Executive Summary | Learning to improve
Setting the stage
Section 1: Deliver Change Goal (SRH services) 6
Opening remarks Expected outcomes of the forum
Making pregnancy safer among poor rural women: lessons from an FGAE run community-based maternal health initiative in Sidama Zone, Southern Ethiopia Community implementation of the integrated family planning, HIV/AIDS, maternal health and child care package in Togo’s Haho health district Male involvement learning centre initiative in Hoima, Uganda
Sustaining programmes through local resource mobilisation: a collaboration between AMPPF and the Embassy of The Kingdom of The Netherlands in Mali Practice of Kotter’s theory of managing change in performance-based project funding from Nigeria
Section II: Perform Change Goal (Research & Knowledge Management, M & E) 26
Final project evaluation “Fighting female genital mutilation in the Séguéla region of Côte d’Ivoire”
Hormonal contraceptives and heterosexual acquisition and transmission of HIV infection: evidence from a quantitative meta-anaylsis, a study from Zimbabwe
Comparative analysis of clinical service statistics in 2011 and 2012 for decision-making purposes from Central African Republic
Implementation of ACCESS database in Senegal: an IPPF Model
Addressing monitoring and evaluation gaps in the provision of integrated SRH and HIV services in Kenya
Innovations will improve health outcomes Tapping into new social media for change Integrating services and demonstrating value
7th Annual Dissemination Forum 2012
Glossary Bodies ACABEF
Association Centrafricaine pour le Bienêtre Familial
Association Ivoirienne pour le Bien-être Familial
Acquired Immunodeficiency Syndrome
Local Area Network
Leadership, Management and Governance
Multiple Indicator Cluster Survey
Maternal Mortality Rate
Memorandum of Understanding
Oral Hormonal Contraceptive
Association Malienne pour la Protection et la Promotion de la Famille
Action for West Africa Region
Behaviour Change Communication
Association Sénégalaise pour le Bien-être Familial
Association Togolaise pour le Bien-être Familial
Convention for the Elimination of all forms of Discrimination against Women
Family Guidance Association of Ethiopia
Community Emergency Fund
Family Health Options of Kenya
Community Health Worker
Global Fund to Fight AIDS, Tuberculosis and Malaria
Performance and Accountability Initiative for better Results
Clinic Management Information System
Prevention of mother-to-child transmission (of HIV)
International Planned Parenthood Federation
Contraceptive Prevalence Rate
Corporate Social Responsibility
International Planned Parenthood Federation Africa Regional Office
Quality of Care
Demographic Health Survey
Return on Investment
Female Genital Mutilation
HIV Testing and Counselling
Network of People living with HIV/AIDS in Nigeria
Service Delivery Area
Health Extension Worker
Service Delivery Point
Planned Parenthood Association of Zambia
Human immunodeficiency virus
Information, Education and Communication
Southern Nations Nationalities and People’s Region (Ethiopia)
Sexual and Reproductive Health
Cervical Immunoglobulin A
Sexual and Reproductive Health and Rights
Cervical Immunoglobulin G
Injectable Hormonal Contraceptive
Traditional Birth Attendant
Integrated Management of Child Illnesses
Total Fertility Rate Voluntary Counselling and Testing
Planned Parenthood Federation of Nigeria
Riksförbundet För Sexuell Upplysning (Swedish Association for Sexuality Education)
United States Agency for International Development
World Health Organisation
Indicative Planning Figure
Zimbabwe National Family Planning Council
Intermittent Preventive Treatment
Voluntary Pooled Procurement
Key Informant Interview
Wide Area Network
Deliver Change Goal (SRH)
Executive Summary /
Learning to improve The International Planned Parenthood Federation’s Africa Regional Office (IPPF ARO) recognises the importance of learning from its own experience and that of others, and of using knowledge to increase effectiveness. In this regard, IPPF ARO has been organising the Dissemination Forum since 2006, as an interface between theory and practice in sexual and reproductive health and rights (SRHR). The Dissemination Forum seeks to promote the culture of learning in IPPF ARO and the Member Associations (MAs) through the sharing and documentation of knowledge, success stories, lessons learnt and best practices from research, studies and surveys. As the only learning and sharing platform in the Federation, over 50 research studies and innovative projects have been shared and published since its inception. The number of papers submitted has increased every year, while the quality of research has improved exponentially. The 2012 edition of the Dissemination Forum brought together MAs from the Central Africa Republic (ACABEF), Côte d’Ivoire (AIBEF), Ethiopia (FGAE), Kenya (FHOK), Mali (AMPPF), Nigeria (PPFN), Senegal (ASBEF), Togo (ATBEF), Uganda (RHU) and Zimbabwe (ZNFPC) and staff from the Africa Regional Office. A total of ten presentations were made. The themes selected, drawn from the organisation’s Strategic Plan, were based on the organisation’s three Change Goals - ‘DELIVER, ‘UNITE’ and ‘PERFORM’. These Change Goals provide IPPF with focus and priority to achieve results and impact by 2015.
The first day’s presentations focused on the ‘deliver’ goal, which is in line with IPPF ARO’s strategic objective to ‘ensure increased access to integrated, quality sexual and reproductive health and rights services and information by using gender, rights-based and quality of care approaches’. The goal is to double services provided to clients by 2015. The priority areas include family planning and maternal health, adolescents and youth, safe abortion, HIV and AIDS, gender, rights and sexuality, commodity security and emergency response. The second day’s presentations centred on the ‘perform’ goal. This recognises the diversity of MAs in terms of capacities, performance, accountability, leadership, management and governance issues, and in terms of the level of development, service statistics and specific country needs.
7th Annual Dissemination Forum 2012
Setting the stage /
Paulin Tra welcomed participants to the 2012 edition of the Dissemination Forum. In attendance were representatives of 10 MAs, the IPPF Africa Regional Director - Lucien Kouakou, IPPF ARO staff and Catherine Kilfedder - the Organisational Learning Officer, IPPF Central Office.
Lucien Kouakou warmly welcomed the participants to the forum. He particularly thanked the representative of the MA of the Central African Republic for attending the meeting despite the unfortunate events taking place in his country; and Catherine Kilfedder, the Organisational Learning Officer, IPPFCO for her support
Emmanuel Obeng informed the forum that the abstracts selected had met the threshold for best practice – those that provide a benchmark for all MAs to aspire to. The change goal ‘Perform’ is central here, since IPPF Africa cannot improve performance without sharing its knowledge.
IPPF ARO Knowledge and Performance Manager
He took stock of the performance in 2012 highlighting the main achievements: Increase in the volume of SRH services from 27,536,987 in 2011 to 39,473,382 in 2012 Increase in CYP from 1,406,914 in 2011 to 2,370,768 in 2012 Increase in services provided to adolescents and young people from 12,846,472 in 2011 to 14,581,128 in 2012 In addition to these results, in 2012, 88.6% of our clients were estimated PMSEU 7,822,183 people. He acknowledged the contribution of staff, volunteers, donors and partners in helping the Region achieve these commendable results.
Deliver Change Goal (SRH)
IPPF Africa Regional Director
He reiterated that the goal of doubling services is part of IPPF’s Vision 2020 – a bid to put sexual and reproductive health at the centre of new global development goals. He explained that though the target is very ambitious, it is achievable for the African Region which has already provided over 100 million services (as of end 2011), making it the largest provider of sexual and reproductive health services across the global Federation. The Regional Director described the forum as more than a learning opportunity for the Region because it has enabled IPPF Africa share what has worked, what has not and explore ways to make its services more affordable. He looked forward to extending the scope of this forum beyond IPPF Africa to other partners such as Ministries of Health and other NGOs so that by sharing experiences with each other, there is an optimal combined impact. Reaching out to other partners to disseminate success stories would greatly enhance IPPF’s visibility. He added that sharing best practices will help MAs that are lagging behind in some areas. He also wanted to see more participation from women researchers, to reflect the organisation’s diversity.
IPPF ARO M& E Advisor
The 7th Dissemination Forum is expected to bring three key results: 1. Best practices, success stories and experiences shared and lessons learnt 2. Better research and documentation for sharing within and outside the Federation 3. Enhanced visibility for IPPF AR’s achievements and progress towards achieving its strategic plan.
Deliver Change Goal (SRH services) 7th Annual Dissemination Forum 2012
Presenter and author/ Desta Kebede, Programme Director, FGAE (Family Guidance Association of Ethiopia)
Making pregnancy safer among poor rural women: lessons from an FGAE run community-based maternal health initiative in Sidama Zone, Southern Ethiopia Background According to the 2005 Demographic Health Survey (DHS), 43% of the country’s population was under the age of 15 years. 24% of women were in their reproductive age (15-49 years) and approximately 37.4% women aged 15 to 24 years were mothers. The national total fertility rate (TFR) was 5.9 children per woman, while in rural areas it was 6.4 children per woman. The country was characterized by a high prevalence of teenage pregnancies. The under-five mortality rate was 123/1,000 live births, while the infant mortality rate was 77/1,000 live births. The maternal mortality rate (MMR) was estimated at 673 per 100,000 live births. Only 12% of deliveries were attended to by skilled personnel. The high TFR and MMR can be explained by the widespread phenomena of child marriages, early pregnancies and an early start in childbearing, as well as the existence of sociocultural beliefs where rural women prefer home deliveries assisted by relatives and traditional birth attendants (TBAs). The situation is further compounded by their poor economic status, the lack of infrastructure and long distances that do not allow them to access timely and effective health care facilities, as well as inadequately trained TBAs who may not have the skills to 6
International Planned Parenthood Federation
deal with pregnancy-related complications. In 2007, Family Guidance Association of Ethiopia (FGAE) partnered with a UK-based organisation, Safe Hands for Mothers to implement an innovative project to reduce maternal mortality and illness by improving access to skilled health care for rural women in Southern Ethiopia. This initiative, funded by J.A.Com, ran for about three years, until the end of 2010, in selected rural districts of Southern Ethiopia.
Project Objectives The community-based safe motherhood project covered 31 rural administrative units known as kebeles located in 9 districts (woredas) of Sidama Zone of the Southern Nations Nationalities and People’s Region (SNNPR), located approximately 300km from the capital city, Addis Ababa. Its goal was to contribute to the national efforts to reduce maternal mortality and morbidity by improving access to skilled health care for rural women.
The project set itself the following targets: • The number of maternal deaths in 31 kebeles will have reduced from nine in 2007 to less than five in 2010
• The number of maternal morbidities in 31 kebeles will have decreased by a third from an estimated 180 in 2007 to below 120 in 2010 • The number of still births and neonatal deaths in 31 kebeles will have dropped by a quarter from 58 in 2007 to less than 43 in 2010.
Methodology The project adopted a multi-pronged strategy that included awareness-raising and community mobilisation on maternal health through appropriate IEC/BCC approaches. Activities included awareness-raising and community mobilization using a film entitled the “Big Push” on making pregnancy safer. The interactive training film, with local content on pregnancy-related risks, was projected on a prototype solar-powered DVD player, suitable for use in remote areas. Intensive training sessions were organised for Traditional Birth Attendants (TBAs) and government Health Extension Workers (HEWs) on prenatal, intrapartum and postnatal care. The aim was to assist in the early identification and referral of high-risk pregnancies to reduce the delay in the decision to seek care.
