Business Case and Intervention Summary
Title: Reproductive and Maternal Health Supplies in Tanzania
Acronyms
ADC
ADS
AIDS
AM
A/OTAR
BCC
CBM
CIB
CIDA
CO2
COTAR
CPR
CSC
CYPs
DALYs
DFID
DMOs
DPs
EMoc
FBO
FP
GAAP
GBS
GOT
HIV
HQ
IC
I/E
IEC
ILS
IP
IRR
KPIs
IUDs
JSI
KFW
LAPM
MCH
MDGs
MDT
M&E
MIS
MOHSW
MKUKUTAII
MOU
MSD
MSI
MST
MTEF
Arrangement of Delegated Cooperation
Automated Directive System
Acquired immune deficiency syndrome
Activity Manager
Agreement Officers’ technical representative
Behaviour change communication
Community-based mobiliser
Contract Information Bulletins
Canadian International Development Agency
Carbon dioxide
Contract Officer Technical representative
Contraceptive prevalence rate
Critical Success Criteria
Couple Years of Protection
Disability Assisted Life Years
Department for International Development
District Medical Offices
Development Partners
Emergency Obstetric care
Faith-based organisation
Family planning
Generally Accepted Accountancy Principles
General budget support
Government of Tanzania
Human Immune deficiency virus
Headquarters
MSI Impact Calculator
Income/expenditure
Information, Education, and Communication
Integrated logistic system
Infection prevention
Internal Rate of Return
Key performance indicators
Inter-uterine device
John Snow International
German Development Agency
Long-acting and permanent methods (of FP)
Maternal and child health
Millennium development goals
MSI Medical development team
Monitoring and evaluation
Management information system
Ministry of Health and Social Welfare
Tanzanian poverty reduction strategy
Memorandum of Understanding
Medical Stores Department
Marie Stopes International
Marie Stopes Tanzania
Medium-term expenditure framework
NFP CIP
NGOS
NPV
OMB
PFM
PMP
PMTCT
PPRA
PPA
PSI
PSU
QTA
RCHS
REDD
R&R form
RH
RMH
SIFPO-MSI
SORP
SRH
SWAP
TDHS
TFDA
TRCHS
USAID
VCT
VFM
National family planning costed implementation plan
Non-governmental organisation
Net Present Value
Office of Management and Budget
Performance and financial management
Performance Management Plan
Preventing maternal-to-child transmission
Procurement Regulatory Authority
Programme Partnership Agreement
Population Services International
Pharmaceutical Services Unit
Quality technical assessment
Reproductive and Child Health Services
Reducing emissions from deforestation & degradation
Report and request form
Reproductive health
Reproductive and maternal health
Support for international FP-MSI
Statement of recommended accounting practice
Sexual and reproductive health
Sector-wide approach
Tanzanian Demographic and Health Survey
Tanzania Food and Drug Authority
Tanzania Reproductive Child Health Survey
US Agency for International Development
Voluntary counselling and testing (for HIV)
Value for money
Intervention Summary
What support will the UK provide?
UK government will provide £5m per year for three years. This should ensure adequate
supplies of essential medications for ante natal care and safe deliveries across the country,
and adequate resources for contraceptive implants, which offer women effective long acting
protection from pregnancy.
Why is UK support required?
Tanzania’s progress in reducing maternal mortality is slow. The last estimate was that 440
women die for every 100 000 pregnancies. About a third of these deaths could be prevented,
if women who do not want to get pregnant are able to access effective contraception.
To prevent the other two thirds of deaths requires a ‘safe delivery’. Although there has been
significant investment in improving safe motherhood, and now over half of the women give
birth in health facilities, almost all such facilities currently lack basic life saving drugs.
By providing long term contraceptives, this project will really help rural women who find it
difficult and expensive to access effective health services on a frequent basis. Choice over
when to have children not only improves the woman’s life, it increases the health and life
chances of existing children as well.
Maternal health drugs decrease the risks of death from haemorrhage and high blood pressure,
as well as other complications resulting from anaemia and malaria. Women are more likely to
give birth in a health facility if it is known to have adequate supplies of drugs.
Providing the commodities alone however is not enough – so this project will also offer support
to supply chain and policy development, so that the commodities are appropriately stored,
distributed and used.
Providing effective contraceptives and life saving drugs is a core function of the health system
– the project will therefore work at a policy level to build capacity and increase commitment to
ensuring that government takes on this responsibility as a key component of ensuring
women’s health and survival. The project will be implemented through USAID, who are the
lead development partners in this area in the country.
What are the expected results?
The impact of this programme is to reduce maternal deaths and contribute to achieving
Millennium Development Goal 5.
The outcome is to ensure that family planning and maternal health supplies are available in
Tanzania throughout the health system.
The key changes which are expected to result from the support include:
 prevent the deaths of at least 1280 Tanzanian women by improving the quality of antenatal
care and deliveries across the whole of Tanzania
 provide 250,000 contraceptive implants per year which will contribute to 400 couple years
of protection (This in turn will avert 140 000 unwanted pregnancies 20 000 unsafe abortions
and 490 maternal deaths)
 provide drugs used antenatally to prevent malaria and anaemia, and drugs used around the
time of delivery to prevent haemorrhage and eclampsia
 strengthen Government of Tanzania’s drug management and distribution system, and
support policies for improved use.
Business Case
Strategic Case
A. Context and need for a DFID intervention
RATIONALE
Maternal mortality is high in Tanzania, and safe delivery care needs to be available to all
women in childbirth as well as access to family planning.i Both safe delivery care and
family planning in Tanzania are hampered by a lack of reproductive and maternal health
(RMH) supplies in the facilities where they are neededii. The understanding of how critical
these supplies are to good development outcomes is growing internationally. DFID has not
had a health programme in Tanzania for some time and working in RMH supplies (where
there are clear gaps) is an area where the need is great and DFID can quickly make a
difference without large staff investment.
Family planning. Increasing access to family planning could reduce maternal mortality in
Tanzania by as much as one third by reducing the number of births and a woman’s
exposure to the risk of dying. In addition, family planning increases birth spacing between
children, which increase survival for both the child born and the older sibling. Between
2005 and 2010 there has been a significant increase in use of family planning from 26 to
34% (married women using modern contraception). This momentum needs to be
maintained.
Maternal health care. A functioning health system is required to deliver safe delivery
care. Part of a functioning health system is to provide the necessary equipment and
supplies to deliver these services. There are shortages of maternal health supplies within
the Tanzanian health system with considerable anecdotal evidence of widespread stockouts of maternal health supplies in all districts of Tanzania. To begin to understand the
situation better, USAID has just carried out a quantification of drugs for maternal health
which indeed revealed serious shortages. Without commodities the gains from
investments in training and other elements of service delivery will not be realised and
women will continue to die in childbirth. Drug availability is one of the key indicators of
quality that women have when assessing health services.
Without a reliable consistent supply of supplies, maternal and reproductive health services
will not be delivered. The Development Partners must work together to encourage greater
political commitment and investment in these areas to ensure the family planning
programme sustainability. Other donors with in-depth knowledge and years of experience
working on RMH are working to strengthen service delivery and support contraceptive
social marketing. Given DFID’s current plan to keep its health programme slim and
focused on tangible impact, supporting supplies is a good strategic niche for DFID. Buying
supplies allows DFID to make a real impact on Tanzania’s health programme without the
need for major staff input.
DFID is already funding Marie Stopes International Tanzania (MST) to deliver muchneeded family planning outreach services in rural areas. The regionally-funded Evidence
for Action in Maternal Health (E4A) is beginning work in Tanzania in early 2012. This new
business case on RMH supplies will build links with the work of MST and E4A.
CONTEXT
High maternal mortality. Maternal and infant mortality remain high in Tanzania,
especially in rural areas. The maternal mortality ratio is 454 deaths per 100,000iii live births
(2010). This is a non significant fall from 578iv (2005). Maternal health is affected by the
poor coverage, poor quality services and a high unmet need for contraception. Access to
RMH services is critical to Tanzania’s development. Without it, the Millennium
Development Goals (MDGs) cannot be met.
High fertility levels are a challenge to development. The total fertility rate (the number
of children the average woman bears) in Tanzania is 5.4 - with levels of 6.1 in rural areasv.
The population of Tanzania is scheduled to grow to 69 m by 2050 vi from its current 46
million. This will put real pressure on food and water resources in some parts of the country
and on the provision of basic services. However, significant progress has been made over
the last decade in scaling up family planning programmes.
Trends in Contraceptive Use: Tanzania
Percent of currently married women
TDHS 1991-92
TDHS 1996
TRCHS 1999
THDS 2004-05
TDHS 2010
34
25
27
26
20
18
17
13
10
9
7
4
Any method
Any modern method
5
6
7
Any traditional method
Progress: DFID contribution last year is credited with significant impact as it
has ensured that family planning projects and Government services have, for
the first time in several years, had a consistent adequate supply of long acting
contraceptive methods
High unmet need for family planning in Tanzania persists. In Tanzania, despite these
recent gains lack of family planning is a problem. It has been found that one in four
currently married women of reproductive age want to space or limit births but are not
currently using any method of family planningvii. This is called ‘unmet need’ for
contraception and implies that there is a high demand for family planning by women in
Tanzania that is not being met by current services.
Commodity security is a challenge ‘Commodity security’ means that family planning is
consistently available to women, that she has a choice of methods, that she can afford the
method she chooses and that she receives good quality of care. Without it confidence in
any programme will be eroded. While commodity security brings together many complex
issues, there are many countries that have made progress toward securing itviii. Achieving
commodity security involves funding, procurement, supply chain management, and service
delivery. The Government of Tanzania as well as the DPs can work together toward
ensuring that each step toward the achievement of commodity security is supported.
Contraceptive supplies are a key step in commodity security. Without the essential
supplies, the family planning programme cannot function. Whether the GoT or the DPs
fund the contraceptives, they must be purchased and in the warehouse for the family
planning programme to work. DFID sees the importance of RH supplies and has played
an active role in the global Reproductive Health Supplies Coalition at the central level.
Support to the RMH supply system will continue this work at country level where it is most
important. DFID’s 2010 contribution was positive with real evidence of increasing
confidence in programmes and demand from women.
Maternal health supplies for safe delivery
DFID provides general budget support and other donors fund the health basket. The GoT
states that maternal health is a ‘top priority’. Commodity supply is however dealt with as a
part of the general health system, without specific attention or prioritisation. However with
the increased focus on improving maternal health outcomes, the move to focus specifically
on maternal health products, in conjunction with reproductive health supplies, is occurring
in other countries as well. There are risks associated with the proliferation of condition
specific vertical programmes, but in resource poor countries such as Tanzania, without
some specific attention supply chain management will remain inadequate. (Note that RMH
supplies in Tanzania are integrated into the essential medicines supplies and are not a
vertical programme. Additional attention to seeing they are prioritised would ideally be
temporary.)
Why do mothers die? The majority of African maternal deaths are from obstetric
complications around childbirth including haemorrhage, hypertensive disease (eclampsia),
infection, and prolonged labour.ix These complications can be managed within a facility
but require trained staff and adequate supplies of simple medications.
The quality of maternal health services must improve. About half of Tanzania women
give birth in health facilities and 51% of these are assisted by health professionalsx and
these proportions have been increasing in recent years. There is a big push internationally
and in Tanzania to cut maternal mortality by increasing the numbers of women giving birth
in facilities. This will only be effective however if these facilities offer a quality service
including essential medications. A recent study found that one of the barriers to increased
births in facilities in Tanzania was that the facilities were not perceived to be adequately
equipped or supplied.xi
Maternal health commodities are not priority within the essential medicines list.
While FP commodities are well tracked with good logistics support, maternal health
commodities have been dealt with as a part of the general health system. The essential
drug budget is under funded. It is only in 2011 that there has been a study by USAID on
maternal health drugs. These would include magnesium sulphate (for eclampsia), ferrous
sulphate (for maternal anaemia), and uterotomics, such as misoprostol and oxytocin (to
ensure the management of the third stage of labour and prevent post partum
haemorrhage). The USAID quantification study has shown no GoT attempt to prioritise MH
supplies as essential medicines, widespread stock outs and only one month’s supply of
drugs in the country (with no provision to purchase more for this financial year).
Maternal health commodities are not expensive. These maternal health commodities
are relatively cheap and the quantification study determined that all the maternal health
commodities required for one year was under £3 million. Quantification of maternal health
commodity needs is additionally complicated because many products uses are not
confined to maternal health--and maternal health services are part of the general health
service.
Logistics systems also need to be supported to ensure MH supplies reach facilities.
Considerable donor effort (particularly by USAID) has been put toward the tracking of
family planning and HIV commodities in the supply chain over the past twenty years. No
particular effort has been made to determine whether key maternal health commodities are
present in facilities. Supporting maternal health commodity logistics would include
attention given to how these commodities are prioritised and tracked within the system
and—ultimately, whether they are available at the health facilities.
Political support is required for RMH supplies to remain a priority. Despite expressed
commitments to maternal health, there is much less willingness to invest in family planning
and safe delivery and address the many constraints that prevent women from accessing
services. To develop a sustainable high quality system, that is not continually reliant upon
external support will require focused policy and advocacy (see Political Appraisal).
Beneficiaries. The beneficiaries of the programme will be poor women of Tanzania who
have not had reliable access to safe delivery and family planning services in the past.
EVIDENCE
Who delivers reproductive and maternal health services in Tanzaniaxii
Public sector. The majority of RMH services are delivered by the Ministry of Health and
Social Welfare. About 96% of women receive some antenatal care and the vast majority of
this is at public sector facilities. While half of Tanzanian women chose to give birth at
home, 41% of women used public sector facilities to deliver their babies. About two thirds
of women using contraceptives received their family planning from the public sector.
