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May-11-2008 |
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Community-Based Family Planning Strategies and Approaches WorkshopMay 16, 2006USAID Flexible FundCSTS+ Project CORE Group
Workshop Summary OverviewIntroduction Session 1: Family Planning Integration into Health and Non-Health Programs Session 2: Linking Mission Bilateral Activities to PVO/NGO Programs Session 3: Assessing the Synergies Between a Mission Bilateral Program and Complementary PVO Programs in Guinea Session 4: Operations Research Conducted and Planned in PVO Programs Closing Remarks Meeting Participant List.doc Overview
On May 16, 2006, USAID’s Office of Population and Reproductive Health’s PVO/NGO Flexible Fund, CSTS+ and the CORE Group held a one-day workshop for Flexible Fund grantees and partners to share program experiences in community-based family planning. The meeting drew 97 participants representing 45 PVO/NGO grantees, cooperating agency, private sector, and donor organizations. There was a mix of HQ and field-based presenters and participants. Presenters discussed program experiences from India, Madagascar, Ethiopia, Nepal, Guinea, Uganda and Mali. Each of four themes had presentations in a panel format followed by discussion from the audience. Themes included: family planning integration to health and non-health programs; linking USAID Mission bilateral activities to PVO/NGO programs; how bilateral programs complement PVO programs; and the application of operations research to field programming. All presenters made powerpoint presentations that may be downloaded at this site. IntroductionWorkshop Agenda.doc Community-Based Family Planning: PVO/NGO Strategies & Approaches.ppt Margaret NeuseMargaret Neuse, Director, Office of Population and Reproductive Health, USAID, said the Flexible Fund was established in 2003 to support community-based family planning through PVOs and NGOs and to complement USAID Mission programs supporting PVOs and NGOs. The Flex Fund currently manages 24 PVO/NGO projects in 14 countries, with a focus on Africa.
The Flex Fund increases PVO/NGO technical capacity for including family planning in development programs. Some PVOs such as CARE, Save the Children and ADRA strengthen local NGOs to collaborate with local communities to incorporate family planning into maternal health, child health and nutrition programs.
Family planning programs can build democracy. Democracy is strengthened when structures such as health committees are strengthened to create a local voice, address problems and demand better health services. These structures also develop community leadership, which feeds into district and national leadership
The US government’s new foreign aid structure incorporates health, education and the environment into the third of five functional areas, “Investing in People.” The Flex Fund anticipates changes in planning and budgeting, but the restructuring is still evolving. USAID staff will share information with partners as it becomes available . Country operational plans are currently under review.
The new structure outlines new country categories for five different types of states – rebuilding, developing, transforming, sustaining, and reforming. Community-based activities will continue to be important, and USAID will continue to emphasize local partners. The Flex Fund will do a lot more in collaboration with other U.S. government agencies. USAID has identified 35 “fast track” countries which will complete FY07 country operations plans by the end of the year.
Victoria Graham Victoria Graham, Senior Technical Advisor, USAID Flexible Fund, gave an overview of the Flex Fund’s mission, program components and funding breakdown. The Flex Fund manages 24 projects in 14 countries, and has 16 grantees. Project duration ranges from 1 to 5 years. Grants range from $160,000 to $2.5 million and include grantee match and USAID Mission buy-in. The Flexible Fund has provided support to its grantees, CSTS+, Grants Solicitation and Management Project, and the CORE Group.
Emerging issues for the Flex Fund include: 1) What models are emerging for integrating family planning into health sector activities or other development activities?; 2) In what ways can Flexible Fund programs collaborate with Mission bilateral programs?; and 3) To what extent can a Flexible Fund program complement a Mission bilateral program that is already established and implementing family planning activities?
Examples of Flex Fund program collaboration with Mission bilateral programs include: 1) exchange of knowledge and experiences; 2) shared training opportunities with PVOs/NGOs; 3) utilizing partnerships to expand service delivery; and 4) technical assistance.
