evidence to action for strengthened family planning and

Evidence to Action for Strengthened Family Planning and Reproductive Health Services for Women and Girls

Cooperative Agreement #AID-OAA-A-11-00024

YEAR THREE WORKPLAN

July 1, 2013 – June 30, 2014

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EVIDENCE TO ACTION FOR STRENGTHENED FAMILY PLANNING AND REPRODUCTIVE HEALTH SERVICES FOR WOMEN AND GIRLS

Year 3 Workplan

Table of Contents Acronyms ..........................................................................................................................................3

Section 1: Overview ...........................................................................................................................5

Section 2: Management .....................................................................................................................8

Section 3: Technical Leadership in Scaling Up ......................................................................................9

Section 4: Integration (FP/RH into Health and non-Health Sectors) .................................................... 25

Section 5: Youth ......................................................................................................................................... 34

Section 6: Service Delivery Strengthening (Community-based Approaches and Provider Capacity) ..... 39

Section 7: Additional Activities .................................................................................................................. 43

Section 8: Field Support Summary .................................................................................................... 47

Section 9: Core Activity Integration at Country Level ......................................................................... 54

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Acronyms

ACHAP African Christian Health Associations Platform ADDOS Accredited Drug Dispensing Outlet AGBEF Association Guinéenne pour le Bien-être Familial AOR Agreement Officer’s Representative APHRC African Population and Health Research Centre AYSRH Adolescent and Youth Sexual and Reproductive Health BOP 8 Bureau Operating Procedure Number 8 BP Best Practice BSR Business for Social Responsibility CHEW Community Health Extension Worker CHW Community Health Worker CoP Community of Practice CSR Corporate Social Responsibility DFID Department for International Development (British Aid) E2A Evidence to Action for Strengthened Family Planning and Reproductive Health Services

for Women and Girls E4A Evidence for Action Project EC Emergency Contraception ECSA East, Central, and Southern African Health Community ET Executive Team FP Family Planning FP/RH Family Planning/Reproductive Health FTP First-time Parents GAFP Gender and Family Planning GBCHealth Global Business Coalition for Health GBV Gender-based Violence GEM Gender-equitable Men GHI Global Health Initiative HER Health Enables Returns HEW Health Extension Worker HIM Healthy Images of Manhood HIP High Impact Practices HIV Human Immunodeficiency Virus HoPE-LVB The Health of People and Environment in the Lake Victoria Basin HTC HIV Testing and Counseling HTSP Healthy Timing and Spacing of Pregnancy IBP Implementing Best Practices IC Improvement Collaborative ICEC International Consortium for Emergency Contraception IPPF International Planned Parenthood Federation K4H Knowledge for Health KU Kenyatta University LA Learning Agenda LAFP Long-acting Family Planning LARC Long-acting Reversible Contraception LGA Local Government Authority

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M&E Monitoring and Evaluation MCH Maternal and Child Health MNCH Maternal, Newborn, and Child Health MOH Ministry of Health MSH Management Sciences for Health NGO Non-governmental Organization PAC-FP Postabortion Care – Family Planning PC Partners’ Committee PHE Population, Health, and Environment PM Permanent Methods PMT Project Management Team PMTCT Preventing Mother-to-Child Transmission PPFP Postpartum Family Planning PST Pre-service Training QI Quality Improvement RFA Request for Application RH Reproductive Health SAI Social Accountability International SMS Short Message Service SRH Sexual and Reproductive Health TA Technical Assistance TAG Technical Advisory Group TOR Terms of Reference TRPFP Training Resource Package on Family Planning TWG Technical Working Group UNFPA United Nations Population Fund UNGC United Nations Global Compact USAID United States Agency for International Development VFCP Virtual Fostering Change Program WAHO West African Health Organization WHO World Health Organization WRAP Worldwide Responsible Accredited Production

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Section 1: Overview Background Evidence to Action for Strengthened Family Planning and Reproductive Health Services for Women and Girls (E2A) is USAID’s global flagship project for strengthening quality family planning/reproductive health (FP/RH) service delivery. The project’s objective is to strengthen quality FP/RH service delivery (facility- and community-based) and increase family planning use. It is led by Pathfinder International, in collaboration with the African Population and Health Research Centre (APHRC), ExpandNet, IntraHealth International, Management Sciences for Health (MSH) and PATH. E2A focuses on gender-equality and uses a life-cycle lens to strengthen programs in ways that address FP/RH needs at all ages. E2A also uses the principles of the USG Global Health Initiative (GHI) to guide its’ programming and its’ learning agenda around best practices (BP). The Year 3 Workplan covers the July 2013 – June 2014 period.

To meet its objectives of strengthening service delivery and increasing FP use, E2A works with

and through public, NGO and private sector implementing, research and advocacy partners at the

country level to identify, apply, evaluate, document, disseminate, and refine emerging, promising

and proven, evidence-based FP/RH interventions, while advocating for and facilitating their

scale-up. At the same time, the project supports the testing of innovative approaches to

strengthening service delivery. E2A places strong emphasis on integration between health and

non-health sectors and seeks to advance the global knowledge base around FP/RH best practices

and integrated program approaches, with a particular focus on learning more about the process of

implementation.

The project’s three Result Areas are:

1. Global support increased for the use of FP/RH best practices to strengthen service delivery. 2. Knowledge synthesized and disseminated about the use of FP/RH best practices to strengthen

service delivery. 3. FP/RH best practices applied and scaled-up in ways that strengthen service delivery.

The E2A team views the results as requiring simultaneous action. They are interrelated, and each informs the other. E2A looks for interest at country level to demonstrate promising and emerging practices to build the evidence base for these, while taking advantage of field support opportunities to assist country programs in the use and scale up of existing, underutilized best practices. Throughout the process, E2A analyzes, synthesizes and disseminates approaches and experiences in the application of best practices that strengthen service delivery, in this way helping to move innovative and emerging BPs along the continuum towards the category of proven BPs and helps implementers to apply BPs in effective ways. In order to develop its global learning and implementation agendas in project year 1, E2A considered country needs, previous and current efforts to define priorities in best practices as well as USAID and GHI priorities, GHI country strategies, and strengths and weaknesses of relevant FP/RH alliances. In Year 2, E2A finalized its learning agenda and summarized its components in the Overview of the Year 2 workplan, in order to lay the foundation for understanding the interconnected nature of activities that fell under different areas of the project results framework. In Year 3, we move away from organizing our workplan by Result Area. While each activity still ties to one or more of the project Result Areas – and these are referenced in the accompanying E2A Goals and Activities table, they are now grouped by four, over-arching themes that can be used to categorize E2A areas of emphasis:

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Technical Leadership in Scaling Up

Integration (FP/RH into Health and non-Health Sectors)

Youth

Service Delivery Strengthening (Community-Based Approaches and Provider Capacity) E2A has also more broadly defined a conceptual framework for service delivery strengthening that links health systems building blocks and essential elements of quality family planning and reproductive health service delivery. The framework serves as a foundation for defining tools and approaches that E2A will continue to employ for strengthening services at country level, depending on country needs. It also forms the backdrop for analyzing best practices and their contribution to service delivery. In implementation, E2A works through key international, regional and national partners and alliances, supporting efforts to implement international agreements and national policies –global guidance as well as country-level policy, standards and protocols – which facilitate the successful application and scale up of BPs. In research, documentation and implementation, partners extend to subgrantees. A number of proposed Year 3 activities reflect this modality. Finally, for scale-up of activities through field support, the project will maximize the existence of its current partner projects in-country, building on their various elements and resources for synergy, greater impact and smooth program start-up and implementation. Year 3 Highlights In Year 3, E2A will complete many activities initiated in Years 1 and 2 under all three Result Areas. A small number of new activities, consistent with E2A’s mandate and learning agenda, will be added. Examples of activities that will follow-on Year 2 activities include: Finalization of reports and dissemination for key research, research synthesis and scaling up activities that will have been largely completed by the end of Year 2:

The assessment reports of the application of Virtual Fostering Change for integrating FP into PAC services in four Francophone West Africa countries - The survey was conducted in Senegal, Guinea, Togo and Burkina Faso in Year 2. Country and regional reports will be finalized in Year 3, along with derivative documents such as program briefs. A regional meeting will be co-sponsored with USAID and the RESPOND Project in October, 2013, in order to disseminate results and provide continuity to this ongoing, regional effort.

Final reports for evidence syntheses around First Time Parent (FTP) approaches and Emergency Contraception (EC) programming – Year 3 will move these activities to the next stage, wherein for example, E2A will continue to support FTP programming in Guinea, including development of FTP messages and systematic documentation of the program approach and its results.

Final reports on the use of data by Health Extension Workers in Ethiopia, as well as on the Sustainability of Management Approaches in Ethiopia will be disseminated; E2A will provide continuity to the theme of data use via Year 3 activities.

The Uganda Improvement Collaborative final report will be produced, reflecting E2A’s two-year collaboration with the STRIDES Project to introduce and scale up an integrated package of FP/MNCH best practices. The report will be disseminated within and beyond Uganda.

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E2A will also provide continuity to ongoing activities geared towards making use of alliances, partnerships and networks for greater scale-up of best practices in FP/RH, including:

Continued technical assistance (TA) to the Implementing Best Practices (IBP) Initiative, including the IBP Advisor, multiple Technical Working Groups and country level exercises.

E2A will move forward with its Resource Partner, the African Christian Health Associations Platform, on a program of subgrants to ACHAP member organizations for introduction and scale-up of best practices and experience sharing among this important network for service delivery.

E2A will continue to actively pursue contributions to FP2020 Collaborating and Technical Working Groups, along with other, key international networks and alliances.

The project will follow-through on activities that build on earlier achievements and that are geared towards strengthening service delivery. To name just a few:

E2A plans to explore with partners in 1-2 countries how to make use of the Training Resource Package for Family Planning (TRPFP) that was finalized in Year 2. Examples include Niger and DRC.

We will identify opportunities to produce evidence around workplace-based FP/RH service provision and advocate for the scale up of successful worksite models, especially those that fill gaps in both men’s and women’s needs for FP/RH information and services.

While the majority of Year 3 activities will provide continuity to those that were initiated in Years 1 and 2, there will be a small number of new activities that do not emerge from ongoing ones. Some of these are:

E2A will refine, continue to build and maintain a Community of Practice on Scaling Up that it will have launched in June, 2013. The CoP will work in close concert with IBP and draw on IBP members, while at the same time seek to be inclusive of a wide array of members in order to fill a gap in wide and effective dissemination of systematic approaches to scaling up in FP/RH.

The project will support initiatives to strengthen comprehensive adolescent and youth sexual and reproductive health service delivery in francophone West Africa. One example in project Year 3 will be E2A support to youth friendly service provision for and by nursing and midwifery students in Niger. Another one, in Cameroon, will support an integrated model of FP/HIV mobile outreach services for youth.

E2A plans to work with the East, Central, and Southern Africa Health Community to build capacity in the region for the application of scaling up approaches and will initiate this work in Year 3.

We will contribute to and build on work already accomplished by others around the monitoring and evaluation of scale-up by developing simple M&E tools for project-level application. While this activity will be an internal, cross-cutting one, our aim is that it contributes to the evidence around approaches to scale-up.

E2A will look for opportunities to assist in the planning for introduction and scale up of best and promising practices in task shifting in countries and/or regions of countries where these have not yet been applied and to support new methods, such as Jadelle or EC, using E2A experience built during Project Year 2.

E2A will continue to build a strong M&E component into all activities and systematically document BP promotion, evidence-building and implementation. We will seek to the greatest extent possible to develop products that can be submitted to peer review journals but will also pursue a wide array of

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dissemination channels for all program results and synthesis documents. These include relevant eToolkits, the E2A website, list servs, technical working groups and presentations at conferences and workshops.

Section 2: Management During Year 2, E2A’s management and partnership structures solidified, while key planning and review processes became more systematized, and administrative systems and procedures were fully operationalized. At the same time, office renovations were completed. The learning agenda (LA) was also implemented via Year 2 activities, which were and are consistent with the LA. Year 2 management accomplishments set the stage for Year 3 project management. Regular meetings are now well-established and have helped to move activities forward and ensure comprehensive team and partnership communications:

The Partners’ Committee (PC) – comprised of a high level representative from each core partner agency – again met twice, completing its bi-annual cycle for the year. This year, the AOR’s participation in sections of these meetings proved valuable for information sharing and exchange between USAID and E2A partner representatives.

The Executive Team (ET) – comprised of one core or key staff from each E2A partner agency – met on a monthly basis to communicate on partnership issues, including country level opportunities related to each of the partners.

Staff and technical team meetings, and meetings with the USAID Project Management Team (PMT), rounded out the series of regular meetings.

The Project Director and technical staff have developed systematic ways of assessing progress to date and using this information to feed into ongoing supervisor-employee communications as well as new workplan development; these modalities are expected to continue. Between December, 2012 and January, 2013, three, full-team meetings (E2A project staff and USAID PMT) were held in order to review progress against activities and against the PMP, set new goals and develop Year 3 activities. These exercises preceded the Year 3 budget request. For the latter, Activity Owners (technical team staff) worked with finance and management staff to develop Activity Budgets in order to ensure ownership of budgets and budget management going forward in Year 3, when Activity Owners will meet on a regular basis to review spending performance with supervisors and the finance team. In terms of staffing, Year 2 saw the departure of the Deputy Project Director in January, 2013, and recruitment started for her replacement. The new Deputy started with E2A in mid-June. APHRC hired a full-time Advisor, who is based in Nairobi and who attended E2A workplanning meetings in Washington, and a new Communications Specialist was hired and began work in May, 2013. Each of these new additions to the team fills a key gap and will enable improved program and management performance in Year 3. An important component of management has been E2A/Washington working closely with country level programs (Burundi, Ethiopia and Tanzania) and Pathfinder Headquarters to adequately plan and address TA and contractual/administrative support needs. Regular modes of communication between all three

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parties are established and should ensure smooth planning and implementation of Field Support going forward. Finally, the project’s website (www.e2aproject.org ) was developed and was launched in May, 2013. With the new Communications Specialist on board, we anticipate quickly populating it with our successes to date in the short term, and with a variety of resources as more technical documents are produced. In summary, in Year 3, we anticipate continuation of the project’s key management structures, regular team meetings and administrative systems. The start-up of the new Deputy Project Director following a gap of several months will alleviate some of the technical workload of the Director and enable renewed attention to systems for improving efficiencies as well as continuous attention to country-level opportunities.

