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Commodity securitySupply cha<strong>in</strong> <strong>and</strong> logisticsmanagementThe status of Reproductive Health Commodity Security <strong>in</strong>Papua New Gu<strong>in</strong>ea must be considered poor. Although itwould be extremely difficult to survey every service deliverypo<strong>in</strong>t <strong>in</strong> <strong>the</strong> country, <strong>the</strong> evidence from several partialassessments <strong>and</strong> many local studies suggests that suppliesof contraceptives are unreliable <strong>and</strong> <strong>in</strong>consistent across <strong>the</strong>full range of health facilities from aid posts to hospitals.At <strong>the</strong> same time, <strong>the</strong> unavailability of contraceptives <strong>in</strong><strong>the</strong> rural health facilities that actually deliver services maycoexist, with large surpluses of commodities <strong>in</strong> area medicalstores or prov<strong>in</strong>cial transit stores. The problem is not that<strong>the</strong> country cannot afford supplies; <strong>the</strong> primary reason for<strong>in</strong>consistent supplies is poor distribution result<strong>in</strong>g fromweak logistics management. This is <strong>in</strong>dicated by <strong>the</strong> factthat <strong>the</strong> government budget allocation for medical supplieswas underspent by 11.3 million k<strong>in</strong>a (US$ 1 = 2.21 k<strong>in</strong>a)<strong>in</strong> 2004 (Midire et al., 2005).The <strong>in</strong>security of supply of contraceptives at variouslevels of <strong>the</strong> health services delivery system is a majorimpediment to <strong>the</strong> cont<strong>in</strong>uous use of modern contraception<strong>in</strong> Papua New Gu<strong>in</strong>ea. Village-level studies, such as thatundertaken by Maibani-Michie (1998), show that lack ofor <strong>in</strong>consistency <strong>in</strong> supply, along with difficulty of access,are <strong>the</strong> primary reasons for discont<strong>in</strong>uation of familyplann<strong>in</strong>g methods <strong>in</strong> rural areas. This arises <strong>in</strong> part because<strong>the</strong> system of village aid posts – <strong>the</strong> lowest level of facility<strong>in</strong> <strong>the</strong> Papua New Gu<strong>in</strong>ea system of rural health care – hasbeen collaps<strong>in</strong>g over <strong>the</strong> past 20 years. It is estimated that,<strong>in</strong> 2000, 37 per cent of aid posts <strong>in</strong> <strong>the</strong> country had ceasedoperat<strong>in</strong>g (NDOH M<strong>in</strong>isterial Task Force, 2009). In someprov<strong>in</strong>ces <strong>the</strong> proportion of aid posts still function<strong>in</strong>g iseven lower. Midire et al. (2005) found that only 59 per centof aid posts <strong>in</strong> Morobe Prov<strong>in</strong>ce were operational.Even if <strong>the</strong> village has a function<strong>in</strong>g aid post, <strong>the</strong> deliveryof contraceptives, as with o<strong>the</strong>r medic<strong>in</strong>es <strong>and</strong> supplies,is generally erratic <strong>and</strong> unreliable. A conscientiousstaff member of an aid post, an “Aid Post Orderly” orCommunity Health Worker (CHW), would need to behighly creative <strong>and</strong> energetic to ensure cont<strong>in</strong>uity of supplyby seek<strong>in</strong>g emergency supplies from a health centre or adistrict hospital when “stock-outs” (an event that causes<strong>in</strong>ventory to be exhausted) occur.In any case, aid posts are normally able to provide onlycondoms, <strong>in</strong>jections <strong>and</strong> pills; however, stock-outs of<strong>the</strong>se commodities are common, frequently last<strong>in</strong>gseveral months. 15 Some aid posts had never provided anyfamily plann<strong>in</strong>g services because staff were not tra<strong>in</strong>ed or<strong>in</strong>terested. The unreliability of supply at <strong>the</strong> rural villagelevel encourages women to go directly to a health centre,district or prov<strong>in</strong>cial hospital where <strong>the</strong> chances of f<strong>in</strong>d<strong>in</strong>g<strong>the</strong> service or commodity wanted are higher. However,even at <strong>the</strong>se levels stock-outs can occur (Midire et al.,2005), although less frequently than at <strong>the</strong> aid post level.The closure of an aid post or <strong>the</strong> unavailability ofcontraceptives <strong>the</strong>re can have dire consequences for womenwho wish to avoid pregnancy <strong>and</strong> have to seek