Session 1: Family Planning Integration into Health and Non-Health ProgramsIntegrating FP into CS Activities : Pragati, India - Expanded Impact Child Survival Project.ppt Family Planning Integration Through a Community-Based Approach: Ihorombe - Madagascar.ppt Integration of FP into Madagascar Faith-Based Organizations Network.ppt FAMILY PLANNING INTEGRATION PROJECT: Angola and Zambia.ppt Moderator: Janet Meyers, ORC Macro
Peggy McLaughlinWorld Vision, presented on the World Vision “Pragati” Child Survival Project in Uttar Pradesh, India, which provides services to approximately 312,000 children under three years of age. Family planning is integrated at the community level through community worker home visits and folklore performances. The Ministry of Health is coordinating all health interventions, including family planning, between its auxiliary nurse midwives and Anganwadi workers. Family planning messages are included in the project’s “timed counseling” approach and delivered through folklore teams. Other opportunities and challenges for integration were also highlighted
Dr. Rija Fanomeza presented on MCDI’s integration of family planning in a community-based water and sanitation project in Madagascar. Integration is carried out at the community and health facility levels. Family planning will be added to the services provided at the basic health centers. At the community level, family planning is integrated through “champion communes,” which mobilize communities for behavior change around a set of common objectives and indicators. Integration also occurs through village health workers, community festivals, village health workers, and joint promotion of water purification products, bednets and family planning products.
Marcie Rubardt presented on behalf of SAF/JKM Madagascar, on the integration of family planning into a national faith-based organizational network. Strong Ministry of Health and USAID Mission support are critical to the successful integration of family planning into their activities. Activities include sensitizing religious leaders to family planning messages, introduction of family planning into church activities such as pre-marital counseling, introduction of family planning messages into sermons, and linking religious leaders with health centers. Various challenges and other opportunities for integration were presented.
Tracy Dolan, Christian Children’s Fund, presented on CCF’s organization-wide, three-year strategy to mainstream family planning into all their development programs starting with Angola and Zambia. For community-based programs, CCF’s strategic planning will link child poverty and family planning objectives and will include family planning interventions in all existing health programs. There are two major entry points of integration: 1) Existing CCF non-health and health programs and their staff; and 2) Three year area strategic planning process and family planning will be highlighted in community and district participatory diagnosis of root causes of child poverty.
Discussion Points
+ The panel on integration demonstrated how PVOs integrate family planning programs into development programs by working through and strengthening community-based structures. Examples included MOH outreach services, community health worker / TBA programs, Ministry of Education program in India that combines early childhood and development and nutrition, water and sanitation committees, church structures of faith based groups, local community festivals, women’s groups and other community structures, community associations, and PVO/NGO structures such as child sponsorship. Challenges to integration of family planning included MOH and community worker coordination, MOH lack of clear policies on community-based distribution, pervasiveness of myths surrounding family planning, reticence of some community leaders, range of partner capacity, technical skills, and values, provision of supervision to ensure quality.
+ The PIP (Project Implementation Plan) development process has been critical to integration in the FBO network in Madagascar. There are a wide range of cultures within the network; this requires a lot of collaboration. The idea that integration requires fewer resources isn’t necessarily true. Developing common reporting mechanisms is time-consuming and difficult.
+ From USAID’s perspective, the CCF strategy linking the importance of family planning to poverty reduction is exciting. CCF has started to develop an advocacy strategy and is raising resources and doing sponsor education for the integration plan.
+ Each of the four projects reported challenges in developing messages targeted to men. In many settings, sterilization is not an acceptable option for men.
+ For the Champion Communes in Madagascar, the key approach is one of community mobilization. Volunteer health care workers are recognized as community leaders. The Mission Bilateral, SanteNet, helps develop common tools, predefined indicators, and monitors activities.
+Depo Provera is a needed service. Sub-Q Depo Provera will be tested in Madagascar this year. The government is encouraging community-level availability.
+For the timed counseling approach in India, counseling is done at home by the Anganwadi workers. They use a notebook designed in three parts, for the prenatal, postnatal and newborn periods. The notebook includes BCC messages for each period. The integration of family planning messages into the “timed counseling” registers is at the discussion stage for Uttar Pradesh State.
+ Within the FBO network in Madagascar, each partner works in a small area; areas do not overlap. All partners agreed to accept all family planning methods. No Catholic groups are represented in the network. Muslim groups did accept all methods. One Muslim group chose not to work in one area where the chief Imam did not approve of family planning. Partners need basic training on M&E. While there is a high level of enthusiasm and potential for scale, the partners have never worked together in this way and require technical and managerial capacity building. Session 2: Linking Mission Bilateral Activities to PVO/NGO ProgramsLinking Mission Bilaterals to PVO/NGO Programs: The Case of Ethiopia.ppt Reaching Marginalized Groups: Towards Social Inclusion in Nepal.ppt Linking bilateral activities to Flexfund projects: Madagascar's Santénet Project.ppt Moderator: Susan Wright, USAID
Winnie Mwebesa, Save the Children, presented on behalf of Save the Children, Plan and ADRA, partners in a bilateral project in Ethiopia managed by Pathfinder. The project, funded in 2003, is showing preliminary results, including increased numbers of family planning users, an expanded method mix, training of traditional birth attendants to promote LAM, and creation of women’s support groups for family planning users, in hard to reach rural and urban areas. PVOs key role is community mobilization through community-based reproductive health agents.
