Rapid Contraceptive Increase in a Post-Conflict Setting

Publication date: 2005

Expanding family planning and reproductive health services in Africa 4301 N. Fairfax Drive, Suite 400 Arlington, VA 22203 Tel: (703) 310-3500 Fax: (703) 524-7898 www.advanceafrica.org Partner organizations: Academy for Educational Development • Centre for African Family Studies Deloitte Touche Tohmatsu • Forum for African Women Educationalists Family Health International • Management Sciences for Health Advance Africa is sponsored by the United States Agency for International Development Ph ot o co py rig ht A dv an ce A fr ic a DR CONGO PROGRAM RAPID CONTRACEPTIVE INCREASE IN A POST-CONFLICT SETTING INTEGRATING SERVICES THROUGH LOCAL PARTNERS, 2003-2005 JUNE 2005 Expanding Reproductive Health and Family Planning Services in Africa DR CONGO PROGRAM RAPID CONTRACEPTIVE INCREASE IN A POST-CONFLICT SETTING INTEGRATING SERVICES THROUGH LOCAL PARTNERS, 2003-2005 END OF PROJECT REPORT June 2005 Advance Africa 4301 North Fairfax Drive, Suite 400 Arlington, Virginia 22203 1 © 2005 Advance Africa Working to improve the health and well-being of African families through strengthened family planning and reproductive health services 4301 North Fairfax Drive, Suite 400 Arlington, Virginia 22203 USA E-mail: npruyn@advanceafrica.org Website: www.advanceafrica.org Funding for DR Congo Program: Rapid Contraceptive Increase in a Post-Conflict Setting was provided by the United States Agency for International Development (USAID). The views expressed are those of the authors and do not necessarily reflect those of USAID. 1 TABLE OF CONTENTS I. EXECUTIVE SUMMARY. 3 II. INTRODUCTION . 4 III. ACTIVITIES . 4 1. INTEGRATING FP SERVICES WITHIN THE PHC SERVICES IN SANRU III HEALTH ZONES. 5 A. Background . 5 B. Interventions . 6 C. Results. 9 D. Lessons Learned. 12 E. Recommendations. 13 F. Conclusion. 13 2. LAUNCHING FAMILY PLANNING ACTIVITIES IN THE IDP ZONES . 13 A. Background . 13 B. Interventions . 14 C. Results. 14 D. Lessons Learned. 15 E. Recommendations. 16 F. Conclusion. 16 3. INTEGRATION OF FAMILY PLANNING INTO CONSERVATION ACTIVITIES. 16 A. Background . 16 B. Interventions . 17 C. Results. 18 D. Lessons Learned. 20 E. Recommendations. 21 F. Conclusion. . 21 IV. OVERALL OUTCOMES . 21 V. LESSONS LEARNED . 22 VI. RECOMMENDATIONS . 23 ANNEXES . 24 Reports used in preparation of this report . 24 Memorandum of understanding between Advance Africa and SANRU III . 26 2 ACRONYMS AIDS Acquired Immunodeficiency Syndrome BCC Behavior Change Communication CAFS Centre for African Family Studies CBD Community-based Distributor CPR Contraceptive Prevalence Rate DR Congo Democratic Republic of Congo FP Family Planning HIV Human Immunodeficiency Virus IDP Internally Displaced Populations IEC Information, Education, and Communication IRH Institute for Reproductive Health, Georgetown University IUD Intrauterine Device JGI Jane Goodall Institute MAQ Maximizing Access for Quality MSH Management Sciences for Health MOH Ministry of Health MOU Memorandum of Understanding NGO Nongovernmental Organization PHC Primary Health Care RH Reproductive Health PNSR National Reproductive Health Program (DR Congo MOH) SANRU “Santé Rurale” SDM Standard Days Method TACARE Lake Tanganyika Catchment Reforestation and Education Project WHO World Health Organization UNICEF United Nation’s Children’s Defense Fund USAID US Agency for International Development 3 I. EXECUTIVE SUMMARY It is recognized by the international community that DR Congo, “Even after years of strife, conflict and neglect, possesses a health system that in its fundamental structure is better than many African countries” (WHO/UNICEF, 2001). Nevertheless for more than ten years Family Planning activities had completely disappeared because of the war. The USAID/DR Congo mission engaged Advance Africa to provide technical support to the reproductive health and family planning (RH/FP) component of the SANRU III project, a five year primary health care project. The Advance Africa intervention was implemented in 23 health zones including three zones housing internally displaced populations (IDPs). In addition to this work with SANRU III, Advance Africa was asked to work with the Jane Goodall Institute (JGI) in its effort to integrate RH/FP into conservation activities replicating the Lake Tanganyika Catchment Reforestation and Education Project (TACARE) in Tanzania. Due to the highly religious nature of the population in DR Congo, the majority are either Catholic or Protestant, family planning is a very sensitive issue and not a routine topic in the public health arena. Thus the concept of “desired births” was used in place of “family planning” as a more palatable idea for all involved. The 1820 European law which banned the use of any means to prevent or stop a pregnancy has yet to be abolished and the use and promotion of modern contraceptive methods is still unlawful in the country. Therefore the Advance Africa interventions focused on promoting Optimal Birth Spacing as a health intervention to improve the life and well being of the mothers and children. Advance Africa’s key interventions in DR Congo included building capacity through training and supervision, improving management at services delivery points, promoting advocacy, and behavior change communication (BCC). By the end of 2004 Advance Africa trained more than 280 providers in 23 health zones in the 5 provinces covered by the project: Bandundu, Equateur, Katanga, Bas Congo and Kasai. The BCC materials were revised to include Birth Spacing messages and updated information of FP methods. These materials were made available in all 23 health zones including the IDP zones and later expanded to include the JGI conservation sites. Providers were re-trained in mini-laparatomy and intrauterine device (IUD) insertion, given supervision guidelines and training, and benefited from a Maximizing Access to Quality workshop. The combined interventions resulted in an increase of the utilization rates of FP services in all 23 covered health zones covering a population of 2.8 million with a target population of 626,447 (females age 15-49). Within 22 months of implementation the number of new users was 86,938: 57% condoms, 23% injectables, 15% oral contraceptives, 3% traditional methods 1% IUD, and 1% mini-laparatomy. That 14% of eligible women were new users of FP with a broad method mix shows a substantial shift from earlier contraceptive patterns which were strongly traditional with very little use of modern methods. The initial results from the intervention with JGI are also encouraging. Remarkably within four months of implementation there were 1165 (20%) new users from a target population of 5860 with a broad method mix. Rapid and substantial increases in modern contraceptive use can be achieved in an African post- 4 conflict country. Appropriate integration of family planning with other initiatives does succeed. II. INTRODUCTION In February 2003, at the DR Congo Mission request, Advance Africa made an exploratory visit to the SANRU III PHC project to provide technical assistance in the areas of FP/RH. The SANRU III project is the continuation