Section 3: Technical Leadership in Scaling Up Activity 1: Global Technical Leadership on Scale-Up E2A seeks to support the scale-up of best practices in RH/FP while also building the evidence around systematic approaches to scaling up by assessing the scale-up approaches themselves. In this way, E2A aims to continuously support the expansion of evidence-based approaches and services while adding to our shared knowledge base of what works and does not work in the process of implementation and scale-up. To this end, when supporting relevant country-level activities, E2A will work with country-level counterparts to determine if there are known, documented, systematized approaches to sustainable scale-up that are relevant and potentially applicable to country needs. In such cases, E2A will endeavor to support the adoption and adaptation of such approaches to country/local context and carefully monitor, document and disseminate the results. Year 3’s Community of Practice on Scaling Up will provide one platform for dissemination. E2A will also continuously present its experiences in the application of scaling up approaches at national and international conferences, and indeed has already done so during its first two years. Ultimately, we hope to have produced a body of evidence around diverse scaling up approaches and to be able to synthesize lessons. At the same time, E2A will focus on disseminating the approaches as widely as possible and building partner capacities at country and regional levels to multiply the dissemination and application of the approaches. Thus, this project year brings proposed activities with ECSA as well as country teams that will at once expand services and build capacity in scale-up. Finally, E2A will look for opportunities to review experiences retrospectively where systematic approaches to scaling up have been applied, in order to assess the sustainability of the approaches and review outcomes in the long term. Some of the approaches that E2A will work to apply, document and disseminate include: ExpandNet/WHO’s conceptual framework, approach, and tools to systematically apply and scale up BPs; the Improvement Collaborative; and Virtual Fostering Change. These three approaches all foster country

http://www.e2aproject.org/

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ownership and build capacity for country leadership to scale up best practices. The approaches emphasize systems, sustainability and scalability.

The Improvement Collaborative is an approach for rapidly improving the quality and efficiency of healthcare. It focuses on a single technical area and seeks to spread existing best practices to multiple settings through systematic efforts in a large number of “resource teams.” A collaborative is a time-limited improvement strategy usually lasting 12-24 months.

Virtual Fostering Change is an approach that creates country stakeholder teams through a highly participatory facilitated four-phase process that covers 1) selecting a best practice; 2) supporting teams during its introduction; 3) creating a scale-up action plan, and 4) bringing the practice to scale

ExpandNet’s Nine Steps for Developing a Scale-up Strategy is a systematic approach that for institutionalizing and expanding innovations that have been successfully tested in pilot projects and other field tests. For initiating a process, Beginning with the End in Mind underscores the importance of considering scale-up when planning to introduce BPs, so that field tests yield knowledge of what is needed for successful scale-up.

A fourth key approach will be to build on existing platforms for scale-up in the private sector, including NGO networks and associations and global business coalitions. This approach can be broken into two main categories:

NGO networks such as E2A’s Resource Partner, the African Christian Health Associations Platform. With member associations in more than 20 countries and a strong tradition of convening and sharing technical updates and experiences, ACHAP is an example of one such platform.

Corporate Social Responsibility Approaches, such as those undertaken by the RAISE Health initiative of the Meridian Group, a current subawardee under E2A. Meridian’s work uses partnerships with global companies, coalitions and regulatory agencies to develop and disseminate successful models of improving women’s health and leveraging these private sector entities to scale up best practices and approaches that strengthen both the policy environment as well as RH/FP service delivery. The approach is an effective one for reaching large, underserved populations.

The thread that links these two sectoral approaches is the concept of making use of structures that naturally provide a platform for scale-up, be it through information-sharing mandates and practices or business incentives, policy and regulatory mandates. Finally, there are other systematic approaches for scaling up that have been documented; for example, Management Sciences International has developed a Scaling Up Framework and Toolkit. This and other approaches will be added to the options to be considered at country level as E2A seeks partnerships for scaling up BPs. Finally, E2A will adopt and adapt already-developed tools to measure scale-up, including those that have been recently developed by other USAID-funded partners. The different models may provide planning resources, tools and approaches that can also be combined and adapted to specific, local needs.

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As with all activities, E2A will document the process of identifying and applying scale up and M&E for scale-up approaches, and synthesize lessons. Our M&E of scale-up effort will receive special attention, with plans in place to create tools for the application of scale-up indicators across different activities. In Year 3, in addition to specific application of approaches and case study learning, we will consolidate an over-arching plan to draw lessons on a wider scale regarding systematic approaches to scale up and will begin to synthesize experiences in Year 4, with the ultimate aim of systematically documenting lessons around approaches to sustainable scale-up by Year 5, while continuing to promote and apply those approaches that are successful. In the Year 3 workplan, this multi-year activity consists of four sub-activities, each of which is described below. Each sub-activity contributes to E2A’s efforts to provide technical leadership in the scaling up of family planning and reproductive health (FP/RH) best practices.

Sub-activity 1: Lead a community of practice on science and practice of scaling up

Background This is a new multi-year activity aimed at leading a community of practice (CoP) on scaling up best practices in family planning and reproductive health (FP/RH), through increased utilization of systematic scaling-up approaches. The CoP addresses E2A’s mandate of improved FP/RH service delivery through building synergies with partners and dissemination of systematic approaches for scaling up FP/RH BPs. The CoP objectives are as follows:

Advance the science, knowledge and evidence base on scale up through an exchange of experiences and lessons learned from using systematic approaches and existing tools to support scaling up (e.g. the ExpandNet, Improvement Collaboratives, Fostering Change, MSI’s Scaling Up Management Framework, use of organizational networks including private commercial and NGO sectors, etc.), advocate for their wider use, the monitoring and evaluation of the process and their outcomes, and advance new areas of learning.

Disseminate information and lessons learned about practical tools and guides for scaling up including approaches and new tools for the documentation, monitoring/evaluation, and costing of scale up.

Share experiences and lessons learned from country programs or projects scaling up interventions intended to strengthen service delivery and generate demand, including interventions related to quality of care, gender inequalities, the needs of young people and men and rights and choice.

Review existing toolkits to support scaling up and explore producing a consolidated one for K4H.

Identify critical research/knowledge gaps on scaling up (i.e. need for more case studies, especially studies on failures; research on the impact of using systematic approaches to scale up) and share findings on gaps as well as emerging research findings on scaling up.

Help achieve the goals of IBP and its members who are seeking to advance knowledge about, and the practice of scaling up, and reach a broad range of audiences including those with limited access to information on scaling up. In Year 2, a small resource team, comprised of key implementing partners that have experience with scaling up approaches, was established to guide the CoP and draft the terms of reference (TOR) before opening the CoP to a larger number of partners. A first draft of the TOR was

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developed and reviewed by the resource team. The CoP will be managed virtually with periodic face-to-face interactions between the resource team members and the larger membership of the CoP. E2A launched the CoP at the June, 2013 IBP meeting. Year 3 Activities and Expected Results In Year 3, E2A will:

Finalize the TOR for the CoP, based on discussions with the Implementing Best Practices (IBP) consortium and other partners (July 2013). This will include clarifying and establishing the CoP’s linkages with IBP, resource team, and other partners

Conduct outreach efforts to encourage IBP partners, regional, and country partners to join (July 2013-June 2014)

Establish and manage the CoP website. The IBP Knowledge Gateway will be utilized for this purpose, following agreements with IBP and other partners to support E2A as needed in managing and supporting the site (August 2013-June 2014).

Update an annotated bibliography of scaling up literature, building on a past bibliography developed by ExpandNet and drawing on recent efforts of the Futures Group to compile related resources. (July – Sept 2013).

Upload on the website systematic approaches and tools for scaling up, annotated bibliography on scaling up, events related to scaling up and successful global and country experiences (August 2013-June 2014).

Organize three webinars on scaling up to provide an overview of systematic approaches to scaling up and share experiences and lessons learned from the use of various scaling up approaches (January 2014-June 2014).

Organize two to four face-to-face meetings with CoP members to complement the virtual platform with discussions on systematic approaches for scaling up and successful experiences (October 2013-June 2014)

E2A achievements will be measured by:

The number of partners (organizations and individuals) that join the CoP.

Number of webinars conducted by E2A and other partners.

Number of website content materials posted on the topic of scaling up.

The number of comments, questions, and answers provided by CoP members with expertise in a given area.

The number of hits on the website.

The number of face-to-face meetings with CoP partners.

The above achievements will contribute to the following E2A performance indicators:

Number of technical consultations held within the scale-up community of practice of which E2A is a member.

Number of individuals participating in community of practice established by E2A.

Number of organizations participating in community of practice established by E2A. Milestones/Deliverables

A CoP for systematic approaches for scaling up FP/RH BPs established.

Routine CoP workshops and meetings held, both virtually and face-to-face.

Updated, annotated bibliography of literature on scaling up.

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Sub-activity 2: Participate actively in global meetings and contribute to working groups at global and country levels Background This is an ongoing activity that started in Year 1 under the title, “Participate in global meetings and working groups which provide forums for linking evidence to practice.” This activity aligns with E2A’s mandate of improving FP/RH service delivery through building synergies with partners, and advocating for best practices. In Year 2, E2A:

Participated in more than 25 technical working groups (TWGs) and Communities of Practice (CoP) for strengthening family planning and reproductive health (FP/RH) service delivery.

Participated and presented at numerous global, regional, and country level meetings, including the Health System Research Symposium in Beijing, 2012 FIGO Congress in Rome, 2012 EuroNGO Annual General Meeting in Brussels, AFP’s Advocacy to Action Meeting for FP2020 follow-up that was held in September, 2012 in Dar es Salaam and 2013 Women Deliver in Kuala Lumpur, among others.

Year 3 Activities and Expected Results E2A will continue to highlight its activities, achievements, and findings through presentations in regional and global meetings and membership of TWGs (July 2013 – June 2014). The participation in these meetings will also facilitate knowledge of and opportunities for partnership with a wide array of organizations, projects and networks with goals and objectives that are in alignment with those of E2A. E2A will also continue to collaborate with the DFID/UKaid funded Evidence for Action (E4A) Project, an activity that was initiated in Project Year 1. The objective of the activity is to ensure adequate inclusion of information and evidence related to family planning (FP) best practices and other relevant E2A technical areas (such as youth, gender, and scale-up) in the communication and advocacy campaigns of E4A, a maternal and newborn health focused project. In doing so, E2A makes use of the E4A communications platform, thus achieving wider dissemination of FP/RH best practices, and builds the partnership for coordinated programming at country level as well. E2A has already contributed to E4A’s compendium of seminal articles and resource materials on the relationship between FP and maternal and newborn health. In Project year 3, E2A will focus on supporting joint regional or in-country women and girls’ health initiatives in one to two countries (possibly Nigeria and Tanzania), such as supporting the inclusion, periodic updating and dissemination of national and sub-national level FP accountability indicators within an overall maternal and newborn accountability framework, or providing technical support for capacity building of advocates related to FP/RH best practices. E2A achievements will be measured by the number of events where E2A actively participates and the number of presentations by the project that either disseminate its achievements or contribute to the learning agenda. Milestones/Deliverables

Presentations by E2A at– 2-3 regional and global meetings, such as the International Family Planning Conference, that are relevant to E2A’s mandate.

E4A joins CoP on the science and practice of scale-up.

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Sub-activity 3: Support efforts of the Implementing Best Practices Consortium, including support to the IBP Advisor Background This is an ongoing, multi-year activity that started in Year 1 under the title, “Support to IBP for scaling-up FP/RH best practices.” This activity contributes to E2A’s efforts to garner global support for increased use of family planning and reproductive health (FP/RH) best practices (BPs). The Implementing Best Practices (IBP) Consortium and E2A have a shared goal of establishing global partnerships that provide leadership in FP/RH BPs with a view to strengthening service delivery. In Year 2, E2A:

Collaborated with the IBP task force to update the Fostering Change Guide and develop a related toolkit on systematic approaches for scaling-up best practices. The first draft of the toolkit was produced and disseminated at the December 2012 bi-annual IBP meeting. A plan for dissemination of the guide has been developed. The toolkit is currently located at the K4H website because it was produced as an electronic guide (http://www.k4health.org/toolkits/fostering-change ). When is ready as a printable file, it will also reside in the Knowledge Gateway on the IBP website, www.ibpinitiative.org.

Made presentations to improve IBP members’ knowledge of three methodologies for scaling-up (ExpandNet tools, Improvement Collaborative, and Fostering Change).

Participated in three IBP task teams - Knowledge Management, M&E for scale-up and Resource Development - and supported IBP in achieving several workplan milestones.

Supported the IBP secretariat in creating an IBP presence in Zambia.

In project Year 2, E2A hired an IBP Advisor to support the IBP secretariat functions. The advisor works at E2A office and is supported by the E2A team. His location at the E2A office has enabled productive coordination between IBP and E2A activities for maximum synergies. In Year 2 the IBP advisor: o Finalized Terms of Reference and facilitated the work of all IBP task teams: Fostering

Change; M&E; Knowledge Management; Marketing; High Impact Practices in FP; Resource Mobilization. This resulted in six active task teams working on advancing the IBP workplan and strategy and scaling up FP effective best practice.

o Supported the IBP Chair and Secretariat in organizing and implementing the IBP bi-annual meetings.

o Supported the IBP Secretariat to introduce IBP in its first focus country, Zambia, through building a partnership with ECSA and organizing a national meeting on scaling up FP with Zambia stakeholders,

o Marketed IBP and attracted new partners to join IBP. o Participated in regional and global technical meetings to disseminate systematic

approaches of scaling up FP best practices

Year 3 Activities and Expected Results Year 3 activities are a combination of Year 2 activities, which were not completed in Year 2 and new ones that will strengthen the partnership with IBP and support the scaling up of FP BPs. Activities surrounding the Fostering Change scale-up methodology will also be included.

http://www.k4health.org/toolkits/fostering-change

http://www.ibpinitiative.org/

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The Year 2 roll-over activities include:

Continue to support the dissemination of the Fostering Change toolkit through 1-2 trainings on the Fostering Change Guide, for United States and regional-based partners (July 2013-June 2014).

Continue to support and maintain close partnership with the IBP Technical Advisor in order to facilitate dissemination and application of evidence-based practices and scaling up approaches through membership as well as the CoP (July 2013-June 2014).

Continue to support the three IBP task teams (July 2013-June 2014). The new activities are as follows:

This year, the IBP Advisor will: o Continue the support to IBP chair, Secretariat, Steering Committee and Task Teams

in implementing the IBP strategy and workplan. o Support the IBP consultant’s work on mapping of best practices in Zambia. The IBP

consultant was hired through WHO funding and will report to the IBP Advisor and Secretariat.

o Support the transitioning of the IBP Chair from MSH to Pathfinder International planned for July 2013.

o Support the Secretariat and Chair in organizing an IBP track in the FP international conference in Addis Ababa.

Support IBP in planning a scale-up session, to be held during the FP International Conference in Addis Ababa (July – December 2013).

Work closely with IBP to develop panels and learning sessions around systematic approaches for scaling up for the International Family Planning Conference, the ECSA Best Practices conference and others. (July 2013-June 2014).

E2A achievements will be measured through participation in IBP task teams, dissemination and application of the Fostering Change Guide, and contributions to the FP2013 IBP session.

Milestones/Deliverables

IBP Consortium on Fostering Change Guide disseminated and utilized in-country with E2A support.

Meeting/workshop conducted for IBP country resource team/task force to build its capacity in scaling up.