services at<strong>the</strong> next highest service delivery po<strong>in</strong>t. Maibani-Michie(1998) cited <strong>the</strong> case of a woman from a remote part ofMilne Bay Prov<strong>in</strong>ce, who said:I had discont<strong>in</strong>ued depo not by choice butwas forced to by natural circumstances.When my depo <strong>in</strong>jection was due it wasdur<strong>in</strong>g <strong>the</strong> wet season <strong>and</strong> <strong>the</strong> rivers hadflooded so I could not go to <strong>the</strong> healthcentre because to get <strong>the</strong>re I had to gothrough 20 or more river cross<strong>in</strong>gs. As aconsequence of that I fell pregnant to my7th child…Comprehensive reviews of Reproductive HealthCommodity Security (RHCS) <strong>in</strong> Papua New Gu<strong>in</strong>ea wereconducted <strong>in</strong> 2003 <strong>and</strong> 2005. The most recent of <strong>the</strong>se(Midire et al., 2005) described <strong>the</strong> situation that wouldhave prevailed around <strong>the</strong> time of <strong>the</strong> 2006 DHS. Majorproblems identified <strong>in</strong> 2005 <strong>in</strong>cluded <strong>the</strong> follow<strong>in</strong>g:Forecast<strong>in</strong>gThe methods used for forecast<strong>in</strong>g future requirements are<strong>in</strong>adequate. Order<strong>in</strong>g is done annually based on previousyears but no account is taken of <strong>the</strong> “stock-outs” that haveoccurred dur<strong>in</strong>g <strong>the</strong> year, result<strong>in</strong>g <strong>in</strong> a chronic undersupplyof contraceptives. Deliveries to village aid posts are notbased upon an assessment of dem<strong>and</strong> or needs <strong>in</strong> <strong>the</strong>catchment area. Ra<strong>the</strong>r, a fixed quantity of contraceptives is<strong>in</strong>cluded <strong>in</strong> medic<strong>in</strong>e kits that are supposed to be deliveredevery six months.ProcurementGovernment procedures for procur<strong>in</strong>g contraceptives arecomplex, time-consum<strong>in</strong>g <strong>and</strong> poorly implemented. Whilepart of <strong>the</strong> problem is that <strong>the</strong> procedures are cumbersome,<strong>the</strong> ma<strong>in</strong> reason for delays is weak management, which isexacerbated by shortages of staff <strong>and</strong> <strong>in</strong>adequate tra<strong>in</strong><strong>in</strong>g.370
Pipel<strong>in</strong>e managementSurpluses of stock <strong>in</strong> area medical stores coexist withshortages <strong>in</strong> district hospitals, health centres <strong>and</strong> aidposts. The overstock<strong>in</strong>g of supplies at one stage of <strong>the</strong>distribution cha<strong>in</strong> accompanied by <strong>the</strong> understock<strong>in</strong>gof supplies at service delivery po<strong>in</strong>ts is <strong>in</strong>dicative of poorlogistics management.Fund<strong>in</strong>g sourcesIt is not possible to provide a def<strong>in</strong>itive account<strong>in</strong>g of allexpenditure on RH commodities. It is clear, however, that<strong>the</strong> Government of Papua New Gu<strong>in</strong>ea provides <strong>the</strong> bulkof <strong>the</strong> funds to f<strong>in</strong>ance <strong>the</strong> purchase of contraceptives.The purchase of contraceptives is carried out throughm<strong>and</strong>ated procurement systems that require <strong>the</strong> call<strong>in</strong>g oftenders, with <strong>the</strong> f<strong>in</strong>al decision on <strong>the</strong> supplier be<strong>in</strong>g madeby various bodies up to <strong>the</strong> Executive <strong>Council</strong>, depend<strong>in</strong>gon <strong>the</strong> amount. In 2004, <strong>the</strong> Government of Papua NewGu<strong>in</strong>ea spent K1.97 million on contraceptives <strong>and</strong> afur<strong>the</strong>r K1.3 million was provided by AusAID under <strong>the</strong>Health Sector Improvement Programme. These figuressuggest that <strong>the</strong> government furnished 60 per cent of <strong>the</strong>costs of contraceptives. However, if <strong>the</strong> private sector <strong>and</strong>NGOs are <strong>in</strong>cluded, <strong>the</strong> government share would decl<strong>in</strong>eto about 50 per cent.The contraceptives <strong>in</strong>cluded <strong>in</strong> medical kits supplied tohealth centres <strong>and</strong> aid posts are purchased by AusAID <strong>and</strong><strong>the</strong> <strong>Asia</strong>n Development Bank, respectively. The HealthSector Support Programme spent K928,500 <strong>in</strong> 2005 oncondoms <strong>in</strong>cluded <strong>in</strong> <strong>the</strong>se kits. AusAID provided anadditional K9.5 million for condoms <strong>and</strong> o<strong>the</strong>r medicalsupplies through <strong>the</strong> National HIV/AIDS Project(Midire et al., 2005).It is estimated that less than 5 per cent of contraceptivesare purchased directly by <strong>in</strong>dividuals from pharmacies orprovided by private doctors. However, <strong>the</strong>re are <strong>in</strong>stanceswhen hospitals that have run out of supplies send patientsto pharmacies to purchase <strong>the</strong>ir requirements. The PapuaNew Gu<strong>in</strong>ea <strong>Family</strong> Health Association (an IPPF affiliate),which provides contraception free, obta<strong>in</strong>s commoditiesfrom IPPF Headquarters <strong>in</strong> London. O<strong>the</strong>r NGOs nowoperat<strong>in</strong>g <strong>in</strong> Papua New Gu<strong>in</strong>ea, <strong>in</strong>clud<strong>in</strong>g PopulationServices <strong>International</strong>, Marie Stopes <strong>and</strong> <strong>Family</strong> Health<strong>International</strong>, purchase contraceptives locally or fromabroad.There is little or no coord<strong>in</strong>ation between <strong>the</strong>se agencies <strong>in</strong>terms of <strong>the</strong> purchase of contraceptives. It is not possibleto estimate <strong>the</strong> total expenditure, but it is likely that <strong>the</strong>government’s share of <strong>the</strong> total is decl<strong>in</strong><strong>in</strong>g <strong>in</strong> relativeterms.Commodity security planA wide range of recommendations have followed from <strong>the</strong>recent RHCS reviews, but <strong>the</strong> extent to which <strong>the</strong>se havebeen implemented over <strong>the</strong> past few years is not currentlyknown. Foremost among <strong>the</strong>se are:Establishment of <strong>the</strong> National RHCS Coord<strong>in</strong>at<strong>in</strong>gCommittee/Work<strong>in</strong>g GroupDevelopment of <strong>the</strong> National RHCS StrategyStreng<strong>the</strong>n<strong>in</strong>g <strong>the</strong> Logistics Management System (newprocedures, equipment)Capacity-build<strong>in</strong>g (appo<strong>in</strong>t<strong>in</strong>g logistics manager,tra<strong>in</strong><strong>in</strong>g <strong>in</strong> forecast<strong>in</strong>g etc.)Procurement of additional commodities not currentlyavailable (e.g., vasectomy kits)Improved mechanisms to ensure susta<strong>in</strong>ability of RHCS(policy dialogue, resource mobilization, communitybaseddistribution)Preparation of an essential drugs list.The status of implementation of <strong>the</strong>se recommendations isunclear at this po<strong>in</strong>t, but <strong>the</strong> 2005 report reviewed <strong>the</strong> statusof <strong>the</strong> recommendations of <strong>the</strong> 2003 RHCS assessment,some of which reappeared <strong>in</strong> 2005. Implementationappeared to be limited over <strong>the</strong> two-year period follow<strong>in</strong>g<strong>the</strong> 2003 review. Importantly, progress had been slow <strong>in</strong>establish<strong>in</strong>g an RHCS coord<strong>in</strong>at<strong>in</strong>g body. 16Adolescents, youth <strong>and</strong> olderpersonsAdolescents <strong>and</strong> youthThe teenage fertility rate <strong>in</strong> Papua New Gu<strong>in</strong>ea, at 65 per1,000, is at <strong>the</strong> high end of <strong>the</strong> range for <strong>Pacific</strong> countries<strong>and</strong> territories, provid<strong>in</strong>g some obvious outliers, such asMarshall Isl<strong>and</strong>s (127) <strong>and</strong> Nauru (78), are left out of <strong>the</strong>comparison. Essentially, Papua New Gu<strong>in</strong>ea, SolomonIsl<strong>and</strong>s <strong>and</strong> Vanuatu all have <strong>the</strong> same teenage fertilityrate. Teenage fertility patterns are largely determ<strong>in</strong>ed bycultural-behavioural conditions <strong>and</strong> are not closely relatedto overall fertility (Hayes <strong>and</strong> Robertson, 2010). Teenagefertility does not necessarily follow <strong>the</strong> overall TFRdownward if it is decl<strong>in</strong><strong>in</strong>g.Although very strong socio-cultural pressure can br<strong>in</strong>gteenage fertility down to significantly lower levels, as <strong>the</strong>special case of Tonga suggests, most <strong>Pacific</strong> cultures areei<strong>the</strong>r unwill<strong>in</strong>g or unable to practise <strong>the</strong> necessary degreeof social control of teenage girls (less so of boys) that Tonga371
