Closing the Gap
through Procurement of Family Planning Commodities
Business Case
August 2011
Contents
Page
Acronyms
3
Clarification of terms
4
Intervention Summary
5
1. Strategic Case
A. Context and need for DFID intervention
A1. Rationale
A2. Justification
A3. Relation to other strategies
B. Impact and outcome
6
6
7
8
9
2. Appraisal Case
A. Critical Success Criteria
B. Feasible options
B1. Theory of change
B2. Options
C. Appraisal of options
D. Comparison of options
E. Measures to be used to assess value for money
10
10
13
17
17
3. Commercial case
A. Procurement or commercial requirements
B. Use of competition to drive commercial advantage
C. Response of market place
D. Underlying cost drivers
E. Procurement process
F. Contract and supplier performance management
19
4. Financial Case
A. Financial resource requirements
B. How will it be funded
C. How will funds be disbursed
D. Monitoring and reporting
20
5. Management Case
A. Oversight
B. Management
C. Conditionality
D. Monitoring and evaluation
E. Risk Assessment
F. Results and benefits management
21
Logframe
22
Acronyms
BCC
CMS
CPR
CSC
CSO
CYP
DALY
DFID
FP
GFATM
GHS
ICC/CS
M&E
MDG
MMR
MoH
MoU
NGO
PHC
PrG
QALY
RH
RMNH
SBS
TFR
UK
UN
UNFPA
USAID
VfM
WHO
Behaviour Change Communication
Central Medical Stores
Contraceptive Prevalence Rate
Critical Success Criteria
Civil Society Organisation
Couple Year of Protection (from pregnancy)
Disability Adjusted Life Year
Department for International Development
Family Planning
Global Fund for AIDS, TB and Malaria
Ghana Health Services
Inter-agency Coordinating Committee for Commodity Security
Monitoring and Evaluation
Millennium Development Goal
Maternal Mortality Ratio
Ministry of Health
Memorandum of Understanding
Non Governmental Organisation
Primary Health Care
Procurement Group (DFID)
Quality Adjusted Life Year
Reproductive Health
Reproductive, Maternal and Newborn Health
Sector Budget Support
Total Fertility Rate
United Kingdom
United Nations
United Nations Population Fund
United States Agency for International Development
Value for Money
World Health Organisation
Clarification of terms
Commodity Security exists when people are able to choose, obtain and use the
contraceptive supplies they want at the time they want. Achieving that requires a full
supply of contraceptives at the end user/consumer level of the supply chain (service
delivery points and communities).
Contraceptive Prevalence Rate (CPR) is the proportion of women of reproductive age
using a family planning method. Conventionally this is measured for married woman and
refers to modern methods only.
Couple Years Protection (CYP) is an estimate of the number of years (or fractions of a
year) of protection provided to a couple by each unit of contraception. Each unit of family
planning commodity is multiplied by a conversion factor relevant to that particular method
in order to calculate the expected duration of contraception provided. For example, one
injection will provide 3 months of protection, so 4 injectables are needed for 1 CYP; an
IUD insertion = 5.5 CYP; a 5-yr implant = 3.5 CYP etc.
Disability-adjusted life year (DALY) extends the concept of potential years of life lost
due to premature death to include equivalent years of “healthy” life lost by virtue of being
in states of poor health or disability. One DALY can be thought of as one lost year of
“healthy” life, and the burden of disease can be thought of as a measurement of the gap
between current health status and an ideal situation where everyone lives into old age,
free of disease.
Method Mix. Women’s preferences for child spacing or limiting their total number of
births influence their choices of contraceptive methods. Those wanting to stop
childbearing are likely to use one of the most effective and long-term methods while those
wishing to postpone a birth choose amongst short-acting reversible methods. A family
planning programme should offer the full range of methods.
Social marketing is the use of commercial marketing techniques to achieve a social
objective. Social marketers combine product, price, place, and promotion to maximize
product use by specific population groups. In the health arena, social marketing programs
in the developing world traditionally have focused on increasing the availability and use of
health products, such as contraceptives or insecticide-treated nets. Different models of
social marketing have been used. While some of the models rely heavily on donor
support, others include built-in exit strategies that depend on the commercial sector to
ensure sustained product supply.
Unmet need is the difference between the proportion of women who say they would like
to use contraception and those that are actually doing so. It reflects the desire for
contraception and its availability.
Intervention Summary: Closing the Gap through the Procurement of Family
Planning Commodities
What support will the UK provide?
Up to £2.7 million from 2011-2012 (15 months)
Why is UK support required?
It has been estimated that world-wide one third of maternal deaths can be attributed to non-use or
unavailability of contraception. Use of family planning means unwanted pregnancies and resultant
abortions can be prevented. Fewer pregnancies reduce the risk to women directly, due to the inherent
risk of pregnancy and delivery. There is evidence that longer spacing between births benefits the child
as well as the mother, and smaller families have broader economic and social benefits.
The millennium development goal on maternal and reproductive health (MDG 5) is a priority in Ghana,
where more than one in every 300 pregnancies results in the death of the mother (compared with less
than one in every 8000 pregnancies in the UK). However maintaining a supply of family planning
commodities remains a problem. Ghana has a strong coordination mechanism for family planning
which produces an annual estimate of needs and gaps for commodities. But, despite good analysis
and planning, the latest estimates for 2011 show that there are only 2 months supply of implants and
only 5 months supply of injectable contraceptives in country.
DFID’s proposed input is a short-term intervention, required as an emergency stop gap while
interventions to ensure long-term availability of family planning start to have an effect. There is a need
to respond quickly to an increasing demand for commodities and to take the opportunity of expanding
the number of couples using contraception. By not intervening, we will put at risk the well-being, and in
some cases the lives, of the thousands of women who are currently using family planning and where a
stockout of commodities can have devastating effects. Short-term procurement will allow participation
in ongoing policy, funding and programming to improve longer-term availability.
DFID’s funds will be used to procure medium and long-term family planning commodities for the
Government’s central medical stores primarily for use in the public sector.
What are the expected results?
This project will procure 2.5 million doses of injectable contraceptive and 66,350 doses of implant
contraceptive which will benefit almost 690,000 family planning users for one yeari. It is estimated that
this will avert 178,000 unwanted pregnanciesii.