Given the remote location and scarcity of public transport to health posts and the health centre in the SNNPR’s capital, Hawassa, the project used available local means (gari) for emergency referrals, namely horse-drawncarts and a motorcycle with a side car. TBAs and HEWs used mobile phones to communicate on referrals, and some homes were identified as waiting areas for those requiring rapid transport to Hawassa. In addition, a 24/7 four-wheel drive ambulance service provided by FGAE partly covered the project’s target area through a costsharing mechanism. The two latter activities addressed the delay in reaching care through an emergency referral network. To ensure community participation and ownership of the project, community conversations bringing together a broad range of stakeholders were organised to discuss maternal health and come up with collective decisions on making the project work. A community emergency fund (CEF) was established by locals to assist women to quickly access cash for transport or defray health care costs during emergencies.
Results In 2011, a final project evaluation was conducted by an independent consultant to gauge its success in mobilising communities to effectively and sustainably address their growing health needs. The process was participatory and representative, and used both qualitative and quantitative methods.
Overall, the project left an indelible mark...maternal mortality significantly decreased in the target communities and the project surpassed its goal of reducing maternal deaths from nine in 2007 to less than five by 2010 Thirty three key informant interviews (KIIs) and nine Focus Group Discussions (FGDs) were conducted with Ministry of Health staff including HEWs, FGAE staff, the woreda cooperatives office staff, leaders of Community Emergency Fund (CEF) groups, womens group leaders, TBAs, and gari and ambulance drivers. Health facilities and health workers covered by the project were also monitored. In addition, three in-depth case study interviews were held with clients and service providers. Overall, the evaluation findings indicated that project left an indelible mark in the sense that maternal mortality significantly decreased in the target communities (with only one maternal
death reported in 2010 in the target kebeles) and the project surpassed its goal of reducing maternal deaths from nine in 2007 to less than five by 2010. The number of deliveries at health facilities (health posts, health centres and hospitals) increased by at least 10% annually between 2007 and 2010, while the percentage of deliveries at home attended to by family, traditional healers or completely unattended declined from 41% in 2008 to 20% in 2010. Furthermore, the number of referrals for delivery by TBAs and HEWs to health centres and hospitals increased by 10% annually. Other notable gains were the increase in antenatal care coverage (minimum of three visits) and postnatal family planning to 90% and 70% respectively at the end of third year of the project. The quality of care and knowledge, skills and attitudes of TBAs and HEWs significantly improved. Using the Big Push film and other tools, 73 health professionals, 45 HEWs and 57 TBAs were empowered to support women during pregnancy. Their training covered the facilitation of educational talks, community conversations, service delivery, life skills and technical expertise on maternal health. It was noted that the intervention promoted their compliance with the minimum standards set out in MoH and IPPF protocols. The evaluation highlighted the innovative aspects of the project including the use of context-appropriate approaches such as solarpowered DVDs as education tools - a first in the region. The use of horse-drawn carts and the three-wheeled motorcycle as alternative means 7th Annual Dissemination Forum 2012
of transport in an area where public transport is not readily available was also commended. However, to ensure a continuum of transport, the FGAE also made its ambulance available to ferry clients to the nearest health facility. There was buy-in to the project from community members and TBAs who recognised the importance of the community emergency fund and transport systems in reducing maternal deaths. Each member of the community was committed to supporting pregnant women. The evaluation noted that as a result, there was improved access to antenatal and postnatal care and other SRH services. The number of women attending educational sessions based on the “Big Push” film motivated health seeking behaviour among them. A successful partnership was formed between the Government and FGAE. In fact, public health officers, service providers and supervisors closely monitored the developments in project during its implementation. The Regional Health Bureau (RHB) adopted the “Big Push” film into the HEW curriculum and the MoH plans to replicate the initiative demonstrating the Government’s commitment to guarantee safe motherhood and achieve MDG 5, in other words, to improve maternal health. Although progress was made in collaborating with the Government, the project obtained a low score for missed partnership opportunities with other stakeholders. There were other NGOs that FGAE could have partnered with to pool resources and have a greater impact.
Deliver Change Goal (SRH)
Conclusions The Government’s commitment to reducing maternal mortality is very high and should be capitalised on. FGAE has built a reputation as a credible partner through its collaboration with the Government and NGOs. The project confirmed the importance of strengthening health posts that are ill equipped with few qualified personnel, yet are the closest to grassroots communities. TBAs are still promoting home deliveries and require capacity building. Other lessons learnt included: • Best practices and lessons learnt were not documented. This was a missed opportunity for FGAE to enhance its visibility • The design of next phase should consider focusing on a fewer woredas for critical mass and impact. It was difficult using one ambulance to cover many woredas • TBAs continue to advocate for home deliveries, which are a source of income, with only prolonged and complicated labour cases and deliveries referred to health facilities. TBAs require more capacity building • Projects should target religious leaders and men as partners to prevent risk factors • Women need to be empowered to negotiate for safer sex • HEWs and TBAs working together helped the transition from home deliveries by TBAs to skilled attendance in health facilities • Community
be an important strategy to empower communities to make decisions on their own health issues • Use of innovative communication tools [such as the solar powered DVD and Mobile phones] enhanced community awareness on risks associated with pregnancy and birth • The project successfully assisted women to organize Community Emergency Funds (CEFs) to finance their emergency care. • Emergency transport systems including horse-drawn carts, tricycle and four-wheel ambulance increased the projects reach and efficiency in supporting poor, rural women to reach the care they need during pregnancy and birth-related emergencies.
Recommendations and next steps • Early gains of the project are very promising. Therefore, a second phase of the project as well as scale-up to wider areas of intervention is highly recommended • Some of the activities, including the need for more solar powered DVD players and films, require reinforcing and/or scaling up in the second phase • Many of the CEFs are also very young and thus need follow-up support to become legal entities and remain sustainable • A close relationship founded on a spirit of partnership and transparency should be enhanced between the local partner and the woreda health offices, as well as other NGOs.
7th Annual Dissemination Forum 2012
Presenter and author/ Kossi Ahadji, Programme Director, ATBEF (Association Togolaise pour le Bien-être Familial)
Community implementation of the integrated family planning, HIV/AIDS, maternal health and child care package in Togo’s Haho health district Background
Togo has a low contraceptive prevalence rate of 15%. It is characterised by geographic, sociocultural and financial barriers, particularly for rural populations. The modern contraceptive methods uptake was 11.3% in 2003 and 13.2% in 2010, while the total fertility rate (TFR) was 5.5. The country has a very high maternal mortality rate of 478 per 100,000 live births and child mortality rate 144 per 1,000 live births.
The specific objectives were to:
Despite the integration of SRH activities, in general, and family planning, in particular, into the minimum package of services provided by all primary health centres in Togo, the unmet family planning need increased from 25% in 2003 (cf. AS/SR TOGO-2003) to 40% in 2006 (MICS 3). The USAID/AWARE II Project in collaboration with 21 West African countries, and specifically Togo, identified the high unmet family planning need as the one of the region’s biggest concerns, and community-based distribution of contraceptives, especially injectables, as an essential intervention that could significantly contribute to satisfying this need if scaled up. It also observed the absence of child health care facilities in remote areas of Togo. ATBEF was selected, on the basis of its vast experience, to implement a proactive outreach project entitled « Implementation of the Community Integrated Family Planning, HIV/AIDS, Maternal Health and Child Care Package in Togo’s Haho Health District ». 10
International Planned Parenthood Federation
with the proviso that before scaling it up, it should be evaluated.
• improve the RH environment in Togo by strengthening the capacity of opinion leaders, namely political, community and religious authorities • mobilise the community to get its buy-in for the project • build the capacity of heads of the peripheral health care units (dispensaries) and community health workers (CHWs) • provide integrated services to under 5s and women of child-bearing age in order to contribute to the improvement of their health status and • ensure quality services by CHWs through a monitoring, evaluation and supervision system.
Methodology The project implementation process composed of the following steps:
1st step: There was a lot of resistance to the use of community-based experiments, specifically injectables, and the health authorities did not give their immediate approval for the project. Advocacy was conducted at the highest level targeting political and health authorities with support from USAID. It culminated in the signing of a Memorandum of Understanding (MoU) between the Government and ATBEF authorising the pilot phase,
2nd step: It involved the capacity building of MA after an institutional needs assessment. USAID, guided by its philosophy, supported the MA’s programme management. 3rd step:
A baseline survey was conducted and tools developed.
A grant agreement between ATBEF and USAID was developed and signed.
Community mobilisation and selection of Community Health Workers (CHWs).
6th step: A pool of trainers (FP and IMCI experts) received training to coach CHWs. 7th step: CHWs and their supervisors were trained. 8th step:
Service delivery started.
The project was officially launched. Service provision continued with regular supervision and follow-up on the ground. There were quarterly evaluations of CHWs skills, especially during the pilot phase.
10th step: The pilot phase was evaluated.
Selection of Site In total, 112 villages located over 5 km from a health centre were selected. 75,011 inhabitants were covered by the project with an average of
670 inhabitants per village. There was an average of 2.2 CHWs per village. 18,753 women of childbearing age and 15,002 children under 5 years located over 5 km from a health centre were part of the project. Community sensitisation was conducted targeting local and religious leaders to ensure that they understood the importance of their participation in the project’s success. The criteria for the selection of CHWs to deliver integrated services were explained and the staff steering the project were introduced to the leaders. The project team visited all the 112 villages to win the support of the community.
Selection of CHWS ATBEF’s community-based intervention policy defines the modalities for the election of CHWs. The project team explained the eligibility criteria to the community: the candidate shall be resident of the area; aged above 2o years and literate. Gender parity shall be observed. The community then queued behind the candidate of their choice for CHW position. To support CHWs, the project developed training materials, including FP and IMCI manuals, provided reporting tools; an image box for IEC activities; and a child health care guide for CHWs.
Training CHWs The 6-day training covered all aspects of family planning. CHWs injected oranges to test their expertise. CHWs were equipped with official bags with equipment, a lock box to safely store drugs, contraceptive pills, and injectable contraceptives and bicycles.
After the training, the project was officially launched at a ceremony where all stakeholders were in attendance: village chiefs, religious leaders, government officials, international and local NGO representatives and community members. ATBEF intentionally selected a village where FP is a taboo topic for the launch, which was a huge success. At the launch, the Permanent Secretary in the Ministry of Health was present and symbolically gave CHWs their tools of trade. The ATBEF Executive Director gave bicycles to the CHWs.
Certification of CHWs-Transition from oranges to human subjects To obtain certification, the CHWs had to successfully inject 3 to 5 human subjects. So once they went back to their communities, they recruited women requiring FP services and informed their supervisors who would come to observe them give injections. Their technical supervisors who consisted of chief nurses at peripheral health units and traditional birth attendants closely monitored their progress, and would help them improve their technique before leaving them to work on their own.
Results ATBEF has been able to reach people in remote and under-served areas where a lack of access to family planning resulted in low contraceptive prevalence rates. ATBEF has significantly increased the number of poor, marginalized, socially-excluded and/or under-served clients that it serves (91%, compared to 70% in 2011). This 23% increase in ATBEF’s couple years of protection (CYP) in 2012 was largely due to injectable contraceptives.
ATBEF contributed to 19 % of Togo’s national CYP. The project’s success was built on strong partnerships with the Ministry of Health, local Imams and community leaders. The government has expanded the model to seven other districts, with ATBEF providing technical support to other organisations implementing this approach.
