Analytic and Technical Support to the PRH Program in Sub-Saharan Africa

Final Report to the David and Lucile Packard Foundation

December 13, 2012 Reference Number: 200934969 December 4, 2009 to November 30, 2012

Executive Summary
The Packard Foundation grant has enabled Futures Group and its in-country partners to strengthen family planning advocacy by showing the link between family planning (FP) and national and local priorities, such as womens health and empowerment, food security, and girls education. We have been able to reach diverse audiences not usually associated with FP issues and underscore the continuing need for FP programs and the far-reaching implications of helping couples meet their reproductive desires. The grant allowed us to demonstrate the value of these advocacy-related initiatives, and we are gratified that other donors have committed themselves to moving our work forward. Our initial activity was to inform francophone West African leaders about the health benefits and cost savings of meeting unmet need for family planning and making progress toward the Millennium Development Goals. This activity set the stage for a major initiative supported by multiple donors to strengthen FP programs throughout the region. National governments are making new commitments to family planning, as seen in the 2011 International Family Planning Conference held in Dakar and the 2012 London Summit on Family Planning. Our next set of activities was based in Eastern Africa and focused on new themes related to family planning issues. In Ethiopia, we applied the Climate Change, Food Security, and Population Model using local data to show that population growth will worsen food security in the future, especially considering the likely effects of global warming such as drought. In collaboration with the PHE Ethiopia Consortium, we developed national and regional versions of the materials and held three stakeholder meetings to ensure that the materials would be appropriate in diverse settings in Ethiopia. Dissemination of the model results is continuing with funding from USAID. In Kenya, we helped the Reproductive Health and Rights Alliance (RHRA) to develop an evidencebased advocacy strategy and produce key print materials to explain the serious consequences of unsafe abortion and inform the general public that the 2010 Constitution does allow abortion to be performed by a trained health professional. RHRA and its six member organizations now have the tools to intensify their communication work and make greater use of social media.

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In Tanzania, we adapted the RAPIDWomen model to show the linkages between family planning and other women-centered strategies, such as girls education and prevention of gender-based violence. The highlight of this work was the national launch by the First Lady, Mama Salma Kikwete. Following the launch, we collaborated with three national nongovernmental organizations (NGOs) to disseminate the RAPIDWomen materials to district leaders, councilors, and communities. This work will continue under a USAID-funded project.

Context
In the four projects conducted under this grant, Futures Group sought to strengthen advocacy initiatives to increase support for FP programs and help women meet their reproductive needs. Following is a summary of the priority needs: In the nine francophone West African countries, contraceptive prevalence has remained low, and many women lack access to FP services and information. External donors are the main funders of FP programs. Ethiopia has experienced severe droughts and famine in the past. Recently, the government has increased its support for family planning, and contraceptive prevalence has increased rapidly, mainly through provision of injectables at the community level. Nevertheless, Ethiopia still faces threats to its food supply due to climate change and rapid population growth. In Kenya, some 300,000 women obtain unsafe abortions each year. About 2,600 women die from unsafe abortions, and six times as many women suffer serious complications. Emergency treatment for unsafe abortion costs the public health services about Ksh. 300 million ($3.4 million) annually. Tanzania has a national FP program, and use of modern contraceptives is increasing gradually. However, opposition to family planning remains. Many Tanzanians believe that contraceptive use is against Islamic teachings. Nearly two in five married women respondents in the 2010 Demographic and Health Survey said that they do not intend to use family planning in the future. National political leaders have made public statements about maternal and child health but have avoided mention of family planning until recently, when President Kikwete spoke at the July 2012 London Summit on Family Planning.

Project Description
Futures Groups work under this grant is to provide analytic and modeling services in support of the David and Lucile Packard Foundations Population and Reproductive Health Program. A major activity under this grant is to use the Resources for the Awareness of Population Impacts on Development (RAPID) model to support country-level advocacy efforts to mobilize political support, design and implement favorable policies, and increase allocation of resources for family planning.

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Overview of Accomplishments
West Africa RAPID/MDG Analysis To highlight the challenges facing francophone West Africa countries, Futures Group conducted a RAPID analysis to show the potential impact if all unmet need for family planning were met by 2030. A second analysis showed that every dollar invested in family planning programs would lead to savings of $2.90 in various interventions to reach five Millennium Development Goals (MDGs) by 2020. Based on these data, Futures Group prepared a presentation, Family Planning: Essential Strategy for Development, for the opening session of the February 2011 conference on Population, Development and Family Planning. It can be retrieved at: http://www.futuresgroup.com/resources/publications/planning_familial_strategie_essentielle_pour _le_developpement_west_africa_r . This presentation and the nine country briefs highlighting the cost benefits of FP programs (funded by the U.S. Agency for International Development) have been widely used at the regional and country level to advocate for greater priority for FP programs. This activity set the stage for a major initiative supported by multiple donors to strengthen FP programs throughout the region. National governments are making new commitments to family planning, as shown in the 2011 International Family Planning Conference held in Dakar and the 2012 London Summit on Family Planning. Ethiopia Model on Climate Change, Food Security, and Population This activity was designed to raise awareness of the impact of population growth on food security, taking into account the likely effects of climate change on food production. To provide the evidence base for advocacy, Futures Group team developed a complex computer model with three submodels that calculate population projections, food energy requirements, and projected food consumption. The model is dynamic and takes into account many interacting variables that often have non-linear relationships. The results of the Ethiopia model showed that family planning is a policy lever that could be applied to lessen the effects of climate change by reducing population growth and hence overall demand for food, leading to fewer underweight children over the next 40 years. During the final year of the Packard grant, Futures Group completed the following activities: The PowerPoint (PPT) presentation, On the Edge: Linking Climate Change, Food Security, and Population in Ethiopia, was finalized in December 2011 following three validation meetings at the national and regional levels with 75 participants. Two policy briefs were publishedone for international audiences to present the case for including FP as an adaptation strategy to climate change in the food security sector (available at: http://www.cpc.unc.edu/measure/publications/fs-12-71); and the other one for Ethiopian audiences, with a focus on policy recommendations (http://www.pheethiopia.org/pdf/Policy_Brief_on_Improving_Access_to_FP_and_Food_Security.pdf). Dr. Scott Moreland presented the model at the Climate Change and Population Conference on Africa, held in Ghana from July 14, 2012, and at the Fourth International Conference on Climate Change: Impacts and Responses, sponsored by the University of Washington in Seattle from July 1213, 2012. He also presented the Climate Change, Food Security, and Population and RAPID Women models at the Packard Foundation on July 16, 2012.

