future. Of<strong>the</strong> four essential conditions for achiev<strong>in</strong>g contraceptivesecurity, <strong>the</strong> ability to procure commodities has been <strong>the</strong>most difficult for Bangladesh (GOB, 2004b).The contraceptive requirements of Bangladesh are metby <strong>the</strong> public sector, SMC, <strong>the</strong> private sector <strong>and</strong> NGOs.Except for <strong>the</strong> private sector, <strong>the</strong> public sector, with grantsfrom development partners <strong>and</strong> loans from <strong>the</strong> WorldBank/<strong>International</strong> Development Association (IDA), isprocur<strong>in</strong>g contraceptives for <strong>the</strong> public sector <strong>and</strong> NGOs.SMC currently receives commodities directly from donors<strong>and</strong> procures some products us<strong>in</strong>g <strong>the</strong> sales proceeds fromdonated contraceptives.Before 1998, most contraceptives were supplied to <strong>the</strong>Bangladesh FP programme by donors (Department for<strong>International</strong> Development, KfW Entwicklungsbank,CIDA, UNFPA <strong>and</strong> USAID). Under HPSP, with abudget of approximately US$ 3 billion provided by <strong>the</strong>government, <strong>the</strong> World Bank <strong>and</strong> a pool of developmentpartners, about half of <strong>the</strong> funds were allocated for <strong>the</strong>procurement of goods <strong>and</strong> services. Procurement was to becarried out <strong>in</strong> l<strong>in</strong>e with IDA <strong>and</strong> World Bank procurementguidel<strong>in</strong>es. Ow<strong>in</strong>g to a lack of experience with<strong>in</strong> MOHFWregard<strong>in</strong>g such procurement guidel<strong>in</strong>es, <strong>the</strong> DevelopmentCredit Agreement called for MOHFW to contract a privateprocurement agency; however, this approach did not workout. Subsequently, <strong>the</strong> responsibility for procurementwas assigned to <strong>the</strong> two directorates, DGFP <strong>and</strong> DGHS.However, ow<strong>in</strong>g to <strong>the</strong> lack of prior experience of DGFP<strong>and</strong> DGHS with procurement <strong>and</strong> <strong>the</strong> lack of familiaritywith IDA <strong>and</strong> World Bank procurement guidel<strong>in</strong>es,<strong>the</strong> procurement process was <strong>in</strong>effective, lead<strong>in</strong>g toconsiderable delays <strong>in</strong> process<strong>in</strong>g orders <strong>and</strong> <strong>the</strong> deliveryof commodities. To address this problem, <strong>the</strong> DELIVERProject of USAID provided technical assistance to tra<strong>in</strong>procurement staff of DGFP <strong>and</strong> DGHS (USAID/DELIVER Project, 2008).The procurement <strong>and</strong> supply of goods under IDAguidel<strong>in</strong>es, Work Bank procedures <strong>and</strong> <strong>the</strong> government’sPublic Procurement Regulations <strong>in</strong>volve a complexprocess, tak<strong>in</strong>g between a year <strong>and</strong> a year <strong>and</strong> a half underideal conditions. The DGFP contraceptives procurementprocess, funded dur<strong>in</strong>g <strong>the</strong> cont<strong>in</strong>gency period (2003-2005), was <strong>in</strong>itiated <strong>in</strong> late 2005 <strong>and</strong> early 2006. The delay<strong>in</strong> cont<strong>in</strong>gency plan fund<strong>in</strong>g was accompanied by delaysencountered throughout <strong>the</strong> procurement process, result<strong>in</strong>g<strong>in</strong> delayed commodity deliveries <strong>and</strong> eventual “stock-outs” 4of condoms, IUDs, <strong>in</strong>jectables <strong>and</strong> implant contraceptives.There was a shortfall of 247 million condoms betweenFebruary <strong>and</strong> March 2008; 614,000 IUDs betweenMay <strong>and</strong> June 2007; <strong>and</strong> 20 million <strong>in</strong>jectables betweenNovember <strong>and</strong> December 2006 (USAID/DELIVER,2008). Such shortfalls led to high discont<strong>in</strong>uation ratesamong users; <strong>and</strong> <strong>the</strong> method-mix, be<strong>in</strong>g dom<strong>in</strong>atedby temporary methods, resulted <strong>in</strong> a high <strong>in</strong>cidence ofun<strong>in</strong>tended <strong>and</strong> unwanted pregnancies. Accord<strong>in</strong>g to<strong>the</strong> 2007 BDHS, 3 <strong>in</strong> 10 births <strong>in</strong> Bangladesh are ei<strong>the</strong>runwanted or mistimed <strong>and</strong> wanted later, with no changefrom 2004 (NIPORT, Mitra <strong>and</strong> Associates <strong>and</strong> Macro<strong>International</strong>, 2009). The overall availability score decl<strong>in</strong>edbetween 2004 <strong>and</strong> 2009 (see Appendix Table 1).O<strong>the</strong>r constra<strong>in</strong>ts on <strong>the</strong> availability of contraceptivemethods <strong>in</strong>clude: (a) a considerable shortage of tra<strong>in</strong>edproviders hamper<strong>in</strong>g provision of tubal ligation, no-scalpelvasectomy <strong>and</strong> IUDs; (b) non-availability of <strong>the</strong> emergencycontraceptive pill, <strong>the</strong>refore leav<strong>in</strong>g menstrual regulation<strong>and</strong> abortion as <strong>the</strong> only back-up method for method <strong>and</strong>/or user failure; (c) non-availability of progest<strong>in</strong>-only pill;(d) stock-out of <strong>in</strong>jectables; <strong>and</strong> (e) stock-out of implants.With technical assistance from donors, Bangladeshhas developed large, successful supply cha<strong>in</strong>s for both115
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Family Pla
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ForewordThe Asia <
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Part 1Part 1Asia <
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Ensuring that <str
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of methods for all, in</str
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and undertake <str
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Report on the Regi
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SESSION 1: Changin
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that improving <st
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at a hospital would be offered post
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Bounkoung Phichit, Deputy M
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medicines
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Thus, while knowledge of modern met
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Hon. Mr. Malakai Tabar, Chairman, P
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curricula. If the
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dialogue as well as regional <stron
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BackgroundGlobal development effort
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TableTable1EventNational policyYear
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A third observation is that reporte
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TableTable2Current Contraceptive Pr
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Figure(-1.2), Cook Island</
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FigureTableTable3Trends in<
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Nam. Nearly all economies i
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2008 2009% Bilateral % Multilateral
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family planning wi
Page 73 and 74: IntroductionFamily
Page 75 and 76: The advent of the
Page 77 and 78: FigureFigure1Oceania and</s
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Page 81 and 82: FigureFigureFigure2Total fertility
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Page 96 and 97: The concept of “unmet need” has
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Page 131 and 132: ConclusionThe Bangladesh Fa
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Page 137 and 138: IndiaIndiaFamily <
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International supp
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in development has
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__________ (2007). Population <stro
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170
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TableTable2What has the</st