The Chief of Kpèlè, a village next to Togos main transport hub with a high concentration of sex workers, unwanted pregnancies and abortions, said: Men and women would fight over sex, but this is no longer the case; the number of abortions has reduced, and also cases of diarrhoea, malaria and pneumonia in children. There are no more maternal deaths reported in my village.
Lessons learnt • Training of directors of peripheral hospital care units and the district senior management team is essential • Candid collaboration between actors of public health structures and ATBEF officials contributed to the project’s success • Regular training of CHWs, monitoring and technical supervision guaranteed quality care and services, and reliability of data reported • Involvement of community leaders, religious leaders and organised groups in the project’s activities led to comprehensive buyin from the community • Organising strategies for neighbouring villages, drawing on the experiences of other programmes (malaria prevention ones) 7th Annual Dissemination Forum 2012
• Identifying couples who are FP champions and who support the CHWs help sensitise communities and dispel misconceptions • A documentation of the project was essential record the process and result.
Recommendations and next steps With support from both the Government and UNFPA, the project is now being implemented in six districts. The 7th district will soon be included through the IPPF PAIR Project. ATBEF intends to continue conducting advocacy in order to integrate community-based injectables in its intervention policy. It hopes that the project will not just be limited to Togo, but will be replicated across the West African Region.
ATBEF has significantly increased the number of poor, marginalized, socially-excluded and/or underserved clients that it serves (91%, compared to 70% in 2011). This 23% increase in ATBEF’s couple years of protection (CYP) in 2012 was largely due to injectable contraceptives.
Deliver Change Goal (SRH)
Plenary discussions Participants asked how the project assessed progress if no targets were defined from the outset in line with the USAID policy. They also wanted to know whether an acceptability and feasibility study was conducted to ascertain if the clients supported injectables. It had become common practice to conduct such studies before implementing any CBD injectables project to document risks, safety and the supply chain’s capacity to manage stock. Participants also wanted information on how CHWs in Togo used the check list to implement the project and whether they had all the information necessary before administering injectables and other contraceptives to clients. They sought clarification on who certifies CHWs: TBAs or the Chief Nurses. They commended the presenter on the good results on youth recruitment for FP and wanted more information on strategies used. They expressed surprise that there were no cultural barriers in the villages and that FP was readily accepted. In response to the questions, the presenter noted that a baseline study was conducted and indicators were defined. At the end of the project, ATBEF conducted a similar study, using the same tools and indicators and noted that there were positive developments. The MA was able to demonstrate added value of project. The presenter confirmed that a feasibility study was conducted covering aspects like involvement of CHWs in the communities; collaboration between CHWs and decentralised MoH structures; areas of intervention by CHWs; and most accepted FP methods. A six-day training for CHWs was carried out covering the check list: counselling; injections; administration of pills; child care. The CHWs were evaluated on each aspect. Initially, there were challenges with counselling, but this improved. CHWs had all the information on FP methods and were able to explain the advantages and
side effects to clients. The presenter clarified that during the Training of Trainers in FP, there were TBAs and nurses. He confirmed that TBAs were skilled to certify CHWs and supported nurses in supervision. Regarding strategies to recruit clients, CHWs were trained in IEC activities, and facilitators would accompany CHWs to conduct talks, mass awareness-raising, community sensitisation targeting leaders, especially women. Through them, the recruitment was easier. The presenter noted that the idea that the project team had about major sociocultural barriers was proved false. FP was not being used simply because the services personnel and finances were not available. Once the community got wind of FP services, there was no turning back. A participant was curious to find out what happened to CHWs that did not receive certification. She was concerned about the use of the term “discontinuation” to refer to a client who leaves one FP method for another. She asked the presenter to indicate whether incentives were given to CHWs and what their status in the health system is. The presenter said that the project recorded 100% success in administration of injectables by CHWs, after all any weaknesses were corrected by the technical supervisors. The term “discontinuation” may be considered a misnomer, but for the purposes of this project, it is the word that was found to be appropriate to describe a change in method. CHWs are the focal points for nurses in villages where there is no dispensary. CHWs work with the MoH’s decentralised structures, but ATBEF keeps recruiting new CHWs with new programmes. They are included in the cohort of Government CHWs. The CBD intervention policy states that CHWs should receive CFA F 17,500 (US$35) a month. The Government pays them CFA F 3,000 (US$6).
ATBEF pays them a monthly stipend of CFA F 10,000 (USD$20). Participants spoke about embracing the concept task shifting to CHWs. Some MAs envision involving CHWs in the administration of long-term methods like Norplant and IUDs, and even malaria treatment. They wanted information on whether CHWs referred clients to the MA or Government facilities for long-term methods or were authorised to administer these methods. ATBEF has put in place a good referral system so that women opting for long-term methods are sent to the peripheral health care unit where there is qualified staff. In addition to systematic referrals, USAID supports some facilities to provide long-term methods free-of-charge, and in such instances, women are referred to nearest centre. The presenter clarified that the MoU signed with the Government only provided for the administration of injectables by CHWs. The Moderator summarised the discussion that had raised three critical issues. First, task shifting seems to be the way to increase human resources for health. In many countries, guidelines are being developed including the assessment of skills so that lower cadre staff can provide services that have been the preserve of doctors, nurses and clinical officers. The challenge is the resistance from doctors and nurses, and therefore advocacy is essential. Second, there is perception that there is opposition to family planning, but the reality on the ground different. Opposition is often at policy level, not at utilisation level. Third, it is imperative to think outside the box. As demonstrated by this project, qualitative data proved to be useful in showing results, even though targets were not set.
7th Annual Dissemination Forum 2012
Presenter and author / Nathan T. Kipande, Project Officer, Male Involvement Learning Centre (Reproductive Health Uganda)
Male involvement learning centre initiative in Hoima, Uganda
Background From 2005 to2009, the Regional Young Men as Equal Partners (YMEP) Project was implemented in four countries, namely Kenya, Zambia, Uganda and Tanzania targeting young men to make decisions that promote young women’s health. For a long time, young women had been the primary beneficiaries for projects, but there was one gap. While young women became knowledgeable on SRH issues, young men were still making decisions that had a negative impact on women’s health. YMEP tackled the issue by interfacing with decision makers and changing their mind-set. Although young men were the main target group for the project, curiously at the end of the project 80% of the beneficiaries were young women. In Tanzania, there was a drastic decline in unintended pregnancies, while in projects sites in Hoima, Uganda and Nyando, Kenya school drop-out rates decreased. No teenage pregnancy was reported in the last 3 years of project in Nyando compared to non-project sites where there were many teacher-related pregnancies. The gender transformative programming approach avoided injury to the male ego, empowering men to support women’s health, unlike other methods that excluded men. At the end of the YMEP project, 14
International Planned Parenthood Federation
the intention was to have 3 learning sites, in Uganda, Zambia and Tanzania. The Uganda and Zambia learning centers took root and Uganda got new partner to support the project. The initiative is a three-year project, funded by SIDA through RFSU (managed by SONKE Gender Justice, the chair of Men Engage Africa Network) and implemented by RHU and PPAZ, began in 2011 and ends in 2013. The project builds on the YMEP project that focused on male involvement in 3 sub-counties and 9 parishes in Uganda.
Objectives The project is designed to create a mechanism to ensure that good practices and lessons of male involvement in SRH are shared to improve SRHR practices. The project goal is to increase male involvement in SRHR with three main outcomes of implementation of successful strategies in community (capacity building and implementation of SRHR); learning (learning from experiences, successes and failures and documenting lessons learnt) and sharing (sharing information and lessons to inform stakeholders and advocate for policy changes). The project targets actors in SRH, HIV/AIDS and development sector such as
practitioners, NGO and community stakeholders as primary audiences, while policy makers and technical experts are secondary audiences.
Methodology Developing a model for involving men A model was developed and is in the final stages of testing. There are eight components important for male involvement: Model looks at men as equal partners, users of SRH services and change agents. Men who promote SRH services can act as equal partners, feel free to accompany their partners for antenatal care and share benefits of using services. Beyond the “Ideal Man” there are other components: H. Men who have not yet been reached and do not take health seriously. B. Men who lack services. They may be good partners and agents of change but lack services, or avoid services because they are not men-friendly and not attractive. Then, E. men who use services but are not equal partners. They change partners and more prone to domestic violence and F. Most men don’t practice what they preach.
Men as equal partners
corners, community advocacy meetings, surgical camps, integrated community outreaches, training of service providers, partners and peer educators in male involvement, monthly meetings with peer educators and implementers, radio programmes using champions and role models, door to door/ home visits and stakeholders meetings to share lessons learnt and success stories.
H (All other men)
Men as agents of change
I A (the ideal man)
Men as users of SRH
Strategy The main strategies employed in the initiative include: • men as active service users, men as equal partners and men as promoters of SRHR or change agents. • positioning and scaling up SRHR services; • building capacity to design, deliver, and support SRHR services; • sharing experience; monitoring evaluation;
• operations research; • documentation and; • advocacy The project has employed several activities including the formation of male dominated community clubs, men’s platform, genderfocused discussions, male-only days, men
The initiative engaged with religious leaders to share information on SRH using the church platform. Church leaders were more amenable to discussion on FP when condoms were not mentioned. Sports activities proved popular with young men. Before these activities, a question and answer session was organised.
Results • capacity building of 23 staff including staff from government, CSOs, RHU staff and 100 peer educators through training in the area of male involvement • increased couple involvement in service usage, including family planning, HCT and care of the children • operational research, which is at analysis stage, to inform project implementation and garner lessons learned • increased male involvement in SRHR especially service use and active promotion of SRHR • a community volunteers programme to reach the community to address gender equality issues • consistent involvement, through intensive
advocacy, of politicians and public health officers.
Lessons learnt • Through such initiatives, men can take more responsibility for their own health and this has an effect on the health of their families as well; when men were empowered with knowledge instead of harmful notions of masculinity, they provide more care; support and develop more gender-equitable relationships • Community male-dominated clubs with an income-generation component are a good entry point for discussing male involvement in SRH • Integration of services during community outreaches increases demand for services. Combining services like VCT, STI management among others attract many clients. • Peer educators (90% men and 10% women) successfully reached more men because of the trust that the men had in them • Targeting places of work, like markets, increases utilisation of services by men. Working with male dominated institutions (religious and political leaders) can influence change, increase impact and improve gender relations and mens health • Men who usually shy away from using services can feel more comfortable using services when men-only days are set aside for them.
Recommendations and next steps • Mainstream male involvement in school curriculums 7th Annual Dissemination Forum 2012
• Hold weekly male-only days at all health centres in the country and advertise them widely • A National Reproductive Health Strategy which focuses on the expansion of RH care services, strengthening of service providers capacity, the strengthening of Ministry managerial capacity, effective information, education, and communication (IEC), research, and the development of political support (including multi-sectoral and civil society support) • Incorporate male involvement activities in the package of the services offered at government health facilities • A male involvement policy developed in accordance with the principles of the ICPD (International Conference on Population and Development) Plan of Action. At present, while a limited number of government strategies and policies make reference to men, implementing agencies do not necessarily translate words into practice • Build and support mens coalitions and their linkage to the womens movement for the fight against gender inequality • Male involvement campaigns - all men should be educated in all aspects of sexual and reproductive health, as both direct beneficiaries and partners. A focus solely on traditional high-risk groups is no longer likely to succeed, now that HIV/AIDS has spread beyond these groups • Visible support of influential people in the community (most of whom are men) –this encourages people to perceive health programmes as relevant and socially acceptable.