Session on scaling up approaches designed and implemented during the IBP track of the International FP Conference in Addis Ababa.

For the Advisor: (1) Minutes of the two IBP bi-annual meetings and six IBP task team meetings; (2) Zambia mapping report on FP best practices completed; and (3) Report on the multiple IBP panels organized and implemented at FP international meeting in Addis Ababa

Sub-activity 4: Pregnancy Spacing Literature Review Background This is a new activity that will help strengthen the evidence that shows family planning (FP) as a practical intervention for improving maternal, newborn, and child health (MNCH) outcomes through optimal pregnancy spacing. Studies have shown a potential link between negative

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MNCH outcomes and closely spaced pregnancies, which could be prevented through the use of FP methods. The Extending Service Delivery (ESD) project played a pivotal role in generating and disseminating evidence linking closely-spaced pregnancies to adverse maternal and child health outcomes. Although there had been original research commissioned by CATALYST, ESD’s predecessor, calling attention to the inadequacy of existing birth spacing guidelines, ESD helped push the agenda forward by discussing the healthiest time for pregnancies to occur (i.e., the healthy timing and spacing of pregnancies/HTSP). Much of this evidence came from several sponsored studies, including:

In 2007, researcher Conde-Agudelo’s Effects of birth spacing on maternal health: a systematic review. This paper looked at 22 studies examining the relationship between interpregnancy intervals and adverse maternal outcomes, finding that both long and short intervals are associated with increased risk of negative maternal outcomes.

In 2008, another key study was published by Julie DaVanzo, The effects of pregnancy spacing on infant and child mortality in Matlab, Bangladesh: How they vary by the type of pregnancy outcome that began the interval. Using longitudinal data from Matlab, Bangladesh, DaVanzo and colleagues assessed the effects of duration of intervals between pregnancy outcomes on infant and child mortality, ultimately finding that shorter intervals are associated with higher mortality and stating that “…many relationships found are consistent with the maternal depletion hypothesis, and some with sibling competition,” although the need for more data was cited.

In 2012, Agudelo and colleagues published Effects of Birth Spacing on Maternal, Perinatal, Infant, and Child Health: A Systematic Review of Causal Mechanisms which examined emerging evidence showing that short intervals between pregnancies are associated with “an increased risk of adverse neurodevelopmental and cognitive outcomes such as autism” and calling on researchers to “examine these associations further, to advance knowledge about causal mechanisms.”

The new literature review that E2A is proposing for Year 3 will build on this existing evidence while more closely examining the relationship between pregnancy spacing and maternal and child morbidity, specifically infant/child developmental and cognitive delays. In Project Year 3, E2A will engage a researcher to conduct a literature review on the relationship between pregnancy spacing and maternal and child morbidity and infant/child developmental and cognitive delays. This activity contributes to the USAID Technical Priority Areas of healthy timing and spacing of pregnancy, and FP/MNCH integration. Year 3 Activities and Expected Results

Hire a consultant (July 2013 – September 2013) who will: o Prepare an outline of literature review and submit for review and approval by E2A

and USAID/Washington (October 2013 – December 2013). o Prepare first draft of literature review and submit for review and approval by E2A

and USAID/Washington (February 2014 – April 2014). o Submit final draft of literature review by June 2014.

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E2A achievements will be measured by the completion of the literature review to the satisfaction of E2A technical staff and USAID/Washington. Milestones/Deliverables

First draft of literature review

Finalized literature review

Publication submission Activity 2: Application of a systematic approach to scale-up best practices in family planning in multiple countries This is an ongoing, multi-year global activity that addresses an E2A core mandate of providing leadership in scaling up evidence-based best practices (BPs). This year, in consultation with core partners, USAID/Washington, and Missions, E2A will work with country stakeholders to identify and select potential BPs to introduce and/or scale-up using systematic scale-up approaches. Documenting the processes and outcomes will contribute to the evidence on the science and practice of scaling up. Several, proposed sub-activities are covered under this main activity and each of them is described below. E2A will explore opportunities for implementing each of the proposed sub-activities. Sub-activities 1 and 2 are ongoing and are therefore assured, as is sub-activity 6; sub-activities 3, 4 and 5 will depend on country-level needs and interest, the scope of those needs (i.e. budgetary implications) as well as USAID mission approval.

Sub-activity 1: Application of small grants methodology to introduce and scale up family planning and reproductive health best practices among African Christian Health Associations Platform members Background This is an ongoing multi-country activity that started in Year 2 under the title, “Promote and scale-up FP/RH best practices to strengthen service delivery by linking existing advocacy initiatives to program implementation.” The objective of this activity is to develop approaches to scale up family planning and reproductive health (FP/RH) best practices among faith-based and community-based organizations. In part, the scale-up approach is based on the use of the ACHAP platform itself, which has established communication and experience-sharing activities among the member organizations which encourage scale up based on shared experience of successful approaches. The E2A support will give added impetus to this aspect of ACHAP’s work around RH/FP. The objective is expected to be achieved through small grants, technical assistance to build capacity of the network, and strong monitoring, evaluation and documentation of approaches. It is anticipated that the interventions will strengthen: (i) FP/RH counseling and services; (ii) referral, monitoring, and supervision systems; and (iii) quality of data at community and facility levels. This activity will contribute to the USAID Technical Priorities of community-based FP services, and repositioning of FP in sub-Saharan Africa. In Year 2 E2A:

Developed and issued the Request for Applications (RFA).

Worked with the African Christian Health Associations Platform (ACHAP) to identify common priorities and member CHAs.

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Participated and presented on FP topics during the regional meeting for ACHAP in Zambia. Year 3 Activities and Expected Results The Year 3 activities will include a roll-over of Year 2 activities and new ones. The Year 2 roll-over activities are:

Review proposals in response to the RFA, and select the best applicants (Sept. 2013).

Conduct pre-award assessments for best applicants (Oct.-Nov. 2013).

Obtain USAID Mission approvals (Oct.-Nov. 2013).

Collaborate with ACHAP to develop a proposal that specifies ACHAP’s role in monitoring, dissemination, and documenting the processes and results of the country projects (October 2013).

Award grants to ACHAP and 4-5 ACHAP members (Oct.-Nov. 2013).

The new Year 3 activities are:

Provide technical assistance (TA) to support ACHAP members in developing improved quality of FP services at the community and facility levels (October 2013-June 2014).

Support ACHAP to implement project activities (October 2013-June 2014).

E2A achievements will be measured through: the award of 4-5 grants to ACHAP members, one grant to ACHAP, monitoring progress against workplan of each grantee, and provision of virtual and on-the-ground TA. This activity will contribute to the below E2A performance indicators:

Number of small grants awarded to scale up FP/RH BP

Number of BPs adopted and/or scaled up, by country or organization


4-5 grants awarded

Virtual and on-the-ground TA provided to monitor grant implementation, based on grantee needs as identified during the pre-award analyses.

Training of ACHAP and grantees in the application of M&E tools for scale-up as applicable, and application of the tools by grantees.

Sub- activity 2: Application of Improvement Collaborative methodology to scale-up family planning and reproductive health best practices in Uganda Background This is an ongoing activity that started in Year 1 under the title, “Support Improvement Collaborative (IC) methodology to scale-up FP/RH best practices in Uganda.” This activity contributes to E2A’s efforts to build country capacity in systematic approaches for scaling up, and in documenting the processes and results of scaling up. E2A has provided technical assistance to the MSH STRIDES project in Uganda for the integration of family planning (FP) into a maternal, newborn, and child health (MNCH) package, utilizing the IC approach. This activity contributes to the USAID Technical Priority Areas of FP/MNCH integration, and the repositioning of FP in sub-Saharan Africa.

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In Year 2, E2A:

Supported STRIDES to expand the implementation of IC from 10 to 46 facilities.

Collaborated with STRIDES to design, plan, and implement the second learning session for 19 facilities.

Supported the quality improvement (QI) teams and STRIDES through the verification of data, and trained QI teams in data quality, reporting, and use of data for decision making.

Conducted a survey on gaps in leadership for all IC champions, and provided recommendations to STRIDES on how to address those gaps in the next leadership training for the IC champions.

Supported STRIDES in documenting the IC work for the period of March 2012-December 2013.

Year 3 Activities and Expected Results

Continue virtual TA to STRIDES to improve quality and integration of FP in the expansion sites (July 2013-June 2014).

Complete a Technical Brief which documents the process and results of the IC (July 2013-September 2013).

Present the IC process and results at the International FP Conference in Ethiopia (dependent on the acceptance of the abstract submitted) (November 2013).

Support STRIDES in its advocacy efforts through participation in the national dissemination workshop for the IC (pending STRIDES approval) (September 2013).

Support STRIDES to develop a plan for national spread and sustainability of the clinical package (pending STRIDES approval) (September 2013).

E2A achievements will be measured through the effect of IC on FP integration, improved quality of services, and scaling up. This information will contribute to the following E2A performance indicators:

Number of countries in which FP/RH BPs are introduced and/or scaled up with technical support from E2A, by BP

Number of scale-up methodologies/approaches that are systematically monitored and evaluated to analyze effectiveness

Number of instances/incidences where systematic scale-up approaches (e.g., Improvement Collaborative, Fostering Change, ExpandNet, Grant mechanism, network mechanism) were adopted by host country government or institutions, by type of scale-up approach

Number of countries or instances where FP/RH services are integrated into (or linked to) other health programs (for example, HIV, PPC, PAC, ANC, GBV, and/or immunization)

Number of countries where both government and other relevant stakeholders (civil society, MOH) participate in planning and implementing scale-up of FP/RH BPs

Number of BPs adopted and/or scaled up, by country or organization Milestones/Deliverables

Technical Brief that documents the process and results of the IC and M&E of scale up.

Participation in the national dissemination workshop for the IC (pending STRIDES approval).

National expansion (pending STRIDES approval of E2A involvement).

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Sub-activity 3: Application of the ExpandNet or other systematic methodologies to scale-up and strengthen postabortion care-family planning integration in two or more countries in the West Africa Region Background This is an ongoing activity that started in Project Year 2, under the title, “Document and share lessons learned on success and failures of introduction and scale-up of PAC/FP best practices.” This multi-year activity builds on the postabortion care – family planning (PAC-FP) assessment conducted in four Francophone countries: Senegal, Guinea, Togo, and Burkina Faso. The activity aims to use the findings of the PAC-FP assessment to improve quality of PAC and if applicable, introduce planning for systematic scale-up of PAC-FP, a USAID high impact practice, in one to two countries. This activity contributes to the USAID Technical Priority Area of PAC-FP. In year 2, E2A conducted an assessment of the application of the Virtual Fostering Change Program (VFCP) to strengthen PAC-FP in four Francophone West Africa countries. Specifically, E2A:

Conducted an extensive desk review (published and grey literature), which included country action plans, and progress reports on the implementation of action plans and the VFCP.

Conducted key informant interviews with members of the action plan teams from the four countries that attended the PAC-FP 2008 regional meeting in Saly, Senegal. Interviews were conducted with MOH policy makers, PAC focal point persons, US-based and in-country stakeholders, VFCP facilitators, and development partners.

Conducted focus group discussions with service providers at pilot facilities where the action plans were implemented.

Reviewed PAC registers for: client volume, client age, parity, type of abortion, whether the client received counseling, method accepted, and referral for other reproductive health services (from 2008-2012).

Started data analysis and report writing. Year 3 Activities and Expected Results In year 3, E2A will complete activities that were rolled over from Year 2 and initiate new ones that help to maximize program effects. The Year 2 rollover activities include:

Complete data analysis and report writing (June - September 2013)

Present assessment findings at the PAC-FP regional meeting (October 2013)

Introduce scaling up approaches, ExpandNet Nine Steps and Improvement Collaborative, at the PAC-FP Francophone regional meeting (October 2013)

Finalize country and consolidated assessment report and share with countries, USAID missions, and other partners (November 2013)

Prepare fact sheets and peer-reviewed journal paper (Finalize: March 2014) In addition to the above year 2 roll-over activities, the following activities are proposed, with final country level implementation to be determined based on country level need and interest, as well as USAID mission approvals:

Conduct workshops for MOH and FP/RH stakeholders in at country level, based on needs and country requests.

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Workshop objectives may include: o Support country teams to disseminate findings from the assessment to in-country

stakeholders and develop strategies to address gaps in quality, access, guidelines, tools and/or scale-up to other facilities.

o Introduce scaling-up approaches, such as ExpandNet Nine Steps and/or the Improvement Collaborative. Support the team to select appropriate approach(es) to address gaps and/or scale-up.

o Facilitate the development of implementation and monitoring plans for PAC-FP quality improvement, scale-up planning or other technical assistance.

o For scale-up, establish a resource team and build its capacity to lead implementation and monitoring of PAC-FP scaling up plans.

In addition to other milestones and deliverables, achievements will be measured by E2A’s performance indicator:


Milestones /Deliverables

PAC-FP assessment reports: one for each country, and one consolidated report

Fact sheets

Paper for publication in peer review journal

Technical assistance reports

Quality improvement and/or scaling-up plans for PAC-FP for countries where E2A provides TA.

Sub-activity 4: Systematic introduction and scale up of contraceptive implants Background This activity will build on lessons learnt from the technical assistance provided by E2A to the USAID supported Burundi MCH Project to introduce Jadelle with a view to expanding method mix. E2A will identify countries from among those where it is receiving field support (or where field support is anticipated) that are either registered for the Jadelle price reduction, and/or those that are introducing or scaling up Implanon, and will provide technical assistance based on country need to introduce use of dedicated service providers to provide implants and other long acting contraceptives. Year 3 Activities and Expected Results In Year 3 E2A will:

Identify countries that are actively seeking to introduce/scale-up implants (ongoing). Illustrative countries are DRC and Nigeria, pending field support.

Conduct a rapid assessment of the policy, service delivery, training, supervision, and information systems for the introduction of implants in 1-3 countries (September-December 2013), dependent on field support and country context.

Provide technical assistance to adapt Trainers Modules that include competency based training methods, counseling for implants and other family planning methods, insertion and removal for relevant implants (November-January 2014).

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Conduct first country’s Training of Trainers (ToT) workshop to build skills on counseling, FP update, infection prevention, insertion and removal and application of competency based training methods and training follow-up (February 2014).

Support trainers to conduct initial training and provide a follow-up of trainers as they roll out on-the-job training for providers. If field support is provided or if existing projects support roll-out, more extensive cascade training can be supported. (March-June 2014).

Document the process and outcomes of introducing the respective implants (November 2013-June 2014).

Prepare orientation materials and job aids for CHWs that will enable them to: conduct education sessions on implants and other LARCS to generate demand; counsel clients for voluntary informed choice; refer for LARCS; follow-up clients and encourage continuity on implants and other LARCS (January 2014).

Integrate supportive supervision for provision of implants within current supervision system for family planning (March 2014).

