Documentation of the Use of sparhcs: Ukraine Introduction

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The Strategic Pathway to Reproductive Health Commodity Security (SPARHCS), developed by the DELIVER, POLICY, and Commercial Market Strategies (CMS) projects (in collaboration with the United States Agency for International Development (USAID), the United Nations Population Fund (UNFPA), and other donors and technical agencies), serves as an assessment, planning, and implementation tool to help countries address contraceptive security (CS) issues and determine areas for strengthening and intervention. SPARHCS examines six key areas that factor into a country’s CS situation: client utilization and demand, context, commitment, capital, capacity, and coordination. Moreover, it is a universal assessment tool that can be tailored to specific timelines, country contexts, or program objectives.
The following brief outlines the experience of using the SPARHCS tool in assessing contraceptive security in Ukraine. Overall, SPARHCS served to identify key weaknesses and focus attention on developing and implementing solutions.

Documentation of the Use of SPARHCS: Ukraine
Introduction
Contraceptive security (CS) is achieved when individuals have the ability to choose, obtain, and use contraceptives and condoms whenever they need them. The Strategic Pathway to Reproductive Health Commodity Security (SPARHCS) framework provides countries with a tool to assess contraceptive security and to design plans for advancing it in both the short and long term.

At the end of 2004, to initiate its CS efforts, Ukraine’s Ministry of Health (MOH) collaborated with POLICY and used SPARHCS to conduct an assessment of Ukraine’s current CS situation. The following brief tells the experience of using SPARHCS in Ukraine, including the CS context in the country; the application of the SPARHCS tool; CS-related advocacy efforts; SPARHCS findings, recommendations, lessons learned from using the tool; and outcomes since the SPARHCS application.

CS Context in Ukraine^¹
The MOH and POLICY reviewed available data and information on demographics, the history of donor financing of contraceptives, the family planning (FP) market, and the economic and political environment in Ukraine to understand the context related to achieving contraceptive security (Zhylka, 2005; Armand et al., 2005; Hudgins and Wright, 2004; Seltzer et al., 2003).
Demographic indicators.^² The contraceptive prevalence rate (CPR) was 68 percent among married^³ women ages 15–44, in 1999 (CDC et al., 2001).^⁴ The CPR for modern methods among married women, ages 15-44, was 38 percent. Use of family planning is lower among women living in rural areas, women with low levels of education, and adolescents. Unmet need was 15 percent in 1999. While reliance on abortion as a form of family planning has decreased in recent years due to increased use and availability of modern contraceptive methods, rates are still fairly high compared with other countries—1.6 abortionsper woman (PRB, 2003). The total fertility rate (TFR) in Ukraine is well below the replacement level at 1.2 births per woman—a trend that is seen throughout Eastern Europe (PRB, 2005). Given the abortion rate of 1.6 and the TFR of 1.2, on average, women tend to have more abortions than live births in their lifetime (CDC et al., 2001).
History of donor financing of contraceptives. In the last decade, donors of contraceptive commodities to Ukraine’s Ministry of Health (MOH) have included USAID, the United Nations Population Fund (UNFPA), and the International Planned Parenthood Federation (IPPF). From 1995–2000, USAID provided contraceptive commodity donations only to select provinces/regions or oblasts. UNFPA’s contraceptive commodity donations to the MOH began in 1994 and were phased out in 2003.
FP providers and methods. Ukrainian women obtain their contraceptive methods from a range of sources but predominately from those operating within the public sector. In 1999, sources for FP methods among MWRA using family planning included the MOH’s women’s consultation centers (42%), public hospitals (13%), maternity homes (5%), parastatal pharmacies (29%), private drug kiosks (3%), and other sources (5%) (see Figure 1) (Borda, 2005; CDC et al., 1999).
In 1999, the method mix among MWRA included traditional methods (46%) and modern methods (54%). Of the MWRA using family planning, reported modern methods included IUDs (27%), condoms (18%) oral contraceptives (OCs) (4%), female sterilization (2%), and other modern methods (3%) (see Figure 2) (Borda, 2005). FP provider interviews and pharmaceutical industry data suggest an increased use of OCs in recent years; however, this trend is likely driven by provider bias and the pharmaceutical industry’s interest in marketing and selling OCs (Armand et al., 2005; Hudgins and Wright, 2004).