1. Strategic Case
A. Context and need for DFID intervention
A1. Rationale
Scale and costs of family planning commodity shortages
Reducing unwanted pregnancy and related maternal mortality is a priority for the UK Government
and the Government of Ghana. The latest survey showed contraceptive prevalence rate for modern
methods in Ghana was only 17%, a decline from 19% since 2003iii. Although this is the highest in
West Africa, it compares badly with an average of 21% across Africa and 56% in developing
countries world-wideiv. The decline measured in the 2008 survey has been confirmed by routine data
which show that women getting family planning from public facilities dropped from 31% in 2009 to
24% in 2010v.
Only 40% of the current demand for family planning is being met. Unmet need is greatest in 15-19
year olds, in the less educated and in the poorest households. Thirty six percent of women in Ghana
want to delay their next birth and a further 36% do not want more childrenvi.
Overall, 51% of women in Ghana obtain their contraceptives from the private sector. But for
injectables and implants, over 80% obtain these from public facilitiesvii. The Government of Ghana
has recognised that contraceptive products are not always maintained in adequate quantities, with
frequent shortages particularly for long-acting methods. The most recent report shows that there will
be a central stockout of implants within the next 2 months and injectables and intra-uterine devices
by the end of the yearviii unless more are procured urgently.
Stockouts occur for a variety of reasons but, at national level, it is mainly due to inadequate
procurementix. Stockouts of any drugs are a problem but for family planning it can be particularly
devastating, resulting in a lack of confidence in the method and service, increased ‘failures’ and
unwanted pregnancies.
The majority of family planning users in Ghana pay for their methods, although in the public sector
these are provided at a highly subsidised rate of approximately 50 pesewas (20p British) for a 3month supply of pills, injectables and condoms.
Evidence of benefits of family planning
Evidence on the benefits of family planning on reducing maternal mortality is strong. There is also
some evidence on broader benefits of family planning to economic and social development although
exact figures and evidence of causality is weaker because of multiple factors contributing to these,
many of which cannot be studied in isolationx.
The health benefits of family planning to women and their children are multiple as well as preventing
maternal deaths. Pregnancy and childbirth are inherently risky and in Ghana the maternal mortality
ratio is 350 per 100,000, compared with 12 in the UKxi. Many of these deaths are preventable and it
is estimated globally that one third of maternal deaths can be attributed to non-use or unavailability of
contraceptionxii. A global drop in fertility between 1990 and 2005 is estimated to have resulted in 1.2
million fewer maternal deathsxiii. Use of family planning means unwanted pregnancies and resultant
abortions can be prevented. Although abortion is legal under specified circumstances in Ghana, it is
frequently performed as an ‘unsafe’ procedure and illegal abortion is estimated to be the cause of
15% of maternal deaths xiv . A maternal death affects the whole family: unsurprisingly, maternal
orphaned children have worse outcomes in both health and educationxv.
The benefits of fewer children and smaller families extend beyond health and include improved
education, nutrition and vaccination for girls; and improved status for women. There is also evidence
of improved productivity, savings and investment; potential for higher economic growth; reduced
public sector spending on health and education; and reduced pressure on natural resourcesxvi. A
recent evidence paper suggested that for each percentage point of fertility reduction, per capita GDP
growth would likely increase by 0.25%xvii.
Longer spacing between births is good for the health of the mother and there is some evidence that it
also benefits children. The World Health Organisation recommends a gap of between 36 and 60
months between births: in Ghana the average is 40 months but almost 15% of births occur within 24
months of the last onexviii.
Family planning is a cost-effective intervention. It has been estimated that, globally, covering the
need for family planning would cost only about $28 to avert an unintended pregnancy and $62 per
disability-adjusted life year (DALY). Furthermore, providing modern contraceptives to all women who
need them would more than pay for itself, saving $1.30 in the cost of maternal and newborn care for
each one dollar investedxix.
It is not clear how closely these figures reflect the situation in Ghana as this type of data is not yet
available. However one study demonstrated that if family planning commodities were added to the
National Health Insurance benefits, spending 5 million Ghana cedis (£2 million) on family planning in
2011 would save 16 million cedis (£6.4million) from avoided pregnancies and lower child care costsxx.
Response so far
Ghana’s most recent reproductive health strategy xxi had family planning as one of six strategic
objectives and commodity security (defined as every person able to choose, obtain and use
contraceptives whenever they need themxxii) as a specific output. The government acknowledges that
there are challenges in reaching the expected results and a new commodity security strategy is being
designed to address some of thesexxiii.
A national Inter-Agency Coordinating Committee for Commodity Security (ICC/CS) meets on a
regular basis. With the support of USAID, it has been producing an annual estimate of needs and
gaps for commodities. This includes requirements for the public sector, some non-governmental
organisations working in the public and private sectors, and requirements for social marketing for the
private sector.
The Government of Ghana routinely budgets for the procurement of family planning commodities but
the funds have generally not been released as required so that supplies have been inadequate.
Meanwhile, different organisations in the public and private sectors have been using social marketing
and behaviour change interventions to increase demandxxiv, contributing to shortages.
Between 2001 and 2008, DFID provided support to the national HIV/AIDS programme which included
procurement of condoms. Apart from this, DFID Ghana did not engage directly in family planning until
late 2010. DFID is now a member of the ICC/CS and has contributed to the new Reproductive Health
Commodity strategy as well as a draft workplan to “Reposition Family Planning for Health and
Development” being developed by the National Population Council.
A2. Why DFID intervention is justified
Ghana has a strong coordination mechanism for family planning, chiefly through the ICC/CS.
However, despite good analysis and planning, the latest estimates for 2011 show that there are fewer
than 2 months supply of implants and only 5 months supply of injectable contraceptives in the
countryxxv.
DFID’s proposed input is a short-term intervention, required as an emergency stop gap whilst longer
term interventions start to have an effect. There is a need to respond quickly to the increasing
demand for commodities and to take the opportunity of expanding the number of new acceptors. By
not intervening, we will put at risk the lives of the thousands of women who are currently using family
planning and where a stockout can have devastating effects. This procurement will complement
others who are supplying condoms, pills, intra-uterine devices and sterilisation services, ensuring the
availability of a complete method mix for the next 12 months.