of the SANRU I and II projects previously funded by USAID and the Congolese government and implemented from 1981 to 1992. The goal of SANRU III is strengthening the management capabilities in rural health zones to increase their capacity to promote a minimum package of primary health care including maternal and child health and reproductive health and family planning. It is comprised of partners Interchurch Medical Assistance (IMA) and the Protestant Church Christ of Congo (ECC) and funded for five years by USAID (mid-2001through mid-2006). During this first visit a comprehensive desktop analysis of the existing project data was completed, two of the health zones covered by the project were visited, and in-depth interviews with project managers and services providers at all levels were conducted. The priority needs identified were: improvement of the day to day management of activities with a focus on service delivery points, reinforcement of the providers’ and community workers’ capacities, and community participation with particular focus on male involvement. The corrective measures recommended included the application of the Advance Africa Performance Monitoring and Improvement strategy, advocacy, training and behavioral change activities. A follow up visit was made in July 2003 to implement a demonstration project aimed at stressing the optimal birth spacing perspective as an integral component of the Primary Health Care minimum package of services. An initial 2003-2004 work plan covering the Vanga and Kimpeses health zones was also drafted. This work plan was subsequently revised at the annual SANRU III planning meeting in New Windsor, Maryland to expand Advance Africa’s RH/FP technical assistance to all the 23 zones covered by SANRU III by the end of 2004. A Memorandum of Understanding (MOU) was signed between Advance Africa and SANRU III to clearly define the Terms of Reference of the collaboration and specify the expected technical assistance from Advance Africa. III. ACTIVITIES All Advance Africa activities were developed through effective partnerships with all key players involved in reproductive health and family planning as reflected in the Memorandum of Understanding (MOU) signed with SANRU III project and the workplan developed with JGI. Selected key activities are outlined below. 5 1. Integration of FP services within the PHC services in SANRU III health zones • Capacity building: for service delivery providers in contraceptive technology, including mini- laparatomy and IUD insertion; training of supervisors, providers and community health workers (“community relays”); and quality improvement through the MAQ initiative course • Development and use of BCC/IEC and supervision materials • Development and promotion of a Performance Monitoring and Improvement guide • Advocacy for repositioning FP as health and development intervention through a national advocacy conference and provincial activities. Targeted provider level support and momentum in conjunction with the MAQ workshop • Advocacy activities to assist the MOH revision of the existing law prohibiting the promotion and use of family planning methods 2. Launching FP activities in the IDP zones • Situational assessment of the IDP zones and the subsequent design of a community-based strategy for SANRU and the PNSR/MOH (National Reproductive Health Program) • Implementation of the community-based strategy and social mobilization activities 3. Integration of FP into conservation activities (JGI) • External Evaluation of TACARE Project, Tanzania and adaptation of model for DR Congo • Assessment and selection of the Kahuzi Biega Landscape in DR Congo for intervention implementation • Training of RH/FP providers and provision of tools and commodities 1. INTEGRATING FP SERVICES WITHIN THE PHC SERVICES IN SANRU III HEALTH ZONES A. Background Advance Africa’s collaboration with SANRU III was defined under a Memorandum of Understanding signed between the two projects. This collaboration, among other opportunities, permitted Advance Africa to rapidly start operating in DR Congo. The MOU outlined the conditions, procedures, and sharing of resources between Advance Africa and SANRU III to ensure practical results in the implementation of their of Reproductive Health and Family 6 Planning programs. Resource-sharing was a crucial strategy to ensure efficient administration and cost savings for both parties. The Advance Africa project applied the “Desirable Births” component to the Primary Health Care program by providing technical assistance to the SANRU III project in the implementation of Family Planning in the health zones covered by the two projects. B. Interventions The intervention activities to integrate FP into the PHC package focused on capacity building for providers, reinforcing community participation, developing and using innovative management and BCC/IEC materials, and improving management procedures and systems through the performance monitoring and improvement strategy. 1. Capacity Building Clinical and Management Training of Providers and supervisors In collaboration with the Centre for African Family Studies (CAFS) regional office based in Lome/Togo, Advance Africa revised the national training curriculum integrating innovative aspects related contractive technology and client centered management strategy. A total of 319 providers were trained using the new curriculum. Twenty-seven supervisors who participated in the provider training also received supervisory training in Performance Monitoring and Improvement. In the third quarter of 2004 Advance Africa and the SANRU III team conducted an evaluation of all medical officers in the 23 health zones. Training in Mini-laparatomy and IUD Training in mini-laparatomies (mini-lap) & IUD insertion began at the end of 2003 and continued throughout 2004. The doctors from the health zones around Kamina, Kimpese, Vanga, were trained on IUD insertion techniques. Training on mini-lap was completed in 18 of the 23 health zones for 85% of the 82 target providers. The training on IUD insertion has been completed in 13 of the 23 zones for 64% of the 440 target providers. This training was limited by the lack of necessary equipment for mini-lap or IUD services. The materials were ordered by SANRU for most of the facilities which now offer these long term methods. In March 2005 health zones in Bandundu and Kasai received a contraceptive technology update combined with a supervisory review that emphasized the necessity of male involvement in FP in the community. Training of community health workers and networks The Advance Africa country representative worked in direct collaboration with the SANRU RH team in identifying, sensitizing, and strengthening community organizations for full involvement in RH/FP activities. The community organizations were first organized into networks in the IDP zones (Katanga province) and, based on the lessons learned there, this social network approach was expanded to the other provinces covered by the project. The RH team used the framework 7 below to sensitize and involve 150 social networks in Katanga and in Bas Congo in FP activities. Other