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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
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IntroductionFamily
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The advent of the
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FigureFigure1Oceania and</s
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next 25 years, however, TFR fluctua
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FigureFigureFigure2Total fertility
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family planning pr
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esponsible for the
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that estimates of CPR for earlier p
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Figuremarried at an older age compa
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As previously mentioned most <stron
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FigureFigure945Relationship between
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The concept of “unmet need” has
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TableTable8Percentage of th
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TableTable9Percentage of reasons fo
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family planning pr
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As far as the supp
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Socio-cultural challenges tofamily
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likely to use contraception than yo
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15 Tests of statistical significanc
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of the South <stro
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104
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Figurewill exceed the</stro
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in urban (67%) tha
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ased service delivery poin<
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Most FWAs who were recruited two to
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are considered, unmet need for effe
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Households pay the
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Effective public-private partnershi
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ConclusionThe Bangladesh Fa
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the Family
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National Institute for Population R
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IndiaIndiaFamily <
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IntroductionThe use of contraceptiv
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TableTable2Indicators of tra<strong
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FigureFigureFigure1Contraceptive pr
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TableTable5Indicators of contracept
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TableTable6Adjusted odds ratios for
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FigureFigure3Contraceptive prevalen
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TableTable7Adjusted and</st
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the north
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TableTable10Differences between nor
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TableTable11 Total fertility rate <
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End Note1The first camp was success
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152
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154
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Figure1980s and ex
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health care and ed
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assistance from UNFPA and</
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in CPR. Likewise,
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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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Page 348 and 349: includin</
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Page 390 and 391: Population: Views from Men
Page 392 and 393: 1545-1730Day 2: December 9Session 2
Page 394 and 395: Day 3, December 10Session 50830-100
Page 396 and 397: 15Mr. Tong Sithen1
Page 398 and 399: 54Ms. Shadiya IbrahimAssistant Repr
Page 400 and 401: 93Mr. Melkie AntonProject OfficerUn
Page 402 and 403: 131Dr. John P. SkibiakDirectorRepro
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