In addition to other milestones and deliverables, achievements will be measured by E2A’s performance indicators:



Milestones/ Deliverables:

Country-specific Jadelle training curricula and job aids for nurses and midwives.

Orientation materials for CBD on LARCS

Job aids on LARCS for CBDs

Tools for supportive supervision for implants provision.

In Year 4 E2A will prepare and disseminate a program brief on Introduction of implants in various settings.

Sub-Activity 5: Introduction, system strengthening or planning for expansion of evidence based YFS models, including in Niger and Cameroon Background This is an activity that builds on Year 2’s activity, “Develop guide to design Youth Friendly Services for in and out of school youth.” The guide is expected to be completed in October of 2013. E2A will support the process of planning for the introduction and scale up of YFS models in countries, as well as documentation of the scale-up process. The YFS Guide will guide community and facility-based adolescent and youth sexual and reproductive health programs implemented, or whose implementation is supported, by E2A. Additionally under this activity, E2A will respond to a request for technical assistance from USAID West Africa to strengthen and scale up YFS services in Niger and Cameroon. Specifically, E2A will co-share the cost (with core funds) of two activities to be supported by USAID West Africa (with field support).

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Under this scope of work, E2A will:

In Niger, adapt successful model curricula to build the skills of nursing and midwifery students as well as skills of practicing nurses and midwives to deliver family planning counseling and services for young clients, first-time parents, postpartum and postabortion women. This activity provides a possible opportunity for application of components of the FP Training Resource Package which was developed under E2A in previous project years.

In Cameroon, support integration of youth-friendly family planning services into HIV mobile outreach platforms, OVC services or PMTCT, based on preliminary findings of a September, 2013 visit and discussions with USAID West Africa and key counterparts in the country.

In Year 2, E2A:

Conducted a preliminary desk review of models of YFS and compiled a concept paper describing the rationale and need for such a guide, main approaches to YFS and the structure of the proposed guide.

Presented preliminary recommendations on different YFS models during the Women Deliver Conference.


Complete the YFS Guide that was started in Year 2;

Provide technical assistance to country level counterparts in Niger and Cameroon: o Niger – all activities to be coordinated with existing USAID family planning

projects and activities: - Adapt existing curriculum for nursing and midwifery schools and nurses and

midwives professional associations, adding YFS components. - Conduct trainings for students, nurses and midwives (in collaboration with

professional associations), including skills training on insertion and removal of long-acting reversible contraceptives and provision of youth-friendly services.

- Monitor and evaluate implementation to build knowledge for sharing across the region.

o Cameroon – all activities to be coordinated with existing USAID family planning

and HIV projects and activities: - Identify and train HIV providers in mobile outreach teams to provide quality

family planning services to youth. - Identify and build onto existing behavior change approaches for practicing

safe sex for prevention of both pregnancy and HIV transmission.

Monitor and evaluate implementation to build knowledge for sharing across the region

As mentioned the Cameroon activities may vary from this initial description following a joint E2A/USAID visit to Cameroon in September, 2013. Similarly, USAID West Africa has encouraged E2A to fill gaps in youth programming in Niger, such that the final activity will be designed to

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complement other existing efforts of RH/FP partners in Niger. In both cases, youth friendly services will remain a focus. E2A achievements will be measured by the development and dissemination of a program brief, and the number of countries in which YFS are introduced or scaled up with technical support from E2A. Additionally, this activity will contribute to the following E2A PMP indicators:

Number of countries where both government and other relevant stakeholders (civil society, MOH) participate in planning and implementing scale-up of FP/RH BPs.

Number of BPs adopted and/or scaled up, by country or organization.

Number of countries in which FP/RH BPs are introduced and/or scaled up with technical support from E2A, by BP.


Program Brief

Updated training curricula in Niger

Model developed and documented for integrated outreach services in Cameroon

Process and output measure will also be reported as a part of a more detailed PMP linked to the field support in Niger and Cameroon.

Activity 3: Build Capacity of the East, Central, and Southern Africa Health Community to systematically scale-up family planning and reproductive health best practices Background The objective of this new activity is to create a regional resource for systematic scaling up of family planning and reproductive health (FP/RH) best practices (BPs). The objective will be achieved through capacity building of a technical team from the East, Central, and Southern Africa (ECSA) Health Community. ECSA is collaborating with the IBP Secretariat on the application of Fostering Change to scale-up BPs. This activity contributes to the USAID Technical Priority Area of repositioning family planning in sub-Saharan Africa. Year 3 Activities and Expected Results Activities planned for Year 3 are intended to create awareness of systematic scaling-up approaches and their contribution to sustainability of FP/RH BPs. The activity will strengthen the capacity of the technical team at ECSA to facilitate the introduction and support application and documentation of scaling-up approaches. E2A will build the capacity of ECSA to use the ExpandNet tools, “Beginning with the end in Mind” and “Nine Steps for Systematic Scaling,” and the Improvement Collaborative approach. As much as possible, E2A will leverage ECSA’s planned regional interventions to implement these activities. Member training institutions from Zimbabwe, Kenya, Malawi, and Tanzania have expressed interest. In the longer term, ECSA-led scaling up exercises will also provide an additional platform for learning around scaling up as they adapt the approaches to their unique needs. E2A will work with ECSA to implement the following activities:

Leverage the FP/RH Best Practices Forum to introduce scale-up principles and methodologies: Fostering change, “Beginning with the end in Mind,” “Nine Steps for Systematic Scaling,” and

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Improvement Collaborative. E2A will also provide examples of country experiences in applying systematic approaches and tools, such as the Health of People and Environment in the Lake Victoria Basin (HoPE-LVB) Project, and the Tupange Urban Reproductive Health Initiative in Kenya (August 2013).

Organize a three day seminar to train the ECSA technical team as scaling up resource persons (October 2013-January 2014, dependent upon ECSA’s availability).

Support ECSA to facilitate and document systematic scaling up of a selected BP in the region, or in one of the member states. (January 2014-June 2014, dependent upon ECSA’s plans).

E2A will measure achievements by documenting the number of FP/RH BPs scaled up with ECSA support, by type of BPs. This will contribute to E2A’s performance indicators:

Number of instances/incidences where systematic scale-up approaches (e.g., Improvement Collaborative, Fostering Change, ExpandNet, Grant mechanism, network mechanism) were adopted by host country government or institutions, by type of scale-up approach

Number of BPs adopted and/or scaled up, by country or organization Milestones /Deliverables

Training report

Technical Brief on application of scaling-up methodology.

Section 4: Integration (FP/RH into Health and non-Health Sectors) The integration of FP into MNCH, Nutrition, HIV/AIDS and non-health sectors has been recognized as a key strategy towards attainment of the Millennium Development Goals to improve maternal health (MDG 5) and to combat HIV/AIDS, malaria and other infectious diseases (MDG 6) and has potential to have a positive impact on MDG 3 (Promote Gender Equality and Empowerment) and MDG 4 (Reduce Child Mortality). Many successful approaches to implementing integrated services have also been documented and have the direct potential to improve FP/RH outcomes. Integration is among the top priorities in GHI country strategies. At the same time, information about integrated services is still lacking. More evidence is needed to answer questions relating to the most effective and cost-effective elements to integrate, at which levels of service delivery, models of integration, types of providers involved, types of training and supervision and effects on quality of care, among others. E2A will take a dual approach to integration, working to establish opportunities to scale up integrated services while also documenting approaches and outcomes to contribute to the body of evidence for integrated services. As this is a vast topic, E2A will focus its core resources on specific elements of integration where the project may add value and contribute to impact, including FP integration into PAC services (An example will be reflected in the upcoming report on the E2A assessment of the FP component of PAC services in four West African countries.), PPFP and FP into non-health programs, with a gender and youth focus. E2A will focus some of its core funding on this work but will also rely on obtaining field support funds to contribute to evidence around integration, especially FP/HIV integration, and for all scaling up activities. During Project Year 1 and continuing into Year 2, for example, Burundi Field Support was directed through E2A to support the introduction of Jadelle into national family planning guidelines and curricula; E2A is currently finalizing a report and will produce a

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program brief describing the process of the introduction of this method within the integrated MCH/FP project. In Year 3, we proposed to deepen the project’s contribution to learning about integrated services (practices and approaches as well as scale-up models), with an emphasis on gender programming and workplace and private sector for scale-up. The two workplace activities are examples of health-to-non health sector integration and will enable learning around service delivery modalities that work (or do not work) in this context. They offer additional learning opportunities as well, for how to strengthen service delivery in worksite health services and/or though referral systems. The one population-environment-health activity offers a unique opportunity for additional health-to-non health integration learning, with an added learning objective around the application of ExpandNet approaches. Finally, two FP/health integration activities – one that strengthens FP within PMTCT and another that will develop integrated HIV/GBV/FP activities – offer the possibility of looking at ways in which these models may improve service quality or use through changes and improvements in multiple service delivery components. Where feasible, we will integrate costing components in order to also develop information around the cost of integrated services and explore any analyses that may shed light on cost efficiencies of integration, although we do not propose to undertake research on this subject. Activity 4: Evaluation of the Business for Social Responsibility approach as a possible model to scale up integration of family planning and reproductive health services into workplace settings Background This is an ongoing, multi-year activity that started in Project Year 2 under the title, “Support Business for Social Responsibility’s (BSR) implementation of workplace FP/RH services.” This activity builds on an ongoing collaboration with BSR/HER (Health Enables Returns) Project. This activity contributes to the following USAID Technical Priorities: community-based family planning services, healthy timing and spacing of pregnancy, gender, and youth. The activity will be implemented to generate evidence that informs strategies to expand the implementation of workplace based family planning and reproductive health (FP/RH) service delivery interventions with a view to improving access of women and girls to FP/RH services. In this regard, the partnership will implement an operations research with the objective of determining whether the BSR/HER model can increase the uptake of FP/RH services among factory workers. It was originally proposed as activity in up to two countries. However, due to Year 2 challenges described below, E2A will advance in Year 3 to exploring Bangladesh – an active BSR country- as the focal point for implementation of this activity. Another objective is to establish and document a replicable model for increasing access to FP/RH services for women and girls through effective workplace services. The study will have an intervention and a non-intervention site. The outcomes of interest will be tracked over a 12 month period, commencing immediately after the training of peer-educators on FP using tools that will be measured at baseline, midline (6 months after baseline) and at endline to determine the effects of the intervention on utilization of FP. The proposed Bangladesh study affords E2A the opportunity to generate evidence on the potential of the BSR/HER project model to increase uptake of FP services from a non-sub- Saharan Africa setting and in a different sector (garment factory instead of the horticultural farms that have been the site of much of the HER work in SSA). It is anticipated that the Bangladesh study will be implemented in partnership with a local research organization and/the BSR HER project’s local partner in Bangladesh.

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Because of the initial delays occasioned by the intricate, multi-layered negotiations on the selection of research sites among various BSR stakeholders (brand owners, local suppliers, farm owners and local BSR implementing partners) coupled with the process of securing the necessary USAID mission concurrence and ethics clearance, the activity was not initiated as scheduled in Year 2 in the first country that was identified. Year 3 implementation in Bangladesh will require and depend upon new discussions to ensure a good fit with country level needs and capacities. Despite the implementation challenges, E2A, in collaboration with BSR/HER and its local partners were able to do the following in Year 2:

Concluded negotiations and planning for the conduct of the research.

Developed the research protocols for the initially proposed country (Kenya) and sought clearances from the USAID Mission.

Developed and submitted a concept note to USAID Egypt for consideration of support to this model in Egypt. (Note: E2A did not obtain approval for application of this proposal in Kenya or Egypt.)

Began planning for the Bangladesh study as a proposed Year 3 site. Year 3 Activities and Expected Outcomes As stated above, the Year 2 activities will be rolled over to Year 3 Activities include the following:

Engage potential local partners and USAID Bangladesh to determine interest and unique research needs applicable to Bangladesh, as well as approval. (July-August 2013)

Develop study protocol and seek clearance from appropriate ethics review board. (July-September 2013).

Obtain IRB clearance for the Bangladesh study (July – September 2013).

Conduct baseline survey (October-December 2013).

Conduct endline survey (April – June 2014). The study will contribute to the following E2A performance indicators:

Number of countries or instances where FP/RH services are integrated into (or linked to) non-health programs.

Number of operations research conducted. Milestones/Deliverables

Technical Report on the studies

Summary reports on baseline and endline surveys of the Bangladesh study.

One to two small grants issued to local implementation partners to undertake surveys. Activity 5: Strengthen the integration of the family planning component and preventing mother-to-child transmission services in Nigeria Background This is a new activity aimed at supporting the integration of family planning (FP) into a field-funded preventing mother-to-child transmission (PMTCT) program in eight states of Nigeria, as part of the Nigerian accelerated PMTCT plan. Though the first two prongs of a PMTCT program relate to family planning services, program experience has shown that operationalizing the two prongs and leveraging

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the integration opportunity of PMTCT to deliver FP services to PMTCT clients require dedicated and focused attention and investment. E2A will identify gaps in the provision of FP counseling and methods within PMTCT. Information from the gap assessment will guide the design of innovative ways to provide FP counseling and methods in PMTCT services. E2A will ensure the inclusion of FP in the skills-building strategies of the PMTCT program that target service providers and their supervisors from the health facilities. This activity contributes to the USAID Technical Priority Area of FP/MNCH and FP/HIV integration and to the E2A learning agenda to deepen understanding of sustainable approaches to strengthening FP service delivery within PMTCT services. This activity will leverage existing materials and resource persons from ongoing FP, PMTCT, and other HIV prevention programs both nationally and within the eight project states. This is to ensure full integration of FP counseling and service provision into the facility and community level PMTCT program using relevant government structures at national and state levels, other USG/development partner implementers, and civil society organizations. Year 3 Activities and Expected Results E2A Year 3 activities will include the following (The timing of implementation of this activity is dependent on the timing of the expected field support funded PMTCT activity):

Provide technical assistance to incorporate FP counseling and provision of a broad range of methods in the training material.

Provide skills-building for the training of trainers using competency-based training methods and step down trainings that will strengthen the FP component of the PMTCT program across the eight states.

Build capacity of trainers to supervise the service providers and support any reorganization of services required to provide FP counseling within antenatal care services and FP counseling and methods during the immediate and extended postpartum period.

Strengthen community-based FP and referral through the community component of the PMTCT program.

E2A achievements will be measured by the extent to which milestones and deliverables are achieved as well as through a standard set of PMTCT indicators to be included in a separate PMP for the Field Support activity. Milestones/Deliverables

Report, outlining improvements in FP counseling and services linked to PMTCT, including process documentation regarding how FP services were integrated at ANC and within postpartum services as well as outcomes, the scale-up process and programmatic implications in relation to PMTCT provision elsewhere in the project states as well as nationally.

For task shifting, gap analysis report.