Procurement is necessary for, and will complement, other DFID-funded programmes which will use
research, evidence and social marketing to strengthen demand and family planning service provision,
in both the public and private sectors. Other partners are also working on increasing demand by
understanding and trying to address barriers to greater use. There is now evidence that demand is
exceeding supplies, which has contributed to the imminent stock outs i.e. during 2010, when
commodities reached the stores and facilities, they were immediately used upxxvi. These all suggest
that closing the gap in supplies will immediately lead to increased utilisation.
Ghana’s new reproductive health commodity security strategy recognises the challenges of securing
a regular supply of commodities and has done a good analysis of the main bottlenecks. There are
now a series of interventions planned to ensure better security in the medium and long-termxxvii .
There is ongoing work with the Ministry of Health and National Health Insurance Agency to review
the exclusion of family planning from services covered by the insurance scheme. In addition, there is
ongoing advocacy work with the National Population Council and civil society to increase government
funding for family planning.
DFID will procure enough implants and injectables to secure stock for the next 12 months. There is a
risk that steps being put in place to increase the Ghana government’s contribution will not have
shown impact by mid 2012 when further procurement will be required. However, this does not obviate
the immediate need. DFID will monitor the situation and work with the government and donors to
avoid future gaps in supplies.
A3. Relation to DFID strategies
This project is included in DFID Ghana’s operational plan. Support to family planning is entirely
consistent with the Government of Ghana and DFID commitments to the health MDGs. This project
will directly contribute to MDG 5 (maternal and reproductive health) and indirectly impact on MDG 4
(child mortality) and MDG 1 (poverty).
This project will complement several other DFID-funded programmes supporting MDG 5 in Ghana.
DFID Ghana has an additional programme planned to support reproductive health in private and
public sectors. There are also three DFID-funded regional programmes that will provide support to
reproductive, maternal and newborn health: one will strengthen safe abortion and family planning
services in the public and private sectors in northern Ghana; one will research barriers to the use of
family planning; and one will generate and use evidence to support advocacy for a greater focus and
priority to MDG 5.
This project will help secure the commodities that will be necessary for these to have impact.
Additional support will come through DFID Ghana’s inputs to health system strengthening (through
sector budget support), strengthening of safe delivery and support to emergency obstetric care.
This project is fully in line with DFID’s Framework for Results for reproductive, maternal and newborn
health. It will provide opportunities to communicate our contribution to DFID global commitments to
enable at least 10 million more women to use modern methods of family planning by 2015. It is in
keeping with the principles of supporting national priorities and interventions.
B. Impact and Outcome
B1. Expected results
This project will procure 2.5 million doses of injectable contraceptive and 66,350 doses of implant
contraceptive which will benefit almost 690,000 family planning users for one year xxviii including
approximately 290,000 new usersxxix.
It is estimated that this will provide 857,000 couple years of protectionxxx and avert 178,000 unwanted
pregnanciesxxxi.
B2. Goal and outcome (purpose)
The Impact of the project will be a decrease in maternal and child mortality
The Outcome of this project will be an increased use of injectable and implant contraceptives
The Output is:
1. Increased availability of injectable and implant contraceptives in the public sector
2. Appraisal case
A. Critical Success Criteria (CSC)
CSC
1
2
3
Description
Speedy procurement of commodities to the central medical
store
Quality of family planning commodities
Cost of procurement
Weighting (1-5)
5
5
4
B. Feasible options
This project will support the availability of medium and long-term family planning commodities.
B.1 Theory of change.
The theory of change for the benefit of family planning is clear, well established and supported by good
evidencexxxii.
£2.6m
Procure 2.5m
Injectables
& 66,350
implants
Procurement &
Distribution to
central
medical stores
Increased
and secure
availability
Increased
use
of family
planning
Decreased
unwanted
pregnancies
& MMR
nets
Maternal mortality is high in Ghana, fertility is still relatively high and there is low use of contraception.
This is partly due to a significant unmet need and shortage of commodities in both the public and private
sectors. Ensuring commodity security is needed to increase acceptors, facilitate consistent use, reduce
the number of unintended pregnancies and, therefore, contribute to a reduction in maternal and child
mortality rates.
B.2 Options
The need and provision of family planning commodities is well analysed and coordinated in Ghana: the
problem lies in procuring in adequate volumes on time, not least due to inadequate investment by the
Government of Ghana. This planned procurement is intended to close the short-term gap in two types of
commodities. Partners are planning to procure other commodities whilst there is ongoing advocacy and
strategy development to ensure commodity security in the longer term.
As other interventions are already planned to support further along the Theory of Change (work on
supply chain, behaviour change communication, staff training etc.), the only alternative option is to do
nothing and rely on other donors or government to fill the gap.
Option 1 – Close the gap through procurement of injectables and implants
What it would consist of
This option would procure adequate injectables (Depo-provera) and implants (Jadelle) to cover the gaps
in commodity supplies for the next 12 months for the public sector.
How it would work
This option is fully in line with the national gap analysis and commodity security planning process and
would allow full participation in national planning and coordination meetings. A contract or memorandum
of understanding (MoU) would be signed with an organisation that could procure the commodities and
deliver them to the government central medical stores. They would then be available for distribution to
regional and district levels through the public supply system and to some non-government service
providers.
The evidence
The evidence for the effectiveness of family planning is strongxxxiii. There is excellent data on the gaps
and immediate requirements for commodities including a division of labour amongst government and
donors to procure different itemsxxxiv. There is also increasing evidence that, at the moment, one of the
main barriers to increased use is the absolute shortage of commoditiesxxxv.
An important assumption in the theory of change is that the commodities are distributed to the end user.
In Ghana, supplies from the central medical stores are available to facilities in the public sector, selected
non-governmental organisations and private sector clients. Distribution is done on a ‘pull’ system; that is
based on consumption, stock levels and requests from facilities. Health facilities need to buy new stock
using funds generated by sales of existing commodities. Although there are recognised weaknesses in
the current supply chain, the data on stockouts is from national level, indicating that commodities are
moving rapidly from national level to lower levels and to end users when available.
Another assumption is that the end user will use the contraceptives correctly. By distributing only through
trained providers, incorrect techniques and advice are avoided. The nature of implants and injectables
means that their success is not dependent on user behaviour e.g. there is no need to remember to take
a pill to be effective.