Health is a basic right for all human beings so making reproductive health services available and accessible to men is a human rights issue and not a privilege. Like women, men also have reproductive health needs which must be addressed if we are to achieve gender equality. 16
Deliver Change Goal (SRH)
Plenary discussions The moderator indicated that for a long time gender practitioners did a disservice to the gender agenda, because of confrontational approaches. Although gains were made regarding women’s empowerment, in some health projects the desired results were not delivered forcing implementers to use gender transformative programming. Many men were ignorant on health issues and disadvantaged on where to seek services. Young African men are socialised into being macho, which means that this negatively influences their risk perception. Church programmes have been blossoming in RHU for the last 5 years, as well as in Ethiopia and Swaziland. Churches recognise that their clients need RH services. This is an opportunity for MAs to bargain for what is acceptable to church. He added that practice and research show that health alone as a common bond cannot sustain a group. In the MAs’ programming, especially for men, complementary activities are vital. The moderator recalled that the initiative was a learning centre, not a typical project. RHU one of the 4 initial learning centres for the Africa Region. He encouraged participants to directly communicate with RHU via email, physically visit, invite RHU, and identify issues of mutual learning. Participants requested the presenter to give more tangible results on the impact of male involvement on women’s health. They sought to know why the gender-focused discussions had more than the recommended 8 to 12 participants. The presenter was asked to
indicate whether the church programmes were conducted during services or otherwise. The presenter indicated that within one year, at the RHU clinic, the client load for men for various services was 50,000 and Hoima contributed 42%. The initiative had also attracted clients for male circumcision on the male only days, held on Saturdays. On average, 23 men were circumcised per day, with a total of 328 men in 2012. Hoima contributed over 50 % to male circumcision service. In addition at the RHU clinic, 228 couples came for STI management services. The group sessions catered for a maximum of 15, beyond recommended 12 since the numbers were overwhelming. Church activities are conducted on Sundays and other days to talk to the faithful. Modalities, time allocated and topics are agreed on in advance. The importance of balancing a project’s paradigm was underscored since if men are empowered on SRH, they will do same for women. Donors were encouraged to include men in SRH programmes involving their partners, like PMTCT. Clinics should find ways to engage men who accompany their partners for services. The change in PMTCT guidelines to Option B where every woman who is HIV positive is eligible for antiretroviral treatment, brings to the fore the fact that partners may not be included. It is a hard discussion in the SRH arena, since the fear is if women go home with ARVs and their infected partners do not have similar access, it could fuel gender-based violence.
7th Annual Dissemination Forum 2012
Presenter and author / Moussa M’bo, Programme Director, AMPPF (Association Malienne pour la Protection et la Promotion de la Famille)
Sustaining programmes through local resource mobilisation: a collaboration between AMPPF and the Embassy of The Kingdom of The Netherlands in Mali Background Mali’s high population growth of 2.2% and precarious reproductive health are hampering economic development and stand in the way of the country achieving the Millennium Development Goals. This is due to a number of factors including the extremely high fertility rate (6.6 children per woman, 2006 Mali Demographic and Health Survey [MDHS]), and a high number of adolescent birth rate (190 births per 1000 women aged 15-19 years, 2010 UNICEF Statistics and Monitoring Section/Policy and Practice), high the maternal mortality ratio (464 per 100,000 live births, 2006 MDHS) and high infant mortality rate (99 per 1000 live births, 2010 UNICEF Statistics and Monitoring Section/Policy and Practice ) due to a combination of poor follow-up of women during pregnancy, lack of emergency obstetrical care, low contraceptive uptake and a high fertility rate. Despite these appalling statistics, there is a low level of uptake of family planning in Mali (only 8% of married women ages 15–49 used any family planning method and only 7 percent use a modern method according to the 2006 MDHS). The reasons include a lack of access to health information and services, especially in rural areas; a lack of trained health workers; 18
International Planned Parenthood Federation
running out of essential drugs including contraceptives; weak monitoring and referral systems; and, most pernicious, the low status of women and their lack of decision-making power when it comes to family planning.
populations • Improve the MAs image in the area of SRH • Increase the MAs audience and services • Identification of allies to mobilise resources
Due to all these factors, AMPPF decided to implement a project to reposition family planning (FP) in Mali and address the high incidence of adolescent pregnancies. The MA also saw the need for diversifying its resources to guarantee the sustainability of its programmes and strengthen its SRHR leadership in the country.
• Building coalitions with the Government, NGOs, elected leaders, community and religious leaders, traditional and modern communicators and consultants. AMPPF recruited a Dutch consultant to draw up ToRs (terms of reference) for the project in line with the Netherlands objectives for developing countries
• Partners and activities carried out in the context of negotiations with the Embassy.
At national level: • Reduce maternal and infant mortality rates and increase contraceptive prevalence rate • Reduce unintended pregnancies among adolescents (15 to 19 years) • Increase antenatal and postnatal services • Reduce STIs/HIV prevalence rates, among the population in general, and young people in particular. At AMPPF level: • Increase access to services to the most vulnerable, under-served and marginalized
The partners included: • the Reproductive Health Division • FENASCOM (The National Federation of Community Health Centres) • the Imam of the Torokorobougou Mosque • RECOTRADE (network communicators)
• Association Balanzan (a local NGO collaborating with Dutch Embassy to teach sex education in schools) • Segou Teaching Academy also supported by Dutch to provide SRH information to pupils and
• Sido and Sikoro stations in Segou.
Methodology AMPPF began by building partnerships with the Government, NGOs and media, such as community radio stations, as well as Imams and mosques. AMPPF forged a strong partnership with the Embassy of the Netherlands and recruited a Dutch consultant to draw up terms for the project in line with the Netherlands’ objectives for developing countries. Activities included: • Development of a consensus document • Conference on RH issues • Advocacy trips (During a conference in the Netherlands, the Coalition partners supported the AMPPFs Initiative) • Development of a final document which includes the proposals from all the coalition partners (for example a project by the multimedia centre run by the Association Balanzan ; an international conference on Islam and female circumcision organised by the Torokorobougou mosque) • Amendment and adoption of the final programme • Signing of the MOU • Setting up of programmatic and financial procedures for the implementation of the Programme.
Results The results speak for themselves: family planning services increased from 56,400 in 2008 to 284, 200 in 2012. Post-abortion care services increased from 15 in 2008 and 118 in 2012. There was a marked decline in HIV/AIDS services from 4,485 in 2008 to 410 services in 2012. Youth SRH services increased sevenfold by 2012. AMPPF contributed 10% to the national Couple Years Protection The new approach saw a huge leap in fundraising too: CFAF 4, 169,121,799 was raised - a 243.2% increase on their 2003-2007 fundraising results.
Lessons learnt AMPPF concluded that: • Building coalitions means better access to local resources • The Government, community and religious leaders must be involved in any coalition • Renewed confidence in a programme from financial partners depends on the results presented on completion of initial phase. AMPPF completed an initial phase in December 2012 and was able to secure funds for a second phase from 2013 • Negotiations for the next phase of a programme should start as soon as the implementation of the first phase kicks off.
Recommendations and next steps • Implement the programme using the strategies shared; • Use the results to negotiate the subsequent phases of the programme; • Consolidate the gains of the first phase of funding; • Integrate an advanced strategy in the provision of long- term contraceptive methods.
Plenary discussions The moderator noted that AMPPF used traditional communicators to package the project’s messages to the community in an appropriate language. In most African countries, the communication sector to key to health so the use of community radios was important. Having experts give the right information to the populace using such channels is crucial. He noted AMPPF’s 10.21% CYP contribution to the national figure was excellent. In Mali, out of 100 CYP, 10 are from IPPF. The clarity of data and information are important tools for resource mobilisation. The strategic choice of the consultant who was familiar with the donor’s policy was crucial in the proposal development and resulted in resource mobilisation.
7th Annual Dissemination Forum 2012
Presenter and author / Ibrahim M. Ibrahim, Director – General, PPFN (Planned Parenthood Federation of Nigeria)
Practice of Kotter’s theory of managing change in performance-based project funding from Nigeria Background PPFN was selected as a Principal Recipient for Round 9 of the Global Fund. However, since the inception of the Global Fund (GF) project in July 2010, implementation of project activities was hampered due to a shortage of commodities arising from RH commodities and supply chain management issues. During a monitoring visit done by the Office of the Inspector General (OIG) to Nigeria, most Principal Recipients (PRs) were lagging behind on their procurement. To mitigate this in round 9, GF decided the PRs must procure through the Voluntary Pooled Procurement (VPP) mechanism. When this decision was made, the lead time was too short for VPP to supply the commodities on time. VPP requires adequate lead time to pool resources in order to supply commodities in-country. This led to a crisis at PPFN with regard to its PR obligations. GF was funding 65% of PPFN budget so it needed to act fast in implementation of the project activities. The GF agreement with recipients is based on performance framework defined with mutually agreed targets. When GF allocates funds, and the recipient fails to meet targets, it withdraws funds. The PPFN management team had a meeting 20
International Planned Parenthood Federation
to mitigate the situation, made overtures to IPPF AR which recommended the book, Leading Change, by Prof John Kotter, a former professor at the Harvard Business School and an acclaimed author, and now Chief Innovation Officer at Kotter International. Kotter is regarded as an authority on leadership and change. The PPFN management internalised the contents of book and developed strategies to address backlog of targets.
creating demand for HIV testing and counselling through community mobilisation, by organising outreach campaigns and door-to-door visits.
PPFN was the PR for two Service Delivery Areas (SDAs): HIV testing and counselling; and SRH and HIV integration. By the 4th quarter, almost a year after project started, commodities eventually arrived from VPP. The US Government through PEPFAR gave PPFN some kits and IPPF commodities had arrived. However, by the 6th quarter none of the targets had been met, and there was a cumulative backlog of 87% of the overall agreed targets.
PPFN merged this approach with Professor Kotter’s theory in managing change which states that the fundamental purpose of management is to keep the current system functioning and produce useful changes. Kotter gives a sequence for organisational change. For him, people-focused change is the essence of leadership.
Objectives PPFN proposed a new distribution ratio for its service delivery strategy: 70% in outreach and 30% in clinics instead of the previously planned 70% in clinical settings and 30% in outreach. GFATM approved this new strategy. The key to achieving this goal depended on
PPFN also needed materials, human resources, facility clinic officers, the help of PPFN’s Youth Action Movement volunteers (YAM), and staff of the regional and state offices to coordinate the efforts of the volunteers.
Kotter identified key barriers to change within the organisation and came up with an 8- step change process in sequential order which PPFN adapted to its needs: 1. Establish a sense of urgency:
PPFN could not afford to lose its role as a principal recipient.
2. Form a powerful, guiding coalition: PPFN
NEPWAN, the State HIV Control Program and its Coordinator and set up a committee at each site. In the North, PPFN met traditional and religious leaders and formed nuclei at state and regional levels. 3. Create a Change Vision: PPFN management went to National Executive Committee for approval of 13-month bonus for all staff - an incentive for the staff to work during Christmas. 4. Communicate the Vision:
Managers were sent to the six regions to communicate the same sense of urgency. This was replicated at state level and at the cluster level, and at five primary and one secondary health care centres.