As mentioned above, this activity is meant to build on a Field Support-funded PMTCT project. If that project materializes, enabling this added component, E2A will develop a separate PMP for the field support, within which E2A will include indicators of program and population coverage, as well as quality indicators. These will include essential PEPFAR PMTCT indicators as well as recommended ones as determined by the PEPFAR country team. Examples include: Number of pregnant women with known HIV status (includes women who were tested for HIV and received their results); Number and percentage of HIV-positive pregnant women who received antiretrovirals to reduce risk of mother-to-

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child-transmission during pregnancy and delivery, by regimen type; Number of health facilities providing ANC services that provide both HIV testing and ARVs for PMTCT on site, among others.

Sub-Activity: Implementation of injectable contraceptives (CBA21) at the community level in support of national policy in Nigeria Background This is a new, multi-year activity to be implemented in select facilities in one or two states of Nigeria, in conjunction with anticipated PMTCT Field Support. This activity provides support to the recent policy shift that approved the provision of injectables at the community level, and offers opportunities to strengthen service delivery and improve access to quality family planning (FP) services for women and girls at the facility and community levels. The activity contributes to the USAID Technical Priority Areas of gender and contraceptive security. It also aims to strengthen service delivery through multiple channels, depending on specific needs to be identified, but which may include improved access to methods, improved quality of care, better organization of services and efficiencies through task shifting, as well as tools development as needed. Year 3 Activities and Expected Results This activity will be implemented within the cluster model of the Nigerian health system that links a hierarchy of health facilities with a defined population catchment area for purposes of service delivery strengthening and referrals. E2A will implement the following activities, designed to translate the policy into practice:

Conduct an assessment of the capacity of CHEWS and health facilities to expand the method mix (to include injectables and emergency contraception) through community-based outreaches and facility-based services. The assessment will also identify gaps in referral linkages and data use at community level (July -September 2013).

Explore opportunities to address the gaps identified through the assessment and identify appropriate technical assistance (TA) role for E2A (September- October 2013).

Share the findings from the assessment with relevant stakeholders (September- October 2013).

Provide TA to support implementation and documentation of processes and outcomes (December 2013-June 2014).

This activity will contribute to the following E2A performance indicators:

Number of countries or instances where FP/RH services are integrated into (or linked to) other health programs.

Number of countries where both government and other relevant stakeholders (civil society, MOH) participate in planning and implementing scale-up of FP/RH BPs.

Deliverables:

Report outlining key gaps and opportunities for the expansion of method mix through the provision of injectables at community level by CHEWs in Nigeria.

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Activity 6: Integrate family planning (FP) into gender-based violence (GBV) screening tool in community-based HIV counseling and strengthen FP and GBV referral network system in Zambia Background This is a new activity through which E2A hopes to contribute to knowledge on successful integrated program approaches, with additional focus on referral systems. E2A proposes to work with the Zambian Ministry of Health (MOH) and IntraHealth's CDC-funded HIV Testing and Counseling (HTC) Project in three provinces of Zambia (Western, Southern, and Lusaka) to integrate family planning (FP) into a GBV screening tool. Since 2007, IntraHealth has been strengthening HIV counseling and testing services in Zambia in rural and underserved districts. The HTC Project targets the Southern, Lusaka, and Western provinces—all of which have particularly high HIV rates—to expand access and use of testing and counseling services; link individuals, couples, and families to referral and follow-up services; and improve service quality. The project builds on previous work that included training and deploying both lay counselors and health workers in HIV testing and counseling. The project supports the districts to scale up individual and couples HTC at facility and community level, including outreach services as well

as door-to-door HTC services by lay counselors.

There is a growing recognition of the need and request for the project to address and incorporate elements of GBV, an issue that is closely tied to access and use of health services and risk of HIV infection. At a national level, HTC is supporting a revision of the HTC training curriculum, including updates that will incorporate GBV. At community level, IntraHealth’s local partner, the Zambia Health Education Communications Trust, works to raise awareness of GBV as well as the importance of HIV counseling and testing, couples counseling and disclosure, and male involvement. The HTC Project intends to complement these activities with the development and introduction of screening tools for GBV and FP within its outreach and door-to-door counseling and testing. At the same time, there are several recent efforts underway to improve access and quality of FP services in the country.

To address the high fertility rate in Zambia and increase the uptake of family planning, the First Lady Christine Kaseba launched the National Family Planning campaign on Feb 22, 2013. This eight-year campaign is aimed at scaling up the use of contraceptives among women to prevent unplanned pregnancies and raise the nation's contraceptive prevalence rate from 33% to 59% by 2020. Furthermore, to improve the problem of frequent stock outs, the government set up a Reproductive Health Commodity Security (RHCS) Committee, comprising officials from the Ministry of Health, Ministry of Finance and National Planning, NGOs and Cooperating Partners, including UNFPA.

Abt Associates, with funding from DFID, is leading a four-year, $18.9 million project to improve FP services in Zambia, especially for adolescents and couples in underserved communities (2012-2016). The goal of its Scaling Up Access to Family Planning Services in Zambia (SUFP). The project targets 26 Zambian districts with the most unmet need in family planning, including HTC districts. The project is engaging influential people, such as community leaders, men, and especially adolescents, to address major barriers to the use of family planning.

MSI and the Planned Parenthood affiliate PPAZ are key FP providers in the country, among others.

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While the HTC Project is exploring possible partnership with providers of GBV services, such as the YWCA, and ensuring linkages and expansion of FP services – including options for collaborative efforts that might enable the HTC lay counselors to also implement community-based distribution of FP - E2A’s technical assistance is requested in particular to support the FP integration into the screening tool and referral system. The integrated approach will be implemented first in a district with high prevalence of GBV and high need for family planning and E2A will provide technical assistance toward systematic scale-up to other districts. It will be designed and implemented within the frameworks of government services –i.e. taking referral systems and existing GBV and FP services into account – and with consideration for long-term adoption and scale up by national systems. Currently, IntraHealth is planning a service mapping in the project districts that will help to define the referral approach. Lay counselors who provide the HTC services are already linked to the formal health system, from which they gather test kits and report back, and via joint HTC-MOH supervision. Other partners and projects supporting related activities in these districts will also be taken into account as the activity is developed, including services of the IPPF affiliate. This activity will contribute to the USAID Technical Priority Areas of gender, FP/HIV integration, and repositioning of FP in sub-Saharan Africa and the E2A Learning Agenda around GBV and FP/health integration. Learning will primarily be process-oriented. Year 3 Activities and Expected Results The Year 3 activities are:

Support HTC’s service mapping to inform design of a service delivery model that incorporates GBV screening, FP counseling and referral into ongoing community-based HIV CT and referrals. (October-December 2013).

Collaborate with the HTC project in the development of integrated models of FP/GBV/HIV programs.

Hold workshops/meetings with local counterparts, including key stakeholders (October-November 2013):

o Share results of service mapping and elicit recommendations o Develop strategy to strengthen FP/GBV/HIV screening process and referral systems keeping

in mind how this screening process and referral system will function as the project expands into 12 additional districts in the following year

o Provide technical assistance to the HTC project to strengthen the indicators/tools to monitor whether clients referred for FP-GBV services did seek those services and as result if they opted to leave with an FP method (disaggregated by type of method and age of client, when possible.)

E2A will explore possibility of integrating FP messages into social and behavior change communications activities, as well as other related community-based work, to generate demand for FP (October 2013).

Support activities to strengthen the FP/ GBV referral system in the remaining districts (Jan-June 2014).

Support adaptation and application of the Healthy Images of Manhood (HIM) program, a male engagement approach implemented extensively by partners of the Extending Service Delivery (ESD) Project in Tanzania, Kenya and Guinea. HIM can change harmful male gender norms that impact negatively on sexual and reproductive health behaviors and outcomes, and build demand for both HIV/AIDS services and reproductive health and family planning products and services. E2A will rigorously document the HIM experience and its effects on attitudes as well as uptake of services.

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Assessment report outlining findings from the gap assessment on FP and GBV services

Strategy to strengthen FP and GBV services, based on recommendations from stakeholders

Screening tool integrating FP into GBV services

Program Brief that will document the model of integration, screening tool, considerations for scale up, and the outcomes such as persons screened, referred, and receiving appropriate GBV treatment and FP counseling and method

HIM program brief Activity 7: Provide technical support to the Health of People and the Environment – Lake Victoria Basin project (HoPE LVB) This is a new activity for E2A, which provides continuity to two activities previously funded under other USAID mechanisms. Since 2011, Pathfinder International has implemented the Health of People and the Environment-Lake Victoria Basin (HoPE LVB) project, in an effort to reduce threats to biodiversity conservation and ecosystem degradation in the LVB while simultaneously increasing access to family planning and sexual and reproductive health to improve maternal and child health in project communities. The HoPE LVB project is developing and testing two scalable models for building capacity and promoting an integrated set of Population, Health, and Environment (PHE) interventions, to be adopted by Ugandan and Kenyan communities, and local and national governments. In Project Year 3, E2A has been asked to support two components of this project with additional funds: one component focuses on the application and testing of the scale up model, while the other ensures rigorous monitoring and evaluation.

Sub-activity 1: Provide technical support to the systematic introduction and scale up of integrated "population, health and environment" (PHE) interventions in the Lake Victoria regions of Kenya and Uganda Background This is a new activity for E2A, but is an ongoing USAID-supported ExpandNet activity. The Health of People and Environment in the Lake Victoria Basin (HoPE-LVB) Project is a Pathfinder-led Population, Health and Environment (PHE) initiative to test the implementation of cross-sectoral integrated interventions in ways that will facilitate future scale up in the Lake Victoria Basin regions of Uganda and Kenya. This activity will help advance E2A’s global learning agenda to demonstrate emerging practices for integrating family planning into non-health areas, as well as the application of systematic approaches to planning for scaling up. This activity will contribute to the USAID Technical Priority Areas of: community-based family planning (FP) services, and the repositioning of FP in sub-Saharan Africa. Year 3 Activities and Expected Results

Assist the project team, including Pathfinder International/Uganda and Kenya and local non-governmental conservation/environment organizations, to identify ways in which the project interventions can move towards sustainability and scalability (October 2013-June 2014).

Draft a Technical Brief documenting lessons learned from designing and implementing the project (October 2013-June 2014).

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Organize and facilitate a scaling-up strategy development exercise with the project resource team and other key stakeholders (June 2014).

E2A achievements will be measured by: (i) gathering feedback from key HoPE-LVB implementing partners on the value of the technical assistance provided; and (ii) whether the expected outputs/deliverables are produced. Milestones/Deliverables

Technical assistance reports produced and shared with project team and other relevant stakeholders.

Draft Technical Brief that highlights lessons learned from “Beginning with the end in mind.”

Development of a scaling-up strategy through a participatory process with key stakeholders. Sub-activity 2: Support Monitoring and Evaluation for the HoPE-LVB Project Background This is a new activity for E2A, but is an ongoing activity for HoPE-LVB. E2A will provide funding to capture all of the learning from the existing baseline survey results; and enable the midterm review for the multi-donor funded HoPE-LVB Project, which is has until now been implemented by a partnership between Pathfinder International, Conservation through Public Health, the Ecological Christian Organization and Osienala in Uganda and Kenya. This activity was previously supported by USAID/Washington through the Population Reference Bureau. The midterm review will be key to this project’s evaluation, as donors have agreed to conduct elements of a final evaluation following the end of the project beyond 2014. The funding request will also cover the plan for dissemination of midterm results and review of an ecological assessment to be produced under another funding component. Funding will not be required next year. Year 3 Activities and Expected Results

Assist the project team, including Pathfinder International/Uganda and Kenya and local non-governmental conservation/environment organizations, on the further interpretation of baseline survey results for the HoPE-LVB project and its implications to ongoing activities and M&E efforts, as well as to ongoing project implementation and documentation of results.

Complete an ecological assessment for additional baseline conservation information requested by one of the HoPE-LVB donors, the MacArthur Foundation.

Provide technical advice to the project team on the plan for the midterm review meeting to report back on the three years of the HoPE-LVB project (mid 2014, TBD pending discussion with donors).

E2A achievements will be measured by: (i) gathering feedback from key HoPE-LVB implementing partners on the value of the technical assistance provided; and (ii) whether the expected outputs/deliverables are produced. Milestones/Deliverables

A project partners’ meeting at the end of July 2013 to discuss baseline survey implications and improved M&E indicators and targets as needed

An additional ecological assessment report covering the HoPE LVB project sites

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Completed Year 2 report to donors including a section on integration/value added of the PHE approach to date

An identification of the best stories to be told from the implementation to benefit the PHE learning community

The design of the midterm project review event to be held in the mid 2014; dissemination report (likely to be produced after June 2014)

Section 5: Youth Young people face social and economic barriers in accessing reproductive health information and services. E2A views the need for investment in AYSRH as being driven not only by the risks and vulnerabilities of young people, but also the opportunities and the future that they represent. For E2A, investing in AYSRH will contribute to the project’s overall goal of reducing unmet need for family planning and unintended pregnancies by enabling women and girls to make - and act on - informed decisions about delaying sexual debut, delaying the first pregnancy until at least age 18, spacing and limiting their pregnancies in order to ensure the healthiest outcomes. From a broader perspective, efforts that focus on reaching adolescents and youth also contribute to the attainment of the Demographic Dividend in countries that are poised to take the actions that are necessary to capitalize on a young age structure with declining fertility. The primary goal of reducing unmet need for FP will only be achieved by strengthening the quality FP/RH service delivery (facility- and community-based), increasing adolescent and youth access and utilization of quality and equitable SRH services. Guiding principles orient E2A’s work on the AYSRHR practices: youth friendly approaches; equity; gender transformative; rights-based; and integrated, systems-oriented. The framework that guides E2A’s learning agenda involves moving practices from proof of concept (POC) (i.e. new/innovative to emerging to promising to proven) to proof of implementation (POI) (i.e. introduction to sustainable scale-up). This framework underlies all strategies in E2A’s learning agenda areas and specific themes. Regarding the E2A AYSRH legacy, three areas emerge which respond to gaps and lay a foundation for interventions that can strengthen quality FP/RH service delivery and increase adolescent and youth access and utilization of services:

Increase evidence-based knowledge on BPs that address specific AYSRH needs

based on the life cycle approach

Support, strengthen and document different models of AYSRH program

implementation

Support scaling-up AYSRH programs

E2A’s proposed Year 3 youth-focused activities support all three of these areas, while also cutting across the other key thematic areas of integration and strengthening service delivery.

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Activity 8: Reaching first time parents with healthy timing and spacing of pregnancy messages and FP Services in Guinea Background This is an ongoing activity that started in Year 2 under the title, “Test program approaches for effecting youth HTSP-related outcomes.” This activity builds on Pathfinder International/Guinea’s youth multi-sectoral approach to reach youth with sexual and reproductive health services. Applying knowledge gained from the synthesis document prepared in Year 2 E2A will strengthen the first time parent (FTP) component of the Guinea youth program. In this regard E2A will support the development of FTP-focused materials and document Pathfinder International/Guinea’s approach to healthy timing and spacing of pregnancies (HTSP) among youth. The documentation will provide careful evidence on what works and does not work with respect to FTP. This activity contributes to the USAID Technical Priority Areas of gender, youth, and HTSP. In year 2, E2A:

Held meetings with Association Guinéenne pour le Bien-être Familial (AGBEF) (an affiliate of the International Planned Parenthood Federation and Pathfinder/Guinea’s implementing partner for the youth activity) to map/discuss their youth strategy and the resources and tools for the community-based component of the youth program.