For more sustainable results, regular supplies will need to be assured and accompanied by changes in
attitudes and behaviour to increase demand. This has already been started through support from USAID
and others, and DFID Ghana is supporting reproductive health knowledge and behaviour change in
adolescents. There is a need to further analyse and address the barriers to women using family
planning. There is some evidence from Ghana that women and men appreciate the advantages of
smaller, better spaced familiesxxxvi but increasing demand can be counter-productive if the service is not
available to respond to increasing requests.
As discussed in the Strategic Case, there is significant input planned to support other aspects of the
Theory of Change. There is good evidence therefore that the proposed inputs to close the gap in
supplies will indeed lead to the expected outcome in the short term and, with additional planned inputs,
will contribute to the expected impact and broader maternal health, social and economic benefits in the
longer-term.
Option 2 – Counterfactual
What it would consist of
The counterfactual would be to do nothing related to family planning. This would allow the money to be
used for other work in health or other sectors.
How it would work
DFID would not provide its expected support in this area. It may compel the government to procure
instead but evidence from 2009 and 2010 suggests this is unlikely. There is also no indication that the
government has the resources to do so in the next few months.
Evidence
Doing nothing risks an absolute gap in commodities (as happened in 2010). Not only will this result in
increased unwanted pregnancies but it also risks the public’s faith in the family planning service,
reducing their uptake even when commodities return. Inadequate supplies would jeopardise DFID’s
other current and planned programmes for family planning and reproductive health more broadly.
Climate and Environment Relevance of Options
Option
Description
1
Close the gap through
procurement of
injectables and implants
2
Counterfactual – do
nothing and withdraw
commodity support
Evidence
rating
Climate
Comments
change
and
environment
category (A, B,
C, D)
Medium/High B – medium
This option is likely to have a
positive impact on climate
opportunity
change and environment
provided due attention is paid
to the measures
recommended.
Medium/High C – no issues
This is likely to have a
negative impact due to its
loss of influence on decisions
and implementation of
infection / healthcare waste
management and collection
of routine data on climate
disruption to logistics and
services
C. Appraisal of options
For Option 1, increasing the availability of family planning will produce the immediate benefits expected
of delayed first pregnancy, fewer pregnancies and greater spacing between pregnancies. But the health
benefits of family planning to women and their children are multiple beyond improving women’s health
and preventing maternal deaths. Measurement of short-term health outcomes do not generally capture
the social, economic and environmental benefits of controlling timing and number of children, as these
are difficult to quantify. There is increasing evidence from studies around the world suggesting that
benefits to women and their families includexxxvii:




Increased family and child well-being
Improved women’s education
Increased female labour force participation
Greater equality between men and women
Examples of potential societal benefits result from the economic and environmental benefits of smaller
families, changing demography, more people in working age with fewer children to support and fewer
people to be sustained by the land. This leads to:




The amount needed to spend on the health sector is lower
The amount needed to spend on the public sector education, water and sanitation is lower
Improved productivity and higher income, greater savings and investment
Reduced pressure on natural resources
1. Social
The primary social benefit is of increased maternal, child and family well being. Evidence shows that a
healthy mother can take better care of the family. Orphaned children have worse health outcomesxxxviii,
particularly those that have lost a mother. Increased birth intervals have a positive effect on outcomes
both for that child and his/her older siblingxxxix, with the mother having longer-time to breast-feed. Fewer
children mean parents having more time and income for each child. Women have increased flexibility to
work, increasing household income. This, along with increased control over their lives, means there can
be greater equality between men and womenxl. Where women wish to use a contraceptive and their
partner does not, they will frequently use an injectable which is less visible than other methods. In
Ghana, the injectable is the most common clinical method but it is not clear how much this is an issue.
There is a high level of knowledge about family planning and nearly 90% of men believe that too many
children are dangerous for a woman and that children from smaller families are more likely to succeed.
Almost 50% of married women who are not currently using family planning intend to do so in the future,
with the injectable as the most popular planned methodxli.
Delaying a first pregnancy means girls are more likely to complete their education with its recognised
benefits. Planned (as a test of fertility) and unplanned pregnancies are frequent amongst adolescents in
Ghana. However there is a high stigma attached to this with a resultant high rate of unsafe abortions.
Although the increasing availability of ‘emergency contraception’ reduces the risk of traditional and
physical substances used to induce abortion, there is still a danger of misuse and side effects.
The majority of family planning users in Ghana pay for their methods, although in the public sector these
are provided at a highly subsidised rate of approximately 50 pesewas (20p British) for pills, injectables
and condoms. It is planned for the supply and payment system to be reviewed because, although it is
heavily subsidised, the cost does place a real, though low, barrier to accessxlii.
2. Political
Family planning has not been high on the political agenda, despite advocacy efforts over recent years.
However, the national Health Summit in April 2011 recognised family planning as a cost-effective
intervention. Resistance to out-of-pocket payments and a parallel logistics system gave rise to renewed
debate about options for financing. The Minister of Health requested evidence on financing options to be
considered at the next sector business meetingxliii. Information on a possible change of policy by the
Minister, to provide family planning free, has been indicated although this still has to be confirmed and
details and implications analysed. If true, it is likely to increase demand and put more pressure on
stocks.
A new DFID-funded regional health programme, Evidence for Actions (E4A), will provide additional
analysis and evidence to strengthen advocacy from civil society and others to put family planning up the
political agenda. E4A links to the new UN Commission on Information and Accountability which will hold
donors accountable for their pledges on maternal and reproductive health and hold countries responsible
for how well the money is spentxliv.
Knowledge of emergency contraception is high and use is reportedly increasing. However it is not well
regulated or monitored and frequently misused. Unless family planning becomes more readily available,
the ongoing unwanted pregnancies and resultant use of ‘emergency contraception’ risks becoming a
headline, politically-sensitive topic. This could produce a negative backlash against family planning more
generally.
3. Institutional
The Ministry of Health (MoH) and the Ghana Health Service (GHS) collectively oversee both the public
health and clinical care sectors in Ghana. The MoH is responsible for funding and procurement of
commodities while the Reproductive Health Department of the Family Health Division of GHS is
responsible for the coordination of inputs and service delivery.