5. Empower Others to Act on the Vision 6. Plan for and create short-term wins:
PPFN rented vehicles for outreach and established four regional commodity stores in order to complete the exercise in three weeks.
7. Consolidate Improvements and Produce More Change:
Youth Action Movement personnel was mobilised to verify all entries in cluster sites, review and correct errors on a daily basis. Chairmen, programme assistants and the national SMT were deployed to field during Christmas and New Year.
8. Make Change Stick
Results • A combination of advocacy and community mobilisation at festivals and the distribution
of RTKs, consumables and Management Information System (MIS) forms to all the project sites meant that the plan to address backlogs was successful. • Supervision was fundamental. PPFN held daily meeting to identify and address challenges; checked data and payments, and managed supplies. • Advantages exceeded challenges. At the end of the 7th quarter PPFN was rated A by GFATM, the highest score among the current principal recipients in Nigeria. The implementation process of the scale up was not without its challenges, such as: • Short timescale - only three weeks to achieve target • Late remittance of funds to project • Inadequate MIS forms to photocopy on site • Late arrival of RTKs • Inadequate supervision, given few staff members • Delay of payment to ad hoc staff • Misconceptions about family planning in some remote areas, such as the NorthEast region where Sharia is practiced • Limited access to some locations due to rough terrain. However,
Recommendations and next Steps • Ensure adequate MIS forms and RTKs • Find local solutions for local problems. This again reaffirmed the importance of community participation to bring about
positive change • Dialogue with staff is vital if they are to take ownership of a new strategy • Doubling statistics through rapid scaleup can be achieved if funds are made available The moderator noted that this presentation showed the importance of pro-activeness and mobilising people to buy into an idea in a sink or swim situation. It highlighted the issue of RH commodities and supply chain management. The community-based component contributes 60-80-% to IPPFAR’s service statistics, yet MAs were still facing challenges in forecasts and effective delivery of commodities. MAs heavily depend on MOHs for supplies and yet, they may not be prepared for scenarios similar to the one in PPFN. PPFN demonstrated the excellent use of data from previous projects. Prof. Kotter book was technical assistance directing PPFN to resources to solve problem. This is why MA to MA TA is promoted. The presentation also captured the importance of cost-efficiency in bid processes. When MAs bid for funding, they are the most expensive per service and per client. If quality is held constant, MAs should demonstrate value for money and be more competitive in their pricing. He followed up on the new salary scale’s implementation. The presenter confirmed that the salary scale was approved with a caveat. For phase 2 of the project, it will be also be used. The PPFN SMT has decided to use this regime for all other projects. PPFN has been able to reduce its cost per target.
7th Annual Dissemination Forum 2012
Plenary discussions For example, the MAs per diem (6,000 Naira is least among 5 PRs engaged in HIV Phase 1 (20,000-30,000 Naira), it provides lunch and transport allowances, but does not cover accommodation. The MA has different DSA regimes for different cadres. Its cost per CYP is very low. Most MAs experience delays in funding and commodities supply. Annual reports commonly mention late disbursement of funds as a reason for missing targets. The presentation showed initiative and efficiency in achieving targets within a limited time. PPFN partnership with the Federal Ministry of Health had resolved the stockouts which no longer affect its programmes. At the beginning of every year, PPFN costs what is needed in terms of salaries and clinical supplies before the 1st tranche of the IPF comes in, at which points it caters for outreach, CBD, etc.
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Perform Change Goal (Research & Knowledge Management, M & E)
the Association Ivoirienne pour le Bien-être Familial (AIBEF) Fighting Female Genital Mutilation in the Séguéla, Côte d’Ivoire Female Genital Mutilation (FGM) is a fundamental violation of human rights, inflicting physical and psychological harm on women and girls and putting their lives in danger.
Through this project, AIBEF was able to mobilise communities in the fight against FGM, now AIBEF are building on their success and working to end the practice for good
Côte d’Ivoire ratified the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) in 1995 and the Convention on the Rights of the Child (CRC) in 1991. These conventions were strengthened by 1998 law to eliminate of all forms of female genital mutilation. Laws and conventions only go so far. According to a 2006 survey, the FGM prevalence rate in Côte d’Ivoire was 36 %, with more alarming rates in the north (88%), north-west (88%) and west (73%). Clearly there was a need to redouble the efforts to eradicate the practice at grass roots level. In response, the Association Ivoirienne pour le Bien-être Familial (AIBEF), a member of IPPF, launched an Anti-FGM Project in the north-western region of Séguéla, between 2009-12. AIBEF’s project team carried out a survey of 500 women and former FGM practitioners, administrative authorities, traditional and village leaders and community health workers . Their survey found that the Ivorian population is beginning to challenge the old justifications for FGM. Only 17% respondents argued that the reasons were still valid and 80% of female respondents in the survey agreed that the practice of FGM should be eradicated because its consequences for women’s health are well known. 79% of the women said that the society does not discriminate between women who had undergone circumcision and those who had not. 66% of girls who were excised no longer agreed with the justifications for FGM. The data also indicates that the majority (81%) of circumcised women were illiterate - the rate decreases with higher levels of education. All were unanimous that FGM makes men poorer as the savings are used to buy gifts for the women who do the cutting. The survey was followed by a communications campaign, peer education and setting up of watchdog committees to ensure compliance with the law on FGM. Through this project, AIBEF was able to mobilise communities in the fight against FGM, now AIBEF are building on their success and working to end the practice for good.
Author: Research and Evaluation Unit. Presenter: Nathalie Yao Ndry, Programme Director, AIBEF (Association Ivoirienne pour le Bien-être Familial)
Final project evaluation “Fighting female genital mutilation in the Séguéla region of Côte d’Ivoire” Background Female Genital Mutilation (FGM) is a fundamental violation of human rights and inflicts physical harm on girls and women. Without medical facilities, FGM exposes girls and women to health risks and puts their lives in danger. According to the Multiple Indicators Cluster Survey (MICS 2006), the FGM prevalence rate in Côte d’Ivoire was 36.4%, with more alarming rates in the north (87.8%), north-west (88%) and west (73.3%). These figures justify the need to redouble efforts on the ground to put an end to the phenomenon. The Anti-FGM Project was implemented in Séguéla between January 2009 and December 2011 by the Association Ivoirienne pour le Bienêtre Familial (AIBEF) to reduce the prevalence of FGM in the Séguéla District, located in the north-western region. At the end of the Anti-FGM Project in Séguéla, the study undertook a final evaluation of its relevance, efficiency, effectiveness, impact and sustainability. A baseline study and mid-term evaluation had been conducted. The findings aimed to: • identify local factors which help curb the 26
International Planned Parenthood Federation
• understand the population’s perception of the fight against female circumcision and the quality of services delivered during the project
Analysis of the findings focused on three key factors: relevance, efficiency and effectiveness.
• evaluate the population’s needs in terms of activities.
AIBEF’s Anti-FGM Project in Séguéla reflects the Government’s aim to curb all forms of FGM. Côte d’Ivoire ratified the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) in 1995 and the Convention on the Rights of the Child (CRC) in 1991. These protective mechanisms were strengthened by the adoption of the law of 18th December 1998 on the elimination of all forms of female genital mutilation.
Methodology The operational research study sought to better evaluate the project and attain the study objectives. Triangulation was used comprising of: (i) the quantitative method (sample survey) and (ii) qualitative method (literature review, focus group discussions and direct observation). For the quantitative survey, a two-stage approach was used. The first stage was the selection of five villages (Diarabana, Tiemassoba, Dualla, Sifie and Frototou) and the second stage, the identification of 500 women to participate in the survey. The qualitative survey was conducted among key informants, including former excisors, women aged 15 and above, administrative authorities, traditional and village leaders, community health workers, as well as other stakeholders in the project.
The approaches used to implement the project included advocacy; peer education; information, education and communication on FGM and the establishment of watchdog committees.
Project’s efficiency The project to combat FGM in Séguéla was scheduled for January 2009 to December 2011 but was extended until December 2012 due to some delays caused by administrative, political and Government stakeholders not being available.
The costs analysis showed that for the project to succeed, a total of CFAF 151,631,625 (US$ 306,766) was needed. As at June 2012, expenditure was CFAF 87,294,254 (US$176,600) – about 57.5% of the total projected budget. The difference between the total projected budget and that spent was CFAF 64,337,372 (US$130,066). Based on the size of Séguélas population, the average cost of the project is CFAF 506 (US$1) per person and CFAF 1,059 (US$2) per woman. The analysis of project activities reveals the target number of trainees (Objective 1) was achieved for Government officers and politicians as well for community leaders and former excisors. In contrast, more than the anticipated number of community workers was trained (43 instead of the 40 initially planned for). The activities for the achievement of Objective 2 were carried out, except the competition to produce a music CD to raise awareness about FGM and reproductive health rights. Various types of committees responsible for the promotion and protection of rights, as well as compliance with the law on FGM in the project areas, were established (Objective 3). However, instead of a regional committee, a departmental committee was set up in Séguéla. In addition, fewer sub-prefectural committees were set up (six instead of eight). In contrast, 18 cantonal committees were established compared to the 15 that were envisaged to cater for high numbers of indigenous populations from
elsewhere who practice female circumcision, specifically the Yabuba and Burkinabè. Out of the 20 possible partners targeted, only one partnership agreement was signed - with the NGO Espérance-Vie. The study noted that the project was satisfactorily implemented on the basis of the six selected focus areas - advocacy, capacity building, IEC/BCC, media activities, partnerships and financial resources.
Project’s effectiveness The findings show: • Out of the five survey sites, 98.3% of women aged over 15 had already heard about female circumcision and 44.6% had undergone it • Of the women surveyed, there was a fairly high proportion of older women. The statistics show that female circumcision is practised less among younger women and that it could be eliminated if efforts to halt its progression are maintained and sustained • The majority (81.6%) of women who are illiterate were circumcised. This rate decreases with higher levels of education • Ivorian people are not as gullible as they were regarding the reasons justifying female circumcision. Only 16.7% respondents argued the reasons were still valid. It was also noted that 66% of girls who were excised no longer supported these reasons
the practice of female circumcision should be eradicated because its consequences on women’s health are well known • 79.6% of the women said that their society does not discriminate between women who had undergone circumcision and those who had not. The controversy over the role of men and women in the organisation of the circumcision ceremonies in Worodougou has always been a subject of discussion. However, an answer to this question seems to have been found in the statements of participants. All were unanimous in saying that it was women who took the initiative to practice FGM. “It is the woman who takes the initiative to circumcise her daughter, even when the man does not approve.” (FGD participants, Frototou). Excision makes men poorer: The savings of an entire harvest are used for FGM (CFAF 3,000 [US$6] to CFAF 5,000 [US$10]) Gifts are bought for the excisors and, after the ceremony, the girls are fattened with good quality food. For women, the fear is that their daughters will not get a husband.
• 80.8% of female respondents agreed that 7th Annual Dissemination Forum 2012
Project’s impact The project’s impact was assessed as follows: • Awareness-raising by community agents • Topics discussed raising campaigns
neighbouring Kani and Mankono • Replicate the project in areas at risk, such as Man and Danané in the western region (region Tonpki) where the prevalence is 73.3% and Korhogo in the northern region (Poro) where the prevalence is 87.8% (MICS 2006).
• The role women play in fighting female circumcision.