Edson Whitney, JHU Health Communication Partnership, presented on providing community-based family planning services to marginalized groups through linking the Health Communication Partnership (JHU/CCP and Save the Children), the Nepal Family Health Program (bilateral) and the USAID/Nepal Mission. Intermediate results include production of a weekly radio drama adapted for Muslim and Dalit cultures and languages; recruitment of Muslim leaders to promote family planning, and using the partnership-defined quality approach in 36 health facilities for quality improvement.
Leanne Evanson, DC Manager for Madagascar’s SanteNet Project, presented on the 4.5 year TASC2 project, which includes Chemonics, JHPIEGO, TRG, Helen Keller International, IRH and MCDI as lead partners. SanteNet’s partnership with the Flex Fund has led to expansion of a national network of community-based distribution agents for family planning methods, and expansion of Champion Communes for community mobilization. Discussion Points
+ All presenters emphasized the importance of USAID Mission leadership to set the vision, define partner roles and responsibilities, and create an enabling environment for collaboration. Missions have taken on an increased role and obligation to make the projects work.
+ Key lessons learned included the need for formalized partnerships such as a clear Memorandum of Understanding from the beginning, joint work plans, and regular partners meetings.
+ Madagascar faces the same problem as Ethiopia: When NGOs work in a few communes and the government decides to scale up rapidly, you can’t use a small local model. It isn’t affordable, and family planning messages are diluted. Linking with the Mission is important, but linking with the government is more important.
+ For community-based providers, a plan is needed for sustainability and ongoing support. In Nepal, HCP is working through government workers who are running radio listening groups in local languages. The project has also developed a radio program for health workers to increase their skills. In Madagascar, there is a high demand for bed nets. Community-based agents can make money by selling bed nets; this is a promising leverage point to keep agents motivated. Session 3: Assessing the Synergies Between a Mission Bilateral Program and Complementary PVO Programs in Guinea Assessing Synergies Between the Mission Bilateral and .Complementary PVO Programs in Guinea.ppt The Synergies Between Mission Bilateral and PVO Programs in Upper Guinea.ppt Moderator: Victoria Graham, USAID
Tanou Diallo, MSH/Guinea, presented on the MSH/PRISM project in Guinea has expanded the nation’s community-based distribution program in villages where 20% of the Guinean population lives. This was accomplished with support from USAID, the Ministry of Health, local communities and in collaboration with PVO partners that strengthened and expanded service delivery in specific geographic areas. PRISM has worked to integrate the CBD program into the formal government health system, and they piloted a program that allowed trained community-based distribution agents to distribute oral contraceptives. PRISM used this successful pilot to affect a change in national policy that allowed CBD agents to distribute oral contraceptives. Project partners include Save the Children, ADRA and Africare.
Eric Swedberg, Save the Children, presented Save the Children’s and ADRA’s family planning activities in Upper Guinea. Their activities, which expand service delivery in Upper Guinea, include strengthening the district health office; training health center staff; creating, training and supervising community structures (such as village health committees); and building the capacity of local NGOs in health. PVOs created a supportive social environment through dialogue with religious leaders, and special peer education programs for youth. The role of USAID’s bilateral program is to coordinate with the regional Ministry of Health, build capacity of health services, provide training and supervision for reporting; and conduct operations research. Does the work of the PVO improve results? Well, PRISM’s 2003 household based surveys indicate significantly higher CPR (as compared to the national average) in geographic areas where Save the Children is implementing family planning activities that complement the activities of the PRISM project. And, ADRA’s recently conducted household survey also indicates a higher CPR in their program areas.
Nannette Barkey of ORC/Macro and the University of Iowa briefly discussed the secondary data analysis she plans to conduct in the next year to assess the synergies between the PRISM and its PVO programs. Ms. Barkey will document the activities and contributions of each program and determine the extent to which program results are higher in geographic areas where PRISM and the PVOs worked together. Used in this analysis will be two comparative household-based surveys conducted by PRISM (2003 and 2006), an extensive CBD database managed by PRISM (data collected since 1998), and comparative household based surveys conducted by the PVOs.