Economic and political environment. Ukraine is a middle-income country with increasing economic stability. Like many countries, Ukraine faces the challenge of meeting the increasing contraceptive needs of its population without the support of donated contraceptive commodities. The presence of a new government and the revitalized political support for reproductive health bode well for advancing contraceptive security. However, the limited awareness among regional policymakers about issues surrounding contraceptive security creates a challenge and suggests an increased need for advocacy around contraceptive security at multiple levels.
The SPARHCS Assessment in Ukraine
The MOH launched CS activities by conducting an assessment of the current reproductive health (RH) situation in Ukraine, using the SPARHCS framework in the last half of 2004. The information drawn from the SPARHCS assessment was used to help Ukraine prepare the CS portion of the new National Reproductive Health Program (NRHP) for 2006–2015.
Key players. The MOH spearheaded the SPARHCS assessment that was conducted by Nadiya Zhylka, M.D., the director of the Maternal and Child Health Care Office of the Department of the Organization and Development of Medical Aid to the Population within the MOH. POLICY staff provided important guidance for Ukraine’s SPARHCS assessment, including introducing the SPARHCS framework and diagnostic tool to Dr. Zhylka.
Information gathering. Dr. Zhylka conducted informal key informant interviews and desk reviews of current statistics, sociodemographic surveys, market segmentation information, and recent studies conducted in Ukraine by cooperating agencies.

Following Dr. Zhylka’s initial round of information gathering for the SPARHCS assessment, POLICY and the MOH jointly held a CS Issues Workshop from February 10–12, 2005, for a group of 70 multisectoral stakeholders, including representatives from various ministries, the NGO sector, the commercial sector, public and private healthcare facilities, universities, foundations, and United Nations organizations. Within this stakeholder group are members of the Ukraine Reproductive Health Network (URHN), a group of NGOs involved in advocacy efforts around reproductive health; and the Policy Development Group (PDG), a group of representatives from the government, NGOs, and the commercial sector. The PDG has been an important player in national RH policy development and implementation.

The objectives of the CS Issues Workshop were to generate a common understanding of CS issues, introduce the SPARHCS framework to a larger group of stakeholders, and present preliminary findings from the SPARHCS assessment. The multisectoral group helped to validate, expand, and fine tune Dr. Zhylka’s findings and recommendations. The group defined and created a list of the main CS issues and identified seven priority CS issues to focus on in Ukraine’s CS strategy.
Findings and dissemination of results. A working document titled “Contraceptive Security Situation Analysis in Ukraine” was created and distributed to all workshop participants. The document included SPARHCS assessment findings and additional issues that arose from the CS Issues Workshop. POLICY DC and POLICY Ukraine prepared a “Contraceptive Security Issues Workshop Report,” which provided a summary of the topics presented and included the priority CS issues identified by participants (Huk et al., 2005).
Overview of SPARHCS Findings
Dr. Zhylka and the stakeholders determined challenges and opportunities in the following areas: service delivery, financing, procurement and logistics, policy and regulatory framework, leadership and commitment, and coordination mechanisms (Zhylka, 2005; Huk et al., 2005)
FP service delivery. Existing operational barriers affect the provision of FP products and services to all those who may want them. First, the prescription and administration of FP methods is restricted to obstetrician-gynecologists, which creates barriers to access, specifically in rural areas since most rural health centers are staffed by gynecologists or family medical doctors—requiring rural women to travel for most FP methods and services. Second, the health law states that adolescents under 18 must obtain parental consent to receive FP/RH services. Third, legislation mandates the provision of free medical services in public sector facilities, but many patients purchase their medicines and supplies, including contraceptives, from pharmacies and often make informal payments to providers as well. The cost of FP services and products can thus be prohibitive for poor and vulnerable groups. Even though legislation mandates provision of free FP services and products to select priority groups, such as women with contraindications for pregnancy, adolescents, and those affected by the Chernobyl nuclear disaster, no specific mechanism is in place to carry out the mandate. Finally, inadequate supplies in public sector facilities, limited method choice in some facilities, and high prices of contraceptives limit access to contraceptives.

Contraceptive security will continue to advance in Ukraine given the well-developed commercial sector that can serve those who are able to pay for contraceptives. The participation of the commercial sector will allow the public sector to focus its resources on those people with limited or no ability to pay and other priority populations.