Developmental Sectors Network of Local Community Organizations Health Sector Fig 1: RELATIONSHIP BETWEEN LOCAL DEVELOPMENT STRUCTURES Intersectoral collaboration Community Relays Community Relays In st itu tio na l R ela ys Support system for community networks A total of 390 social networks were identified in the 23 health zones and, so far, 110 social networks in 13 zones have been sensitized. Many social networks have made a commitment to address RH/FP at each meeting. Work with our partners Collaboration in other countries between Advance Africa and the Institute for Reproductive Health/Georgetown University (IRH) was extended to include activities in DR Congo. IRH completed a training of trainers on the Standard Days Method for the SANRU health zones and Advance Africa and IRH have expanded the training of community based health workers in the JGI conservation area. 2. Development of BCC/IEC tools and supervision materials Advance Africa, in collaboration with the MOH/PNSR and SANRU RH team, organized a workshop with participants from various sectors involved in the field of RH/FP to develop and 8 test BCC/IEC materials. This working group method of developing the messages and brochure format itself contributed to consensus building on of the content and methodology to use in educating parents and youths on the health benefits of optimal birth spacing and delayed sexual initiation. The tools were created in a user friendly format and multiplied in sufficient quantity for all service delivery points offering FP services in the 23 health zones. 3. Development and promotion of Performance Monitoring and Improvement guide The country team developed the Performance Monitoring training agenda and curriculum. A “training of trainers” course was held and a refresher course was conducted in a follow-up meeting. These trainers will be conducting trainings in all of the SANRU III-Advance Africa supported health zones. At present 15 Performance Monitoring trainers have been trained and 110 providers have been trained. To harmonize the supervision and BCC tools used in the health zones supported by SANRU III and those supported by PNSR(MOH) multiple meetings were held to streamline the performance monitoring and improvement guide. Ultimately the guide was revised to fit the needs of both SANRU and the MOH and the first application of the tool has been successful and exciting for all parties. The PNSR and SANRU have renewed their commitment to work to continue working together on this project in the future. 4. Repositioning FP National Advocacy Conference and MAQ initiative workshop As part of Advance Africa global strategy to invigorate family planning in DR Congo through its technical assistance to SANRU III, a national advocacy conference was organized in Kinshasa May 13 -14, 2004. The Conference was initiated primarily to increase awareness, interest in and commitment for family planning of the policy makers, program managers, community leaders, services providers, and donors by emphasizing the enormous health and socio-economic impact of family planning. It was expected that the conference would significantly contribute to reinstituting family planning a key priority intervention and this repositioning effort would help sustain recent improvement. The conference was attended by more than 150 participants of diverse background from the different target groups from all 11 provinces. The participants all agreed that the family planning concept should be adopted in DR Congo. Consensus was also reached on the need to appeal to political decision-makers concerning the development of family planning and integrating the provision of family planning into the DR Congo global development plan. In order to mobilize the necessary financing for family planning activities this appeal would be directed at the Ministry of Health level. Another identified need was creating a framework for cooperation among the various actors working in the area of FP from the gender and reproductive health perspective. In summary, it was agreed that family planning is essential for health and the reduction of poverty. 9 Diffusion of the resolutions and recommendations from the national level Repositioning Family Planning Conference was completed in 11 provinces by March 2005. Originally only 9 provinces were programmed to receive follow up measures due to funding constraints, but the Advance Africa representative was able to combine the repositioning follow-up with supervision visits in all 23 sites. 4. Advocacy activities to revise and update the existing RH/FP law Advance Africa worked in conjunction with the Ministry of Health’s (MOH) National Reproductive Health Program (the PNSR) to organize a workshop for parliamentarians and decision makers to discuss options for changing the national reproductive health law and legal age of marriage. Participants reached a consensus which led to the drafting of a reproductive health bill which will be introduced to parliament when the newly elected assembly convenes. The workshop produced a draft document on the proposed changes and follow-up needs within the country context. C. Results As a result of the policy and programmatic efforts launched in DR Congo the utilization of modern contraceptives has begun almost everywhere in the country and has dramatically increased in all 23 health zones supported by the SANRU III – Advance Africa partnership. Considering our brief intervention in the SANRU DR Congo program started in 2003, we have chosen to analyze the results in terms of new acceptors. Analysis of the target population (women aged 15-49) at service delivery points shows large differences among the different provinces. For example, coverage of the population in Bas Congo is very strong in that the number of service delivery points meets the needs of the target population, conversely in Kasaï Katanga there are too few service delivery points for the target population and coverage is subsequently very weak. Thus the best results were recorded in Bas Congo and the weakest results were in the Kasaï Katanga. The aggregate totals for all covered provinces are listed in Table 1. 