Discussion Points
+ Lessons learned for maximizing collaboration include the need for partners to clarify roles, consistently measure and share results, use consistent criteria for selection and monitoring of CBD agents, and increase the number of women CBD agents.
+ The issue of providing family planning to youth is a challenge because of early marriage in Guinea. PVOs try to ensure that peer educators reach youth at school and elsewhere. Strengthening primary education system is another way to deal with early marriage, especially by providing girls access to education. It would be good to see a results framework that includes age of marriage and education.
+ Guinea’s DHS for 2005 showed no change in total fertility rate for the country. According to PRISM, CPR rose from 2.9% to 6.9% in upper Guinea where PRISM is working. Where Save the Children and PRISM overlapped, the PRISM survey shows the CPR rose to 22%. Session 4: Operations Research Conducted and Planned in PVO Programs Operations Research & PVO Programs: Lessons from Save the Children in Uganda.ppt Testing a Strategy to Increase IUCD Use in Nepal: ADRA/Nepal Operations Research Proposal.ppt Operations Research:.Expanding Contraceptive Choice in World Vision/India.ppt Moderator: Virginia Lamprecht, USAID
The panel of PVO presenters were either conducting operations research or had recently participated in a two-week Operations Research workshop conducted by the Flex Fund, Frontiers Project (Jim Foreit of The Population Council served as the lead trainer), CSTS+, and the CORE Group. Each participant formulated a research design as part of the workshop.
Winnie Mwebesa, Save the Children, presented on a 2005 Save the Children/Family Health International study in Uganda to assess the safety and feasibility of community-based distribution of DMPA. The study found that community-based provision of injectable contraception is safe, feasible, acceptable and improves access and use of family planning services. FHI and Save the Children now plan to scale-up the provision of DMPA to several new districts while assessing continuation rates, quality of counseling and effects of agent’s gender to provide evidence for policy change.
Save the Children has designed another study to assess the cost-effectiveness per user of family planning service delivery plus CPR in Segou, Mali. Partners include the MOH, Groupe Pivot, and two local NGOs. The study will compare a health systems strengthening model with a health systems strengthening model plus community-based distribution services. The study will assess cost per user and CYP. Save the Children is seeking endorsement of the study design by the Ministry of Health and refining costing tools.
Regenta Kumar Raul, ADRA Nepal, presented an operations research proposal to test a strategy to increase IUD use in Nepal. The study would be conducted in six districts in Eastern Nepal and would assess interventions such as promoting knowledge of the IUD, addressing socio-cultural myths, and training providers in IUD insertion, removal and counseling, increased new acceptors of IUDs.
Peggy McLaughlin presented on behalf of colleagues at World Vision India who participated in the two-week Operations Research Workshop. Their research project examines whether adding SDM and LAM to the existing method mix increases contraceptive use among postpartum mothers in India. Study results would provide added evidence to policymakers on natural family planning methods.
Discussion Points
+ Does LAM get recorded in family planning registers? Yes, LAM is being recording in the registers, as there is space to record any method that the couple is using. The registers have been modified and are being used in the project areas; however, it is still being negotiated with the MOE whether or not the modified registries will be scaled up for the State of Uttar Pradesh.
+ How do we transition from LAM to SDM without risking pregnancy? The training includes instruction on this. After 6 months on LAM, women need 3 months of 26-32 day periods before starting SDM. This is expanding choice; women would have the choice of another method. The study design looks at uptake of all methods, but only follows women up to 1 year post-partum. Closing Remarks Victoria Graham, USAID
The Flex Fund has several promising models for integrating family planning into health and non-health sector activities. Many entry points for family planning were shared; we should continue to explore these. We need to try and document the contribution of community-based programs to democracy building at the local level. Characteristics of community-based programs include involvement in community planning and implementation, building community structures, and strengthening community decision-making. Local bilateral programs should seek out PVOs and NGOs as partners. Alternatively, PVOs should seek out bilaterals to strengthen their programs. We learned about the important role that USAID Missions can take, and heard about the need for role clarification amongst all partners. We still have a lot to learn about the synergies between bilaterals and PVO programs and how to maximize collaboration. For example, technical assistance is needed for operations research if results are to be disseminated and contribute to the knowledge base. PVOs can be a major contributor to the research base for family planning demonstrating the importance of community mobilization efforts for increasing contraceptive use.
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