Private sector. A smaller proportion (7.5%) gave birth in a voluntary/religious hospital and
less than two per cent gave birth in private hospitals. Marie Stopes Tanzania is delivering
about one-fifth of the contraceptive services in the country. Less than a fifth of women
bought their contraceptive through private pharmacies or shops. Some faith-based
hospitals were not choosing to provide family planning while others were.
Health benefits of family planning. There is a wealth of strong evidence that the health
benefits of family planning to women and their children are multiple. Unfortunately,
pregnancy and childbirth are risky. In developed countries, 1 in 7,300 women will die in
childbirth or from pregnancy related causes. In Tanzania in 2005, the chances of dying in
childbirth were 1 in 25xiii. (These risks have fallen slightly in the last five years) And most of
these deaths are preventable. Internationally, if every woman had the number of children
she wanted when she wanted them, maternal mortality would drop by one thirdxiv. This is
because there are safer times to be pregnant (between 18 and 35 rather than earlier or
later) and spacing and limiting births reduces risks. Birth-spacing also has benefits to the
children. Babies born less than two years after their older sibling are twice as likely to die
before they reach their first birthdays as those born more than three years apartxv. When
women are unable to practise family planning, they have unintended pregnancies.
Unintended pregnancies are more likely to end in abortion. In Tanzania, where abortion is
illegal under most circumstances, this is likely to be unsafe and extremely risky for women.
Recent estimates suggest that approximately 19% of Tanzania’s maternal mortality is due
to unsafe abortionxvi. Family planning can avoid many of these unintended pregnancies in
the first place.
Method Mix. Women’s preference for spacing births versus limiting their total number of
births influences their choices of contraceptive methods. Those wanting to stop
childbearing are likely to use one of the most effective methods while those wishing to
postpone a birth choose among short-acting reversible methods.xvii It is well documented
that a family planning programme must offer the full range of methods to all womenxviii.
Long-acting and permanent family planning methods are more effective but are often
difficult for clients to access and are not used as widely as other methods, particularly in
Africaxix.
Reducing maternal mortality
Eleven countries account for 65% of all global maternal deaths: India, Nigeria, DRC,
Afghanistan, Bangladesh, Indonesia, Pakistan, Ethiopia, Niger, Tanzania, and Angola.
The evidence on how to reduce maternal mortality is strong.
Causes of death. Haemorrhage accounts for the greatest proportion of maternal deaths
(34% in Africa). Hypertensive disorders are responsible for a further 9% of deaths while
infections count for a further 10%xx. These are all direct obstetric complications that occur
around the time of childbirth and all require the availability of maternal health supplies.
Postpartum haemorrhage (PPH) remains the leading direct cause of maternal mortality in
Africa and Asia, contributing to approximately 30%xxi or 140,000 deaths per annum. A
further 2 million women suffer severe morbidity due to the effects of anaemiaxxii. In efforts
to meet MDG 5, addressing PPH has become a significant focus.
Clinical effectiveness of maternal health supplies. Technologies, including products,
have played a central role in maternal mortality reduction. The international 33 country
Magpie Trial showed that magnesium sulphate halved the risk of eclampsia xxiii.xxiv. xxv. In
addition, the inclusion of magnesium sulphate in the treatment of eclampsia has
substantially reduced fits, morbidity and deaths in Tanzaniaxxvi. A recent study in 33
countries looked at the use of magnesium sulphate for pre-eclampsia and found that
magnesium sulphate was effective - the number of women with pre eclampsia needed to
treat to prevent a death from eclampsia was 43. It was cost effective, particularly in poor
countries , where there was an incremental cost of 456$ (301$-779$) to prevent a case
of eclampsia,
There has been progress in tackling post partum haemorrhage with active management of
the third stage of labour and the administration of misoprostol and oxytocinxxvii. A meta
analysis suggested that the effectiveness of prophylactic misoprostol in reducing PPH
mortality was 45% and oxytocin was 50%. An economic assessment translated into an
incremental cost effectiveness of $34 – 40 per DALY for oxytocin and $53 for
misoprostolxxviii. Misoprostol is more expensive than oxytocin and has more side effects;
however it is more stable and therefore potentially more suited to poorly resourced settings
or those with inadequate cold chainsxxix. WHO has approved misoprostol as a safe
alternative in the absence of oxytocin if administered by health workers trained in its
correct use.
Supplies crucial. Skilled attendants can only perform effectively if they are properly
equipped and suppliedxxx. There is consistent evidence that a lack of, or poor quality,
drugs, equipment and supplies at RMH facilities has an adverse effect on the utilisation of
non-emergency services and on women’s survival chancesxxxi,xxxii. A wide range of
common problems with equipment and supplies within RMH health facilities have been
documentedxxxiii. Supplies are often missing, incomplete or not readily at hand in RMH
facilities. RMH services are highly dependent on the availability of the essential drugs,
identified as effective and relatively inexpensive xxxiv and included in the WHO essential
drugs listxxxv. A national drug policy is a key component of any strategy to improve the
management and use of drugsxxxvi. Despite many essential drugs being cheap and having
long shelf lives, many providers lack knowledge about them, clinical guidelines are out of
date and drug supply systems are inefficient or ineffective, making access to these drugs
either unpredictable and/or entirely absent. Inappropriate handling, storage and
distribution can alter the quality of drugs leading to serious health consequences and
wasted resourcesxxxvii. The drug situation also affects the way in which health services are
regardedxxxviii. Users associate a lack of drugs with poorer quality of carexxxix.
Maternal health supplies for safe pregnancy and delivery
Pregnancy/Birth
Maternal health commodity Condition for which drug is
stage
required
Antenatal Care
(ANC)
Sulphadoxine
Pyrimethamine*
Malaria prevention
Anaemia
FeFol*
Normal delivery (all
women)
Oxytocin
Misoprostol
Ergometrine
Post-partum haemorrhage
Episiotomy pain relief
Lignocaine*
Delivery with
complications
(emergency cases)
Magnesium Sulphate
Calcium gluconate
Hydralazine*, Methyldopa*
Pre-eclampsia and eclampsia
Antedote to Magnesium
Alternate anti-hypertensives
*Multiple uses beyond safe motherhood
Procurement as a mechanism to strengthen access to essential drugs, supplies and
equipment. Ensuring the right drugs, supplies and equipment are in the right place
whenever they are needed depends on a functioning and effective procurement system.
As safe motherhood tend to fall within government essential drug budgets, procured and
supplied through government channels, they are exposed to the systemic problems of drug
supply management described abovexl. With contraceptive commodities often funded and
procured by donors, national governments face the challenge of managing multiple funding
and procurement routes for maternal, STI, family planning and HIV/AIDS products, which
can lead to fragmented procurement with high transaction costsxli.
Government capacity needs to be strengthened. A study of Reproductive Health
Commodity Security (RHCS) in four countries with poor MNH SRH indicators (Cambodia,
Nigeria, Uganda and Zambia)xlii highlights the drawbacks of multiple donor and government
procurement where government systems lack adequate oversight capacity. One of the
main findings was the inability of the countries to translate national policy objectives into
implementation and results. Wider political will was found to be questionable and there was
weak ownership, capacity and coordination at all levels. This affected the allocation of
funds to RMH commodity procurement and logistics at local and devolved levels, where
RMH may not be a priority. Contraceptives were found to be on the countries’ essential
drugs lists, but some maternal health drugs and equipment were not. Missing products
included magnesium sulphate, oxytocin and MVA kits. All the countries lacked information
and strategies for addressing maternal health commodity security, although the importance
of supplies was usually stressed in reproductive health policies.
In Tanzania, a recent reportxliii found a very similar situation with inadequate oversight
capacity of government systems with a need to improve capacity and coordination
throughout the system. The just completed DFID-funded Support for Family Planning
project found that purchasing contraceptives to fill commodity gaps works in the short run
to ensure there are no contraceptive stock-outs at the district level. But the Project
Completion Report (PCR) also reported that short-term gap filling did not solve the
persistent problem—that government did not address the underlying problems and that
future programmes should build in appropriate political advocacy.
An audit of the medical supplies department by the controller and auditor general, raised
very significant concerns around the robustness of control systems and financial
management in MSD, and offered wide ranging recommendations xliv REPORT OF THE ER
AND AUDITOR GENERAL ON
What are the Reproductive and Maternal Health supply gaps in Tanzania?
The following table shows the forecast for Tanzania’s total contraceptive needs from 2012
to 2014. These estimates are based on long experience of estimating Tanzania’s
contraceptive needs.
Tanzania 2012-2014 Contraceptive Forecast
Contraceptive
Commodity
Microgynon
Microval
Depo
IUD
Implanon
Jadelle
Condoms
2012
amount
4,273,998
1,093,134
3,816,000
55,222
184,828
52,131
11.7m
2013
amount
4,487,698
1,147,791
4,044,960
57,983
199,614
56,301
12.5m
2014
amount
4,712,082
1,205,180
4,287,658
60,882
215,583
60,805
12.9m
Determining the RMH supplies gap
The following table shows the forecast for Tanzania’s maternal health supplies from 2012
to 2014. These estimates are based on a modelling exercise using estimates of numbers
of deliveries and proportions of women suffering from various birth complications. In
contrast to the contraceptive estimates, this is the first time these estimates have been
collected for maternal health supplies. It is possible that use will be lower than expected,
because of clinician and patient behaviour. (This may be particularly true for commodities
such as iron which despite clinical benefit are not popular products. Less Fe-fol will be
purchased accordingly. )
Maternal health supplies: 2012-2014 Forecasts estimated costs (US$)
(based on morbidity/demographic data)
TANZANIA - MCH Commodities.
£1.00
Equal
$1.56
January-12
MATERNAL HEALTH SUPPLIES 2012 FORECASTS ESTIMATED QUANTITY AND COST
COMMODITIES
unit cost
Quantitie
s
1 Oxytocin 5IU/ml in 1ml vials
0.18
2,400,870
2 Misoprostol 200mcg tabs
0.15
0.268
3 Ergometrine 0.5mg/ml in 1ml vials
Magnesium Sulphate 500mg/ml in 10ml
4 vials
1.3
product
cost$
freight$
total cost
(prod. +
fr.) $
782,500
432,157
$
117,375
86,431
$
23,475
518,588
$
140,850
70,015
18,764
3,753
22,517
380,325
494,423
98,885
593,307
224,162
$
53,438
1,344,971
$
320,627
5 Fe-Fol 200 + 0.25 tabs
Sulphadoxine + Pyrimethamine 500+25
6 tabs
0.0033125
338,357,4
15
0.039834
6,707,570
1,120,809
$
267,189
7 Lignocaine 2% in 50ml vials
Calclium Gluconate 100mg/ml in 10ml
8 vials
0.951249
93,090
88,552
17,710
106,262
5,820
4,429
886
5,315
0.761
9 Hydralazine 20mg/ml in 1ml vials
1.42
39,650
TOTAL:
56,303
11,261
67,564
2,600,000
520,000
3,120,000
£2,000,00
0
TOTAL UKP:
MATERNAL HEALTH SUPPLIES 2013 FORECASTS QUANTITY AND ESTIMATED COST
COMMODITIES
unit cost
Quantities
product
cost$
total cost (prod.
+ fr.) $
freight$
1 Oxytocin 5IU/ml in 1ml vials
0.18
2,670,000
480,600
96,120
576,720
2 Misoprostol 200mcg tabs
Ergometrine 0.5mg/ml in 1ml
3 vials
Magnesium Sulphate
4 500mg/ml in 10ml vials
0.15
835,000
125,250
25,050
150,300
0.268
40,000
10,720
2,144
415,000
539,500
107,900
647,400
303,750,000
1,006,172
201,234
1,207,406
6,909,000
275,213
55,043
330,256
101,500
96,552
19,310
115,862
0.76
6,400
4,864
973
5,837
1.42
43,000
61,060
12,212
73,272
2,599,931
519,986
3,119,917
5 Fe-Fol 200 + 0.25 tabs
Sulphadoxine +
6 Pyrimethamine 500+25 tabs
1.3
0.0033125
7 Lignocaine 2% in 50ml vials
Calclium Gluconate 100mg/ml
8 in 10ml vials
Hydralazine 20mg/ml in 1ml
9 vials
0.039834
0.95125
TOTAL:
12,864
TOTAL UKP:
£2m
MATERNAL HEALTH SUPPLIES 2014 FORECASTS ESTIMATED QUANTITY AND COST
COMMODITIES
unit cost
product
cost
Quantities
freight
total
cost
(prod. +
fr.)
$
644,61
3
$
158,93
7
1 Oxytocin 5IU/ml in 1ml vials
0.18
2,984,322
$
537,178
$
107,436
2 Misoprostol 200mcg tabs
0.15
882,985
$
132,448
$
26,490
-
-
585,642
$
884,444
117,128
$
176,889
702,77
0
1,061,3
33
$
283,461
$
56,692
340,15
3
$
$
125,86
3 Ergometrine 0.5mg/ml in 1ml vials
Magnesium Sulphate 500mg/ml in
4 10ml vials
5 Fe-Fol 200 + 0.25 tabs
0.268
1.3
0.0033125
Sulphadoxine + Pyrimethamine 500+25
6 tabs
0.039834
7 Lignocaine 2% in 50ml vials
0.951249
450,494
267,002,060
7,116,060
Calclium Gluconate 100mg/ml in 10ml
8 vials
110,266
104,891
20,978
9
0.761
6,892
$
5,245
$
1,049
$
6,293
1.42
46,966
66,692
13,338
80,030
2,600,000
520,000
9 Hydralazine 20mg/ml in 1ml vials
TOTAL:
TOTAL UKP:
3,120,0
00
£2,000,
000
* The quantities of Fe-Fol were adjusted slightly to meet the
anticipated budget.
NB: An inflation factor has not been applied to unit costs.
The maternal health drugs gap is currently not possible to determine as attempts to track it
have only begun in 2011. The above estimates are not based on drugs in the system but
on rough estimates of the need for maternal health supplies.
What DFID would fund
DFID would like to work with GoT, USAID and UNFPA and other donors to determine the
RMH supply gaps and to ensure that they are filled for 2012-2014. This is likely to involve
purchasing the entire estimated demand for implants and most maternal health
commodities. (In these instances the ongoing active management of the supply chain will
allow more accurate projections of demand and use to be made.)
DFID will therefore support the active logistical management of five maternal health
product lines across the country to minimise the risks of stock outs. The cost of this is
about $100 000 per product per year. In addition, DFID would like to assist in
strengthening the logistics around MH supplies. (The US are already funding this for
contraceptive products) Finally, DFID will fund some policy and advocacy around
increasing the GOT’s commitment to prioritising and funding these RMH supplies in future.
Possible annual funding breakdown
Output 1: Contraceptive supplies
Output 2: MH supplies
Output 3: MH Logistics
Output 4: RMH supply policy/advocacy
Annual total
TOTAL (three years)
Amount
$US
$3.1m
$3.1m
$0.78m
$0.78m
$7.8m/yr
$23.5m
Amount
£UK
£2m
£2m
£0.5
£0.5
£5m/yr
£15m
Why would DFID concentrate on RMH supplies?
Other donors with in-depth knowledge and years of experience working on RMH are
working to strengthen service delivery and support contraceptive social marketing. These
projects are being compromised by the lack of commodities. DFID had no health
programme in Tanzania until recently when DFID decided to support the contraceptive
commodity supply in 2010. Buying supplies and working with other donors with more
dedicated staff time, allows DFID to make a real impact on the health and lives of women
in Tanzania whilst minimising transaction costs for DFID and government.
DFID filled a key commodity gap in Tanzania’s contraceptive supply in 2010-2011. DFID
bought much of the country needs for contraceptive implants and injectables (the most
popular method) and these supplies are what are currently filling Tanzania’s medical
stores. Without these key commodities, there would have been many unintended
pregnancies and health staff would have been unable to answer women’s demand for
family planning.
Maternal health drugs have been somewhat overlooked in Tanzania and internationally –
but they are a key component of preventing death and suffering for women. By investing in
this area, we are adding value to the scale up of activity in this area by ourselves and other
donors.
B. Impact and Outcome that we expect to achieve
The impact of this programme is to contribute to achieving MDG5 and reduce maternal
deaths, which is in line with DFID’s Business Plan action 5.2 to lead international action to
improve maternal health. The current UK Government has committed to 10 million new
users of family planning world-wide and save the lives of 50,000 women in pregnancy and
childbirth. This business case ties well into DFID’s RMH strategy DFID has two strategic
priorities:


prevent unintended pregnancies by enabling women and girls to choose whether,
when and how many children they have; and
ensure pregnancy and child birth are safe for mothers and babies.
In the RMH Framework, this BC fits under pillar 3: Commodities (‘getting supplies in the
right place at the right time and... making them more available’).
The outcome of the programmes is to ensure that family planning and maternal health
supplies are available in Tanzania throughout the health system.
The expected results for the family planning commodities alone will be the commodities to
contribute to 400,000 couple years of protection (CYPs) in total. (NOTE: these
commodities are considered to contribute to one third of a full CYP as service delivery
costs are not included.) This will avert 139,455 pregnancies, prevent 19,697 unsafe
abortions and save 490 maternal lives. The maternal health commodity will provide
essential medications for safe deliveries. While MH supply intervention measurements are
less well developed, we speculate that 260 women’s lives will be saved per year (to total
1270 maternal lives saved by the project as a whole).
Output 1 CONTRACEPTIVE SUPPLIES: would purchase contraceptive commodities to
provide contraceptive implants for a half a million women across Tanzania, access to longterm and permanent methods of family planning.
Output 2 MH SUPPLIES: will be the purchase of the majority of maternal health drugs for
Tanzania, which will result in more safe deliveries.
Output 3 MH LOGISTICS SUPPORT: MH logistics support will be included in the
intervention package to ensure a steady supply of MH supplies, in good condition, to end
users.
Output 4 POLITICAL COMMITMENT: will help to build political commitment to sustaining
these essential reproductive and maternal health supplies (including DFID working with
USAID on high level political advocacy).
Not intervening would result in:


Irregular supplies of family planning commodities, stagnation and de-motivation in
family planning programmes and women being unable to routinely and reliably have
the choices to control their fertility. Recent gains in improved CPR would be lost.
Childbirth would remain riskier as supplies to ensure safe delivery would not be
available within the health system. Maternal mortality would be less likely to be
reduced.
Appraisal Case
A. What are the feasible options that address the need set out in the Strategic case?
The Strategic Case sets out a clear need to work in RMH supplies as without reliable and
consistent supplies, maternal and reproductive health services cannot be delivered.
As DFID Tanzania has decided to work on RMH supplies, there are three options to consider:
1) Do nothing to support RMH services to women across Tanzania beyond budget support
and existing projects;
2) DFID funds commodities directly to the Tanzanian Government (through the Medical
Stores Department).
3) Fund a package of support toward delivery of reproductive and maternal health
commodities in partnership with other development partners.
Here are DFID’s critical success factors for the programme:




Integrated RH and MH commodity supply at all levels of the health system in Tanzania;
Longer term commitment to sustain RMH supply by GoT;
Low DFID transaction costs; and
Effective logistics and coherent policy around RMH supplies.
Option 1: Do nothing to support RMH services to women across Tanzania beyond
budget support and existing projects
What to do: DFID is already supporting the Government of Tanzania with an annual aid
framework of £150m (approx Tsh 300 billion)—one of DFID’s largest programmes in Africa. A
significant percentage of the DFID Tanzania programme is provided as General Budget
Support (GBS) to assist the Government in implementation of its National Strategy for Growth
and the Reduction of Poverty (the MKUKUTA). This assistance is complemented by
programmes to increase domestic accountability, tackle corruption, improve public financial
management, improve both the quality of basic service delivery and the quality and availability
of national statistics on development and poverty. DFID contribution to general budget
support already supports the health sector indirectly.
How to do it: Continue to put DFID funding directly into budget support and various
programmes.
Why are we doing it? DFID believes that the GoT will make its own priorities in
implementation of its National Strategy for Growth and the Reduction of Poverty (the
MKUKUTA) and that in this process, they will grow stronger as a government supporting its
population with RMH services. DFID believes the GoT has a good understanding of the
balances between curative health and preventative health and will make the right decisions in
a transparent manner.
Option 2: Funds for RMH supplies directly to the Tanzanian Government (through the
MSD)
What to do: DFID could fund the Medical Stores Department to procure RMH supplies
directly. This ensures the RMH supplies will be purchased at the central level. The MSD
would then distribute these RMH supplies as part of its Integrated Logistics System.
How to do it: Transfer funds directly to the Medical Stores Department and then monitor that
these funds are being used correctly. The Global Fund is using this method and is insisting on
transparency in the use of the funds. This is seriously slowing the process down and using
considerable Global Fund staff resources but this method is slowly yielding results.
Why are we doing it? DFID would do this in order to show trust in the GoT to prioritise RMH
supplies and build MSD capacity. Ensuring transparency of this process would require
considerable DFID staff input and commitment to monitor.
Option 3: Fund a package of support toward delivery of reproductive and maternal
health commodities in partnership with other development partners.
What to do: Fund RMH commodities through the existing USAID or UNFPA systems
including some funding for logistics improvements and policy work. DFID has already once
filled a contraceptive commodity gap in Tanzania (in 2010) via USAID systems. This new
funding would cover some proportion of Tanzania’s contraceptive commodity needs for 20122014. In addition, DFID would fund maternal health supplies for the same timeframe,
including logistics support to better track these commodities (most likely through the USAIDfunded JSI Deliver programme (John Snow Inc)). Finally, DFID would support joint donor
advocacy work toward ensuring the GoT prioritises RMH supplies in future, and policy work to
ensure effective use.
How to do it: DFID sets up an Arrangement on Delegated Co-operation with USAID or
UNFPA. USAID or UNFPA monitors the programmes and reports back to DFID. DFID would
delegate day to day management to the DP to avoid fragmentation and reduce transaction
costs whilst achieving mutually agreed objectives.
Why are we doing it? USAID and UNFPA have recently agreed to jointly lead on RMH
commodities in Tanzania with government. USAID is a leader on RH commodities and is
currently looking into maternal health supplies as well. Their logistics contractor JSI is a
respected organisation working on logistics systems in developing countries. DFID and
USAID have already worked together on two past family planning projects and the systems
have run smoothly resulting in a relationship of high trust. UNFPA has an international
mandate to work on these issues. Working through these partners minimises the risks of
fragmentation and duplication and reduces transaction costs.
Political / Institutional Appraisal
The Ministry of Health and Social Welfare (MOHSW) is the ultimate authority on RMH in
Tanzania. Along with the Development Partners Group, the MOHSW decides how much of
the Basket Funding go to RMH. There is apparently no input into these decisions from other
ministries despite the wider development benefits and potential savings that accrue from
family planning. The hierarchy in the MOHSW includes the Permanent Secretary and then the
Chief Medical Officer, offering overall technical direction. Below him is the Director of
Preventative Service, followed by the Reproductive and Child Health Services (RCHS) branch.
The head of this unit is developing the RH programme to satisfy the unmet need. However,
the RCHS continues to face financial and procurement constraints from a variety of sources.
There is no line item in the National Budget, no guarantee that a portion of basket funds is
earmarked for the purchase of contraceptives or maternal health supplies, no assurance of
funding release once funds are allocated for commodities, little diversification of funding
sources and a laboriously slow procurement process once funds are issued. The national
Contraceptive Security Committee is addressing these critical policy issues that will require
continued advocacy in the months and years to come. In 2010, DFID gave funds to fill a
commodity gap but those funds were not intended to build capacity. When the Government is
responsible for buying the most popular methods and is not fully committed to the programme,
the likelihood of stock-outs and shortfalls increase, making the family planning programme
more vulnerable. There is an implicit assumption that when there is shortfall donors will fill the
gap. This level of scrutiny has not yet been applied to MH supplies.
The Medical Stores Department (MSD) is an autonomous department for the MOHSW and
operates on a commercial basis, being responsible for its own financial self sustainability.
Currently, all donated commodities destined for the Tanzania public sector are distributed
through the MSD central warehouse and zonal warehouses. Under current agreements, the
MoHSW is responsible for the distribution costs (approximately 15% of the purchase price)
owed MSD for any and all donated commodities. The MOHSW currently owes the MSD Tsh
33 billion for the distribution costs that the MSD has already delivered. The system is clearly
not working and requires considerable policy attention. The Auditor General’s report has
flagged significant irregularities, and weak systems in MSD.
An examination of the MTEF funding trends over the past seven years reveals that the family
planning allocation and expenditure was functioning well before 2006. Since that year,
however, irregularities have appeared showing a lagging commitment. Conditions for full
transformation to a transparent system may not yet be present in the Ministry and the
presence of competing factions implies that the managerial and organisational capacity is not
yet sufficiently strong for change to take place.
USAID has conducted extensive dialogue with the GoT to improve the supply gaps and a
written commitment has been provided, however as can be seen from the current MTEF,
funding from Govt of Tanzania continues to fall. To attempt to address these concerns, DFID
is building on the success of the USAID funded programmes and using DFID’s support on
PFM to improve release of Government’s stated budget allocations. There are two issues at
play: one is the political will to allocate funding for RMH commodities and the other is the
technical ability to forecast needs and track the supplies to see they are where they need to
be.
MTEF funding trends
MTEF
Estimated need
Year
(TZ shillings)
2004/05
7.7 bn
2005/06
6.9 bn
Amount
Allocated
7.7 bn
6.9 bn
Amount
Released
7.7 bn
6.9 bn
2006/07
6.9 bn
4.8 bn
8.7 bn*
2007/08
2008/09
2009/10
2010/2011
6.4 bn
9.2 bn
9.6 bn
24.0 bn
4.3 bn
3.2 bn
3.5 bn
3.5 bn
2.2 bn
5.0 bn
7.5 bn
11.3 bn (currently held up in procurement)
2011/2012 6.5 bn
1.2 bn
2012/2013 19.3 bn
1.2bn
2013/2014 14.7 bn
1.2bn
*additional basket funding released
USAID has been tracking family planning supplies for more than a decade in Tanzania. While
the system is not perfect, there is knowledge of what contraceptives are available and where
they are needed. The USAID Cooperating Agency John Snow International works with the
GOT directly to support this work and forecasting family planning commodities needs works
reasonably well. Maternal health drugs, however, have not been routinely monitored to the
extent that contraceptives have. Recently, the USAID-funded Deliver project has undertaken
a drug quantification exercise which reveals an acute shortage of essential maternal health
medicines at all levels of the health service in Tanzania. This is despite the high level claims
that addressing maternal health is a high priority for Tanzania.
UNFPA is currently working on a study of the supply chain of RMH commodities including
logistical and financial flows to the Tanzanian mainland. Their findings imply that the
Government does not prioritise family planning because of a poor understanding of how family
planning benefits Tanzanians. So when budgetary constraints dictate a need to prioritise,
family planning does not rank highly as a lack of family planning drugs does not result in an
immediate and severe consequence. Maternal health commodities are perceived as higher
priority but it is more likely to be technical shortcomings that result in these supplies being
stocked-out. Their study is work in progress and UNFPA is still discussing its findings with the
GOT. In addition, UNFPA is planning to undertake an Initiative in Ensuring Access to Priority
Life Saving Medicines (for Prevention and Treatment of PPH, Treatment of Pre-eclampsia and
Eclampsia and Maternal Sepsis) in selected countries in 2012 including Tanzania. There will
be a bottleneck analysis/exercise in 2012.
Donor context
Many donors contribute to the health basket and budget support and this funding will
contribute to the health system required for improving maternal care. General budget support
and basket donors are focusing on the health system and drug supply.
There is a US, DFID, and Australia alliance at country level around reproductive health which
is part of the international agreement approved by DFID’s Secretary of State in 2009. This
has been cited as a model of good practice in the review of co-operation one year on. The
Germans are working in social insurance for pregnant mothers, social marketing of
contraceptives & delivery packs as well as emergency obstetric equipment.
The US is major players in family planning and on maternal health quality. USAID contributes
funding for well over half of the family planning programme in Tanzania and is widely
recognised as the lead funder in the sub-sector. USAID’s well developed RH programme has
been functioning for over 30 years. Other donors in the sub-sector are the Germans, the Dutch
and the Australians. DFID joined their number in 2010 with its first contribution. UNFPA is
also an active partner in MRH commodities, having helped to fill commodity gaps on
numerous occasions.xlv USAID and UNFPA have recently agreed to jointly lead on RMH
commodities in Tanzania. USAID invests approximately $20m annually in family planning but
are relatively new to maternal health where their programme is much smaller ($2m). DFID
would work with USAID on high level political advocacy to ensure that the GOT gives
adequate attention to RMH supplies.
Challenges to the delivery of RMH supplies in Tanzania
The process of distribution of any commodity is complicated. Private business has the profit
motive to ensure efficient delivery of supplies. The public sector has none of these incentives
and has, indeed, many disincentives. Until there is political pressure to ensure effective
delivery, the delivery of RMH supplies is a complicated process involving (often) expensive
drugs.
Not only is the efficient delivery of these commodities a technically challenging process, the
possibility of corruption at all levels is also present.
It is obvious that it is not easy to maintain a complex delivery system in a country with limited
resources and technical ability. The challenges could be the subject of hundreds of technical
reports although a recent report to DFID presents the challenges as simply as possible.
Based on interviews with Tanzanian informants, the following table identifies challenges to
delivering RMH commodities in Tanzania in eight steps. There are multiple technical
challenges to running a vast delivery system to myriad facilities, many in remote areas. There
are also many political reasons why the system is kept as it is. As the technical and political
challenges will be dealt with differently, Table 1 identifies each type of challenge at each step
in the process.
Table 1. Challenges to the delivery of RMH supplies in Tanzania
Commodity Process (steps) Technical challenges
Political challenges
Step 1: BUDGET. GOT
determines health budget.
MOH determines allocations
based on a formula. Based
on these, the Ministry of
Finance allocates funds to
MSD resulting in ‘credit’ for
each health facility (as funds
are available)
Step 2: PRIORITISATION.
MSD prioritises commodities
according to GOT MOHSW
budget
Determining demographic
service numbers for health
facility calculations
MSD receives only 30-50% of
what it has requested;
Irregularities in budget size;
GoT owes MSD billions for
the distribution of donated
commodities; Release of
funds held for the end of FY
so poor allocation timing;
MSD cannot reveal funding
shortfalls without MOH PS
approval
Lack of clarity or
understanding of commodity
prioritisation process; RMH
commodities not on essential
lists; donations in kind
Ensuring that GOT allocates
adequate funding for essential
health commodities and that
this money actually goes to
MSD; annual funding
fluctuations; funding arrives
late; Assumption that DPs will
come in and fill any gaps.
(And donors are fickle.)
Ambivalence to family
planning for religious or
ideological reasons in
influential individuals
Broader development benefits
not considered
.
important; Stock-outs on RMH
commodities; MoHSW
procurement gets involved in
some commodities
Step 3: CENTRAL TO
DISTRICT. MSD processes
orders for facilities from nine
zonal stores. (MSD only
responsible to deliver to
district level.)
Inadequate stocks to cover
the country because of
inadequate funding
MSD can’t reveal true stockouts (see above); USAID and
the Global Fund are the only
donors strengthening this
process
Step 4: ZONAL
WAREHOUSES. MSD Zonal
Warehouses receive
commodities for health
facilities, processes Integrated
Logistics System (ILS) Report
& Request (R&R) forms, and
drop off supplies at District
medical office.
Varying district capacity; a
mixture of integrated (ILS)
and vertical programmes (as
well as free v pay-for-service)
complicates process
Government has publicly
stated policy on universal
access and commitment to
free care for certain diseases.
Step 5: DELIVERY TO
FACILITIES. Health facilities
must pick-up medicines and
supplies from the District
stores; In some cases District
stores deliver commodities as
they are able.
Ordering with the R&R form is
not easy; Disbursal not
always happening; Lack of
transport or fuel; difficult
roads; inadequate storage
President’s office is pushing
MSD to deliver to the health
facility; Many health facilities
exist in name (and credit )only
Step 6: FACILITY LEVEL.
Health facilities receive partial
delivery of what they need.
(This can be from lack of
funds in their account or a
lack of product availability
from MSD.)
Stock-outs of critical RMH
commodities (these are
greater in more remote
areas); Reactive health staff
make do with what they have,
even if from another vertical
programme
The process that allows
facilities to buy commodities
when MSD is stocked out is
cumbersome.
Lack of MSD transparency on
stock-outs means that districts
cannot spend money to fill
commodity gaps
Step 7: RE-ORDERING.
Health facilities prepare
quarterly requests for further
commodities with R&R form.
A ‘pull’ system means that
health facilities a) need to
understand what they are
ordering; b) must make tradeoffs and do not always make
the best choices; and c) don’t
know what is not in stock and
often expect medicines when
they not available. Many
DMOs do not understand or
don’t care about the Report &
Request (R&R) form and
simply copy out last month’s
form. R&R form is paperbased.
Step 8: REPEAT. MSD
Central receives requests
from health facilities and
prepares to begin the
quarterly process again.
Commodity consumption is
never measured; RCH
Coordinators could strengthen
their role here.
Source: Bradford, C (2011). Tanzania Reproductive and Maternal Health Commodities. Trip Report.
Environmental and climate change effects
The family planning component of the proposed project is likely to have a potentially
substantial positive environmental impact and a limited direct detrimental environmental
impact. See Annex 1 & 2 for the full climate change assurance note. The maternal drugs
component is unlikely to have any significant impact on environmental or climate change
issues.
Positive environment impact. There is a significant benefit associated with higher uptake of
family planning services and smaller family sizes which relates to climate change and
pressure on natural resources. Increased contraceptive use should result in a lower fertility
rate, which in turn results in slowed population growth. Tanzania’s current 45 million people
are currently projected to grow to 67 million by 2025.xlvi Population growth is a major
contributor to environmental degradation. As populations grow, settlements expand and
encroach on natural habitats, often leading to habitat loss. They also put pressure on natural
resources, such as water and ecosystem services. As an example, by 2015, population
growth will mean that Tanzania’s per capita water resources could fall below 1,700 m3 per
person: the definition of water scarcity. Population growth will also lead to environmental
degradation through the demand for additional goods and services, which are particularly
important due to the strong urbanisation trends in Tanzania. Potential increasing demand for
energy and transport will also have an impact on increased use of fossil fuels, potentially
doubling greenhouse gas emissions over the next twenty years, as well as increasing urban
air pollution and congestion. Fewer people generate less green house gases which are the
main determinant of adverse climate changes.
Population growth and increasing urbanisation are key factors as well as climate change in
determining future economic costs. These rapid demographic changes will be important in
future impacts, adaptation and emissionsxlvii. In fact in a recent paper produced by climate
change experts at the Centre for Global Development, family planning was identified as the
best buy for a single intervention to reduce green house gasesxlviii. If family planning is
combined with girls’ education there are even more significant gains, as the table below shows
in terms of the number of tonnes of CO2 saved for $1 million invested. It has been argued that
the combination of family planning and girls’ education would be a better investment than the
UN Reducing Emissions from Deforestation and Forest Degradation (REDD), which aims to
spend $30 billion a year on incentives for developing countries to reduce deforestation and
forest degradation.”xlix
Table 5: Saving CO2 emissions by development intervention
Intervention
Family planning
combined
Tonnes of CO2 saved
&
girls'
education
250,000
Family planning alone
222,222
Girls education alone
100,000
Reduce slash and burn of forests
66,667
Pasture management
50,000
Geothermal energy
50,000
Energy efficient buildings
50,000
Pastureland afforestation
40,000
Nuclear energy
40,000
Reforestation of degraded forests
40,000
Plug-in hybrid cars
33,333
Solar
33,333
Power plant biomass co-firing
28,571
Carbon Capture and Storage (new)
28,571
Carbon Capture and Storage (retrofit)
26,316
It should be noted that, while increased contraceptive use will reduce population growth,
caution should be practised in using this argument without stressing the importance of
voluntary family planning to allow women to meet their reproductive desires. The health
benefits to women alone (e.g. the reduction in maternal mortality) are adequate argument to
the provision of good family planning services.
Better logistics and drug management should decrease the numbers of drugs and
commodities that are damaged or expire, and hence decrease the environmental impacts of
disposing of waste products.
Potential detrimental environmental impact. There are two possible detrimental effects that
this programme might have on the environment:


The release of carbon dioxide through transport of drugs and commodities
Waste generated as a result of used contraceptive commodities.
The programme will attempt to minimise any negative impacts on the environment. Drug and
commodity supplies will be routine and there should be no specific additional deliveries for this
project Waste disposal should follow carefully-designed protocols.
It is on this basis that the programme’s likely impact on climate change and the environment
has been categorised as “B”: medium/manageable potential risk, with good opportunity for
improvement.
Table 6: Evidence rating and climate change and environment category
Option
Evidence rating
Climate
change
and
environment category (A,B,C, D)
1 Do nothing
Medium
C
2 Go through Medical stores Strong
B
3 Work with US
Strong
B
THEORY OF CHANGE
IMPACT:
RH
commodity
supply
£15
m
over
three
years
MH
commodity
supply
High
quality
RMH
services
MH
commodity
logistics
support
Policy
support
Family
planning
need
satisfied
Women
supported in
pregnancy &
childbirth
Convinced
policy-makers
that RMH is
important
Advocacy for
strong RMH
health
services
•Fewer births
• Births are
well spaced
•Fewer
unplanned
pregnancies
and unsafe
abortions
•Safe births
with fewer
complication
WIDER IMPACT
•Healthy
mothers
•Healthy
children
•Less pressure
on social
services
•Improved
welfare
•Political
commitment
to maintain
system
B. Assessing the strength of the evidence base for each feasible option
In the table below the quality of evidence for each option is rated as either Strong, Medium or Limited
Option
1
2
3
Evidence rating
Strong
Strong
Strong
C. What are the costs and benefits of each feasible option?
While measuring family planning results has a clear and proven methodology, maternal health
supplies have never been tracked carefully and there is no clear methodology yet developed
to measure the results obtainable by the presence of MH supplies. (In April 2011, a nascent
Maternal Health Supplies working coalition has begun and in October 2011, a proposal for the
creation of a Commission on commodities for women’s and children’ health has been put
forward as part of the ‘Every Woman, Every child’ global effort. Doubtless, better measures of
maternal health supplies will soon follow.) Meanwhile, this work puts DFID Tanzania in the
vanguard for seeing the importance of these supplies and attempting to ensure their
availability.
The cost-benefit analysis below has used a modelling framework based upon the MSI impact
calculator which is used by most DFID projects, and forms the basis of the DFID RH results
framework. The other assumptions (around the proportionate costs and benefits attributable
to commodity supply alone) are based upon guidance from policy division.
The CYP is calculated by multiplying the quantity of each method distributed to clients by a
conversion factor, to yield an estimate of the duration of contraceptive protection provided per
unit of that method. The CYP for each method is then summed for all methods to obtain a total
CYP figure. CYP conversion factors are based on how a method is used, failure rates,
wastage, and how many units of the method are typically needed to provide one year of
contraceptive protection for a couple. The calculation takes into account that some methods,
like condoms and oral contraceptives, for example, may be used incorrectly and then
discarded, or that IUDs and implants may be removed before their life span is realized.
Once again, here are DFID’s critical success factors for the programme:




Integrated RH and MH commodity supply at all levels of the health system in Tanzania;
Longer term commitment to sustain RMH supply by GoT;
Low DFID transaction costs; and
Coherent logistic and policy around RMH supplies.
Examining the options
Options
Costs
Benefits
(Quantitative &
Qualitative)
(Quantitative & Qualitative)
Option 1:
No commitment cost
Do nothing to
to DFID
support MRH
services to
women across
Tanzania beyond
budget support
and existing
projects
Option 2:
Funds for
commodities
directly to the
Tanzanian
Government
£15m over three
years (extendable to
five years)
DFID staffing: 1.5
FTE (based on
Risks &
Assumptions
Risks
Benefits:
GoT’s resource allocation to FP and
maternal health supplies, which may
improve if donor funding is not
available, results in a reduction in
maternal mortality.
Positive benefits:
RMH supplies where they are needed
would result in a quicker reduction of
maternal mortality and a quicker
increase in contraceptive prevalence
versus option 1, delivering the
following quantified results:
RMH supplies
remain a low
priority
Logistic systems
remain weak
Risk
Fiduciary risk
that funds will
not be used for
their intended
purpose
(through the
MSD)
GFATM experience)
totalling
approximately
£671,000 over three
years
Main cost drivers will
be commodity costs
there is international
pressure to reduce
these – and potential
economies of scale.
Costs will be
explicitly tracked in
the log frame
- 0.6 million CYPs from the
commodities alone resulting in
208,142 pregnancies averted, 29,399
unsafe abortions, 729 maternal lives
saved plus (at least)
780 women saved from haemorrhage
Non-quantified results:
Other lives saved/ disability reduced
through MH interventions
Improved perceptions of quality of
RMNH services and possible
increased utilisation
Negative benefits:
Fiduciary risk that funds will not be
used for their intended purpose
decreases results.
Channelling through MSD results in
considerably slower system in the
short-term – several years (as
evidenced by Global Fund
experience) leading to lower results.
Option 3:
Fund a package
of support
toward delivery
of reproductive
and maternal
health
commodities in
partnership with
development
partners
Current situation
with MSD is
perpetuated
Inadequate
engagement
and support
from GoT
Risks, if
materialised with
result in stockouts continuing
particularly in
the short-term
Results would
not be realised if
distribution and
storage
problems results
in high levels of
waste
Assumptions:
Funding the
commodity only
results in system
changes,
including for
logistics.
Risks
£15m over three
years (extendable to
five years)
DFID staffing: 0.1
FTE totalling
approximately
£45,000 over three
years.
$30 000 per year for
USAID costs
UNFPA unquantified
at present
Positive benefits:
RMH supplies where they are needed
would result in a quicker reduction of
maternal mortality and a quicker
increase in contraceptive prevalence
versus option 1, delivering the
following quantified results;
- 0.4 million CYPs from the
commodities alone which will result in
139,455 pregnancies averted, 19,697
unsafe abortions, 488 maternal lives
saved plus 780 women saved from
haemorrhage (result from the
maternal health supplies).
Non-quantified results:
Other lives saved/ disability reduced
through MH interventions
US Government
political change
makes funding
of family
planning
impossible
Change of
provider by
USAID during
course of
support
Inadequate
engagement
and support
from GoT
USAID staff
over-stretched.
Improved perceptions of quality of
RMNH services and possible
increased utilisation
(Lack of data/evidence prevents their
quantification)
Longer-term impact of logistic and
policy support on RMH supplies,
thereby supporting sustainability.
Fragmentation
and lack of
government coordination of
RMH
Assumptions
GoT is content
that funds are
not being
channelled
directly.
Continued good
experience of
working with
USAID
CSC
Option 1
Option 2
Option 3
Integrated RH and MH
Commodity supply at
all levels of the health
system (Max10)
Longer-term
commitment to sustain
RMH supply by GoT
Max 5
Low DFID transaction
costs Max4
Coherent logistics and
policy support around
RMH supplies Max 6
TOTAL
2
7
9
3
1
3
4
1
3
1
2
5
10
11
20
Comparison of Options
Under option 1, maternal mortality is likely to decline albeit at a slower rate than options 2 and
3. However, any possible reductions could be undermined by the risk that RMH supplies
remain a low priority and that the logistics system would remain weak.
According to the modelling calculations, option 2 could result in potentially 33% more
quantifiable results than option 3 if the funding was completely spent on RMH commodities. It
is also the option that DFID would most like to be able to choose as the ideal would be a
robust and reliable system of logistics for all essential drugs through MSD lead by
Government. But this comprehensive solution has no guarantee of success, noting the risks
and assumptions mentioned above. Working through the MSD would require considerable
DFID staff time to ensure transparency of spend and to assess fiduciary risk. The experience
of the Global Fund shows that this approach may be fruitful in the long run but extremely time
consuming for staff. It could also result in severe stock-outs in the short run, thereby
undermining results in the short-term. The work of the Global Fund may be setting the stage
for DFID to choose Option 2 in future years, particularly if stronger political support for family
planning were to be built. But our analytical conclusion is that selecting option 2 now is likely
to be premature.
Option 3 results in fewer results compared to option 2 as more funds are devoted to policy and
logistics capacity building for GOT. However, the experience of the last commodity project
has demonstrated that simple commodity procurement is not enough to ensure that GOT will
prioritise RMH supplies and ensure they are present in the health system. Ensuring
engagement with the GoT and their long term support to maintaining RMH supplies needs
active dedicated support to quantification and logistics. In addition, working through another
DP will use less DFID staff resources, noting that low transaction costs were identified as a
critical success factors. Our analytical conclusion is therefore that option 3 is preferred as it
delivers a good package of more guaranteed results whilst in parallel supporting the
development of a longer-term sustainable system of RMH supplies. Funding for this option
would be channelled through DPs to carry out the package of interventions.
Detailed Description of the Selected Option
Output 1 Contraceptive commodities are available, particularly long-acting and
permanent methods: would purchase contraceptive commodities to provide a half a million
women across Tanzania access to a long-term method of family planning. DFID works with
USAID to determine that the contraceptive gap is filled for Tanzania. UNFPA may also be
involved in this discussion. USAID contractors procure the commodities and they arrive in the
government medical stores. This process is straightforward and DFID has already purchased
commodities via USAID for Tanzania in 2010.
Output 2 Replenishment of essential obstetric drugs throughout Tanzania: will be the
purchase of essential MH supplies which will result in more safe deliveries. There will be
certain flexibility, as needs assessments are continually evolving, and other donors are
funding specific product lines. It is likely that DFID will fully fund the countries requirements for
oxytocin ergometrine, magnesium sulphate, llignocaine calcium glocomnate and hydralazine.
This work is less well defined as maternal health commodities have been less studied than
family planning commodities. The maternal health commodities list is still under discussion
and there are many challenges to determining the baselines. USAID is beginning to consider
which tracer drugs should be used to track maternal health supplies throughout the system but
there is considerable work still to be defined.
Output 3 Logistics systems strengthened for maternal health drugs: As the logistics
systems for MH commodities are underdeveloped and the MH supply situation in Tanzania is
not yet clear, MH logistics support will be included in the intervention package to ensure a
steady supply of MH supplies. As with output 2, what this support will consist of is not yet
defined. Strengthening MH logistics is likely to look very similar to the support for family
planning commodities but there are additional complications such as the necessary cold chain
for oxytocin and the fact that maternal health commodities can be used for other indications.
DFID plans to invest in improving logistics for five products (at $100,000 per product as part of
the contract). In working with the lead agency in partnership, there will be flexibility, especially
to fill gaps of other donors, if necessary.
Output 4 Political commitment and appropriate policies sustain maternal and
reproductive health commodity supply and use will help to build political commitment to
sustaining these essential RMH supplies. This sort of focused intervention on core public
health priorities should not be necessary – they should be fully funded as priority health
interventions The reasons that they are not are complex – associated with lack of female
empowerment and religious issues as well as weak management capacity and general lack
of prioritisation. The political interest and advocacy around reproductive and maternal health
is increasing at international levels. At this stage, and in advance of more analysis of the
politics and drivers of change around the issue it is not possible to be prescriptive as to exactly
what this project will do, and how it will fit with other initiatives. It will combine support for high
level political advocacy with more technical and localised work on accountability.
Potential advocacy entry points might include:

Budget monitoring for RMH supplies;

Looking at how RMH supplies are prioritised and engage in discussion;

Locate national champions that policy-maker will heed;

Raising awareness of the problem at community level;

Using presence of RMH supplies as an indicator of a successful RMH programme;

Mobilising support for the DFID ‘golden moment around family planning’

Linking up with the Commission for information and accountability and reproductive for
women and children’s health – and supporting country level activities in Tanzania

Linking with the regional project evidence for action, to ensure family planning issues
are adequately reflected in country plans
D. What measures can be used to assess Value for Money for the intervention?
To assess value for money, the two different types of commodities will be discussed in turn: a)
family planning commodities (where there are well developed tools to measure) and b) maternal
health supplies (where there has been little research done as yet to determine good measures).
FAMILY PLANNING SUPPLIES
Family planning is good value for money. At a global level, the Guttmacher Institute has
undertaken research which demonstrates that increasing the coverage of modern family
planning methods is a highly cost effective interventionl. They calculate that meeting the need
for family planning methods for 818 million women in developing countries would cost:



$ 28 to avert an unintended pregnancy
$ 3050 to save the life of a woman or newborn
$ 62 to save a DALY (women and newborns combined)
Putting this in the context of other common health care interventions in developing countries
they demonstrate that such a cost-benefit figure represents relatively good value for money:
Table 7: DALY costs by intervention
Intervention
Insecticide-treated bed nets
Malaria prevention for pregnant women
Tuberculosis
treatment
(epidemic
situations)
Modern contraceptive methods
Antiretroviral therapy (Africa)
BCG vaccination of children
Oral rehydration therapy
Cholera immunisation
Cost per DALY saved in US$
13-20
29
6-60
62
252-547
48-203
1268
3516
Furthermore the Guttmacher Institute in 2009 demonstrated that in Sub-Saharan Africa,
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 dollar invested.
The expected results for the family planning commodities alone will be the commodities to
contribute to 0.4 million couple years of protection (CYPs) in total. (NOTE: these
commodities are considered to contribute to one third of a full CYP as service delivery costs
are not included.) This will avert 139,455 pregnancies, prevent 19,697 unsafe abortions and
save 488 maternal lives. The maternal health commodity interventions measurements are
less well developed. When the measurements for maternal health commodities are
determined, the results for this programme will increase further.
Long acting methods, such as implants, have higher unit costs than methods such as
sterilisation or iUCD insertion that require more sophisticated clinical delivery systemsli. The
importance of a broad family planning method mix that offers women a non-coercive choice of
family planning methods has already been acknowledged, Long-acting and permanent
methods LAPM are more effective and, as a result, save more lives, and implants and
injections are particularly important where clinical capacity is limited, . Short-term methods
rely on the users to remember to take their pills or go to the health facility for their injections.
This higher degree of user dependence lowers a contraceptive’s effectiveness. Many
countries in sub-Saharan exhibit a high proportion of women contracepting (contraceptive
prevalence rate) but this high CPR does not translate into lower fertility rates. This implies that
use of family planning is less effective—in the case of Tanzania, this is partly due to a high
proportion of women using injectable contraceptives. A modelling study lii has shown that if
one-fifth of African women contraceptors switched to LAPM, more than 10,000 maternal
deaths would be averted.
This health benefit to women is a compelling argument on its own but there are additional
benefits to the woman such as less time spent resupplying her short-term family planning.
Poor patterns of short-term hormonal contraceptive use (high discontinuation rates and
incorrect use) contribute significantly to the problem of unintended pregnancy in sub-Saharan
Africa. Increased availability and use of more effective methods, such as implants, will improve
reproductive health in sub-Saharan Africaliii. As women may be using injectable
contraceptives because they can use them surreptitiously, there should be continued work in
Tanzania to increase the acceptability and acceptance of family planning to husbands.
Table 8: Costs of contraceptive methods
Contraceptive method
Male condom
Pill
IUD
Female condom
Injectable
Vasectomy
Sino-implant*
Female sterilization
Implant (Jadelle)
Implant (Implanon)
Unit cost ($US)
0.025
0.21
0.37
0.77
0.87
4.95
8.00
9,09
24.09
24.09
Cost per CYP ($US)
Na
7.80
1.75
Na
7.90
2.25
4.00
4.00
8.15
12.25
Source: Wickstrom and Jacobstein (2011)liv
*Not yet internationally quality assured.
Results from contraceptive supplies only (Total spent: £6m). At the moment there is
some flexibility around proportions of contraptives and MH product purchased, to ensure
complimentality with other donors, and that all needs are met. We have therefore modelled
the use of more expensive methods and a significant spend on advocacy and policy work that
does not yield directly quantifiable results in terms of lives saved. The cost per CYP will be
£15.23. This cost per CYP is more expensive than a full FP programme with a rounded
method mix. Implants are expensive medical devices but, in return, yield one of the best longacting contraceptive methods—important for increasing the effectiveness of Tanzanian
women’s contraceptive use.(See strategic case for more information on the importance of the
method mix and long-acting contraception.) This therefore is a ‘worst case scenario’ and cost
effectiveness may increase if spend is higher on commodities, and if cheaper products are
procured.
Reproductive Health Supplies Coalition (RHSC) increasing VFM
DFID is currently chairing the RHSC, a group of organisations working together to reduce
contraceptive prices and increase their efficient delivery. In 2011, the RHSC had a major
victory when the drug companies reduced the unit price of their implants (see table). This
work is directly increasing the VFM for this Business Case as DFID is able to purchase
implants at the new price. Increased volume in the future may allow DFID to purchase
implants at an even lower price. This reduction in contraceptive commodity price can be
directly attributed to the cross-DP advocacy work carried out by the RHSC.
Table.9 RHSC is responsible for price reduction in implants
Type of implant
Old price
New price (2011)
Jadelle
Implenon
$21.18
$19.60
$19.50
$18.00
Possible lowest
price
$16.50
$16.50
MATERNAL HEALTH SUPPLIES
What is known about determining results from ensuring the presence of MH supplies?
There has been little work and research to date on MH supplies as a whole although several
groups are looking at specific drugs We know that the marginal cost of having ocytocin and
misoprostol in facilities is low, and use of oxytocin or misoprostol has a cost effectiveness of
$35-50 which is compatible with other ‘best buys in health’ An economic assessment of
interventions to reduce postpartum haemorrhage in developing countries found these new
interventions are cost-effective and cost-beneficial technologies with great potential to reduce
PPH and its consequenceslv. The Magipie study in 33 countries looked at the use of
magnesium sulphate for pre-eclampsia and found that magnesium sulphate was cost effective
and costs less and prevents more eclampsia in poorer countries than in richer ones. With little
research on which to base the results that may be obtained from the presence of MH supplies
in facilities, the next paragraph attempts a crude estimate.
Results from maternal health supplies. Offering emergency obstetric care involves a
functioning health system which includes health personnel, facilities and medical supplies.
The African Science Academy has estimated that offering emergency obstetric care to all
women who needed it in Tanzania would save 3500 maternal lives per year lvi. Approximately
30% of these women (1050) died from haemorrhage. It is safe to say that the absence of
maternal health supplies would be responsible for a proportion of these deaths. The Abt study
on preventing post partum haemorrhage PPH suggested on the basis of metanalysis that
prophylactic uterotonics have a 50% risk reduction. These are based on clinical studies – and
under routine conditions low efficiency e.g. suboptimal distribution and administration etc,
may, pessimistically decrease overall impact by 50% This would result in 260 lives being
saved
260
£576,919.00
£149,692.00
£200,000.00
£200,000.00
£1,126,611.00
Number of women saved from haemorrhage by health
supplies
All oxytocin purchased for one year
All misoprostol purchased for one year
Logistics support (two commodities) for one year
advocacy (proportion 40%) for one year
DFID spend (total)
£4,333 Cost per maternal live saved
This is a very conservative estimate, as in addition to lives saved from haemorrhage, lives will
be saved from eclampsia and other causes, and there will be a very significant number of
DALYS saved through reduced anaemia and pre eclamsia. This would imply that supporting
MH supplies offers as good or better value as family planning (at £12,283). (Recall that this
estimate for FP is high as it assumes that DFID is buying the most expensive contraceptive in
a range of methods.)
Investing in logistics for MH supplies. Logistics support good value as it improves the
efficiency of the system over the longterm, in particular because it decreases wastage.
Supporting systems that determine the bottlenecks currently operating in the delivery of MH
supplies will sort problems in the longterm. Improving the medical supply system will support
the entire health system.
Supporting political advocacy. Ensuring that RMH supplies are present in the health
system is not simply a technical problem. Unless RMH services and supplies are understood,
acknowledged, and acted upon, maternal mortality will remain high in Tanzania. DFID will
invest £1.5m over three years to shore up political support and understanding for RMH.
E. Summary Value for Money Statement for the preferred option
Investing in Reproductive and Maternal Health commodities is going to be very good value for
money for DFID as the investment in RMH health is well documented and ensuring the
presence of RMH supplies where they are needed will save both maternal and child/infant
lives.
Table 10 VFM metrics to monitored
Intervention
Economy
FAMILY
PLANNING
Programme cost
for a CYP is £15. Price of
implants is
reduced
Price of all
commodities
MATERNAL
tracked in
HEALTH
logframe
significant
Programme cost economies of
of maternal life
scale
saved: £4,333
anticipated
Commodity
costs –
relative to
international
benchmarks
Logistics
support cost
per product
line monitored
Efficiency
Effectiveness
Avoiding
stockouts and
logistic
support
increases the
overall
efficiency of
RMH services
Increase in CYPs
delivered by the
programme
(Target: 0.4m
CYPs)
Long acting
methods are
more effective
particularly for
rural women
Cost
effectiveness of
maternal health
drugs is v high,
particularly given
‘sunk costs ‘ in
MH services by
govt and other
donors
Build on evidence
base
LAPM are more
expensive but
increase family
planning
effectiveness.
MH supplies are
poorly studied and
there are no models
that determine
results from seeing
that the health
system is supplied.
DFID can begin to
ask the relevant
questions.
Commercial Case
Direct procurement
A. Clearly state the procurement/commercial requirements for intervention
There is no direct procurement in this programme by DFID.
B. How does the intervention design use competition to drive commercial advantage
for DFID?
NA
C. How do we expect the market place will respond to this opportunity?
NA
D. What are the key cost elements that affect overall price? How is value added and
how will we measure and improve this?
NA
E. What is the intended Procurement Process to support contract award?
NA
F. How will contract & supplier performance be managed through the life of the
intervention?
NA
Indirect procurement
A. Why is the proposed funding mechanism/form of arrangement the right one for this
intervention, with this development partner?
DFID will be contracting USAID to deliver RMH supplies and logistical support. DFID will be
contributing to pooled funding with other donors for joint policy work. The activities of this RMH
supplies programme will be procured indirectly, through USAID. This programme is for both
programming and commodities and will use USAID procurement policy and guidelines. .
Up to 0.4% (i.e. £60,000) of the programme cost will be used by USAID to cover the cost of
staff for the additional work.
DFID Tanzania has not been active in the health sector until 2010 when it began supporting
the sector where there are gaps in provision that could not be filled by other partners. In
2010, DFID Tanzania decided to respond to a contraceptive shortage with support to the
Tanzanian family planning programme. However, as there was no dedicated DFID health
adviser or administrative support to supervise such a programme, it was decided to provide
the required resources through USAID—the donor in Tanzania who has the most experience
in family planning, using a Memorandum of Understanding (MOU). It is intended that this
collaboration is continued for the RHM supplies with a new agreement to be called an
Arrangement on Delegated Co-operation (ADC) between the Government of the United
States of America and the Government of the United Kingdom of Great Britain and Northern
Ireland regarding Support for RMH supplies in Tanzania. (See Annex1.)
This programme involves intense involvement in supply procurement; expertise that DFID
does not possess so would be unable to deliver the interventions directly. By partnering with
USAID, DFID Tanzania is able to deliver improved results in CYPS and reduced maternal
deaths. USAID Tanzania has the history, staff, engagement with the MoHSW and robust
management, monitoring and supervision systems to deliver the expected results.
USAID Tanzania has a formal project management protocol that assures the necessary
support and oversight. The activities proposed here fit into USAID’s larger programme.
The indirect procurement component of the programme will be managed under an ADC with
USAID, who will enter into a contractual agreement with the Implementing Agency and other
development partners and is appropriate for the following reasons:




It provides effective means of reducing the management burden to DFID that would be
imposed through the use of commercial contracts;
It enables existing activities by USAID to be harnessed and expanded through the
provision of additional resources to these organisations; and
The use of USAID to manage this programme including financial management,
procurement management, M&E and reporting provides better value for money under the
current DFID environment of doing more development work with less resources.
It minimises fiduciary risk by using existing USAID procedures to manage DFID’s funds.
These instruments will deliver value of money through the assets that USAID will bring to the
programme. These include technical expertise in family planning, contraceptive commodities
procurement, distribution, utilisation and safe disposal and ability to expand quickly. USAID
provides the monitoring of the programming and robust procurement procedures. In addition,
with an ACD with USAID there are very strong and transparent organisational and financial
management processes. If, during the course of implementation, it would be considered
beneficial (and better VFM) to adjust these funding arrangements, it is agreed that funding
could be adjusted, by mutual agreement between DFID and USAID.
The potential financial risks of using these instruments (as opposed to commercial contracts)
will be mitigated through the use of semi annual tranche releases to USAID, including
quarterly progress and financial reports that are reviewed by programme staff, to ensure
that the services provided are appropriate and of high quality.
The programme will procure goods and services from this partnership using USAID’s
procurement mechanisms and delivery channels. DFID have reviewed the procurement
strategy of USAID and find that it is robust and rigorous and focused on achieving the best
VFM. USAID will also conduct cross-checking on the prices of goods and services against
those of similar inputs in Tanzania and the region, when goods are being purchased as part
of their procurement procedures. Cost consideration is also part of an award negotiation and
will be a key activity in selecting the next tender. Value for money is a key element in this
process.
An alternative approach would be to work through UNFPA, as is done in other countries
UNFPA do have procurement capacity, and a mandate to work on these issues. In Tanzania
they procure through the health basket and MSD and are not seen as the lead agency on
commodity security. There current spending is relatively low, and so rapid scale up would be
a challenge. DFID would be keen to see them working more in this role, and it is hoped that
the joint donor working group might facilitate this
B. Value for money through procurement
USAID purchases contraceptives worldwide and their bulk purchases greatly drive down the
unit price of family planning supplies. MH supplies have not been purchased by USAID in
the past but they have robust competitive processes. USAID procurement is not tied to US
products. Where it is going to be cheaper and/ or faster, the in country team will work with
MSD to procure supplies locally.
At a global level, USAID is known for having robust mechanisms in place to ensure good
value for money and quality. DFID Tanzania’s experience of working with USAID at country
level has been good. DFID Tanzania has already three times worked with USAID through an
MOU to provide health services to Tanzania: to support the hang-up malaria bednet
campaign for children under five in 2009 (£800,000), to fill the gap in the supply chain for the
purchase of contraceptive commodities in 2010 (£6.5 million), and to deliver family planning
outreach services via Marie Stopes Tanzania (£8 million). All of these programmes have
performed well and highlight the strong effectiveness of USAID’s management capacity.
Control of administrative costs: The Implementing Agency will develop an annual
workplan and objectives for key performance indicators that will be approved by USAID and
reviewed by DFID Tanzania. On a quarterly basis, they will provide a summary overview of
key activities and outputs to USAID and DFID. This report will also include financial data
and updates on key indicators. USAID Tanzania staff meets regularly with implementing
agencies and the annual planning and quarterly reporting are a formal part of the project
management process, as detailed in the Agency’s formal policy directives and guidelines.
VFM in purchase of programme goods: The Implementing Agency’s procurement policy
and guidelines set out organizational procedures for procuring goods, and services globally.
All procurement will be required to fulfil USAID’s standards and procedures.
Partnership with USAID. The partnership with USAID/ Tanzania will also serve to mitigate
further any fiduciary risk. USAID’s regulation and policy guidelines are rigorous. Prior to
making the central award, The Implementing Agency is fully required to satisfy the Agency
that they have the capacity to adequately perform in accordance with the principles
established by USAID and the US Office of Management and Budget (OMB). A positive
responsibility determination means that they possess or have the ability to obtain the
necessary management competence to plan and carry out the assistance programme to be
funded, and that the applicant will practice mutually agreed upon methods of accountability
for funds and other assets provided by USAID.
Financial Case
A. What are the costs, how are they profiled and how will you ensure accurate
forecasting?
The expected cost of the programme is £15million over three years. The approximate allocation of
funds to components of the programme will be as follows:
Payment Schedule
Annual funding
breakdown
FY 11/12 FY 12/13
Total
FY 13/14
FY14/15 (£)
Feb-12 Aug-12 Mar-13 Sep-13 Mar-14 Mar-15
Output 1: Contraceptive
supplies
2m
0
2m
0
2m
6m
Output 2: MH Supplies
2.5m
0
2m
0
2m
6.5m
Output 3: MH Logistics
0.25m
0.25m 0.25m 0.25m
0.25m
1.25m
Output 4: RMH supply
policy/advocacy
0.25m
0.23m 0.23m 0.25m
0.23m
1.19m
0.02m 0.02m
0.06m
4.48m 0.02m
15m
USAID - Management fees
Annual Total
0.02m
5m
0.5m
4.5m
0.5m
NB: There will be some flexibility in the funding between outputs depending on other donors
contributions and emerging needs.
B. How will it be funded: capital/programme/admin?
All required resources will be programme funds—which will cover procurement of goods and
services. This is part of the budget allocated within the Operational Plan for DFID Tanzania
covering F/Ys from 2011/12 up to 2014/15.
There are no contingents or actual liabilities.
C. How will funds be paid out?
Funds will be paid by DFID to USAID on a six-monthly basis in February 2012 and every six
months thereafter, on receipt of a formal request which includes a financial statement of
need for the forthcoming six month period. This will minimise risks that funds are disbursed
in advance of need at any time. Payments for procurement of goods will be made in
compliance with USAID Procurement Policy.
Funds will be disbursed according to the terms of the ACD between DFID and USAID, which
have a semi-annual disbursement schedule. USAID will then fund the Implementing Agency
and supervise the programme and provide report back to DFID every quarter. Reports will
be available 30 days after the end of each quarter. USAID and DFID are currently using this
mechanism for other activities to mutual satisfaction.
If there are policy changes for USAID that make their administration of this family planning
contract untenable, and therefore could not guarantee that the funds would be released in a
timely manner to ensure delivery of the programme, DFID will engage UNFPA and directly
contracting JSI through accountable grant arrangement during the course of the three year
period (extendable to five years). This transition could be managed smoothly with minimal
impact on project implementation though with some transaction costs to DFID. While this is
unlikely, as it would take a Presidential change, as well as a congressional change (i.e. with
a Democrat for President, they could continue support for family planning, even with a
republican majority in the Congress). The fact remains that family planning is a contentious
issue in American politics and a different presidential administration could have implications
for USAID and its administration of family planning projects.
If the programme is terminated early, through no fault of the implementing partners, USAID,
using its procurement policy and guidelines, will give back any unspent funds to DFID, who
then could either choose to enter into a direct agreement with the implementing partner,
reimburse the suppliers for any costs they have already incurred or that will be necessarily
incurred (and the supplier can’t be expected to avoid or recover).
D. What is the assessment of financial risk and fraud?
As most of the procurement will be done using USAID systems and the Implementing
Agency will be providing Technical Assistance support, we judge the overall level of fiduciary
risk for this programme to be low given the extensive financial controls in place for USAID
contract management. This judgement is based on DFID’s corporate knowledge of USAID
globally, satisfactory experience of working with and through USAID systems in comparable
contexts (e.g. in Tanzania).
Any potential risks of using these instruments as opposed to DFID- managed commercial
contracts will be mitigated through the use of six-monthly tranched releases to USAID, based
on quarterly financial and progress reports that are reviewed by programme staff, to ensure
that the services provided are appropriate and of high quality and to ensure that funds are
released only on clear evidence of financial need.
E. How will expenditure be monitored, reported, and accounted for?
Rigorous monitoring and accounting of expenditure will take place using ARIES in
accordance to the ADAMANT principle to ensure value for money and compliance with Blue
Book requirements and programme arrangements.
USAID will monitor and account for expenditure and will submit to DFID a certified annual
statement showing funds received and expended including quarterly financial and progress
reports. The Implementing Agency will submit an annual audited account. The reporting will
be a single process, with updates as required.
Whilst primary accountability for DFID funds will reside with USAID through the agreed ACD,
the implementing agency will be accountable to USAID.
Management Case
A. What are the Management Arrangements for implementing the intervention?
The overall oversight of this project will be through the emerging government donor working
group on reproductive and maternal health which is jointly lead by the GOT, USAID, and UNFPA.
(This also means that DFID can work through USAID on high level political advocacy and gives
DFID a seat at the policy discussion table.)
This programme is a good example of donor coordination as DFID embarks on its fourth
collaboration with USAID. Working with the lead RMH agency in partnership will allow certain
flexibility to fill gaps of other donors from an overall menu of RMH supplies. While this
programme will be managed by USAID, DFID will need to continue to engage with UNFPA and
other DPs as multi-donor coordination will continue to be very important for this programme. (It is
possible that another DP might be in a better position to carry out some activities and the
programme needs to maintain the flexibility to do that.) The Donor-Government Joint Working
Group has oversight of these activities. In addition, DFID and USAID will need to ensure
synergies with other projects such as E4A.
USAID will have general oversight of JSI and the USAID Family Planning Adviser (Activity
Manager for the global A/OTAR) will supervise. The Agreement Officer’s Technical
Representative (A/OTR) is at Headquarters and the Family Planning Advisor at USAID will serve
as the local Activity Manager (AM) for the award in Tanzania. Specific certification requirements
are outlined in USAID’s policies, Automated Directives System which is a web-based catalogue
of USAID rules and regulations). Locally, the AM will:







oversee the technical activities on the ground;
develop and monitors the statement of work;
is the Mission point of contact for visitors;
is the Partner point of contact (responding to submitted reports);
is responsible for writing up minutes for quarterly meetings and placing them on file;
is responsible for site visits and submitting reports; and
is responsible for tracking finances.
When the agreement moves to a local one, the AM role will become that of the Agreement
Officer’s Technical Representative (A/OTR), or C/AOTR which is the representative under a
contract) who will work to ensure that USAID exercises prudent management over funds. The
relevant sections of Automated Directives System (ADS) Chapter 303, "Grants and Cooperative
Agreements to Non-Governmental Organizations," state the specific duties, authorities, and
limitations that accompany this designation. The ADS 303; 22 CFR 226, "Administration of
Assistance Awards to U.S. Non-Governmental Organizations"; and Contract Information Bulletins
(CIBs) or Acquisition and Assistance Policy Directives (AAPDs) issued periodically lays out the
role and responsibility USAID mandates for oversight of its agreements http://www.usaid.gov/policy/ads/300/ Page 34 of the ADS describes the pre award survey as
we would move to a new agreement- the survey team examines the applicant’s systems to
determine whether the prospective recipient has the necessary organization, experience,
accounting and operational controls, and technical skills — or the ability to obtain them — in
order to achieve the objectives of the programme.
USAID’s Family Planning Strategy and how this programme fits.
The USAID Health and Population Office have updated its strategic vision under the BEST
programme. USAID’s Family Planning priorities include (in order of priority):
 improve contraceptive security and advocate for supportive government policies including
sufficient financing and budget line items (continued and expanding) under the NFP CIP
and fund new partnerships with private and faith- based/non-governmental sector for
commodities;
 increase access to a broad method mix (provide a regular supply of a complete range of
methods) through scale-up of outreach services under a coordinated ‘Catch-Up’
Campaign and through scale up of partnership with local faith based and private sector
partners;