10 Table 1 : New FP acceptors in the 23 health zones supported by Advance Africa-SANRU III, DR Congo, May 2003-March 2005 Years Population total Female population (15-49 yrs) Total # new clients New clients as % of women 15-49 May 03-Mar 05, 22 month total 2,817,571 626,447 86,938 13.9% We can conclude that 14% of eligible women were FP acceptors over the 22 months. Given that these populations are hard to reach, the figures are encouraging in light of the 4.4% CPR reported for all of DR Congo in the MICS2 study preformed by UNCEF in 2001. There was an impressively wide range of modern contraceptives adopted in this presumably conservative population; 86,938 new acceptors in the 23 health zones were served between May 2003 and March 2005 at the 781 service delivery points. The leading method was condoms, followed by injectables, pills, traditional methods (periodic abstinence, withdrawal, etc), IUDs and female sterilization (Figure 2). Figure 2: Method Mix among New Clients, 23 Health Zones, DR Congo May 2003 – March 2005 (n = 86,938) 11 Condoms 57% Injectables 23% Oral Contraceptives 15% Traditional Methods 3% IUD 1% Mini-Lap 1% Not only was there a substantial number of new acceptors in a short period of time, new acceptors chose modern methods. These results are in sharp contrast to data from 2001 showing the national CPR for modern methods to be only 4.4 per 100 women and the use of traditional methods at 27.0% (Figure 3). In addition folk remedies were widely reported to be in use, including herbal teas. 12 These findings demonstrate that there was a large unmet need for family planning in DR Congo. Even for women aged 24-49 use of traditional methods was six times higher than modern methods. This is a clear indication of the very low access to modern method in 2001. Given the massive constraints on human resources the current FP acceptor rate is a strong testimony to the population’s desire for modern FP methods. D. Lessons Learned It is extremely difficult to re-launch and strengthen Family Planning services in a country where the health system has been completely destroyed by the war and where, because of that post- conflict context, emerging and re-emerging diseases and poverty occupy the top priority position in the government’s and donors’ agendas. This context required a combination of multiple strategies implemented concurrently. These include a strong and continuous advocacy program for repositioning the Family Planning services that corrects gaps and weaknesses encountered in the past and intensive policy and programmatic support addressing all key barriers identified. In the case of DR Congo the revision of the 1820 law, the national advocacy conference, the revision of the BCC/IEC tools, and the capacity building intervention including the training of the community relays and their connection to the social networks were equally important elements in the successes obtained. The combination of so many interventions requires true partnership and effective coordination among actors from many different sectors and strong support from the government and donors. This last aspect was not as successful as we wished Figure 3: Contraceptive prevalence rates by traditional versus modern methods and by age, DR Congo, 2001 3.6% 20.7% 24.3% 4.0% 25.3% 29.3% 4.6% 28.1% 32.7% 4.4% 27.0% 31.4% 15-19 years 20-24 years 25-49 years Total Modern Traditional Total 13 and will need further work. E. Recommendations Given the lesson learned, the most important recommendation is to maintain and reinforce the advocacy component of the Advance Africa intervention to continuously sensitize and motivate decision makers, program managers and providers to keep family planning services among the key priority health and development interventions. In addition, programmatic interventions successfully initiated in the 23 health zones are still incomplete and should be expanded to the other health zones. In the policy arena the new RH/FP law revision must be finalized and as a sign of its interest and commitment for family planning the government should also start budgeting for FP little by little in local budgets and ensure the integration of the FP activities into HIV and other RH interventions within the PHC strategy. Another challenge in reviving RH/FP in DR Congo remains the assurance of quality services, including BCC modification to continue in the positive trend in user acceptance. It is equally crucial for successful implementation to involve religious leaders and local community leaders, however, buy-in from these two groups remains difficult to obtain in DR Congo. The combination of technical assistance and political advocacy though repositioning family planning has been a crucial element in the successful performances of activities in all 23 health zones. F. Conclusion The Advance Africa technical assistance to SANRU III was very short in duration and limited in scope and funding. It could have produced better results if it had been conceived and applied at the beginning of the project. Nonetheless the DR Congo program demonstrated that good results be achieved in a short period of time and with limited funding if sound strategies and good management are utilized. In less than two years of implementation, SANRU III, despite its full load of primary health care services focused on emerging and re-emerging diseases, succeeded initiating FP services in 23 health zones in five provinces in this large country with few functional roads. With the end of the Advance Africa project the challenge is finding ways and means to maintain and expand the results achieved without any additional support. 2. LAUNCHING FAMILY PLANNING ACTIVITIES IN THE IDP ZONES A. Background Advance Africa’s activities in the IDPs zones began in 2004 and consisted of developing and implementing an innovative community-based strategy linking the community relays (community health educators) and the network of community-based organizations. The first step was identifying the existing community structures within in the three sites, analyzing the way they were organized and functioned, and then selecting the most dynamic and functional ones 14 with which to begin. At the same time 42 selected community relays were trained in RH/FP and instructed on ways to collaborate with and assisting the network of community-based women’s organizations. In addition, 90 leaders of community organizations were informed and sensitized and 35 health providers re-trained in FP. This approach aimed at strengthening the community- based approach in RH/FP in the three internally displaced population (IDP) zones of the SANRU III project, in the Katanga Province. B. Interventions The overall objective of the interventions was to strengthen the community-based RH/FP approach in the three Internally Displaced Populations (IDP) zones of the SANRU III Project in Katanga Province. The key activities conducted in these zones included: ƒ Finalizing the IEC/BCC Family Planning educational materials after pre-testing was completed in April 2004 ƒ Conducting a situational assessment of the structure and functionality of the existing community institutions and organizations ƒ Developing and pre-testing the Community-based BCC modules developed for the selected community networks ƒ Co-organizing with SANRU a BCC/FP/RH workshop for the leaders of the selected community networks ƒ Co-organizing a three-day workshop for health providers to update the community-based approach in BCC/FP/RH ƒ Designing and implementing the community-based strategy for SANRU and the MOH/PNSR and providing technical assistance in the development of the FY 2004-2005 BCC/FP/RH SANRU III work plan C. Results The social mobilization activity Advance Africa visited the three IDP zones (Kabongo, Songa and Kikondja) in Kamina from May 28 to June 22, 2004 where 65 participants attended the social mobilization meeting. The group brainstormed how to respond to the high maternal and infant mortality rate and the early pregnancies among teenagers. We also met with a group of 60 displaced persons in Kime called the “integrated displaced” people as they have lived in DR Congo for many years and are well integrated with the rest of the population. 