Findings show a significant change in the population’s attitudes to female circumcision in the villages that participated in the survey, as well as the following positive aspects of the project:
Awareness-raising was done by community health workers (CHWs).
• Sharing of good approaches to abandoning FGM
• Take steps to provide some security for CHWs
• 374 (i.e.78.7%) of the women surveyed said that a CHW had been to their homes
• Availability of high quality staff in the project team
• Include the management of complications arising from FGM in project activities
• 94.9% of the women who had received a CHW in their homes said that they had been sensitised about female circumcision
• Follow-up and support for the activities.
• Continuous training for people involved in the project
• Knowledge and opinions on the anti-FGM Project
• The majority of the women surveyed (448 out of 475, i.e. 94.3%) said they had been informed about the AIBEF Anti-FGM Project • 96% of these women were supportive of the project. The role of women in the fight against FGM includes sensitising women who have not yet abandoned the practice. To help ensure the sustainability of the project’s activities and secure long-term behaviour change, committees to promote and protect rights and ensure compliance with the law on FGM were established in the project’s sites (one departmental committee; six sub-prefectural committees out of the eight initially planned; 18 cantonal committees of the 15 planned and 20 28
village committees were set up). When CHWs heard of planned female circumcision, they informed these committees and the judge.
Deliver Change Goal (SRH)
Although the results of the survey cannot be extrapolated to the entire population of the area covered by project, it was noted that the practice of FGM declined. Through this project, AIBEF was able to mobilise communities who are united in the fight against this practice. No efforts should be spared in ensuring the continuity of good practices and supporting new attitudes towards FGM acquired during the project.
Recommendations and next steps The following recommendations were made: For IPPF, to: • Consider the continued funding of the project in the Worodougou region • Secure the gains of the project in the regions of Worodougou and Béré and scale up to
For AIBEF, to: • Increase the number of CHWs in order to cover the entire project zone
• Monitor and provide forms for circumcised women and young girls in social centres and maternity hospitals • Set up a monitoring mechanism for incomegenerating activities for former excisors • Formalise the partnership with the local NGO Espérance-Vie to sustain the projects achievements.
Plenary discussions The moderator wanted to know how to confront communities that use FGM as a rite of passage oblivious to risks to girls and women. He emphasised that IPPFAROs niche is the rights component. The 88% prevalence in some parts of Côte dIvoire literally meant that almost 9 out 10 girls had gone through FGM, which impacts negatively on the quality of life and delivery. He emphasised the link between FGM to level of education, with the higher levels of exposure translating into lower prevalence, indicating the need to partner with organisations that promote the education of the girl child. Although the men interviewed claimed no responsibility in FGM, the fact that women feared that their daughters will not get a spouse was a pointer to mens negative role. Men should be engaged as agents of change. He recommended that IPPF continues supporting such projects to consolidate gains. The presenter was asked to shed light on encouraging behaviour change through economic empowerment of excisors. Some participants recommended that excisors be trained as CHWs to link women to FP services in health facilities as an alternative source of income. The presenter mentioned that an income-generating activity was created in the form of seed money to the tune of CFAF 50,000 given to each ex-excisor to conduct trade. From the 20 who had abandoned the practice, 17 received the money and currently sell wares such as millet and pepper on the market. In Mali, AMPPF has created revenue streams for excisors. It uses ex-excisors as communicators and community workers to explain the dangers of FGM to the community. This has more impact. There was a proposal that since FGM is a cultural belief and will continue being practiced in hiding, measures should be taken to ensure that it is done safely to prevent HIV transmission. The presenter was categorical that medicalised excision in any form was not acceptable. The negative effects on health included changes to vaginal orifice which is meant to be elastic, but becomes scarred after FGM. The fibrous muscle cannot dilate during child birth endangering the health of the mother and the child. The MA’s policy is to STOP FGM. She also noted that the practice was not rooted in culture or religion. Imams and other religious leaders in the watchdog committees say that the holy books do not support FGM. 7th Annual Dissemination Forum 2012
Presenter: Edmore Munongo, ZNFPC (Zimbabwe National Family Planning Council)
Hormonal contraceptives and heterosexual acquisition and transmission of HIV infection: evidence from a quantitative meta-anaylsis , a study from Zimbabwe 1
Background Recent studies suggesting that use of injectable hormonal contraceptives (IHCs) might increase the risk of women acquiring an HIV infection seemed like a major setback in family planning, particularly as IHCs are particularly popular among young women, who have a greater risk of sexually transmitted infections. In fact, after the recent publication of one such study in the Lancet, a leading medical journal, the WHO convened a meeting of experts to review the medical eligibility criteria for the administration of hormonal contraceptives. Dr. Edmore Munongo, from the ZNFPC (a collaborative partner of IPPF) with his co-authors Drs. Jotam Pasipanodya and Munyaradzi Murwira) set out to examine the evidence for a link between hormonal contraceptive use and HIV acquisition or transmission. Their research comprised a meta-analysis - a statistical technique which compares independent studies.
Quantitative methods were used to examine and measure the heterogeneity of effect, and determine the association between concurrent hormonal contraceptive use and acquisition or transmission of HIV between heterosexual couples in prospective studies.
Objectives The research set out to: 1. determine the association between the concurrent hormonal contraceptive use and HIV acquisition or transmission 2. quantify the heterogeneity of effect Definitions The key terms used in this research are defined below: 1. HIV-acquisition
Presenter: Edmore Munongo, ZNFPC (Zimbabwe National Family Planning Council) refers to documented seroconversion in previously negative patients
2. HIV-transmission refers to documentedlinked sero-conversion in a previously sero-negative partner in sero-discordant couples in mutually monogamous sexual relationships. 3. HIV test covers both HIV-1 and HIV2 types. 4. Oral Hormonal Contraceptives (OHCs)ingested orally. 5. Injectable Hormonal Contraceptives (IHCs)parental: combined or progesterone only It is important to note that none of the studies selected used combined IHCs.
Methodology The research comprised a meta-analysis, which is a statistical technique to compare estimates of treatment effects of independent studies, when studies giving inconsistent and inconclusive results. Three databases, Medline, Embase and Cochrane were used to search for studies.
1 Notes: Jadad et al., 1996, Assessing the quality of reports of randomised clinical trials: Is blinding necessary?, Oxford Regional Pain Relief Unit, University of Oxford, UK. ZNFPC partnered with a colleague from the University of Texas South-western Medical Centre for this study. A paper on it had already been submitted to Lancet for publication.
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The preferred reporting items for systemic reviews and meta-analyses guidelines were used, restricted to prospective observational cohort and interventional studies. Two measures of effect - sero-conversion incidences and risk ratios - were used to compare hormonal contraceptive users to non-users. Groups examined were injectable hormonal contraceptive (IHC), oral hormonal contraceptive (OHC) and a combined group comprising women who used either IHC or OHC. For all comparisons, the control group was women who did not use any hormonal contraceptive. Based on earlier data, the researchers decidedÂ a prioriÂ to use the Dersimonian and Laird random effects methods to pool effect estimates across studies for the meta-analyses, because previous studies have demonstrated significant heterogeneity. Meta-regression methods were used to adjust for study-level covariates; while, the visual inspection for funnel plots asymmetry and use of EggerÂ’s test examined publication bias and small study effects.
Panel 1: Non-Users versus IHC Users
Panel 2: Non-Users versus IHC Users
Results Eighteen studies, from 256 titles and abstracts, comprising over 37 000 participants enrolled between 1985 and 2007 and drawn from SubSaharan Africa, Western Europe and Asia, met the inclusion criteria. Overall HIV seroconversion incidence for all studies was 6.2 (95% confidence interval [CI] 3.3, 9.1) per 100 person-year. Only three studies were of high quality and they reported divergent 7th Annual Dissemination Forum 2012
findings. The study quality ranged between 2 to 5, with the median score being 4. All studies met ethical considerations as they provided free comprehensive care for STIs, condoms and unlimited HIV counselling.
Panel 3: Non-Users versus Any HC users
Panel 1 shows the forest plot of studies that exclusively examined patients on IHCs and Panel 2 shows those that examined OHCs. Nine homogeneous (I2=0%) studies revealed that IHC use was significantly associated with increased HIV acquisition, the risk ratio (RR) was 1.30 (95% CI 1.12, 1.50), compared to non-hormonal contraceptive users. The use of OHCs was not statistically significant: RR 1.26 (95% CI 0.98, 1.61).
Funnel Plot 1: OHCs
Funnel Plot of Standard Error by Log risk ratio
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Funnel Plot of Precision by Log odds ratio
The meta-regression analysis revealed that quality of study did not significantly influence the HIV risk estimates for both IHC and OHC groups. No significant publication bias was observed as indicated in the funnel plots below.
The data were insufficient to demonstrate association between OHC or any HC use and increased risk for acquisition of HIV. However, the evidence was unequivocally in support of increased risk for HIV association among IHC users. On average, the multivariable adjusted risk for increased HIV acquisition was 0.46 (95% 0.21, 0.71) percent. HIV transmission was similarly significantly increased among IHC users.
Funnel Plot 2: IHCs
6 Precision (1/Std Err)
However the combined group comprising patients who used any form of hormonal contraceptive revealed inconsistent results. Both OHCs and IHCs were significantly associated with increased risk for HIV among commercial sex workers in subgroup analysis as indicated in Panel 3.
5 4 3 2 1 0
0.0 Log risk ratio
0.0 Log odds ratio
The evidence suggests that there is an increased trend for HIV acquisition among populations with HIV transmission regardless of the quality of studies examined (cf. Graphs 1 and 2). There is no evidence of study publication bias.
Graph 1: Study Quality
Implications of findings • Advice for patients receiving counselling for contraception; • Increased risk ratio for HIV of between 13% and 50% is disturbing; • Reiterate the importance of dual contraception, including barrier methods particularly among population at high risk for HIV; • Call for a research in design of single user-independent contraceptive device capable of preventing HIV and unintended pregnancies.
Limitations • Significant heterogeneity between studies; • Ascertainment of hormonal contraceptive and HIV exposure was not uniformly determined between studies; • Accounting for difference in behaviour is difficult in all studies;
Graph 2: HIV Incidence
• The study could not account for age differences.
Conclusions The evidence suggests that there is an increased trend for HIV acquisition among populations with HIV transmission regardless of the quality of studies examined. There is no evidence of study publication bias.
Recommendation Service providers should adjust their advice to clients, in the light of these findings.