Assessed AGBEF‘s tools and noted the need to develop additional ones for the community-based component of the youth activity (job aids; information, education, and communication materials; supervision checklists; and monitoring forms) to determine if they address the sexual and reproductive health needs of young married women and their partners. An upcoming mapping exercise will complement the existing background information for tools development, which is based on other, recent program implementation experiences by Pathfinder and others in the region.

Held discussions with Pathfinder International/Guinea team regarding the FTP activity; analyzed work plan activities and identified potential tools/ resources required to implement and document the community-based component of the youth program.

Year 3 Activities and Expected Results The Year 3 activities will build on the Year 2 activities in order to document the FTP component of the youth program in Guinea. Two categories of activities will be implemented in Year 3: (i) Proposed Year 2 activities that could not be implemented or completed in Year 2, due to delay in startup phase of the project, and (ii) new activities to ensure adequate technical, M&E, and documentation support. The Year 2 roll-over activities include:

Develop the draft M&E tools and documentation template(s), which will assist the local M&E staff in capturing necessary data for activities, challenges, and processes (July 2013).

Strengthen and build upon the current indicators from the framework developed by Pathfinder International/ (July 2013)

Support ongoing monitoring, documentation and reporting in support of the measurement of project achievements and E2A process documentation. (ongoing)

Provide technical assistance in developing tools for the community-based component of the FTP activity (July – September 2013)

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In addition to the roll-over activities, the following new activities will be implemented in Year 3:

Finalize documentation template(s), timeline, and communication strategy (July 2013)

Provide technical assistance in drafting indicators for additional activities required to address issues of interest to E2A (August 2013).

Strengthen AGBEF’s tools and resources related to data collection (August–September 2013).

Initiate and monitor the documentation of the activity (August 2013-June 2014) Please note the implementation of these activities is subject to obtaining USAID Guinea Mission concurrence. E2A achievements will be measured by documenting the number of AGBEF and Pathfinder International/Guinea staff trained to use modified and new tools and resources; and, number of people reached through the FTP activity. A full PMP will provide process and outcome results. Milestones/Deliverables

Resource and instructional materials (e.g. job aids, check lists);

Midterm assessment report Activity 9: Assess the impact of SMS messaging on increased knowledge, and improved attitudes and self-efficacy toward contraceptive use among youth in Mozambique Background This is an ongoing activity that started in Project Year 2, under the title, “Test Program approaches and assess impact of the use of mobile technology in AYSRH programming.” It is a multi-year activity aimed at assessing the effects of short message service (SMS) messaging on knowledge, attitudes, and self-efficacy toward contraceptive use among male and female youth in Mozambique. As part of the research activity, SMS messages will be sent to all participants at baseline and endline periods, in order to monitor changes in contraceptive use and intentions, as well as frequency in condom use. Baseline and endline surveys will be conducted with a select sample of participants in order to gather both quantitative and qualitative responses towards knowledge, attitudes, and self-efficacy in regards to contraception use. Additionally, endline questionnaires will also gather evidence on the acceptability of the SMS intervention. This activity contributes to the USAID Technical Priority Area of youth. E2A has completed most of the following tasks and expects to complete all of them by the end of Year 2:

Conducted a desk review and drafted concept paper.

Developed, in collaboration with Pathfinder International Mozambique/HQ teams, a draft protocol for the study and shared this with USAID/Washington for input and subsequently with USAID/Washington and USAID/Mozambique for approval.

Developed the draft research instruments for baseline and endline surveys.

Full, revised protocol in process, following USAID/Mozambique approval of revised draft.

Participated in developing message profiles and enrollment process for the study.

Prepared the groundwork for conducting the baseline.

Year 3 Activities and Expected Results The Year 3 activities will build upon Year 2 activities to plan and implement the research activity.

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Full protocol and instruments to be submitted to BOP8 and Mozambique IRB (July 2013).

Visit Mozambique to work with Pathfinder International, Mozambique team to pre-test research instruments and prepare for the baseline (October 2013)

Conduct the baseline (October-November 2013)

Conduct the endline (January 2014)

Convene bi-monthly meetings with Pathfinder International HQ /Mozambique teams to monitor data collection (November– January 2014)

Analyze data (January-March 2014)

Develop draft of final report (March-May 2014)

Finalize report (June 2014) In addition to other milestones/deliverables accomplished, E2A achievements will be measured by the formalization of partnerships between Pathfinder International and E2A, a final, research technical report as well as a synthesized technical review paper, and the drafting of a peer reviewed publication. E2A will aim to publish the latter during Project Year 4. Milestones/Deliverables

Technical Report produced and shared with Mission and other relevant stakeholders.

Technical Review presenting findings from the research. Activity 10: Expand Access to family planning, including long-acting reversible contraceptives, for university students Background This is an ongoing activity that started in Project Year 2 under the title, “Test program approaches for provision of long-acting family planning (LAFP) methods within university-based health services”. It is planned as a multi-year activity aimed at contributing to E2A’s efforts to strengthen service delivery and sustainable scale-up approaches, particularly in trying to reach university students. It is anticipated that the intervention, tailored to the needs of the student population, will contribute to: i) increased family planning uptake with an emphasis on adding or expanding the choice of long-acting reversible methods; ii) reduced number of unintended pregnancies and unsafe abortions among students; and iii) strengthened health service delivery system. This activity contributes to the USAID Technical Priority Areas of: long-acting reversible contraceptives (LARCs) and permanent methods (PMs), youth, and post-abortion care. In Year 2, E2A:

Conducted desk review and drafted concept paper.

Shared brief concept paper with Pathfinder International/Kenya and USAID/Washington.

Held two meetings with the Director of Health Services, Kenyatta University, to discuss students’, YFS and peer education needs, as well as possible areas for collaboration and the proposed, joint activity.

Visited public sector health facilities in areas of Nairobi surrounding Kenyatta University (KU) in order to gain initial understanding of YFS and their connections to KU students.

Held meetings with Chief of Party of the APHIA-Plus Project/ Pathfinder International to establish mechanisms for collaboration with E2A on implementation of activities at KU.

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Because the Mission concurrence to implement the study in Kenya was not granted, E2A will identify another country where this study, perceived to be highly important for E2A mandate, will be implemented. Consequently, the Year 3 activities will include revisiting the original design to fit university/country needs, as was done in Kenya in Year 2.

Liaise with potential partner institutions in one or more new countries to ascertain the RH needs of university students and partner involvement in peer education programs at the university level (July 2013). Possible countries include Ethiopia and Nigeria.

Identify a university/country that can benefit from E2A support and where E2A could contribute to addressing a program and/or evidence gap (July-August, 2013)

Draft concept paper on the program (September, 2013)

E2A team will visit the new country to meet the selected university(ies) and locally based partner to plan the E2A support, including its research component if/as applicable (October 2013)

Share concept paper with local partners, USAID Mission and USAID Washington. (October, 2013)

Submit research protocol if applicable to relevant US and local IRBs (November, 2013)

Finalize research instruments and conduct research if applicable (December 2013-March 2014) and/or initiate support to service delivery model (November, 2013 – June, 2015)

If a research component is included, develop report (April-June 2014) and disseminate (June 2014) This activity is envisioned for a minimum of two project years, to allow sufficient time for process and result documentation, and a possible research component. If there is research, a formal article to be submitted for possible publication would be developed following the completion of the overall intervention after Project Year 4. Similarly if the intervention adapted to local needs points towards the need for a greater emphasis on process documentation and not research, a program and/or technical brief will be produced towards the end of the overall intervention. E2A achievements in Year 3 will be measured by: formalization of partnerships between selected country, university, local partners and E2A; technical advisory group meetings in the case of research; and a research technical report. Milestones/Deliverables (Year 3)

Technical Report and/or interim program report produced and shared with USAID Mission, selected university/country, TAG and other relevant stakeholders.

If applicable, intervention protocol and research instruments produced and shared with TAG, Mission, selected university/country, and other relevant stakeholders.

Activity 11: Strengthen comprehensive adolescent and youth sexual and reproductive health service delivery introduction and sustainable scale-up in francophone West Africa Background This is an ongoing activity that started in Project Year 2 under the title, “Establish initial contacts and generate plans for partnerships with global, regional, and in-country organizations and donors that will promote and scale up FP/RH best practices to strengthen service delivery.” It is a multi-year activity aimed at contributing to E2A’s efforts to support existing or new country priorities for scaling up adolescent and youth sexual and reproductive health (AYSRH) best practices. It is anticipated that the activity, tailored to the youth health needs of each country, will contribute to: i) increased access of youth (15-24) to FP/RH services; ii) increased uptake of FP services by youth iii) decreased unwanted

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pregnancies and unsafe abortions; iv) and reduced maternal mortality/morbidity. This activity contributes to the USAID Technical Priority of youth. In Year 2, E2A:

Established contact with the West African Health Organization (WAHO) to discuss the status of the Ouagadougou Partnership country action plans and the work that WAHO is doing in relation to that initiative.

Held meetings with Pathfinder International and the International Planned Parenthood Federation (IPPF) to discuss the agenda, participants, budget, and dates for a West Africa Youth Regional Meeting on AYSRH best practices, approaches and scaling up.

Held meeting with ExpandNet team to develop the strategy for the scale-up component of the regional meeting.

Prepared documents and tools for the regional meeting.

Year 3 Activities and Expected Results The Year 3 activities will build upon Year 2 activities:

Finalize the technical background and planning documents for the regional meeting (October 2013)

Contact the Ministry of Health participants of different countries to send preliminary documents in preparation for the meeting ( November-December 2013)

Convene the meeting with partners ( January 2014)

Develop meeting report and disseminate (February 2014)

Provide virtual and on the ground support to country resource teams, depending on country buy-in Please note that activities planned after January 2014 are subject to obtaining mission concurrence and may require additional financial resources depending on the nature of technical assistance required. Mission support has already been offered by USAID West Africa for activities in Niger and Cameroon that are described under Activity 3, Sub-activity 6. E2A achievements will be measured by the convening of the regional meeting and partnerships between Pathfinder International, IPPF, and E2A. This activity has the potential to promote FP/RH best practices to strengthen service delivery, particularly among youth. Milestones/Deliverables

Youth Regional Meeting convened

Technical Report

Technical Assistance customized to country needs.

Section 6: Service Delivery Strengthening (Community-based Approaches and

Provider Capacity) Service Delivery encompasses the provision of FP/RH information and effective, quality services to prevent unintended pregnancies and adverse reproductive health outcomes. The overarching strategy for E2A’s service delivery strengthening is to increase access to quality family planning and reproductive health services appropriate at each stage of the life cycle to meet changing FP/SRH needs over time in order to increase family planning use and reduce unmet need for contraception. Strengthening service

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delivery to ensure accessibility, affordability and quality will help to maximize the reach of family planning services to different populations including men, adolescents and other underserved groups. E2A will target multiple service delivery components from among the community- and facility-based facets (e.g. counseling, training, protocols, curricula, job aids, community mobilization, QI approaches, data for decision making, referral systems, organization of services, etc.) in order to strengthen family planning services as needed, based on specific activity and country needs. E2A will approach service delivery strengthening from both demand and supply sides and strategically support development of an enabling environment, and will make use of fundamental tools such as the ten elements of success in FP programming and WHO’s building blocks of systems strengthening, as well as existing gap analysis and planning tools, in order to analyze needs with country counterparts and support country-owned efforts to strengthen systems and services. At the same time, we will apply our expertise in ensuring attention to gender issues and the needs of youth. An example of Service Delivery Strengthening The E2A SDS framework provides one tool (among many) for structuring E2A assessments and analyses of best practice implementation modalities. It also can serve as a guideline for program design, enabling us to ensure that SDS is comprehensively addressed in activities focused on scale-up. Following is an example taken from the Year 1-2 PAC-FP documentation activity, which also employs WHO’s six building blocks for health systems strengthening. E2A has assessed the implementation experiences of PAC-FP in four West African countries. The introduction of PAC-FP in these countries addressed several components of service delivery strengthening and WHO’s building blocks for HSS. These included: advocacy with Ministry of Health leaders, professional associations and other stakeholders (Leadership/Governance), training of service providers including counseling (Health Workforce), procurement of equipment including MVA kits (Access to Essential Medicines) and budget line items (Health Financing), community mobilization and raising community awareness (Health Service Delivery), and integrating indicators for PAC in the routine health information system (Health Information Systems). Analyzing what works and does not work in implementation against the components of such frameworks provides us with a way to structure conclusions and recommendations. There are also many fully developed tools for assessments and QI that the project will employ as appropriate. Activity 12: Build capacity of the East, Central, and Southern Africa Health Community to promote and operationalize healthy timing and spacing of pregnancy in pre-service training in three member countries Background In Year 2, E2A responded to a request from the East, Central, and Southern Africa (ECSA) health community to provide an update on healthy timing and spacing of pregnancy (HTSP) to nurse educators during a family planning (FP) update training in Uganda. The request came through the USAID HTSP Champion. It is expected that this activity will build the capacity of ECSA to expand provision of healthy timing and spacing of pregnancy (HTSP) services, long-acting reversible contraception (LARC), and postpartum family planning (PPFP). In this way, E2A hopes to have wider impact on strengthening service delivery through training, improving client-centered care, expanding method mix and meeting the needs of different stages of the reproductive life cycle. In addition to the three aforementioned

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USAID Technical Priority Areas, this activity will also contribute to a fourth Priority Area, repositioning family planning in sub-Saharan Africa. In Year 2, E2A:

Adapted the HTSP training materials for pre-service educators and FP service delivery managers in Uganda.

Conducted training on HTSP for 26 participants from public and private health service and training/education institutions in Uganda. This FP update training was organized and facilitated by ECSA. ECSA has plans to conduct additional regional FP/RH updates for representatives of Nursing and Midwifery schools, as well as regulatory councils from the 14 member states of ECSA, with support from USAID East Africa mission.

Year 3 Activities and Expected Results In Year 3, E2A will further build the capacity of ECSA to expand HTSP, LARC, and PPFP. E2A will:

Provide technical assistance to ECSACON to update its regional FP/RH training materials and provide other training resource materials on HTSP, LARC, and PPFP (October 2013 - February 2014).

Build the capacity of ECSA’s FP/RH training team to implement the revised training materials in two of the FP/RH update trainings planned by ECSA (January - June 2014).

Provide technical assistance in training implementation, e.g. planning and implementation of clinical practicum for LARCs, strengthening service integration at training sites and build on existing programs and projects that can support service provider training.