Family planning commodity security is well coordinated through the Inter-Agency Coordinating
Committee on Commodity Security (ICC/CS). Regular participants include DFID and USAID with its
implementing partners, several international NGOs and local CSOs. Representatives of social marketing
and service providers in the private sector are also active members.
The National Population Council is the highest advisory body to the Government of Ghana on population
issues xlv . It has a strong advocacy role on population and to mobilise support and resources for
implementation of programmes. It is currently writing a paper on “repositioning family planning for health
and development” but, as an institution, it is still seen as relatively weak.
As noted above, there are plans to review the current system for the replenishment of commodities at
facility level. This links to a broader need to strengthen the supply chain for all drugs and commodities.
The Ministry of Health is currently implementing recommendations from a Commodity Security Study in
2010 although concerns have been raised at their slow implementation. DFID centrally is considering
funding a second phase of the Medicines Transparency Alliance in Ghana which may contribute to
strengthening of the drug supply system. For meaningful design of any new system, commodities will
need to be available.
4. Corruption/fiduciary risk
Corruption and fiduciary risk in this project are considered to be relatively low. DFID will procure only
through reputable partners (based on Commercial and Management appraisals) and is involved in
ongoing coordination and monitoring. DFID funds will be managed by a procurement agent, which DFID
will appoint under an existing framework arrangement.
The risk of misuse of the commodities is reduced by the close collaboration and information sharing
between those working in the public and private sectors. Requirements are based on estimates for the
public sector, the major NGO providers, and social marketing needs in the private sector. Risks will be
reduced by commodities being procured by several partners with ongoing monitoring and coordination of
inputs. Having a gap rather than a surplus reduces the risk of misappropriation although it may
encourage ‘leakage’ between the public and commercial sectors. Weak management and accountability
at health facility level has already been noted and there are plans for this to be addressed.
5. Impact on climate change and the environment
There are some important environmental issues attached to this intervention. Evidence from Ghana and
elsewhere suggests that attention to infection management and health care waste management is rarely
adequate. Given the volumes of commodities in this programme (2.5 million injectables, 66,350 doses of
subcutaneous implants), there are environmental impacts related to the management of sharps’ waste,
and a risk of potential nosocomial infections linked to injections and the insertion of implants.
The supply of auto-disable syringes and sharps disposal containers with shipments of the injectable
contraceptive Depo-Provera will help to reduce these risks and should be taken into account in
considering value for money and procurement. Further dialogue about the best options for Ghana in
improving waste management, together with consideration of monitoring protocols for infection
management to underpin service delivery, will be taken up as part of DFID’s other current and planned
health interventions.
Climate variability effects may pose risks to the project’s success by increasing difficulties with transport
and logistics due to extreme or intense rainfall events. In addition temperature rises may threaten drug
efficacy. These are recognised challenges for other health interventions such as child immunisation and
may have limited effect on this short-term project. They are something to continue to pursue with the
Inter-Agency Coordinating Committee on Commodity Security and in broader health policy dialogue fora.
In the interim, it is recommended that provision is made to track any disruption to logistics stemming
from rainfall.
There is some research to show that family planning has a potentially impressive impact on carbon
emissions. A paper last yearxlvi concluded that family planning (with or without girls education) is one of
the cheapest strategies for carbon emissions abatement.
Carbon emission reductions from spending $1 million on various interventions
Source: Wheeler D and Hammer D The Economics of Population Policy for Carbon Emissions Reduction in Developing
Countries. Centre for Global Development Working Paper 229 Nov 2010.
Although the grounds for this level of carbon mitigation are somewhat speculative at present and there
are evident measurement challenges, it is accepted that reduced population growth will have a broadly
positive impact through a reduced rise in carbon emissions in a developing country such as Ghana.
6. Costs, benefits and risks
Expected Costs
The expected cost to DFID for procuring the specified family planning commodities will be £2.5mxlvii over
a one-year period. Distribution and supply of the commodities to facility levels across the country and to
the user will be done through the public service system and the associated costs will be borne by the
government and its partners involved in the delivery of family planning services. These delivery costs
include: human resources, supply chain logistics, promotion, information systems, monitoring and
evaluation. Unfortunately there is limited data available to quantify these costs. For purposes of a costeffectiveness analysis we will assume these costs to equal the DFID funding, which is likely to be an
overestimate resulting in conservative benefit-cost calculations.
Expected Benefits
The intervention is expected to generate both direct and indirect benefits particularly health-related
benefits. This analysis looks at the cost-effectiveness of sustaining investment in selected family
planning commodities over a limited 12-month period, as the Government of Ghana and its partners plan
for the longer-term. DFID will close the gap in expected supply shortages of injectables and implants out
of the mix of methods, as their unavailability could erode results and gains to be made from DFID related
programmes on reproductive health.
The primary beneficiaries of this intervention will be over 690,000xlviii women across the country who will
have new and continued access to the commodities over the period. Increasing the mix of methods
available to women has been shown to be an important factor in increasing effective coverage of family
planning services.
The main health benefits associated with the correct use of family planning services are:

Reducing the numbers of unintended pregnancies thereby reducing maternal mortality

Better timing and spacing of births resulting in healthier babies and mothers

Preventing unwanted pregnancies thereby reducing complications arising out of unsafe abortions
There is evidence that over time this will contribute to improved economic security through larger
incomes, greater accumulation of wealth and higher levels of education, and improve overall standard of
livingxlix. In addition, the evidence suggests savings to public-sector spending on health servicesl, higher
productivity leading to higher incomes and faster economic growth and less population pressure on
scarce natural resources.
Quantifying and Valuing the Benefits
The standard measure of output performance of family planning services is the Couple Years Protection
(CYP). One full CYP is the equivalent of one year protection from unintended pregnancy for one couple.
Marie Stopes International (MSI), with support from the Guttmacher Institute, has developed an Impact
Estimator, a mathematical model which calculates CYP (using sub-regional figures rather than country
figuresli) and convert these into estimated demographic, health and economic impacts.
The Impact Estimator lii suggests the following health benefits (without considering costs) for the
proposed project in Ghana:
Quantity
Couple Year Protection
Total
Pregnancies averted
Total
DALYs
Total
Injectable
2.5m
625,000
Implant
66,350
232,225
857,225
130,348
48,432
178,779
154,135
57,270
211,406
A pregnancy averted has health benefits including averting injury to mothers and infants and unsafe
abortions. Using the MSI model, an estimated 455 maternal deaths will be averted through this
intervention.