Plenary discussions The moderator stated that this meta-analysis brings to fore the process of generating WHO Technical Guidance Notes. When an article is published in Lancet, a medical journal of repute, one cannot refute the body of evidence without conducting further research through a meta-analysis by selecting relevant research, analysing the findings, context and population that formed the sample group and extrapolating the findings to specific contexts. He noted that many researches are conducted in different contexts, and for some of them, there are inadequate controls for co-founding factors. For example, in terms of assessing risk, a woman using IHCs may lower her risk perception on the use of dual protection. If she feels safe using an injectable, she may not feel the need to use a condom, since her risk perception for HIV is lower. In fact, many young women fear getting pregnant than they do getting infected with HIV. In such cases, the risk of HIV acquisition is higher because of behaviour and not IHCs. He added that studies should not be considered at face value, encouraging participants to always interrogate study findings in the context of other research studies. Where there is high HIV prevalence and high use of injectables, it is likely to get false associations (ecological fallacies) attributed to populations. He hoped that the findings of this research would be widely disseminated to service providers and their supervisors in a reader-friendly format, 7th Annual Dissemination Forum 2012
using language that is more comprehensible. A participant noted that it was impressive that the MA had the capacity to do this kind of research. She wanted to find out whether ZNFPC recruited short-term staff to assist in the research and how the findings were being disseminated. She also wanted to know whether the authors had contacted Lancet and the latterâ€™s reaction. In response, the presenter indicated that he initiated the study but unfortunately, ZNFPC did not have adequate resources. He partnered with his colleague from the University of Texas South-Western Medical Centre who provided the software and resources. Regarding dissemination, he mentioned that the paper had already been submitted to Lancet and was in the final stages of review prior to publication. In Zimbabwe, the Zimbabwe Medical Association has invited him to make presentation in August 2013 during its annual congress. Another participant asked how many intervention studies (gold standard) were included in final analysis. He was concerned that the forest plot on non-users versus users of OHC, by Kleinschmidt et al (2007) and Heffron et al (2011) had high relative risks of 2.61 and 2.11 respectively. The presenter indicated that 8 intervention studies were used out of the 18 selected.
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He concurred with Nathan about the high relative risks, stating that the study by Heffron et al, unequivocally points to the fact that that OHCs increase the risk of HIV infection. Participants wanted to know if there is an organic preparation in mono injectables that may make acceptors susceptible to HIV infection and why the researchers singled out IHCs yet women used IUDs, pills and Jadelle that gave them similar comfort as the injectables. Recognising that implants also have hormones, the presenter clarified that the meta-analysis looked at studies done on injectables. He explained that injectables inhibit ovulation due to the large dose of progesterone. During the follicular phase of a womanâ€™s menstrual cycle, oestrogen levels are high and the cervical area is thick producing antibodies that protect women from IgGs and IgAs. However, during the luteal phase, high progesterone levels make the cervical walls thinner, exposing women to infection. Similarly, the use of progesterone-based injectables is thought to contribute to the thinning of cervical walls, making women vulnerable. The moderator gave further clarification that it was not a new issue arguing that the quantities of steroids in HCs cannot result in significant immunosuppression. There is room for more research. Noting that unwanted pregnancies result in unsafe abortions causing maternal mortality and morbidity, HCs have been a
lifesaver. It would be unfortunate to bash FP without clear evidence. He urged MAs to enter into partnerships with research institutions considering the fact that MAs are programme implementers and have the data, while researchers have the expertise. A participant wanted information on the decision made by experts who met under WHO in Geneva in January 2012 since the evidence on IHCs and HIV transmission was inconclusive. He also asked whether there were new studies after the controversial Lancet article. The presenter indicated that the experts, after looking at medical eligibility criteria and noting that there is no association between HIV and IHCs, decided that women could continue using IHCs, but those at high risk should use dual protection, while further research is conducted. The guidance was updated. He was not aware of new studies, but indicated that some could be in the review pipeline in preparation for publication.
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Authors: Emmanuel Litté Ngoundé, Head of Monitoring and Evaluation, Alphonse Ndotiga Biansere, Executive Director, Association centrafricaine pour le bien-être familial (ACABEF) Presenter: Emmanuel Litté Ngoundé, Head of Monitoring and Evaluation, ACABEF
Comparative analysis of clinical service statistics in 2011 and 2012 for decisionmaking purposes from Central African Republic Background The Central African Republic is a landlocked country in Central Africa that covers 623,000 km2. It has a population of 4 ,216, 664 inhabitants i.e. a density of 6.3 persons per square kilometre with a TFR of 6.2 children per woman. It neighbours Chad to the North, Cameroon to the West, Sudan to the East and South Sudan and the Democratic Republic of Congo to the South. In light of the commitments made by the international community in the area of reproductive health, the Central African Government has adopted and implemented various policy documents and strategies that seek to address the country’s challenges in this domain. The CAR is not short of instruments on SRH including the National Health Development Plan II (2006-2015), the Poverty Reduction Strategy Paper (PRSP) II (2010-2014), the National Reproductive Health Programme 2003, the Roadmap to accelerate the reduction of maternal and neonatal mortality (20042015) as well as the policy and strategy on the prevention of mother to child transmission of HIV (PMTCT). The main challenge is for the Government and NGOs in the sector is 36
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implementing them to improve SRH. Contraceptive use is 26% in urban areas and 8% in rural areas. This low contraceptive uptake has significantly contributed to the high maternal mortality ratio (860 per 100,000 live births). HIV is still one of leading causes of death with a national rate of 4.9% (Multiple Indicator Cluster Survey (MICS 4). For the past 25 years, the Association centrafricaine pour le bien-être familial (ACABEF), as the pioneer non-governmental organisation working in sexual and reproductive health (SRH), has been supporting the Government’s efforts through its Maternal and Child Health Policy to reduce maternal mortality in Bambari and Bossangoa in the country’s stable areas as well as Bozoum and Paoua in post-conflict areas. The SRH environment has become increasingly competitive due to (1) the growing number of stakeholders, NGOs and Member Associations (MAs) working in the domain; (ii) the reduction of funds earmarked for activities; and (iii) new donor requirements with regard to the performance of each MA. Against this backdrop, it was important for ACABEF to have
up-to-date data for decision-making in order to continue receiving funding from IPPF and other partners. Against this backdrop, ACABEF decided to boost its data collection and analysis to prove its value to donors and make effective evidencebased plans for future services.
Project Objectives From 2011 to 2012, IPPF ARO piloted a new approach in ten West and Central African countries aimed at enabling the Monitoring and Evaluation Officers to report accurately and improve the quality of data from their respective countries. Recognising the importance of service statistics, ACABEF, introduced a quarterly mini- workshop in its annual programme budget to present the results of Member Association’s (MA) performance to all staff and volunteers. This was done with a view to demonstrating the use of statistics in decision-making and increasing the volume of service statistics in 2012. The specific objectives were to: • evaluate statistical data of the 2011 and 2012 services;
• identify the trends in programmatic areas or clinical services to readjust programmes; • measure the performance of the Member Association; • draw lessons from the period under review.
Methodology The study compared the MA’s performance in 2011 and 2012 in family planning, abortion, HIV/AIDS, and the other youth SRH services.
Results The results were impressive. The volume of ACABEF ‘s family planning services increased to 120,000 in 2012 from 44, 000 in 2011, while HIV services jumped from 26,000 in 2011 to 39,000 in 2012.
Family Planning Services The statistical database shows that the volume of FP services provided increased to 120,312 in 2012 compared to 44, 836 in 2011 for a CYP of 6,637 as opposed to 4,293 in 2011 (several unwanted pregnancies were prevented). The main beneficiaries of these services were women aged over 25. It was also observed that young girls and women under 25 years have a greater preference for injectable methods, oral contraceptives, condoms, etc. compared to figures for 2011. For example, 2, 171 against 257 in 2011. The MA attributed this to its earlier campaign about hormonal contraceptives.
Abortion Service As abortion is illegal in the CAR, the MA intervenes only in counselling, management of post abortion care and treatment for incomplete abortions. In 2012, ACABEF provided services to 11,452 clients compared to 2,007 in 2011. The MA also ran quarterly awareness-raising sessions on abortion targeting women under 25 – the main recipients of services (7,135 compared to 4,317 for women over 25).
HIV/AIDS Services The volume of HIV services provided increased from 26,002 in 2011 to 39,077 in 2012. Women above 25 years accounted for 14,367 services compared to 13,775 for younger women.
in 2012 (29,221), as patients were cured of their conditions. Women over 25 (7,789) and young men under 25 (3,453) benefitted the most from the services, indicating that STIs are still an issue for people in these age groups despite the counselling and information campaigns.
Sexual and Reproductive Health Services The number of young people served continues to grow thanks to a popular youth club/clinic managed by the young people themselves. Young women under 25 (97,166) visited the MA’s clinics more than young men (5,266).
HIV prevalence is twice as high among women above 25 years and young men under 25.This could be attributed to the systematic integration of HIV testing into family planning services as opposed to the case of young women and men under 25 years who use voluntary testing.
In the past, the MA carried out many activities that were not reported due to the lack of data collection tools. The introduction of IPPF’s new M&E approach in West and Central African countries was very beneficial, not only in terms of quantity but also in the improved quality of the data collected.
The MA was recognised as a centre where free medication for the treatment of opportunistic infections (OIs) is dispensed and nutritional support from USAID for persons living with HIV (PLHIV ) is provided.
As a result, the MAs data collection tools were reviewed, made more userfriendly and adapted to this new approach. There were several benefits:
This approach explains the high number of consultations and services provided to women over 25 and men under 25.
STI Services Although the volume of STI services provided in 2011 (32,653) was high, the number decreased
• This readily available information helped the Ministry of Health and other reproductive health NGOs source data for projects they are implementing. Mercy Corps GBV project is a case in point • The dissemination of results of the MAs performance to volunteers and staff during the mini-workshops had 7th Annual Dissemination Forum 2012
a positive impact • The mini-dissemination workshop is now run every quarter • By raising the visibility of ACABEF at the national level, its clinics have been inundated by clients. At least 111,021 clients were served in 2012 compared to 90,203 in 2011.
Recommendations and next steps The findings of this comparative study have assisted the MA to adjust its programmes and improve its performance in 2012. It is envisaged that in 2013, even more statistics will be collected as the technical capacity of clinics is improved. User-friendly data collection tools have meant staff, volunteers and service providers can all make use of the statistics to fine tune their programmes and improve services in the future.
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Plenary discussions A participant noted that the change in reporting from number of clients to number of services was cause for confusion. He asked for the definition of the term “services”. Clarification was given on what services constitute. The number of services is higher or equivalent to the number of clients or visits. He gave the example of VCT. A client goes for pre-counselling, undergoes the HIV test and attends a postcounselling session. In this case one client has received 3 services. Services are delivered by trained service providers. In the context of a communitybased distribution of injectables, CHWs are considered to be service providers. Participants were informed that IPPFARO had developed a service statistics manual in English, French and Portuguese that gave a series of examples of services. Giving a set definition of the term “service” would be limiting as it would not be exhaustive, since the range of services offered varies from one MA to another.
HIV prevalence is twice as high among women above 25 years and young men under 25. This could be attributed to the systematic integration of HIV testing into family planning services as opposed to the case of young women and men under 25 years who use voluntary testing
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Presenter: Moussa Mané, Programme Director, ASBEF (Association Sénégalaise pour le Bien-être Familial)
Implementation of ACCESS database in Senegal: an IPPF Model
Background Research has shown that an effective monitoring and evaluation (M&E) system contributes accurate, timely, and relevant data to inform decisions on an organisation’s projects. Before 2008, the Association sénégalaise pour le bienêtre familial (ASBEF) had no M&E system. Its indicators were neither aligned to the national health system nor did they meet IPPF’s requirements. Data were not disaggregated by sex and age, there was underreporting of service statistics and the use of Excel posed a challenge because of corrupted files. In addition, the MA’s donors required evidencebased reports on a quarterly basis which proved to be a Herculean task since there was no automatic production of reports in real time. In view of the above, the 2008-2012 Strategic Plan of (ASBEF) and the IPPF AR’s accreditation mission in 2008 strongly recommended that ASBEF recruits an M&E Officer to establish a Research, Monitoring and Evaluation Unit (RMEU). The RMEU was operationalised and implemented the recommendations made after the accreditation review including training of staff in M&E, disaggregation of indicators on the basis of sex and age, harmonisation and submission of data to the national system. The MA recruited a consultant to establish an M&E system, but unfortunately there were still challenges generating data. This situation 40
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negatively influenced the performance of the RMEU and the MA requested for technical support from the IPPF’s West and Central Africa M&E Advisor in August 2011 to install the ACCESS Database to address the above bottlenecks.