Sources of financing. Until 2003, public sector health facilities received donated contraceptive commodities—the phaseout of which has resulted in less availability of contraceptive methods in those facilities. Financing challenges include the absence of funding for the procurement of contraceptives from the national budget; the lack of flexibility in budget allocations at subnational levels; insufficient financial autonomy for health facilities; the absence of a separate budget line item for priority groups; and the lack of alternative funding mechanisms for contraceptives. To expand availability in the public sector, some types of contraceptives are now included in the list of medications of domestic and foreign production and are purchased by public sector health facilities and partially or fully financed from local and state budgets (Zhylka, 2005).
Procurement and logistics. The government of Ukraine does not currently procure contraceptive commodities because of a lack of funds, as previously mentioned. UkrMedPostach conducts procurement for the MOH for medicines and supplies funded by the national budget, such as tuberculosis and antiretroviral medicines, and it operates as a private company that is heavily regulated by the MOH. UkrMedPostach stores and distributes the medicines to oblasts and select rayons (counties/districts). Each oblast health administration has its own autonomous pharmaceutical distributor, often called a Farmacia, which is responsible for operating the state pharmacies in its oblast and managing supplies from UkrMedPostach. In addition, Farmacias procure contraceptives, medical supplies, and additional drugs from commercial entities. Procured commodities are, in turn, provided to state pharmacies, public hospitals, and clinics (Hudgins and Wright, 2004).
Overall, several systems are in place, though not necessarily in use, to forecast for, procure, and distribute contraceptives in Ukraine. Two supply chain systems have been used and could potentially carry out the targeted distribution of public sector contraceptives once they are procured—UkrMedPostach, an integrated medical supply chain and a vertical system that was established within the MOH to distribute donated contraceptives but is no longer in operation. A Logistics Management Information System (LMIS) was established in local FP centers and the MOH and was used from 2001–2003, along with the vertical supply chain system. The LMIS is not currently in use since there are no donated contraceptives arriving in Ukraine. Few personnel are trained in forecasting for contraceptives, but oblast FP centers do make forecasts based on demographic data and service statistics (Hudgins and Wright, 2004).
Policy and regulatory framework. Ukraine has a favorable policy environment for family planning and reproductive health. The FP subsystem within the MOH is relatively new, having been established in 1995. Currently, maternal and child health is a priority in the government’s action plans. The NRHP 2001–2005 aimed to expand FP services and appropriately equip the facilities providing the services. The NRHP’s continuation, the NRHP 2006–2015, which, at the time of the assessment, was under development, will include components of contraceptive security.
Leadership and commitment. In adopting the National Family Planning Program and the NRHP 2001–2005, the government has shown its commitment to family planning/reproductive health. Overall, in leading the SPARHCS assessment, the MOH exhibited important leadership in working toward contraceptive security. Since 2000, the URHN has been important in raising public awareness, involving the public in dialogue, and advocating for RH policy reforms at national and oblast levels. Improved leadership and collaboration among the public, private, and NgO sectors in identifying and addressing cs issues, as well as advocacy at national and local levels, will improve Ukraine’s CS situation.

Coordination mechanisms. Recently, multisectoral coordination has been improving in Ukraine. Since 1999, through multisectoral partnerships, the PDG ^⁵ has been formulating policies, programs, standards, and regulations that preserve and improve the reproductive health of Ukraine’s population. The MOH is interested in establishing linkages with local NGOs, international organizations, and pharmaceutical companies to address CS challenges.
Main Recommendations for Achieving Contraceptive Security
Through an informed decisionmaking process and a vote, key stakeholders identified seven priority CS issues at the CS Issues Workshop. Issues fell into the areas of awareness raising, information generation and use, service delivery, financing, resource targeting, policy and advocacy, and collaboration.

Raise awareness about family planning at all levels, including among civil society, healthcare providers, and faith-based organizations.

Ensure the availability of reliable information for decisionmaking and evidence-based planning.

Improve technical and interpersonal skills and professionalism among healthcare and FP providers.

Assess potential funding mechanisms for financing FP program and contraceptive requirements.

Establish mechanisms to serve priority populations with FP products and services.

Improve the policy environment for achieving contraceptive security in Ukraine.

Enhance multisectoral collaboration and inter-ministerial coordination in FP products and service provision.