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174
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per cent of women reported us<stron
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is provider bias that such methods
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TableTable7skewed distribution of h
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TableTable8TableTable9182
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that of the nation
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TableTable12 7some policies that ex
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The system guides the</stro
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FigureFigure4Total donor expenditur
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FigureFigureagain
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Impact of family plannin</s
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marketing of contr
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United States Agency for In
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200
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acceptable. From an NGO perspective
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FigureThis trend of limited donor f
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Figureto have the
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FigureFigure5Percentage change <str
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FigureFigure6Desire to limit childb
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coordination betwe
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the 1980s
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Policy Management.__________ (n.d.,
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218
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Population Activities (UNFPA) for a
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where family plannin</stron
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Thus an objective assessment of <st
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226
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Figureeconomic growth durin
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TableTable1TableTable2For spac<stro
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eflect a provider bias (e.g., <stro
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The Indonesian delegation was very
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than in ensur<stro
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in-country <strong
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(Ministry of Healt
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242
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244
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FigureTrends and p
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TableTable3Unmet need for contracep
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TableTable5TableTable6TableTable725
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TableTable8TableTable9Malaysia, abo
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previously mentioned is based on fo
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TableTable16births and</str
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FigureFigure3TRF54.5Scatter plots o
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ReferencesAng, Eng Suan (2007). Stu
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Demographic data sheet: population
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population size, with just 336,000
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NuptialityIn Myanmar nuptiality is
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FigureIn Myanmar, birth-spac<strong
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Scope of coverage and</stro
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FigureIn Myanmar, out of six select
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equirements. The Min</stron
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according to <stro
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Adolescent sexual and</stro
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FigureHIV/AIDS. An HIV-positive wom
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National Population PolicyMyanmar i
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Linkages with o<st
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TableTable4Achievements of Myanmar
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monitoring <strong
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Nay Pyi Taw, 26 October 2010.53 Sit
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TableTableA296
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dispense and adm<s
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(1) I am against a
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FigureFigureFigure3Use of modern co
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FigureFigure7Traditional method use
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Figureprojection, and</stro
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Figure 11 summarizes the</s
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correlating <stron
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Figurethe use of c
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FigureFigure15Sexual behaviour <str
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track the distribu
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Figureservices, which should <stron
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FigureFigureFigure18 Population <st
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National Statistics Office, <strong
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TableTable11326
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TableTable19Laws and</stron
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worker and hours w
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334
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336
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includin</
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TableTable1Contraceptive prevalence
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These results suggest that about 70
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2 The (period) TFR is the</
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346
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FigureThe existence of traditional
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Guinea case by <st
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The establishment of provin
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provide family plannin</str
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Figurelegal requirement nor a condi
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FigureTableTable5TableTable6Figure4
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modern method and
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married or in unio
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Figureolder. Both the</stro
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TableTable15The immediate past Nati
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out that the “ne
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Commodity securitySupply cha<strong
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is able to achieve. In Papua New Gu
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Qualitative assessments by a number
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increasin<
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service delivery poin</stro
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Population: Views from Men
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1545-1730Day 2: December 9Session 2
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Day 3, December 10Session 50830-100
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15Mr. Tong Sithen1
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54Ms. Shadiya IbrahimAssistant Repr
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93Mr. Melkie AntonProject OfficerUn
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131Dr. John P. SkibiakDirectorRepro
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International <str
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