Project Objectives The IPPF AR M&E Advisor for West and Central Africa supported the MA to design and install the ACCESS Database - an electronic statistical management application for clinical and IEC/BCC services. It has a comparative advantage over their existing system in terms of storage capacity, data security and automatic data generation.
Methodology The installation was carried out in four phases:
over eight months, from November 2011 to June 2012, during which there was a revision of the data collection and reporting tools. Finally the new database was thoroughly evaluated. The process was not without challenges. The RMEU had large volumes of data from its eight clinics all delivering a broad range of SRH services. Service providers had difficulties transitioning from the Electronic Waiting Cards Management to the new ACCESS system. Some indicators created difficulties in generating an annual report and there were delays in training service providers on the new system due to lack of funds. However, these were addressed in consultation with IPPF ARO. The strengths were:
Firstly, the team examined existing data collection system, reporting tools and identified the information needs for the MA, IPPF and donors.
• Automatic generation of reports
Then the IPPF ARO Monitoring and Evaluation Advisor designed the application on the basis of the revised data collection and reporting tools. The indicators were disaggregated according by age, sex, branches, years and months.
• Capacity-building for the human resource component of the RMEU with deployment of staff members for data entry
Phase three was piloting the ACCESS database
• Improvement in data reporting • Effective collection of client data • Prompt production of reports
• Significant increase service statistics;
• ASBEF was ranked among the ten best contributors of family planning services and among the five best providers of HIV services in Africa Region
Conclusions • Through the ACCESS Database, ASBEF has improved its data collection system and seen its service statistics increase significantly. • The database facilitates the automatic search for information and stores data securely. • Comparative analysis of the performance across services, clinics, age and sex can now be easily done. • In view of the growing need for services and information, ASBEF staff feel confident when dealing with donors who require evidence of an accurate M&E system. • The application is a concrete example of the efficient technical assistance provided by IPPFAR. Initially ASBEF engaged the services of an external consultant but this proved unsatisfactory, wasting time and resources. Member Association to Member Association and IPPFAR to Member Association assistance should be encouraged to avoid similar situations. • The database contributed to strengthening the human resources, as a full-time data manager was recruited.
Recommendations and next steps The new system meant more work to collect data, but, with a fulltime M & E manager in place, ASBEF can compare performance across all services provided .This has boosted both services and the team’s confidence when dealing with donors who need detailed performance reports. To optimise the ACCESS electronic database application, the next steps will be to install the application in all branches and train staff in 2013 with the support of the PAIR Project. The MA also plans to include financial data (such as income and expenditure) and restricted projects in the database and to establish a budget for maintaining, updating and strengthening staff capacity and evaluating the ACCESS Database on an annual basis. 7th Annual Dissemination Forum 2012
Authors: Muketo E., Muraga R. & Njoka S. Presenter: Stephen Njoka, Monitoring and Evaluation Manager, FHOK (Family Health Options Kenya)
Addressing monitoring and evaluation gaps in the provision of integrated SRH and HIV services in Kenya Background FHOK, initially known as the Family Planning Association of Kenya, has been integrating SRH and HIV services for the last decade, when it realised that clients needed other services beyond FP. The integration of services has been documented as a successful strategy of leveraging existing and scarce resources. Many programmes reported challenges in monitoring and evaluation of integrated services in terms of index service and range of services accessed per client per visit. To address these challenges, the MA piloted Clinic Management Information System (CMIS) in Nairobi West, Nakuru and Meru health facilities between November 2011 and April 2012 to track integration of services. In September 2012, the CMIS was scaled up to 4 other clinics building on the gains made during the pilot phase.
Methodology The CMIS was developed with a local company, Intersoft Technologies Ltd., using both Local Area Network (LAN) and Wide Area Network (WAN) to link the different components of the clinic, from accounts to the pharmacy, human resources to stock management. 42
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Currently, only LAN is being used. Once the system is introduced to all FHOK clinics, the WAN will be used. The CMIS is administered from one point, by a systems administrator who creates accounts for all users. The systems administrator also provides different security levels to all users depending on their duties and responsibilities. The CMIS links all the clinics’ various departments, including: accounts; inpatient; out-patient; theatre; laboratory; pharmacy; procurement; human resources; stock management and system administration. It also connects various sections of the clinic to reception, service provision rooms, laboratory, pharmacy and the admissions wing. The system settings are done in a management module. At the reception, the client’s details are entered. The client states the purpose of their visit to the clinic and is directed to a consultation room. The receptionist can then manage client queues at the consultant’s rooms based on the services required and the number of patients. The service provider can view the name of the client on the screen and access his or her medical history. A client may be sent to the pharmacy with a prescription. The pharmacist
sells the drugs and records the transaction on the system. From the consultation room, the client may be sent to the laboratory by the service provider using an internal referral system. His or her details are shown the screen in laboratory, and the lab technician can conduct tests and send the results online to the consultation room without a paper trail. The receptionist is also able to view which beds in the maternity department are available. All bookings are managed through a doctors diary on a dashboard. The CMIS software was designed to capture services using a unique colour code for each service and generate a summary of all services provided per client per visit. After data entry, providers are required to verify the total number of services provided per client and the system tracks the sequence of services. The CMIS generates daily, weekly, monthly, quarterly, semi-annual and annual summaries and detailed reports on total clients and total number of services provided.
Results The database showed that, on average, a client visiting any of the facilities received at least four services. About 18,000 clients were treated
at FHOK’s facilities, receiving over 90,000 services. Family planning accounts for 34% and VCT for 30%.
The strengths of the CMIS are that it: • generates summaries
• enables the receptionist to manage queues and balance the service providers work load • reduces client waiting time • is versatile and can generate reports using the IPPF, Ministry of Health or donor formats • reduces paperwork • ensures cash collection at one point (reception) • reduces dependence on the internet since the system is not web-based • reduces recurrent expenditure in terms of internet fees • facilitates data retrieval • eases the monitoring of service provision and work load.
Conclusions The implementation of the CMIS has improved FHOK’s capacity to identify index services and track the range of integrated services accessed by each client. As performance can be tracked on a day-to-day basis, the system makes it easier to build capacity where it is needed.
Recommendations and next steps Plans are underway to scale up the CMIS to all FHOK clinics. The WAN will be installed to enable the system to be administered from one point - headquarters - reducing costs incurred during field monitoring. The clinics will be monitored in real time and tabs customised for all projects. The percentage contribution of each clinic to the MA’s statistics can now be monitored. Once the module is complete, all project reports can be merged into one report, and linked to the e-IMS. The next challenge is meeting IPPF’s Federation-wide target of doubling service statistics by 2015. Outreach data accounts for 65% of all the MA’s data - currently one of the clinic managers collects all outreach raw data via mobile phone. FHOK envisages using mobile phone technology linked to a clinic server, which may be costly initially, but should pay dividends in the long term.
Plenary discussions A participant wanted to find out if service providers were computer literate and the number of sessions required for them to attain a level of proficiency. The presenter informed participants that a needs assessment was carried out for the pilot phase. The main need expressed was computer literacy. The first training done that brought together service providers was not effective. FHOK changed its strategy and conducted on-the-job training for service providers and receptionists so that they mastered the basic IT components related to the system. There was a concern that FHOK was not keeping paper records. FHOK had a back-up system that had been set up to protect data. The IT company it partners with holds all the MA’s data. The MA moved away from paper records given the limited space and the fact that most organisations now prefer paperless transactions. For the Global Fund’s projects, the MA still printed its documents in hard copy since this is a requirement of the donor. There was a recommendation for FHOK to explore partnerships with Google and iHub to design an appropriate application so that data from mobile phones is automatically uploaded on the MA’s main system via the Web. Service providers could use mobile phone applications to send in their outreach data. In Mozambique and Zimbabwe, mobile phone companies contributed to a PMTCT project as part of CSR by facilitating data transfer from phones to a server. 7th Annual Dissemination Forum 2012
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Conclusions Innovations will improve health outcomes Concluding IPPF AR Dissemination Forum, Elly Mugumya, the Director, Leadership, Management and Governance at IPPF ARO, briefly spoke about the LMG consortium project between 5 partners, Management Sciences for Health, Yale University, John Hopkins University, Medic Mobile and IPPF, funded by USAID. He said that the papers presented had yielded results that would certainly help to improve health outcomes. He encouraged participants to incorporate the comments they received and submit their abstracts at other major conferences. He reminded participants that the Federation’s focus is on marginalized and vulnerable communities and this is where innovation should be directed. He lauded the use of CHWs who are a valuable asset. He added that the CMIS will be introduced throughout the whole region and the service statistics module will be revised. Capital investment is required to buy equipment to enable MAs to gather outreach data, and funding for this should be considered in annual capacity assessments.
Tapping into new social media for change Angella Githere-Langat, IPPF ARO Knowledge Management Advisor, summarised the key highlights of the forum and indicated that MAs are adopting local solutions for local problems by customising programmes to suit
their contexts. However, there is still a need for greater innovation. In the area of human resources, many MAs are increasingly using CHW to boost services - a good basis for doubling the number of services by 2015. MAs also need to reach out to volunteers who will be essential in delivering this target. She added that according to the estimates of The International Telecommunication Union (February 2013), at the end of 2012, there were 6.8 billion mobile subscriptions, Africa has the world’s fastest growing mobile market with 545millioncellular subscribers. Facebook boasted 38 million users in Africa in 2012 prompting giants like Google and Microsoft to take notice. Most young people use mobile phones to communicate, use social media, transact, surf the internet, etc. 84 million phones are internet enabled and the figure is expected to grow exponentially. UNICEF estimates, 72% of 15-24 year olds have cell phones. She also noted the importance of seeking partnerships in research to inform programmes. The IPPF Innovation Fund had been relaunched and she urged participants to submit innovative ideas. The next Dissemination Forum will have wider participation from outside IPPF to showcase the Member Associations’ good work.
Integrating services and demonstrating value Esther Okwanga, IPPF ARO Director of Operations, reminded participants that research and evaluation are no longer a choice. Just as a shrewd businessman invests his money where there is highest return on investment, so those working in the area of sexual and reproductive health must demonstrate the same. There had been a downward trend in core grants from IPPF and the introduction of performancebased funding. This means the SRH sector will need to use statistics and monitoring to demonstrate how services are being delivered to the disadvantaged groups and how those services are improving lives. Accountability to both donors and clients is the order of the day. Europe, which had been the main donor hub, has been going through a debt crisis and governments are under immense pressure from their taxpayers to demonstrate the impact of their aid. At the same time donors are decentralising aid to individual countries. Aid recipients have to spend meagre funds wisely and demonstrate change. Integrating the way MAs deliver services is a clear way of streamlining business and demonstrating real value for money. It is a more efficient way to address the high unmet needs of women and men and to achieve the goals outlined in IPPF’s Vision 2020 - to put sexual and reproductive health at the centre of new global development goals. 7th Annual Dissemination Forum 2012