scale up youth friendly communication and services including a focus on adolescent pregnancy;
broaden communication efforts to include promotion of healthy timing and spacing and address
persistent myths and misconceptions;
increase availability and skills of providers to deliver long-acting and permanent methods and
expanded access of post-partum intrauterine contraceptive device delivery;
introduce programming to access emergency contraception and scale up post-abortion care
services from the current 21 districts to all 131 districts;
counsel all women and couples on the range of FP methods when accessing MCH and HIV/AIDS
services; and
initiate training and task shifting of minilaparotomy under local anesthesia to clinical officers, and
continued outreach services.
Management structure within DFID: This programme will be managed by the DFID MDG
Advisor, with the support of Deputy Programme Manager, based in Tanzania. The DFID
programme team will meet at least quarterly with the COTAR in USAID.
Quarterly or other reports on the programme will be shared with DFID. Quarterly progress and
financial reports will be produced as well as annual reviews. Regular monitoring will be
conducted and reports shared with DFID on a semi-annual basis. DFID will undertake annual
project reviews. Any revision of the KPIs will be done as part of the annual review process and
this will be linked and jointly conducted. Financial reports, compliance and administrative
functions will be managed by the USAID and shared with the DFID programme team.
Management by USAID. Management by USAID will be as described above as mandated by
USAID regulations and policies. Additional information is provided below for financial
management, for family planning compliance, and for site visit and environmental compliance.
The Mission’s Site Visit Checklist, the Environmental Impact Evaluation and mitigation plan, The
Family Planning Compliance checklists for the Mission have all been provided to DFID for
documentation in detail of oversight procedures.
Financial oversight includes:
 Ensuring that all funding actions comply with USAID's forward funding guidelines (ADS
602, Forward Funding of Program Funds).
 Reviewing the recipient's request for payments or financial reports and providing or
denying administrative approval if required by the procedures in ADS Chapter 630,
Payables Management.
 Monitoring the financial status of the award on a regular basis to ensure that the level of
funding is the minimum necessary.
 Developing accrued expenditures on a quarterly basis in accordance with ADS 631,
Accrued Expenditures, and instructions from M/FM or the mission controller. Reviewing



and documenting the review (for example, signing and dating a copy of the financial
report) of financial status reports for U.S. organizations with letters of credit and periodic
advance payments to monitor financial progress.
Initiating a request to the agreement officer to deobligate funds if at any point it is apparent
that the amount of available funds is more than will be necessary to complete the
cooperative agreement activities (see ADS 621 Obligations and Internal Mandatory
Reference “Deobligation Guidebook”).
Monitoring recipient compliance with the requirement for them to obtain any host country
tax exemptions for which they are eligible; and
Upon completion of the work under the award, reviewing any unliquidated obligation
balance in the award and working with the agreement officer to deobligate excess funds
before beginning close-out actions.
Site visits are an important part of effective award management because they usually allow a
more effective review of the project. When USAID makes a site visit, the AO or AOTR must write
a brief report highlighting his or her findings and put a copy in the official award file.
Family planning compliance is an area of great importance to the USG and principles of
voluntarism and informed choice guide USAID's family planning programme. These principles are
articulated in programme guidelines and a number of legislative and policy requirements that
govern the use of U.S. family planning assistance. USAID works with partners to ensure
compliance with the family planning requirements in their programmes. This is mandatory and
must be well documented and reviewed on an on-going and stringent basis.
B. What are the risks and how these will be managed?
Table 16: Assessment of risks
Risk Description
Risk
1
Fiduciary risks
Impact
on
Success
(L,M,H)
M
Probability
of
Occurring
(L,M,H)
L
Mitigating Actions
Main procurement is through USAID
that has robust process for managing
procurement and funds
Maintain good dialogue with USAID
and suggest additional junior staff, if
required
Undertake consultative meetings with
GOT at all levels to galvanize support
and ownership
Risk
2
USAID staff may be
overstretched
Risk
3
Inadequate
engagement and
support from GOT
L-M
M
Risk
4
Fragmentation of
work in health sector
with many priorities
and DPs
Political risks:
US Government
political change
makes funding of
family planning
impossible
Change of provider
by USAID during
course of support
M
M
DFID is working with lead partner in
the RH sector. USAID will be
coordinating priorities and partners.
M
M
DFID will consider the option of
switching funding to another partners
– such as UNFPA if this occurs
L
M
DFID will consider the option of
directly funding JSI or to remain
funding through JSI
Risk
5
Risk
6
Monitoring
Mechanism
DFID will
monitor
USAID will
oversee and
JSI responsible
for monitoring
USAID will
coordinate and
DFID will
monitor
DFID will
monitor policy
changes within
USAID
DFID will keep
in close contact
with USAID
Risk
7
Conservative
backlash toward
family planning
activities in Tanzania
M
L
Political advocacy is built into
programme activities
DFID and
USAID will
monitor.
C. What conditions apply (for financial aid only)?
Not applicable, as the programme does not involve financial aid to government.
D. How will progress and results be monitored, measured and evaluated?
There are strong synergies between this project and evidence for action the regional project that
will operate in Tanzania, focusing on maternal health data quality and use. This project is in the
design phase. It is likely that they may develop indicators that will be more reliable, and the
logframe should be reviewed once this project is operational. JSI the logistics contractor regularly
surveys 640 facilities across the country on a six monthly basis to review the availability of
malaria drugs. They will add reproductive and maternal health commodities to this process.
Monitoring advocacy and policy change is more difficult and these indicators in particular will be
refined with the evidence for action programme
The results of this project will be fed directly into DFID framework for results around maternal and
reproductive health .
USAID Tanzania has formalized monitoring and evaluation plans as part of their approach for
Managing for Results. The Mission rigorously and systematically assesses progress towards
desired results using a results framework and performance management plan (PMP). USAID
also requires portfolio reviews for investments and partnerships, field visits, data quality
assessments, evaluations and quarterly and annual reports. All partners would have a PMP,
which measures output and outcome levels and are gender sensitive. The central agreement’s
PMP is on file at headquarters and with a new local award, the PMP will be developed and
managed from USAID Tanzania. USAID/Tanzania’s Mission Order for Performance Monitoring
and Evaluation Framework has been made available to DFID.
An M&E plan is currently in place to which JSI is accountable to USAID. JSI submits quarterly
summary reports to USAID and DFID documenting progress against the annual workplan,
monitoring plan and logframe. The programme will be reviewed internally on an annual basis
through DFID systems.
At this stage DFID Tanzania is not planning an independent evaluation. It is possible that it may
be included in some of the learning and evaluation that is being co-ordinated across the
organisation around maternal heatlh
Lograme
Quest No of logframe for this intervention:
i
ibid
SCIENCE IN ACTION: Saving the lives of Africa’s mothers, newborns and children (2009).
Tanzanian Demographic and Health Survey (TDHS), 2010.
iv ibid
v TDHS 2010
vi UN population estimates 2011
vii TDHS, 2010.
viii PRB (2010) Contraceptive security for policy audiences: An Overview. Washington, DC,
Population Reference Bureau.
ix SCIENCE IN ACTION: Saving the lives of Africa’s mothers, newborns and children (2009).
x Tanzania DHS 2010.
xi Kruk, ME et al (2009) Women’s Preference for place of delivery in rural Tanzania: A populationbased discrete choice experiment. American Journal of Public Health Vol 99, No 9.
xii TDHS 2010.
xiii World Health Organisation (2007) Maternal Mortality in 2005. Estimates developed by WHO,
UNICEPF, UNFPA and the World Bank.
xiv Cleland, J (2006) Op cited.
xv Population Reference Bureau (2009) Family planning Saves Lives.
xvi The National Road Map Strategic Plan to Accelerate Reduction of Maternal,
Newborn and Child Deaths in Tanzania 2008 – 2015 (2008).
xvii Ibid
xviii Contraceptive Method Mix (1994) Geneva: World Health Organisation.
xix Singh, s et al (2009) Adding it up: the benefits of investing in sexual and reproductive healthcare.
UNFPA: Guttmacher Institute.
xx African Science Academy Development Initiative (2009) Science in Action: Saving the lives of
Africa’s mother, newborns, and children.
xxi International Confederation of Midwives (ICM) and International Federation of Gynaecology and
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low resource settings. London: ICM and FIGO.
xxii Tse, V and P Coffey (2009) New and underutilised technologies to reduce maternal mortality and
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xxiii Neilson, JP. (1995) Magnesium sulphate: the drug of choice in eclampsia. BMJ Vol 311.
xxiv Altman, D et al. (2002) Do women with pre-eclampsia, and their babies, benefit from magnesium
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xxv Tsu, V and P Coffey (2009) New and underutilised technologies to reduce maternal mortality and
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Gynaecology 116: 247-56.
xxvi Muganyizi, P and M Shagdara (2011) Predictors of extra care among magnesium sulphate
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Vol 11.
xxvii Tsu, V and P Coffey (2009) New and underutilised technologies to reduce maternal mortality and
morbidity: What progress have we made since Bellagio 2003? British Journal of Obstetrics and
Gynaecology 116: 247-56.
xxviii Seligman, B. And X. Liu. (2006) Economic Assessment of Interventions for Reducing postpartum
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xxix WHO (2007) WHO recommendations for the prevention of PPH. Geneva: WHO.
xxx WHO, 2004. Making pregnancy safer: The critical role of the skilled attendant. A joint statement by
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xxxi The Prevention of Maternal Mortality Network, 1995. Situation analyses of emergency obstetric
care: Examples from eleven operations research projects in West Africa. Social Science and
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xxxii World Health Organisation, 2005. World Health Report 2005: Make every mother and child count.
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xxxiii Sundari, T.K., 1992. The untold story: How the healthcare systems in developing countries
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xxxiv WHO, 2004. Pregnancy, Childbirth, Postpartum, and Newborn Care (PCPNC): A guide for
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ii
iii
xxxv
WHO, IPPF, JSI Inc., PATH, PSI, UNFPA, WB, 2006. The interagency list of essential medicines
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Reproductive Health and Research.
xxxvi World Health Organisation, 2002. How to develop and implement a national drug policy. Geneva:
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xxxvii Hutin, Y.J., Hauri, A.M., Armstrong, G.L., 2003. Use of injections in healthcare settings
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xxxviii Oyesola, R., Shehu, D., Ikeh, A.T., Maru, I., 1997. Improving emergency obstetric care at a state
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xxxix The Prevention of Maternal Mortality Network, 1995. Situation analyses of emergency obstetric
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xl Druce, N., 2006. Reproductive health commodity security (RHCS): Country case studies synthesis:
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xli Leahy, E., 2009. Reproductive health supplies in six countries. Themes and entry points in policies,
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xliv REPORT OF THE CONTROLLER AND AUDITOR GENERAL ON
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DEPARTMENT (MSD) FOR THE PERIOD FROM 30 JUNE 2009 TO 30
JUNE 2011
xlv Interview with UNFPA, 1 November 2011.
xlvi 2010 World Population Data Sheet. Washington, DC: Population Reference Bureau.
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xlviii Wheeler D and Hammer D, The Economics of Population Policy For Carbon Emissions Reduction
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li Ross, J. et al (2009) Contraceptive projections and the donor gap: Meeting the challenge.
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lii Hubacher et al (2008) Unintended pregnancy in sub-Saharan Africa: Magnitude of the problem
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liii Ibid
liv Wickstrom, J and R Jacobstien (2011) Contraceptive Security: Incomplete without long-acting and
permanent methods of family planning. Studies in Family Planning Vol 42, Number 4.
lv Seligman, B. And X. Liu. (2006) Economic Assessment of Interventions for Reducing postpartum
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lvi Kinney et al (20019) Science in action: Saving the lives of Africa’s mother, newborns and children.
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