The disability-adjusted life year (DALY) is widely used as a cost-effectiveness measure indicating overall
health impact of an intervention. The estimates are that 211,406 DALYs will be averted.
DFID’s funding of £2.5m will cover the procurement of the commodities but not the associated costs in
delivering the service to the end-user. The MSI model is able to estimate economic value but requires
costs of supplying the family planning commodities to the user. Since the data is not available, we
conservatively assume that costs of delivery will be an additional £2.5m (i.e. 100% added costs). The
total cost of supplying these family planning commodities would therefore be £5m. Entering this figure
into the model generates estimation that for every £1 invested in the injectables and implants
commodities, £2.20 will be saved by health systems and families.
The only Ghana figures available are in a 2008 USAID-funded studyliii looking at the cost and benefits of
including family planning in the Ghana National Health Insurance (NHIS). Their calculations show that for
every cedi (£0.42) invested in family planning, the NHIS would save an average of GH¢ 0.75 (£0.31) in
the short-term and GH¢ 2.75 (£1.14) in the long-term. The study shows that by investing in family
planning services, the NHIS could save approximately GH¢ 100 (£42) in costs for every pregnancy
averted.
Risks and Challenges
Ghana currently enjoys credible assistance from development partners and private providers in the
delivery of family planning services. This means some demand for these commodities has been created
already and there is an existing system in place to ensure the commodities reach the user and are used
appropriately. This lowers the risk associated with this investment. However, there are two potential risks
and challenges that DFID needs to monitor to ensure a positive outcome.
1. Delays in the procurement process could mean that the commodities do not reach users when
required, thereby limiting the potential benefits from the intervention.
2. Sustainability: DFID is meeting an emergency need to maintain supplies of family planning
commodities in the short-term. Government of Ghana and its partners may not allocate sufficient
resources to family planning commodities in subsequent years. In addition, continued
investments are required in information, education and communication to sustain the economic
benefits associated with family planning programmes. A subsequent gap in procurement could
reduce the gains made with this intervention, particularly related to injectables.
Balance of Costs and Benefits
A key factor in considering whether DFID funds should be committed to this initiative is the intervention’s
cost-effectiveness. Since the only other option open to DFID in the short-term is a “do-nothing” option,
we compare the cost-effectiveness of this intervention to other common health interventions as
calculated for developing countries by the Guttmacher Institute. Based on the cost assumptions made
above, the cost per DALY saved from this intervention will be £23.65 (i.e. £5m/211,406 = £23.65) or
$38.67liv . This compares favourably with Guttmacher Institute estimates of cost per DALY saved for
modern contraceptive methods at $62; BCG vaccination of children $48-$203 and $3516 for cholera
immunisation.
The Ghana NHIS study showed a saving of GH¢ 100 per every pregnancy averted. Applying those
figures here means averting 178,779 pregnancies could save GH¢ 17.8m or £7.4m (with a present value
of GH¢ 14.8m lv or £6.2m using a 10% discount rate). This exceeds total costs of £5m (including
associated costs) which is equivalent to GH¢ 12m.
Sensitivity Analysis
Based on the MSI model, costs of delivery could increase up to 240% (i.e. from £2.5m to £8.5m) for the
project to break-even i.e. for every £1 invested, health systems and families could save £1. This is higher
than the globally accepted figure of $1.20 return on every $1 invested in family planning. Based on the
NHIS study, if we were to reduce the pregnancies averted by 20% i.e. to 143,023, the project would
break even: costs will equal savings to be made from pregnancies averted.
The full range of benefits has not been considered in the analysis but the project has already been
shown to be worthwhile. Even increasing the costs and reducing the benefits derived from pregnancies
averted still makes the intervention worthwhile.
D. Comparison of options
DFID’s Framework for Resultslvi for improving reproductive, maternal and newborn health outlines the
different strategies required: no single intervention will reduce maternal mortalitylvii. Multiple inputs are
planned in Ghana through DFID central and Ghana country programme funding as well as increased
focus on MDG5 from other partners. The framework shows support to several pillars but, without family
planning commodities being available, their impact will be more limited. There is good evidence that
neither the government nor other partners have funding to close the immediate gap in supplieslviii which
means that the ‘do nothing’ Option 2 will not produce related benefits.
Family planning is a cost-effective intervention. Along with inputs by other donors and government, there
is confidence that the assumptions in the Theory of Change will be fulfilled.
The preferred option is to procure commodities. Having agreed amongst partners the types and volumes
of commodities that are immediately required, the further options relate to how procurement options will
fulfil the critical success criteria, discussed under the commercial case.
E. Measures to be used or developed to assess value for money
Family planning is proven to be a cost-effective intervention. The major cost in value for money (VfM) in
this project is the timeliness and unit cost of the commodities, along with shipping, handling and
associated costs. The assessment of VfM is done primarily during the appraisal for the business case:
once the project is started, there will be little flexibility to affect it.
In this case, due to the absolute shortage of commodities and risk of a gap in supplies, the timeliness of
delivery of commodities will be the most critical factor in establishing true value for money: the costs of
unwanted pregnancies being greater than any savings possible on procurement costs.
For the future, DFID centrally is looking at options for reducing the cost of family planning commodities
globally. Already one manufacturer of an implant has indicated that they may reduce the global price.
Unfortunately that brand is not yet registered in Ghana although that process has been started.
There is a need to look at which products are registered with the Food and Drugs Board in Ghana as
well as the cost of different brands and quality of generic supplies. The urgent nature of this procurement
means we will focus our assessment of cost in the Commercial Case by comparing a UN, bilateral donor
agency and a commercial procurement agent costs sourcing the same products.
Procurement of commodities will deliver value for money if the commodities are used correctly. There is
enough evidence to conclude that this assumption will be met. Confirmation of their use will be assessed
through routine health data measuring numbers of women using family planning by each method.
3. Commercial Case
Direct procurement
A. Clearly state the procurement/commercial requirements for intervention
This intervention requires the procurement of 2.5m injectable and 66,350 implant contraceptives that
are to internationally accepted quality assurance standard and registered by the Ghana Food and
Drugs Board. Because of the absolute need to avoid a gap in provision for couples now, the
timeliness of delivery is the most important factor.