Support the East, Central, and Southern African College of Nursing to follow-up and document application of learning from the FP/RH update training (October 2013 - June 2014).

E2A will measure the results of this activity through documentation of processes and outcomes. E2A will also monitor ECSA application of learning on HTSP, LARC, and PPFP from the FP/RH training. This will contribute to E2A’s performance indicator:


Milestones/ Deliverables

Training materials/modules on HTSP, LARC, and PPFP adapted for the ECSA regional FP/RH Curriculum

Training reports of E2A supported update workshops

Program Brief from a country where learning from the training was applied and services organized /reorganized to provide LARCs and/or PPFP.

Activity 13: Support USAID Missions to strengthen service delivery and sustainable scale-up approaches Background In order to explore opportunities to support learning and capacity building at country level, E2A must be responsive to USAID missions and other country level partners. This activity is an umbrella activity that

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enables E2A to provide support to assessments, program or research design or addition of small components that add value to ongoing, larger ones. Year 3 Activities and Expected Results Using core funding, E2A will design, document and monitor/evaluate activities that will be implemented with field support. Proposed activities may range from provision of short-term technical assistance to planning for Field Support, depending on the nature of the request. A carryover activity from Years 1 and 2, this activity has enabled flexibility to support Field Support activities in advance of funding, such as E2A preparatory work on Field Support workplans and subagreements, or travel to countries. In Year 2, E2A was also able to operationalize this activity by responding to a USAID request to support the development of a paper for presentation at the International Youth Conference in Bali, Indonesia. Milestones/Deliverables The deliverables will be determined based on USAID Mission or country partner requests but will be consistent with E2A goals and objectives. Activity 14: Build Evidence to Support the Provision of Implants at Community Level through Task Shifting Background This is a new multi-year activity aimed at assessing the effects of providing implants by Community Health Extension Workers (CHEWs) and documenting the process of scaling up this practice in Nigeria. This activity builds on the successful introduction and scale-up of implant provision by Health Extension Workers in Ethiopia. The activity involves bringing E2A’s technical assistance to country programs to implement a demonstration project and document a sustainable scale-up for provision of implants by task shifting to CHEWs. This activity supports the policy shift to expand CHEWs’ current family planning (FP) tasks to include provision of implants and will ultimately contribute to strengthened service delivery by helping to move forward the process of expanding access to new methods at community level. The current Nigerian National Family Planning and Reproductive Health Policy guidelines and standards of practice designate CHEWs as facility-based providers of all FP methods except for surgical methods, implants and intrauterine contraceptive devices. CHEWs are expected to spend half their time on community based functions and the other half in the clinic. However, the chronic shortage of higher cadre health staff in some states of Nigeria, particularly in rural areas, urban slums and underserved and resource constrained high need states of Northern Nigeria has resulted in CHEWs being deployed to work in static health facilities. This activity will sensitize and seek to improve access to underserved and hard to reach populations with long-acting methods through culturally sensitive approaches. This activity contributes to the USAID Technical Priorities of community-based FP services and repositioning FP in sub-Saharan Africa. Year 3 Activities and Expected Results The Year 3 activities will cover the planning, design and implementation of an operations research.

Sensitize national, state, local government authority (LGA), and other key stakeholders on the objectives of the demonstration project. This will be achieved through the following sub-activities:

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o Meetings with the National Working Group on Reproductive Health to orient them with the study, obtain consensus and suggestions for field sites to conduct the study as well as nominations for the proposed Technical Advisory Group (TAG) (July – October 2013).

o Identify and engage State and local level policy makers and key traditional and religious leaders on demonstration project and its potential benefits (July – October 2013)

Convene a TAG to guide the implementation of the demonstration project. (November 2013 – December 2014)

Prepare reports on the stakeholder sensitization engagements (November 2013 - December 2014)

Prepare and share a concept paper with the TAG (December 2013).

Draft and submit the protocol to relevant IRBs (USA and Nigeria), BOP 8, and TAG (January 2014).

Select the local implementing partner/s (February 2014)

Implement the study (February – December 2014) Please note that these activities will commence after obtaining mission concurrence. E2A achievements will be measured by documenting the process and outcomes of the stakeholder sensitization meetings, TAG meetings, IRB approvals, and roll-out of the demonstration projects. Milestones/Deliverables

Stakeholder sensitization meeting reports produced and shared with TAG, Missions, the Ministry of Health (MOH), and other relevant stakeholders.

Concept paper and protocol produced and shared with Missions, the MOH, and other relevant stakeholders.

Training materials produced

Training report produced and shared with TAG Mid-term assessment report produced and shared with TAG

Section 7: Additional Activities Activity 15: Meridian Group to expand systemic workplace health approaches and scale-up model thorough partnerships with relevant stakeholders. Background Meridian’s RAISE Health Initiative is a multi-year, private sector activity from Year Two that focuses on expanding access to reproductive health, family planning and related health areas for women and men workers. It is an ongoing approach for changing corporate systems and standards and scaling up FP/RH and women’s health best practices at workplaces. It is based on the concept that businesses and their supply chains operate in a global system of policies and standards with compliance and regulatory mechanisms that can be influenced to increase investment in women’s health best practices and ultimately access to reproductive health and access to family planning services that E2A is advancing. The RAISE Health strategy, which stems from Meridian’s analysis of the Corporate Social Responsibility (CSR) system as a mechanism for scaling up women’s health, continues to focus on four objectives:

Advocating for corporate/CSR standards by engaging and mobilizing family planning, health, rights and environmental organizations in stakeholder processes.

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Implementing with select corporate partners workplace innovations that demonstrate how companies can adopt new policies and practices that are embedded in CSR systems standards and lead to sustainable, scalable programs and new investments in worker health and FP/RH at the workplaces through their supply chains.

Engaging each of the four types of CSR institutions to adopt new FP/MNCH and work health policies, standards, indicators, guidance materials and other activities that promote and support the incorporation of comprehensive health investments by companies and their supply chains.

Producing and disseminating knowledge documents – standards, guidance, webinars, peer-reviewed articles – that promote scale-up of FP/RH and women’s health services for workers.

No one in public health has addressed CSR as a system and leveraged this system to advance women’s health investments by corporations and their suppliers. Meridian’s strategy has been to target specific groups that can have systemic impact. In Year 2, we have several major accomplishments that highlight the power of the CSR systems approach:

Drafted Workplace Health Facility Standards in partnership with Business for Social Responsibility’s HERproject and the Better Work Programme (a joint initiative of the International Labour Organization and International Finance Corporation). HERproject and Better work will pilot the standards in factories at the end of Year 2. If the piloting goes well, Better Work and BSR are prepared to implement with RAISE Health’s technical assistance the standards the more than 1,000 factories, with a million workers, mostly women, in the 10 plus countries where they operate in Year 3.

Launched a proof-of-concept project in a Haiti-based garment factory to re-engineer its health services and make them integral to overall factory operations. The HRA Pharma Foundation helped fund the pilot activities. Meridian’s initial assessment and start of up preliminary activities (training on HTSP, improving clinic record keeping, providing preventive care) found that nurses were under-used resources (who wanted to do more), management had no idea how to assess the quality of the health services and facility, and it is relatively cheap to improve and expand family planning and other services in the factory. The pilot will be finished early in Year 3, and we expect to promote the clinic re-engineering as a model within CSR systems. With RAISE Health’s technical assistance, Better Work Haiti is interested in replicating this re-engineered clinic model to the other garment factories in the country in Year Three after the new approach has been successfully piloted, reaching 24,000 workers.

Developed collaboration with the United Nations Global Compact (UNGC) to host a webinar series for UNGC member companies (with RAISE Health as the facilitator) that focuses on best practices of workplace programs for women’s health in 2013-14 under the Women’s Empowerment Principles. This stemmed from a successful webinar for UNGC on Business and Women’s Health in February 2013 (suggested by Meridian) in which RAISE Health was a presenter.

Developed a partnership with Worldwide Responsible Accredited Production (WRAP) to develop a training program for factory owners and managers on best practices in workplace safety and women’s and workers health, focusing on the business case for health and cutting edge corporate approaches globally. The training content is planned to be completed in Year 2, but implementation to take place in Year 3. WRAP is a leading CSR organization that sets a social standard for factories to meet and then accredits organizations monitor factories each year and certifies their compliance. More than 1,600 factories with about 1.5 million workers, mainly women, have WRAP certification. WRAP will offer this training, with RAISE Health’s technical

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assistance, to factories for a fee. If successful, RAISE Health and WRAP will then consider collaborating on adding women’s health content into the accreditation program for workplace monitoring organizations.

Promoted the CSR systems approach for women’s health with key CSR and public health organizations, including the CORE groups fall and spring meetings, Maris Stopes FP Implementers group, GBCHealth’s annual conference, the Business and Human Rights stakeholder meeting, the United Nations Water Supply & Sanitation Collaborative Council and the Women Deliver conference.

Submitted standards comments with four CSR standards organizations including Bonsucro, Clean Coal Coalition, and the Responsible Jewellery Council.

RAISE Health has developed several other partnerships with several other organizations – Bayer HealthCare (workplace health education materials), Verite (workplace training with the Walt Disney Co.), and Levi Strauss & Co. (Improving Worker Well-Being initiative) – whose implementation has been determined by corporate timetables that will ramp up late in Year 2 into Year 3. Year 3 Activities and Expected Results In Year 3, RAISE Health will build on these accomplishments, which will enable us to take major steps forwards in reaching our objectives for influencing the key Corporate Social Responsibility institutions and leading corporations to adopt and implement new women's and worker health standards and policies. The activity contributes to E2A’s learning agenda related to assessment of scale-up models, integration of FP into non-health and GHI principles related to CSR/partnerships, and women and girls centered gender equitable practices. The Year 2 roll-over activities with new tasks or expanded implementation include:

Providing technical assistance to Business for Social Responsibility's HERproject and the ILO/IFC Better Work programme for implementation of workplace health facility standards in 3-4 countries. (October 2013-April 2014)

Testing the business and reproductive health benefits of a new model for workplace health services in a Haiti factory that integrates health into business operations and human resources functions. (October 2013 – February 2014)

Providing technical assistance to Levi Strauss & Co. to implement best practice workplace models for women’s health and empowerment at work and in the community. This includes implementing the factory health facility model, developing trainings of factory management on the business value of women’s health programs, and integrating health into workplace operations in up to three countries: Bangladesh, Egypt and Pakistan. (October 2013- May 2014)

Producing a package of workplace educational materials on family planning and reproductive health in partnership with Bayer HealthCare for the 150 factories participating in Business for Social Responsibilities HERproject as well as in the ILO’s Better Work factories (Bangladesh, Cambodia, Egypt, Haiti, India, Indonesia, Jordan, Nicaragua, Pakistan, Vietnam). These materials will be made available through HERproject for any company or NGO to use globally.

Providing technical assistance to the workplace monitoring group as they integrate women’s health information into it auditor training program, initially with the Walt Disney Company. (October 2013 - March 2014.)

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Advocating for the adoption women’s health standards – with particular focus on models tested with HERproject and Better Work – with CSR institutions and leading corporations through stakeholder processes on CSR standards and policies. (October 2013 – August 2014)

Facilitating the advocacy of women’s health and family planning standards for public health groups, environmentalists, and women’s groups, expanding outreach these groups and deepening the outreach.

Providing technical assistance in coordination with E2A (1) to GBCHealth or another organization that integrates family planning and new gender norms into company business operations as it implements the Healthy Images of Manhood approach in one country as well as (2) HERproject for the adoption of workplace standards in its factories .

In addition to the roll-over activities, the following new activities will be implemented by Meridian under E2A to promote corporate workplace standards on women’s health and family planning:

Build capacity of WRAP trainers to facilitate a two-day training program on best practices in women’s health integration at the workplace and monitor implementation of BPS by participants. (October 2013 – February 2014)

Facilitate 3-4 webinars on women’s health and business in collaboration with UN Global Compact. (October 2013- March 2013)

Provide technical assistance to scale up workplace health facility model in up to 23 other Haitian factories in partnership with ILO/IFC Better Work Haiti.

Developing 3-4 partnerships with the organizations that play one of the four roles in the CSR system (standard-setting; policy development; enforcement/certification; and reporting/transparency) as part of scaling up new women’s health standards. Key targets include partnerships with and technical assistance for:

o CERES, a leading CSR NGO that promotes sustainable leadership and manages a network of investors, businesses and public organizations to accelerate the adoption of best practices for sustainable business. RAISE Health plans to join its network for advocacy, participate in advisory opportunities with corporation, and leverage CERES communication platforms to promote CSR standards. (October 2012 – July 2014)

o Social Accountability International (SAI), a leading CSR organization, to pilot test in one or more countries the Gender Equity Seal which it developed with UN Women. We plan to form a partnership with SAI on the integration of women’s health, where possible, into its Social Fingerprint method for monitoring workplaces and into its certification of auditors. (January 2014 – September 2014)

o UNWomen (and UN Global Compact) to incorporate workplace clinic standards and other best practice in its corporate guidance materials and other promotion mechanisms relating to the Women’s Empowerment Principles.

Promote women’s standards and the CSR systems approach with key corporate, government, and NGO stakeholders through:

o Major conferences, including the International Family Planning Conference in Ethiopia, UN Business and Human Rights stakeholder convening, UN Women’s Empowerment Principle’s annual conference, the BSR conference in San Francisco, and the CERES conference in Boston.

o Government and stakeholder meetings on sustainability, CSR and related topics. o Webinars, blogs, and e-newsletters that reach corporate leaders and CSR institutions.

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Monitor and document the scale-up of workplace standards and the workplace health facility model as well as the adoption of women’s health standards in CSR policy development processes.

Deliverables

Implementation and scale-up materials produced as a package of (1) health clinic standards tested, (2) a standards indicators matrix, and (3) a guidance document for workplace managers.

Documentation of increased access to family planning education, products, and services for workers in factory from the health clinic re-engineering pilot in Haiti based on clinic service records.

40 factory owners in 1-2 countries trained in women’s health best practices affecting 20-40,000 workers. (RAISE Health will track number of factories that implement best practices.)

New workplace clinic standards adopted by two other institutions, such as Business for Social Responsibility, Better Work, and UN Global Compact.

FP/RH/women’s health embedded in CSR standards for corporations and supply chains, documented in a report on activities to influence CSR stakeholder processes to adopt FP, gender and women’s health language into standards, including the number of partner groups participating, evidence of standard language changes, and number of companies affected by the new standards.

Documentation of the implementation and scale-up process and results, including worker access to family planning products and service, implementation of best practices, replication of new factory clinic model in Haiti, and number of factories in 7-10 countries that adopt clinic standards.