Lessons Learned Using SPARHCS in Ukraine
Important lessons emerged from Ukraine’s SPARHCS assessment that can be used to inform SPARHCS assessments in other countries.
High-level involvement in a SPARHCS assessment is important for validating and using its findings. The leadership provided by Ukraine’s MOH was critical to conducting a successful SPARHCS assessment. Since Ukraine’s assessment process was led by the MOH and carried out by a high-level MOH official, it is highly regarded and more likely to be used internally in CS strategy development compared with the more externally driven SPARHCS assessments that have been conducted elsewhere.
Consistent and reliable data sources are critical to a successful SPARHCS assessment. Making policy decisions based on evidence and accurate data, as well as monitoring trends in FP use and other demographic indicators, are critical to CS strategic planning and policy development. In Ukraine, the existence of several demographic surveys from different years conducted with different methodologies made it difficult to determine trends in contraceptive use. As a result, data from the most reliable source, the 1999 Ukraine Reproductive Health Survey, were used to inform the assessment—the drawback being the data were fairly outdated. Efforts to enhance the consistency and quality of national data in Ukraine should be encouraged.

Multisectoral collaboration is valuable in a SPARHCS assessment and subsequent CS planning. While the MOH has been leading efforts, representatives from PDG and URHN—which include other divisions of government, NGOs, and other private sector entities—were involved in CS discussions and identifying issues. The existence of already established inter-governmental and multisectoral relationships around family planning and reproductive health set the stage for and facilitated continued collaboration. As a result of being involved in the SPARHCS process and the CS Issues Workshop, the UHRN created advocacy campaigns specifically around CS issues.

Activities and Progress since the SPARHCS Application
SPARHCS served to identify key weaknesses and focus attention on developing and implementing solutions in Ukraine. Since the SPARHCS assessment, Ukraine has worked on advancing contraceptive security by creating an enabling policy environment and improving FP services. Key activities have included advocacy campaigns to build support for CS issues at the oblast and national levels, multisectoral planning for family planning and reproductive health, and policy development. Selected activities and progress include the following:

Following the passage of a resolution to prepare a new NRHP, the Ukraine Cabinet of Ministers issued instructions to the MOH to create a working group that could design the 10-year RH strategy for 2006–2015 and the next NRHP. In May 2005, the MOH ordered the PDG to design this strategy; POLICY assisted the MOH and the PDG in completing it and is helping to draft the new NRHP 2006–2015, which includes contraceptive security as a component. The goal of the new NRHP is to improve the reproductive health of the population, as an important component of ensuring the social and economic capacity of Ukraine.

To ensure successful implementation of the new NRHP, in May 2005, the PDG approved its own five-year RH strategic plan (2005–2009), which will address priority RH issues such as the poor reproductive health of women, high maternal and infant mortality, high abortion rates, and the unsatisfactory status of adolescent reproductive health.

After the CS Issues Workshop in February 2005, URHN members met to rank CS issues for advocacy and created a diverse set of advocacy approaches appropriate in their respective oblasts. POLICY/Ukraine presented the contraceptive security supplement of POLICY’s “Networking for Policy Change: An Advocacy Training Manual,” to help URHN craft advocacy messages around CS issues. As a result, the URHN designed four POLICY-supported advocacy campaigns in 2005 to be run by NGOs, with the goal of ensuring access to contraceptives at the local level. The topics of the campaigns included:

Lugansk Oblast: Gathering support from the oblast hospital administration to institute annual training for all levels of medical staff on modern contraceptive methods and CS issues.
Poltava Oblast: Securing a commitment from the local administration to allocate funds for contraceptives for the youth-friendly clinic in Kremenchuk City in order to increase access to FP commodities together with counseling and information on family planning.
Kharkiv and Zaporozhie Oblasts: Obtaining funds from the oblast budget for NGOs to conduct information, education, and communication (IEC) campaigns on family planning/contraceptive security in order to raise awareness among youth about RH behavior and modern contraception.
Donetsk Oblast: Obtaining funds from the oblast budget for NGOs to conduct IEC campaigns on family planning/contraceptive security in order to raise awareness among youth about RH behavior and modern contraception.