B. How does the intervention design use competition to drive commercial advantage
for DFID?
Procurement of family planning commodities is possible through a procurement agent or through a
UN agency (UNFPA is used by for procurement by the government in Ghana). In addition, USAID
procures globally for its family planning programmes and has the ability to supply other donors.
Comparison of estimated costs through different potential suppliers (commercial and others) has
been done during the completion of this business case.
C. How do we expect the market place will respond to this opportunity?
Globally there are indications that the price of some family planning commodities will reduce. DFID
centrally is in discussion with several manufacturers with a strong indication that the market will
respond. During the writing of this business case, there was an indication in a drop in price of
injectables. Unfortunately that supply will not be available until 2012 which is too late for this
procurement. These options will be explored for any future procurement.
D. What are the key underlying cost drivers? How is value added and how will we
measure and improve this?
The key cost drivers are (i) unit cost of commodities and (ii) freight and handling fees
There are indications from the market that, due to the increased focus on family planning globally, the
unit cost of commodities is likely to reduce in the next year or two. There are also more generic
products coming on market. However the challenge is how to ensure that the quality of new products
is to an international standard and acceptable for Ghana, which has its own registration process.
Cheaper will not add value if the product is not effective or not acceptable and not used.
E. What is the intended Procurement Process to support contract award?
The contract will be awarded to a procurement agent under an existing framework agreement with
DFID. The process will be managed by DFID Procurement Group. The framework agreement will
enable a contract to be put in place quickly without the need for additional competition and will help
meet project timelines agreed with government and other stakeholders.
F. How will contract & supplier performance be managed through the life of the
intervention?
The contract will be guided by terms of reference which will specify clear deliverables. The TOR will
also specify reporting procedures and the role of the Ministry of Health in providing quality checks
and feedback on the process. Time will be of the essence in the delivery of the products to the
central medical store and this will be monitored by DFID Ghana and the Ministry to ensure
compliance.
4. Financial Case
A. How much it will cost
Based on estimates obtained during the development of the business case, the upper limit of the
programme is expected to be £2.7m, all in the 2011/12 financial year.
B. How it will be funded: capital/programme/admin
The programme will be funded from programme resources, and has been budgeted for in the
Operational Plan for DFID Ghana.
C. How funds will be paid out
The payment terms for the procurement will be negotiated by Procurement Group and clearly noted
in the contract. It will be decided during the negotiations whether payment would be made in advance
to initiate the procurement process or on delivery of the commodities in September, October and
January.
D. How expenditure will be monitored, reported, and accounted for?
Rigorous monitoring and accounting of expenditure will take place using the ARIES system and
standard DFID Ghana procedures for inspecting invoices to ensure value for money and compliance
with agreed fees.
The procurement agent will be responsible for all accounting and preparation of financial and
narrative reports on the procurement, in line with the framework agreement.
5. Management Case
A. Oversight
The project will take place within the overall national commodity security planning and management
system. Oversight is by Inter-Agency Coordinating Committee on Commodity Security. DFID is a
member of this committee. The Government of Ghana, through the Family Health Division of Ghana
Health Service has overall responsibility and oversight.
B. Management
A contract for the procurement of the commodities will be signed and managed by Procurement
Group. A report will be required to be submitted by the procurement agent to both DFID Ghana and
PrG after each consignment during the procurement process.
The programme will be managed by the DFID Ghana health adviser and the deputy programme
manager within the human development and social protection team. The health adviser will focus on
technical and coordination aspects while the programme manager will be responsible for financial
reports, compliance and administrative functions.
The Government of Ghana will be responsible for managing the commodities after they reach the
central medical stores.
C. Conditionality
Not applicable.
D. Monitoring and Evaluation
Monitoring and evaluation will be done within the current national system of commodity security and
the project will undergo additional internal DFID review processes.
Contraceptive prevalence rate will be measured towards the end of 2011 as part of the national MultiCluster Indicator Survey and in the 2013 Demographic and Health Survey. Routine health information
provides acceptor data by each method, which is converted into prevalence rate for the annual health
sector review.
Central contraceptive stock status is monitored monthly.
E. Risk Assessment
Risks
1. We are unable to
procure commodities
at the estimated price
or on time.
2. DFID’s procurement
means the government
doesn’t take forward its
medium and longer
term strategies for
commodity security.
3. Availability does not
lead to increased use
Probability
(3 high,
1 low)
2
Impact
(3 high
1 low))
2
2
2
1
3
Mitigation strategies
There are global shortages of Depo. This will
be mitigated by confirming expected costs and
delivery dates as part of the value for money
judgment in the appraisal case.
This will be mitigated by ongoing participation
in the ICC/CS and by other DFID-funded
programmes such as E4A. There is an
opportunity to agree with other major donors
to get government to consent to a contribution
agreement over the next few years.
Complementary DFID programmes will focus
on supply chain, barriers and demand-side
issues affecting utilisation.
F. Results and Benefits Management
Milestones against indicators are set out in the programme logframe.
The economic appraisal quantifies expected results in the number of pregnancies averted. This
concludes that 178,000 unwanted pregnancies will be averted. This will be measured through the
proxy indicator of family planning acceptors.
Improved stock of contraceptives is very likely to be achieved. Under-achievement of the project
would be seen if the contraceptives do not reach the end user and are not taken up. There is good
evidence to suggest this will not be the case and other programmes are designed to mitigate this risk.
Over-achievement would be difficult as the project assumes full procurement and utilisation.
i
Assumes 4 injectable doses per couple in one year.