USAID Technical Priority Areas

Documenting scale up methodologies

Forging strategic partnerships that leverage external resources

Promoting healthy timing and spacing of pregnancy

Integrating family planning into non-health areas

Section 8: Field Support Summary As of September, 2013, E2A had received field support funding from USAID Burundi, USAID Ethiopia and USAID Malawi. Additionally, USAID Tanzania directed core funds into E2A for the first phase of an anticipated multi-year activity in Tanzania. Other USAID missions have expressed clear intentions of working with E2A to develop scopes of work (SOW) for field support funding and/or have already developed such SOWs and have initiated field support processes. In this section, we briefly summarize all of these activities. Longer descriptions of field support activities, together with detailed workplans and budgets, are developed and submitted separate from the E2A core annual workplan as SOWs, proposals and USAID mission workplan requirements. Similarly, the activities are reported in stand-alone reports based on USAID mission requirements. However, the inclusion of summary descriptions in this document aids in explaining intended synergies between E2A core and field support, as well as description of E2A provision of technical assistance from field support activities.

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Ongoing Field Support Burundi: Maternal and Child Health Program The Maternal and Child Health (MCH) Program is a USAID-funded, Pathfinder-led project that over six years, has made a steady and effective investments in the strengthening of health service delivery in Burundi through coordinated technical assistance to service providers and reinforcement of community-based services. The MCH program made measurable and positive impact in its areas of operation: the northern provinces of Kayanza and Muyinga. These include significant improvements in the percentage of deliveries attended by a skilled health professional, use of modern methods of FP, and an increase in the use of antenatal care services. Through E2A, USAID Burundi field support has strengthened the capacity for Jadelle provision in the country, including development of training manuals, a training of trainers for multiple provinces, and rollout training in Muyinga and Kayanza. E2A worked with national counterparts and MCH Program staff to ensure streamlining of youth and gender concerns into these materials as well. Beginning in April, 2013, the MCH Program has been funded under the E2A Project as an extension period. The field support extension period focuses on largely focus on consolidating and maintaining the momentum built under previous periods. It also addresses key recommendations around ensuring that medical infrastructure and equipment provided by the MCH program is used and maintained according to needs and standards. With core funding in Year 3, E2A is exploring possibilities for strengthening the ongoing work in Burundi via application of funds that were previously approved for activities involving task-shifting (“Support diffusion of task-shifting and/or dedicated provider experience”) and use of data for decision making and strengthening referral systems (“Strengthen community-based data for decision making and referral systems in three countries”). Pending confirmation of interest and feasibility at country-level, these activities are proposed to build on other activities in which Pathfinder Burundi is engaged, which build on the MCH experience but do not depend on the MCH Program funding. Ethiopia: Integrated Family Health Program USAID Ethiopia’s flagship FP/MNCH project, the Integrated Family Health Program (IFHP), is led by Pathfinder International in collaboration with John Snow, Inc. (JSI) and local implementing partners. The final phase of IFHP is supported by USAID Ethiopia through the E2A Project. Thus, while ongoing technical assistance to IFHP from Pathfinder and JSI home offices continues, and full workplans and program reports are documented elsewhere, this summary serves to document E2A home office technical assistance to IFHP. E2A has provided three types of TA to IFHP thus far. E2A conducted a study of the sustainability of management approaches, which was presented by IFHP to USAID Ethiopia in the interest of informing future program design. Secondly, E2A provided TA in male engagement training within E2A’s gender-focused program area. Finally, E2A has worked with IFHP to develop an analysis plan for a final document of IFHP’s experience in scaling up the provision of IUCDs and implants at lower levels of the health care system. Additionally, IFHP and E2A collaborated on a Year 2 core-funded activity that studied the use of data for decision making at the community level.

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During E2A’s Project Year 3, we continue to explore a fourth possible area of collaboration: strengthening long-acting family planning (LAFP) within IFHP’s university –based programming. This activity is described above as Activity 10 of the E2A core Year 3 workplan. Other synergies created between IFHP and E2A core and other field support activities include the lessons learned from the leading experience of IFHP in task shifting for implants, which E2A hopes to support in at least one other country where policy allows. Malawi: Evaluation of Youth-Friendly Health Services E2A has been requested by USAID Malawi to coordinate and lead a national assessment of Youth-Friendly Health Services. In Year 3, E2A has already coordinated with Malawi-based counterparts to fully define the scope of work, develop an RFP for a local research organization, issue the RFP and select an implementing agency with which the research team will conduct the study. Simultaneously, we have detailed a protocol and research tools, translated these to local languages. The protocol has been reviewed and approved by an internal IRB (PATH) and submitted for USAID/Washington review as well. The protocol and tools are currently under review by the national IRB, and E2A is awaiting IRB approval before engaging the local research firm and initiating the survey. E2A anticipates completion of the field work during the Project Year 3, compilation of data and report production. An abbreviated version of the SOW, drawn from the initial concept note developed by the Malawi Technical Working Group, follows:

Goal The overall goal is of this assessment is to generate information that will be used to inform policy and programming for YFHS. Specific Objectives 1. To assess the extent and effectiveness of YFHS in terms of access, utilization and service

provision of services to young people. a. To analyze the effectiveness of the YFHS models (approaches) and strategies

currently in use by the MoH and NGOs b. To identify young people’s SRHR needs and collect youth voices, perceptions to

YFHS service delivery and implementation c. To identify existing gaps or weaknesses, strengths and measures to overcome the

shortfalls identified. d. To recommend an efficient YFHS model for Malawi

2. To analyze factors that influence or hinder high YFHS uptake at district and zonal level (i.e. number of providers)

3. To assess the extent of which the YFHS standards, approaches and minimum package for the delivery of YFHS has been met

a. To assess the extent of which the YFHS standards have improved quality of service, access and planning at service delivery level

b. Analyze current data quality in informing planning and policy processes at all levels

Scope The focus of the assessment will be on provision of sexual and reproductive health & rights services, including family planning, to in-and-out of school youth receiving services. The assessment will consider all sites (health facilities, universities, NGOs, etc.) and providers (doctors, nurses, health

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surveillance assistants, community based distribution agents, youth organizations, etc.) and self-reporting delivery of YFHS. Study Size, Sampling Design and Sample Size The assessment will employ purposeful sampling, with a sample size of 6000- 9000 (the exact percentage will be agreed upon with the consultant). It will sample facilities, providers, managers and young people from the identified districts. This sample approach will be agreed upon in consultation with the YFHS TWG by the consultant and will strive to :

1. Provide statistical significant evidence on the impact of the YFHS in Malawi and its programming and service delivery approaches

2. Deliberately target the areas of YFHS implementation including the aforementioned adolescents and girls

3. Document the roles and approaches of various implementers such as government, civil society organizations (CSOs), donor partners and communities

In addition, the sample districts should include well-performing and under-performing districts. It should have regional representation and also cover rural and peri-urban settings. The consultancy team will be expected to apply appropriate research mechanisms to avoid sample bias, and both women, men, girls and boys need to be involved in the assessment exercise. Both qualitative and quantitative methodologies will be used during the assessment exercise. Study Population The study will include service delivery points, providers and clients involved in the actual delivery/receipt of YFHS services. These include:

1. Zonal and district level managers (District YFHS coordinators, DHO,DYO, DHMT ) 2. Health facility managers 3. Heath care providers (both public and private) including NGOs (e.g. FPAM, BLM, PSI,

AYISE, YONECO) 4. Support staff at the service delivery points (including non-clinical staff) 5. Youth clients (school and out of school, including secondary and university) and non- clients

(youth who don’t access YFHS) 6. Youth leaders 7. Community service providers (e.g. HSAs, CBDAs, youth peer educators school aunties/mother

groups) 8. Parents, teachers, religious, political and traditional leaders (as a secondary audience) 9. Policy makers (Ministry, parliament, etc.)

Tanzania: Family Planning Advocacy In order to effect change in stagnant and insufficient resourcing for family planning in the country, USAID Tanzania engaged Pathfinder Tanzania, through E2A, to support and complement other ongoing FP advocacy programs in the country. The activity is ongoing under an initial first phase of funding and is envisioned as a multi-year activity. The first phase was supported by DFID, with funding directed by USAID Tanzania to E2A.

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The multi-year activities aim to address gaps in current FP/MNCH policy and advocacy efforts in Tanzania. They focus on building critical support among four key and influential stakeholder groups: policy makers, influential and religious leaders, civil society advocates (including the media) and Council Health Management Teams. Each stakeholder group will be targeted with specific advocacy efforts that are tailored based on their sphere of influence. Policy makers will be targeted with activities to increase their understanding of the demographic dividend and its benefits. Influential and religious leaders will be brought together to address increase their understanding of the importance of FP/MNCH in improving family health outcomes and the need to ensure greater accountability in the delivery of FP/MNCH services. The project will mobilize civil society groups and their leadership to increase their individual and organizational involvement and support to ensure greater accountability and delivery of FP/MNCH services by the Government of Tanzania. This initiative will also involve fostering greater public awareness and participation in the advocacy efforts. The fourth group to be targeted by this intervention is the Council Health Management Teams that are responsible for the planning, allocation of resources, and delivery of health services, including family planning at the district level. Engaging and securing the support of these district-level policy makers is important for understanding and potentially mobilizing additional funding for FP programs at the district level.

The strategies outlined below have been proposed, with a phased approach. They are designed to expand the advocacy landscape through improved understanding of the reasons why advocacy efforts to date have not yielded desired results, of development of a focused program with specific advocacy asks from different groups of stakeholders, and through that increase national and district level commitment to contraceptive services regardless of external funding availability.

Objective 1: Generate improved understanding of the critical social, economic, and other

interests of policy makers in relation to FP/MNCH in order to tailor advocacy asks

Objective 2: Generate and utilize evidence to increase policy makers’ understanding of the demographic dividend and its benefits to national development

Objective 3: Engage Civil Society Organizations (CSO) and other policy champions to increase their agency in advocacy for FP/MNCH

Objective 4: Strengthen citizen voices and establish mechanisms for citizen voices to be heard systematically

A longer description of the activities for each of these objectives, as well as a full workplan, were submitted to USAID/Tanzania and USAID/Washington prior to receipt of the first phase of funding. The initial phase focuses on objectives 1 and 2. Activities designed to address objectives 3 and 4 are currently being re-formulated at USAID/Tanzania’s request, due to a shift in DFID priorities and an end to DFID funding for this activity.

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Anticipated Field Support Cameroon: Support integration of family planning services into HIV mobile outreach platforms for key populations USAID West Africa provided E2A with a scope of work for activities in Cameroon and Niger focused on youth friendly services. These are described under Activity 2, Sub-activity 5. During the current workplan period, these activities are co-funded by core and field support funds. It is anticipated, per the USAID West Africa SOW, that additional field support funding will enable a second year of activities that will cross over to E2A’s Project Year 4. Democratic Republic of Congo: Community-Based Family Planning USAID/DRC has expressed interest in working with and through E2A to expand a model of community-based family planning service provision that was developed under the earlier, Pathfinder-led Flexible FP Project, which was funded by USAID East Africa. E2A is awaiting a concept note from USAID. This activity may provide a possible opportunity for application of components of the FP Training Resource Package which was developed under E2A in previous project years. It may also provide an opportunity for E2A to support a task shifting activity. Niger: Build Capacity for Youth Friendly RH/FP Service Delivery USAID West Africa provided E2A with a scope of work for activities in Cameroon and Niger focused on youth friendly services. These are described under Activity 2, Sub-activity 5. During the current workplan period, these activities are co-funded by core and field support funds. It is anticipated, per the USAID West Africa SOW, that additional field support funding will enable a second year of activities that will cross over to E2A’s Project Year 4. Nigeria: Scaling up PMTCT Services in Nigeria (SPIN) USAID Nigeria has expressed interest in bringing E2A on board as a partner to support expansion of PMTCT services in the country. USAID Nigeria’s draft concept note for the activity describes the activity as follows:

“… the proposed activity will allow USAID/Nigeria to expand its current platform to meet the commitments made by the USG to the national PMTCT effort. The activity will work in the following eight states: Abia, Akwa Ibom, Anambra, Bayelsa, Cross River, Lagos, Rivers, and Taraba, Through the GON-led, multi-stakeholder supported coordination process, these states were selected for targeted intervention by USG for the following five criteria: (1) HIV prevalence above the national median of 4.1%; (2) high population burden of pregnant women who need prophylaxis for PMTCT (3) low human resource capacity of state-level governments to monitor, oversee and coordinate PMTCT efforts; (4) the availability of ANC services; and (5) the high number of sites without PMTCT services.

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Beyond the geographic scope and service coordination, the mechanism will provide a standardized package of services which combines PMTCT with maternal and child health, family planning and reproductive health as recommended by the National PMTCT guidelines. Delivery of integrated PMTCT services at the facility level in Nigeria is directed by and made operational through the National PMTCT Guidelines as well as the associated guidelines for MCH, FP/RH. Such guidelines give health care providers a minimum package of services for patients and ensure a standard of care. Beyond PMTCT, some illustrative examples of the minimum package of cost-effective interventions include, for antenatal care, provision of prophylaxis against malaria in pregnancy, tetanus toxoid immunization, provision of iron/micronutrient supplementation and detection and management of complications such as hypertension, diabetes or pre-mature labor. For labor and delivery services, a minimum package includes active management of the third stage of labor, use of a partograph for early identification of obstructed labor, and management of pre-eclampsia/eclampsia, hemorrhage and other complications either on site or through effective referral. Newborns need Essential Newborn Care practices such as early breastfeeding and other low-cost interventions for asphyxia, prematurity and other complications. Finally, family planning services need to be able to offer a range of methods and be accessible to all while being attentive to the needs of HIV positive clients and to appropriate referrals from family planning services to HIV counseling and testing. While the existing facilities that will be recruited for this PMTCT program may already have good coverage and quality of many or all of the above MCH and FP practices, this project hopes to support improvements where gaps have been identified. Good quality services are measured in terms of service outputs and outcomes, but it is also necessary that these health facilities meet minimum standards in terms of policy/protocols, human resources, infrastructure, commodities and information systems in order to provide and evaluate these services. “

Pending receipt of field support, E2A will work with USAID Nigeria, national and state counterparts to develop an updated program description and/or detailed workplan and budget as required by USAID. This activity has the potential to serve as a platform for E2A to contribute other, core-funded initiatives, including support to: community-level data for decision-making, strengthening referral systems, provision of community-based injectable contraceptives and monitoring and evaluation of scale up.

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Section 9: Core Activity Integration at Country Level The following table demonstrates – illustratively in some cases – areas of synergy between E2A field support (current or anticipated) and E2A core activities, or between different sets of core activities. This table is not an exhaustive compilation of all points of intersection between different E2A activities. However, we believe that it will provide some insight into our view of building country-level sets of activities:

Original Year Core 3 Activity

Burun-di

Came-roon

DRC Ethiopia Malawi Niger Nigeria Tanzania Zambia

Collaborate with DFID’s E4A

x x

Support diffusion of task shifting

x x

Support introduction of implants

x X

Document implementation experience from HIM

x

Support application of the FPTRP

x x

Support data for decision-making and referral systems

x x x

Implementation of CBA2I

x

Tools for M&E of Scale up

x x

evidence to action for strengthened family planning and

Documents