In November and December 2005, all four advocacy campaigns were successful in securing commitment from administrative officials, which will ensure access to contraceptives at the local level. Specifically, successes included:

Lugansk Oblast: In November 2005, the chief physician of the Popassnaya rayon hospital issued an Order, “On the interventions to improve the reproductive health of the population in Popassnaya rayon, Lugansk Oblast.” One of the planned interventions is to hold annual courses for healthcare workers on FP/CS issues.
Poltava Oblast: In November 2005, the mayor of the city of Kremenchuk issued a mandate to provide free contraceptive products to youth clients of the city’s youth clinic—the costs to be covered by the city budget.
Kharkiv Oblast: In November 2005, the head of the social department of the city administration issued a formal letter ensuring the obligation of state money to hold a competition for NGOs on implementing IEC campaigns on FP/CS issues—all to be conducted under the city program, “Kharkiv Youth 2005–2006.”
Donetsk Oblast: On November 23, 2005, the head of the Makeevka city administration in the Donetsk Oblast approved the city’s new RH program, “The health of women and children of Makeevka City for 2006–2010,” based on the NRHP 2006–2015. The city’s Coordinating Board, created in 2002 by a URHN member, facilitated the implementation of the city’s RH program from 2001–2005 and designed the city’s new RH program in October–November 2005. The new program will provide contraceptive products to youth and vulnerable populations and will produce IEC materials on family planning for youth. The city has allocated a total of 12,000 hryvnias per year (approximately US$2,400) for these activities.
Donetsk Oblast: Additionally, in December 2005, the head of the Makeevka city administration issued an order to include a competition for NGOs on implementing IEC campaigns for youth on FP/CS issues within the 2006 city self-governing program. The program’s budget will include 350,000 hryvnias (approximately US$70,000) for IEC activities.
- Zaporozhie Oblast: In November 2005, the state administration sent a guaranteed letter ensuring funds in the 2006 oblast state budget for NGOs to carry out FP/CS IEC campaigns.

The SPARHCS assessment and technical assistance on developing CS strategies and CS advocacy campaigns have provided momentum for moving toward contraceptive security in Ukraine. Working closely with the MOH and building on established inter- and intra-sectoral relationships will allow Ukraine to continue to expand its efforts in ensuring that Ukrainians can choose, obtain, and use high-quality contraceptives whenever they want them.

References
Armand, F., C. Cuellar, and B. O’Hanlon. 2005. Assessment of Private Sector for Reproductive Health and Family Planning Products and Services in Ukraine. Bethesda, MD: Abt Associates, Inc./Private Sector Partnerships-One Project.
Borda, M. 2005. Ukraine Market Segmentation. Draft. Washington, DC: Futures Group/POLICY Project.
Centers for Disease Control and Prevention (CDC), Kiev International Institute of Sociology, and USAID. 2001. Ukraine Reproductive Health Survey 1999: Summary Report. Atlanta: CDC.
Hudgins, T. and C. Wright. 2004. Ukraine Contraceptive Availability Assessment. Arlington, VA: John Snow, Inc./DELIVER.
Huk, A., O. Truhan, N. Zaglada, V. Galayda, S. Sharma, A. Jorgensen, S. Alkenbrack, and E. Sonneveldt. 2005. Contraceptive Security Issues Workshop Report, Hotel National, Kyiv, Ukraine: February 10–12, 2005. POLICY Project.
Population Reference Bureau (PRB). 2003. Reproductive Health Trends in Eastern Europe and Eurasia. Measure Communication, September 2003. Washington, DC: PRB.
PRB. 2005 World Population Data Sheet. Washington, DC: PRB.
Seltzer, J., P. Bryan, P. Senlet, and K. O’Hanley. 2003. Assessment of Reproductive and Maternal Health in Ukraine. Washington, DC: The Population Technical Assistance Project, LTG Associates, Inc.
Zhylka, N.Y. 2005. Contraceptive Security Situation Analysis in Ukraine. Kyiv, Ukraine: Rayevsky Scientific Publishers.

1 This section reviews the CS context at the time of the SPARHCS application at the end of 2004.

2 Ukraine is home to 47.5 million inhabitants. Approximately 68 percent reside in urban areas (32.3 million). The number of women of reproductive age is 12.5 million or about 26 percent of the total population. Ukraine’s population size is decreasing, as in many countries in Eastern Europe.

3 The “married” classification includes women in either registered or unregistered marriages.

4 Data are drawn from the Ukraine Reproductive Health Survey conducted in 1999. No comparable surveys have been conducted since 1999.

5 The PDG was initially established with POLICY technical assistance to steer the development of the national reproductive health program.