15 Development of a FP/RH community-based strategy In developing the FP/RH strategy for the IDP zones the team followed closely the successful model of the SANRU community-based approach used in the Community Integrated Management and Childhood Illness (IMCI-C) program. This social network approach also includes other PHC messages and thus reinforces the overall PHC program. D. Lessons Learned While the scope of the IDP interventions was very limited in relation to the obvious extent of the need in these areas, nevertheless it created hope and enthusiasm among the providers and beneficiaries. The capacity and motivation of the providers was significantly increased and the extent of community information, sensitization and interest that was generated with very little resources was impressive. In this remote and difficult to access area the visit from a Kinshasa- based team focused on their health problems was extremely important in motivating providers Situational assessment of the social networks and organizations The Advance Africa and SANRU III team interviewed 14 NGOs in Kabongo (women’s groups, traditional healers, agricultural field workers), three in Songa (youth group, women’s group and the religious Adventist group), and nine in Kinkondja (youth, women, and fishermen’s groups). Training In Kamina from May 30 to June 4, 2004 a total of 42 community relays were trained in four zones in collaboration with the SANRU III/World Bank Multisectorial program for reconstruction and rehabilitation (PMURR) change communication approach. A total of 90 leaders have been trained/informed and sensitized in RH/FP and 35 health providers of the SANRU health zones received refresher training in the FP/RH community- based approach. 16 and creating hope in the internally displaced people. E. Recommendations In the IDP zones of Kabongo, Songa and Kinkondja SANRU III and the MOH should seek additional support in order to: (1) provide basic survival kits for each zone; (2) train the traditional birth attendants in BCC RH/FP; (3) train the supervisors along with the rest of the leaders from local women’s organizations; (4) recruit a short term consultant to distribute goods. Fortunately these recommendations will be partly satisfied with the new World Bank project. In the initial IDP assessment report on the SANRU III zone Kamina we recommended moving the local office of the province to Kamina in order to avoid all the risks associated with its previous location and this change has already been made. As a result of the work in the IDP zones it was recommended that all SANRU II zones adapt the community-based strategy comprised of “Social Networking” and use/adapt the FP/RH community-based training modules that were developed and tested. This recommendation has been applied and, as previously mentioned in Section 1, a large number of community-based networks and community relays have been trained and/or sensitized about the BCC approach. F. Conclusion The seed money allocated from USAID’s new initiatives program is certainly not designated to run an entire program. However when used in a context such as the IDP program it can be a tremendous help in achieving good results. Without this modest intervention that literally launched the FP program in this very difficult context nothing would have started to change for these underserved people. The small demonstration project which has now been integrated into the larger scope of SANRU III was well worth the while as it helpe launch FP and improved the capacity of the workers and the population’s education in the IDP zones on RH/FP issues. 3. INTEGRATION OF FAMILY PLANNING INTO CONSERVATION ACTIVITIES A. Background In support of its mandate to improve inter-sectoral collaboration and integrate FP/RH services with health and non-health programs, Advance Africa partnered with the Jane Goodall Institute (JGI). JGI received core funding for the implementation of a conservation program along the Congo River basin and Advance Africa was selected as the service delivery project to offer technical assistance for the integration of RH with special emphasis on FP. This approach had come about as a result of the experience from a similar project implemented in Tanzania. A joint proposal was developed for the project. The first phase covered the development of the 17 proposal, an evaluation of the Lake Tanganyika Catchment Reforestation and Education (TACARE) Project (the similar project in Tanzania), and the field assessment which culminated in the development of an implementation plan. The second phase encompassed the implementation of the activities as well as monitoring and evaluation. B. Interventions 1. External Evaluation of TACARE Project, Tanzania. The Lake Tanganyika Catchment Reforestation and Education (TACARE) Project, a conservation project which in 1999 added a Family Planning component, was implemented by Jane Goodall Institute (JGI) between 1994 and 2003. The external evaluation, funded by USAID Washington, was to document the model for the implementation of the project and key lessons learned during the implementation. The model and lessons were to be used as a basis for the design of a similar project in DR Congo. The evaluation field visit was undertaken in Dar es Salaam and Kigoma in Tanzania between Feb 18 and March 2, 2004 and Advance Africa fielded the Senior Technical Advisor- RH Clinical Services on the team. Prior to the field visit a literature review relating to the project was completed and the draft proposal for DR Congo was considered in guiding the content of the field interviews. The evaluation described the model as “a model for initiating community interest in improving their local environment as a means of contributing to a long term conservation goal.” It also brought up a number of key lessons learned from TACARE project which were highly useful in the development of the DR Congo project. 2. Assessment of the Kahuzi Biega Landscape in DR Congo A process using a set of criteria had been applied to select the Kahuzi Biega Landscape as the most suitable location for the Advance Africa/JGI integrated FP and conservation project. Among the start up activities was the review of already existing IEC materials for their suitability and reproduction for use in the sensitization of community members. A number of flyers and posters were approved as suitable by a team from the RH Unit of the MOH, SANRU and Advance Africa. These were reproduced and used in sensitization. The study covered Kasugho (TAYNA gorilla reserve) and Walikale (gorilla reserve for Utundu and Wassa and Butembo (adjacent to Maiko Park). Discussions were held with the Lubero Zonal Health Director for the selection of nurses and other health workers for training in family planning. Similar discussions were held with community leaders to select individuals for training as Community Based Distributors (CBDs). 