Guttmacher Institute and DFID recommended calculations based on CYPs
iii Ghana Demographic and Health Survey 2008
iv Guttmacher Institute. Adding it Up, The Costs and Benefits of investing in Family Planning and Maternal
and Newborn Health. 2009
v Ghana Independent Review Health Sector Programme of Work 2010. April 2011
vi IFC Macro. Fertility and Family Planning in Ghana: A new look at data from the 2008 Ghana Demographic
and Health Survey. 2010
vii Ghana Demographic and Health Survey 2008
viii USAID DELIVER. Stock Status for Contraceptives June 2011
ix Ghana Ministry of Health. Meeting the Commodity Challenge: The Ghana National Reproductive Health
Commodity Security Strategy, 2011-2016. January 2011 (draft)
x DFID. Improving Reproductive, Maternal and Newborn Health: Reducing Unintended Pregnancies. The
Evidence Overview. 2010: page 26
xi UN. Trends in Maternal Mortality: 1990 to 2008. 2008
xii
DFID. Improving Reproductive, Maternal and Newborn Health: Reducing Unintended Pregnancies. The
Evidence Overview. 2010: page 17
xiii DFID. Improving Reproductive, Maternal and Newborn Health: Reducing Unintended Pregnancies. The
Evidence Overview. 2010: page 17
xiv Ghana Millennium Development Goals Acceleration Framework Country Action Plan. 2010
ii
xv
DFID. Improving Reproductive, Maternal and Newborn Health: Reducing Unintended Pregnancies. The
Evidence Overview. 2010: page 20
xvi Guttmacher Institute. Adding it Up, The Costs and Benefits of investing in Family Planning and Maternal
and Newborn Health. 2009
xvii DFID. Improving Reproductive, Maternal and Newborn Health: Reducing Unintended Pregnancies. The
Evidence Overview. 2010: page 24
xviii IFC Macro. Fertility and Family Planning in Ghana: A new look at data from the 2008 Ghana Demographic
and Health Survey. 2010
xix Guttmacher Institute. Adding it Up, The Costs and Benefits of investing in Family Planning and Maternal
and Newborn Health. 2009
xx Ministry of Health. An Estimate of the Potential Cost and Benefits of Adding Family Planning Services to
the National Health Insurance Scheme in Ghana. 2008
xxi Ministry of Health and Agencies. Ghana Reproductive Health Strategic Plan 2007-2011
xxii John Snow International. http://deliver.jsi.com/dhome/topics/policy/csinitiatives
xxiii Ghana Ministry of Health. Meeting the Commodity Challenge: The Ghana National Reproductive Health
Commodity Security Strategy, 2011-2016. January 2011 (draft)
xxiv USAID-funded EXP Social Marketing and Behaviour Change Support projects
xxv USAID DELIVER. Stock Status for Contraceptives June 2011
xxvi EXP Social Marketing. EXP SM Sales Analysis for USAID 2011
xxvii Ghana Ministry of Health. Meeting the Commodity Challenge: The Ghana National Reproductive Health
Commodity Security Strategy, 2011-2016. January 2011 (draft)
xxviii Assumes 4 injectable doses per couple in one year.
xxix Assumes 36% of injectable users and 100% of implant users will be new acceptors (2010 users data,
USAID DELIVER personal communication)
xxx Marie Stopes International Impact calculator used to convert family planning users to couple years
protection (CYPs): 1 five-year implant = 3.5 CYPs; 4 three-month injectables -= 1 CYP
xxxi Guttmacher Institute and DFID recommended calculations based on CYPs: four CYPs will prevent 1
unintended pregnancy
xxxii Guttmacher Institute. Adding it Up, The Costs and Benefits of investing in Family Planning and Maternal
and Newborn Health. 2009
xxxiii DFID. Improving Reproductive, Maternal and Newborn Health: Reducing Unintended Pregnancies. The
Evidence Overview. 2010: page 17
xxxiv Updated monthly by USAID DELIVER project and Ghana Health Service
xxxv EXP Social Marketing. EXP SM Sales Analysis for USAID 2011
xxxvi IFC Macro. Fertility and Family Planning in Ghana: A new look at data from the 2008 Ghana
Demographic and Health Survey. 2010
xxxvii Guttmacher Institute. Adding it Up, The Costs and Benefits of investing in Family Planning and Maternal
and Newborn Health. 2009
xxxviii DFID. Improving Reproductive, Maternal and Newborn Health: Reducing Unintended Pregnancies. The
Evidence Overview. 2010: page 20
xxxix
DFID. Improving Reproductive, Maternal and Newborn Health: Reducing Unintended Pregnancies. The
Evidence Overview. 2010: page 19
xl Guttmacher Institute. Adding it Up, The Costs and Benefits of investing in Family Planning and Maternal
and Newborn Health. 2009
xli Ghana Demographic and Health Survey 2008
xlii Ministry of Health. An Estimate of the Potential Cost and Benefits of Adding Family Planning Services to
the National Health Insurance Scheme in Ghana. 2008
xliii Joint Ministry of Health and Development Partners Health Summit, Accra, 11-15 April 2011. Aide Memoire.
2011
xliv http://www.who.int/topics/millennium_development_goals/accountability_commission/en/
xlv http://www.npc.gov.gh
xlvi Wheeler D and Hammer D The Economics of Population Policy for Carbon Emissions Reduction in
Developing Countries. Centre for Global Development Working Paper 229. November 2010
xlvii This appraisal is based on the initial project cost estimation of £2.5m. Latest estimates are for £2.65m but
this moderate increase is not believed to affect the validity of this appraisal.
xlviii Projected need for injectables is 2.6m over the period divided by 4 (one user requires 4 injections in a
year)
xlix James Gribble, Maj-Lis Voss, 2009 Policy Brief, Family Planning and Economic Well-Being: New Evidence
from Bangladesh, Population Reference Bureau
l Guttmacher Institute and UNFPA Adding It Up
li Specific country data is not available and therefore sub-regional figures have been used which could
introduce a bias if Ghana is not typical in the sub-region
lii www.mariestopes.org/resources/tools
liii An Estimate of Potential Costs and Benefits of adding Family Planning Services to the National Health
Insurance Scheme in Ghana and Impact on the Private Sector: Report prepared for the Ministry of Health,
Government of Ghana, 2008.
liv £1 = $1.635 as at 5 August 2011, Oanda Currency Converter
lv This is discounted because the benefits flow into the second year but the costs are all incurred in the first
year.
lvi DFID. Choices for women: planned pregnancies, safe births and healthy newborns. December 2010
lvii DFID. Improving Reproductive, Maternal and Newborn Health: Reducing Unintended Pregnancies. The
Evidence Overview. 2010: page 14
lviii Inter-agency Coordinating Committee on Commodity Security. Presentation by Ghana Health Services,
meeting 29/06/11