18 3. Training of the providers and equipment Thirty-one nurses and 32 CBDs were trained in November 2004. Contraceptives and kits for CBDs were also supplied for the trainees’ use. Even though the training was completed in November actual service delivery did not commence until March of 2005. C. Results 1. The Assessment The key finding was that even though all the respondents were aware of the importance of RH/FP they conceded that these services were not functional except for antenatal services to a limited target group. The key constraints identified when starting the program included the following: • Existence of pockets of insecure areas • Geographic inaccessibility of a large number of areas in the zone • Extreme poverty of the inhabitants • High level of illiteracy • Ignorance about FP • Absence of trained FP service delivery personnel • Negative influence of some religious leaders on FP uptake • Absence of Community Based Distributors (CBDs) • Non existence of organized post natal services • Non existence of FP services In spite of these constraints there were a number of factors that supported the provision of RH and FP in the zone. These include the following: • Readiness of the communities to accept family planning • Presence of maternity homes, clinics and hospital • Antenatal services already being provided • Presence of personnel already providing care and treatment • Existence of appropriate infrastructure. • Presence of NGOs who are prepared to support CBD activities • Readiness of community members to contribute financially to the service • Presence in Butembo of an NGO that already undertakes sensitization in HIV/AIDS and FP • Readiness of community members to volunteer to become CBDs 19 2. Contraceptive distribution Preliminary results after the first four months of FP integration activities with JGI in Lubero have been encouraging (Figure 4). These data may be useful if put into the context that there were no FP methods available before the start of this intervention. Figure 4: Monthly counts of new acceptors, all methods combined, first four months in conservation zone of Lubero, DR Congo 298 243 306 318 0 50 100 150 200 250 300 350 Mar-05 Apr-05 May-05 Jun-05 Figure 5: Distribution of contraceptive methods used among new FP acceptors - in Lubero Health Zone, DR Congo, March-May, 2005 (N = 847). Estimated target population of women aged 15-49 is 5860 20 Depo Proera 17% Pills 26% IUD 4% Condoms 33% Tubal Ligation 5% LAM 13% Cycle beads 2% The method mix with newly trained providers demonstrated the potential to deliver a wide range of modern methods a low resource setting. Condoms were the leading method, followed by oral contraceptives, injectables, lactational amenorrhea method (LAM), female sterilization and IUDs in descending order. The zone reached 5% of the 5860 estimated eligible women in the first month. During the first four months almost 20% of women were new FP acceptors. These encouraging results in the first four months suggest good performance can be achieved with continued services in the future. Conservation efforts can successfully incorporate FP services that provide a wide range of contraceptive methods. D. Lessons Learned The integration effort faced a number of challenges including sporadic outbreaks of violence in the areas adjacent to the zone. This violence interfered with planned activities but nevertheless it was still possible to commence service delivery. Key lessons learned included the following. • The active participation of the MOH both at the national and zonal level was crucial. This provided leverage and support which hopefully will ensure sustainability after the project closes in September 2005. • The project liaised closely with the Union of Associations for the Conservation of Gorillas and Community Development (UGADEC) who were the conservation partners already on the ground before the inception of the program. This association created the credibility that was required as the program of integration began. 21 • Close collaboration with SANRU enabled efficient use of resources, for instance the IEC materials already developed by SANRU. • Lessons learned from the TACARE Project in Tanzania were very valuable in designing the DR Congo integration program. E. Recommendations Given the uncertainty of the finding the involvement of the MOH reproductive unit needs to be maintained and strengthened to ensure regular supervision, monitoring and support to the field. This is crucial to guarantee the continuity of the activities after the Advance Africa support ends. The ideal situation would be to continue funding and expand this wonderful experience through the follow-on project of Advance Africa. F. Conclusion. A crucial strategy in repositioning family planning is the integration with non-health programs. The experience in the Lubero health zone in integrating FP into the conservation program being implemented by JGI has demonstrated that it is feasible to provide FP as well as other reproductive health services as an integral part of a larger conservation activity. The FP/RH component indeed satisfies a felt need that enhances the acceptance of the conservation program. With the results that were obtained following the less than one year implementation it is clear that a need is being met and over time it is expected that this will contribute to improving FP uptake in the locality and the country as a whole. IV. OVERALL OUTCOMES Given the multiple facets of the DR Congo program, its multiple locations, and many initiatives we have highlighted some of the key results below. The main results of the SANRU III intervention include almost 14% of eligible women (aged 15- 49) becoming new FP acceptors over the 22 month period of the intervention. Before the project it appeared virtually no women were using a modern contraceptive as none were available. Other results include national advocacy culminating in a parliamentarian working group focused on revising a colonial law prohibiting the promotion and use of family planning; revamping of all IEC/BCC materials for health providers; community relay training in FP methods and the sensitization of social networks on RH/FP needs; expansion of the method mix offered in RH/FP clinics to include IUD and mini-lap training and most recently the Standard Days Method (SDM). Advance Africa provided technical assistance to the DR Congo government as member of the 22 World Bank assessment and planning team for the new health sector rehabilitation project “Projet de Rehabilitation du Secteur de la Santé (PReSS)”. The project goal is “to increase access to and utilization of high-quality primary health care services, with an emphasis on women and children.” It will be funded by the World Bank up to $150M for four years. A significant portion of the project budget, not yet specified, will be allocated to RH/FP as a critical intervention to attaining the project goal and objectives. Key results from IDP zones include training community relays, sensitizing social networks and providing these groups with IEC/BCC materials. All of the community relays have been equipped with CBD kits to continue their work. Providers were re-trained on FP method use and their training expanded to include the SDM. Similarly the results in the JGI intervention also include training community relays, sensitizing social networks, and providing these groups with IEC/BCC materials. All of the community relays have been equipped with a CBD kits to continue their work and providers were also re- trained on FP method use including the SDM. The overall percent of new acceptors as a percent of eligible women reached the first month target of 5% and reached 20% through the first four months. Prior to the intervention no contraceptives were available to this population and similar performance figures are expected for the coming months based on these first few month of the project’s existence. Overall, it is clear that Advance Africa has contributed in significantly increasing the utilization of modern contraceptives methods in the 23 health zones including the 3 IDP zones supported by the SANRU III project and the zones where the JGI conservation program is being implemented. Globally the utilization rate has been multiplied by more than five in places where some residual FP activities existed and significantly increased where there had not been any family planning activities for these last eleven years. V. LESSONS LEARNED The DR Congo experience is illustrative of the many challenges facing family planning in post conflict countries even when the system had been performing well prior to the war. The subsystem that suffered the most from the conflict was the procurement and distribution system for commodities including the contraceptives methods. Without commodities there was no program and the country was left without any serious family planning capacities. After commodities the social mobilization and the advocacy components were the second most critical intervention in the rebuilding effort and in the re-launching of family planning services. We also learned how the integration of FP activities into non-health interventions and the focus on addressing the unmet need of the IDP zones was critical to the success of the rebuilding effort. In the DR Congo’s highly religious context the use of faith-based organizations has somewhat facilitated the integration of FP to improve the global PHC program that includes RH/FP. The 23 push from the mission was instrumental by not only being completely involved at all levels of the FP activity implementation but also by ensuring at the availability of contraceptives methods and the basic equipment. The mission also helped by closely monitoring and pushing the activities at the services delivery points which was definitely an advantage in the DR Congo context. VI. RECOMMENDATIONS Our primary recommendation is to continue funding this activity which at present does not have any chance of being funded by the local government or the other donors currently active in the country. The new DR Congo World Bank project would not be able to support the overall project to ensure complete continuation of the FP activities. While funds have been put aside for RH/FP there will still be a need for more funding to ensure overall coverage of RH/FP. It would be necessary for USAID to continue its support for a few more years to maintain, expand and sustain the FP with the PHC activities. If funds are available it would be prudent to rapidly complete the training in IUD and mini-lap as well as the training in Performance Monitoring and Improvement especially since the model has been expanded to the national level. The extension of the overall approach used by Advance Africa would require the involvement of all donors intervening in RH/FP in DR Congo. The MOH with technical assistance should approach all these in country partners to negotiate the funding for the national family planning for the 11 provinces. With all the tools and approaches already developed and disseminated in a large number of facilities, scaling up to cover the entire country is now more feasible. We strongly recommend, based on the results achieved in the integration of the FP activities with the conservation intervention and the PHC activities, that the principle of integrating FP activities into non-health projects should be further documented, disseminated, supported and expanded to the all provinces. 24 ANNEXES ANNEX I Reports used in preparation of this report • FORMATION des Cadres du Projet SANRU III en République Démocratique du Congo, Formation des Formateurs en Planification Familiale, Formation en Supervision Facilitante, Du 1er au 18 décembre 2003, Présenté par Dr KOALAGA André,Chargé de programme en Santé de la Reproduction Au CEFA • Trip report , Purpose:Exploratory visit to SANRU III project to identify needs for TA from Advance Africa, 17-22 February 2003, Prepared By: Issakha Diallo • Trip Report, Traveler: Suzanne Jessop, Supervise SANRU/Advance Africa IUD and Tubal Ligation Training and new FP structure in Nsona Mpangu, Kimpese, July 9-10, 2004, • Rapport de Formation Des Formateurs En Mini laparotomie Et En Insertion De Diu A Kimpese, AU CENTRE DE FORMATION, du 04-10/07/2004 Soumis par : Dr NLANDU Mangani, • Trip Report Under, Armand L. Utshudi, Pharm., & MPHConsultant, on Performance Monitoring and improvement to support the implementation of primary health care activities at health center and community levels; Activity Code # A3-CGC12XX- 10HH2X, July 30, 2004, • Rapport de Mission Berengère de Negri, Advance Africa/Projet SANRU, concernant la Co- formation en Communication pour un Changement de Comportement (CCC) adressée aux prestataires de Santé de la Province du Kasai Occidental etEvaluation/Développement du Matériel Educatif de Support pour la Santé de la Reproduction, spécifiquement la PF/Naissances Désirables, le 19 mars 2004 • Rapport de Formation En Pre Test Des Matériels De Support Educatif En Santé De La Reproduction, Kinshasa,(RDC) du 08 au 15/04/2004, Présenté par :Dr André KOALAGA ,Chargé de programmes en SR au CEFA, Lomé • The DR Congo progress report , March 2003 • Rapport De La Formation Des Accoucheuses Traditionnelles De Quatre Zones De Santé / Pool Karawa En Santé De La Reproduction Et Counselling Pf, du 29/09 au 05/10/2004, Marie Claude 25 • Trip Report D R CONGO November 29, 2004 – December 11, 2004, Prepared By: Issakha Diallo, Berengere De Negri, And Erin Seidner, • Rapport De La Formation Des Prestataires En CCV Et Counselling Ccv De Quatre Zones, De Santé / Pool Karawa, du 29/09 au 09/10/2004, présenté Marie Cluade Mbuyi et Chantal Mukela • Rapport De La Formation Des Animateurs Communautaires De La Zone De Santé De Kikongo En PCIME-C / PF du 14 au 17 février 2005, présenté Marie Cluade Mbuyi et Chantal Mukela • Rapport de Mise A Jour Des Connaissances Des Infirmiers Titulaires De La Zone De Santé De Kikongo En Technologie Contraceptive, du 12 au 13 février 2005 présenté Marie Cluade Mbuyi et Chantal Mukela 26 ANNEX II Memorandum of understanding between Advance Africa and SANRU III Memorandum of Understanding Between Advance Africa/MSH and SANRU III The Goal The goal of this Memorandum of Understanding is to create an outline for the conditions and procedures for collaboration and the sharing of resources between Advance Africa and SANRU III to ensure practical results in the Democratic Republic of Congo. The sharing of resources was identified in order to provide two elements, an efficient administration and furthermore it functions as a cost saving method for both parties. This collaboration also permits both parties to legally operate in DR Congo. In addition, this Memorandum addresses the collaboration of technical assistance between Advance Africa and SANRU III in DR Congo, which is the principle reason for this partnership. The Agreement This Memorandum establishes that Advance Africa and SANRU III have decided to work in close collaboration for the implementation of their programs in the area of Reproductive Health and Family Planning. The implementation of this collaboration will take place in the districts where the SANRU III project intercedes and in two sites for internally displaced persons where Advance Africa will initiate activities for “Desirable Births.” The Advance Africa project will apply the “Desirable Births” component to the Primary Health Care of SANRU III, and to this end bring technical assistance to the SANRU III project in the implementation of the Family Planning in the health zones covered by the project. The two projects each with experience in their own domain are agreed that Advance Africa will: 1. Identify and adapt communication tools for behavior change use at the clinic and community level with SANRU III – these tools will include but are not limited to a family planning flip chart and a simple one page FP card for the use of clinic workers tailored according to the methods available for distribution at the health centers and referral centers. 2. Design and implement training for Health Zones supervisors (and Médecins Chefs de zones when possible) for the eleven zones and the two new IDP zones based on the national family planning curriculum for providers which is in the process of being finalized. Supervisors will be trained to use a quality monitoring check-list. The training 27 will concentrate on interpersonal and counseling skills which can be transferred to the clinic and the community workers the supervisors work with on a daily basis. Training will also include, but is not limited to ensuring an understanding of health systems information management and contraceptive logistics systems. 3. Assist SANRU III to develop a community strategy for “Desirable Births.” Advance Africa will also assist SANRU III in identifying and adapting a community mobilization (including positive deviance) curriculum which will possibly come from Save the Children US and messages for use in training which will be carried out by a local trainer. The community strategy must establish explicit links with the health care centers and health care workers. 4. Assist SANRU III in preparation for the training of family planning providers at the clinic level based on the national curriculum. 5. Assist SANRU III and the locally hired trainers in preparation of IUD and Mini-lap training through provision of technical updates as well as the most recent research being conducted by FHI and others. 6. In coordination with USAID, the MOH, and other partners including SANRU and PSI, Advance will design and implement a workshop on “Repositioning Family Planning in DR Congo” One of the outcomes of this meeting will be a National Strategy to prioritize Family Planning at the National, Provincial, Zonal, and Community levels and how to involve men as well as women in the program. Participants will need to be carefully decided on, but may include the Médecins Chefs de Zones, District Health Officers, etc. 7. Train SANRU staff and selected “Médecins Chefs de Zone” in Performance Monitoring Plus. This training will include how to rapidly collect and analyze information from the field to improve programming outcomes. 8. Operations Research – will await the finalization of the birth spacing model created by Advance/Pop Council, which will be tested in DR Congo. 9. Assist SANRU in the preparation of an assessment for the two selected IDP zones. This is tentatively scheduled for the week of October 20. Advance will also assist in finalizing a strategy for reaching the target population in these two zones. 28 10. Recruit a Coordinator to help Advance Africa to respond in the most efficient and rapid manner possible to the demand for technical assistance from the SANRU III project entrusted to them by the USAID Mission for the Democratic Republic of Congo. The Coordinator will represent Advance Africa and work closely with the SANRU officers to ensure an effective use of resources. The coordinator will spend 70% of his/her time working with the SANRU III project and 30% of his/her time working on other Advance Africa activities in DR Congo. Together, Advance Africa and SANRU III will detail an elaborate description of the coordinators duties and responsibilities. Since both projects are financed by USAID, and the USAID mission in DR Congo will follow the progress of both projects, if any conflict arises between the two projects due to the nature of this agreement they will first be resolved in an amicable manner between the projects, barring a resolution the matter will be presented to USAID who will advise the projects on the path they should proceed with. The Directors of both Advance Africa and of the SANRU III project are co-signers of this agreement, each charged with its correct and complete execution. Director Advance Africa Date____________________ Director SANRU III Date____________________ Seen by USAID representative in DR Congo Date_____________________ Accord de Collaboration Entre Advance Africa/MSH et le Projet SANRU III/DR Congo 29 Modification No.1 Les termes et les conditions de cette modification sont effectifs le 1 novembre, 2004. L’objectif général est d’apporter un appui technique approprié au projet SANRU III et au Programme National de Santé de la Reproduction pour la réalisation effective des objectifs en matière de la Planification Familiale. Le but de cette modification c’est une augmentation aux taches confiées à Advance Africa. L’accord de collaboration sera amendé comme le suit: 1. Dans la section en titre L’accord, les taches suivants seraient ajouter après le tache numéro dix : 11. Organiser une conférence qui renforce des capacités des prestataires cliniques et non cliniques. La conférence désignait par l’USAID serra une Formation en Maximisation de l’Accès et de la Qualité (MAQ), 51 participants dont 30 personnes de SANRU III et d’autres venant des différentes institutions seront renforcés en compétences en MAQ. 12. Advance Africa assistera l’MOH avec l’organisation d’un plaidoyer sur la loi PF. L’atelier de consensus réunissant 20 experts pour le plaidoyer, la révision des lois relatives à la SR/PF en vue de proposer une loi plus globale sur la SR tenant en compte les recommandations de la CIPD. La coordinatrice des activités Advance Africa serra charge avec le suivi des parlementaires da la révision de la loi PF/SR Tout les autres termes et conditions de l’accord entre Advance Africa/MSH et le Projet SANRU III/DR Congo restent sans changements. Lu et Signé: Pour Advance Africa, Directeur Date Pour le projet SANRU III Date

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