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Dr. Moreland and Ellen Smith completed a technical guide describing the pilot-testing of the model in Ethiopia: http://www.cpc.unc.edu/measure/publications/sr-12-69. This work was co-funded by the MEASURE Evaluation project.

The USAID-funded Health Policy Project is supporting further dissemination of the model through public events, policy dialogues, and technical assistance, with a focus on policymakers, key officials, and media at the federal level and in the Amhara region.

Participants at a validation workshop in Ethiopia gather for a group photo. Photo credit: PHE Ethiopia Consortium.

Kenya: Advocacy for Sexual and Reproductive Health and Rights Under the Packard grant, Futures Group worked closely with RHRA to prepare a comprehensive communication strategy for the alliance and its six member organizations to advocate for improved sexual and reproductive health in Kenya. The main objective of the strategy was to inform opinion leaders and the general public that Kenyas Constitution adopted in 2010 does support provision of abortion by trained health professionals. Nevertheless, most Kenyans are unaware of this policy change. The Ministry of Medical Services added some clarity to the situation by issuing Standards and Guidelines for Reducing Morbidity and Mortality from Unsafe Abortion in Kenya, which emphasizes prevention of unintended pregnancies and clarifies standards for service provision. Thus, RHRA can play an important role in ensuring that the new policy is understood and implemented. During JanuaryJune 2012, consultant David J. Olson worked with RHRA to prepare the strategy. In Nairobi, Kenya, he conducted formal interviews with 38 people24 key employees of RHRA member organizations, 3 government officials, and 11 others (including Friends of RHRA, staff of Planned Parenthood Federation of America Global and International Planned Parenthood Federation). He also organized and led a workshop to build the communication skills of 11 RHRA

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members and facilitated a validation workshop to review the draft strategy. Comments from the validation workshop were incorporated into the final version of the communication strategy. Key components of the communication strategy are as follows: Goal: To expand awareness of, and support for, changes on reproductive health and rights in the 2010 Constitution, particularly on legal and safe provision of abortion, to members of the RHRA and the ministries of Medical Services and Public Health and Sanitation. Objectives: o Increase the number of members in the six membership associations of RHRA who have an accurate understanding of the changes on reproductive health and rights in the 2010 Constitution. o Increase the number of members who also support the changes, regardless of whether they fully agree with them. o Increase awareness and support of these changes in the ministries of Medical Services and Public Health and Sanitation and support their efforts to develop policies, guidelines, and training curricula. Key audiences: o Health providers of RHRA: Family Health Options of Kenya (FHOK), Kenya Medical Association (KMA), Kenya Obstetrical Gynecological Society (KOGS), National Nurses Association of Kenya (NNAK), and Reproductive Health Services (RHS) o Women lawyers of RHRA: Federation of Women Lawyers of Kenya (FIDA-K) o Government health ministries: Ministry of Public Health and Sanitation (MPHS) and Ministry of Medical Services (MMS) Key messages: Abortion is legal in Kenya, yet women continue to die and suffer. o The health message: Unsafe abortion is killing women and is preventable. o The legal message: The new Constitution says that abortion is legal in some specific cases allowed by the Constitution.

Other sections cover: key principles, RHRA members communication assets, the central role of the RHRA secretariat, roles of the RHRA member organizations and the two health ministries, suggested tactics using interpersonal and media channels, and future audiences. The eight annexes of the communication strategy are (1) SWOT analysis of RHRA communications; (2) message box and abortion fact sheet; (3) RHRA member communications assets (websites, social media, staff, etc.); (4) strategic communications workplan; (5) calendar of communications opportunities; (6) list of people interviewed; (7) interview guide; and (8) Biblical references to abortion. With support from Futures Group consultant Monica Wanjiru, the grant also supported the drafting, layout, and printing of the following RHRA publications: RHRA flyer summarizing Who We Are, Our Beliefs, Our Strategies (1,000 copies) Friends of the RHRA booklet (8 p., 1,000 copies) RHRA Talking Points on Abortion (1 p.A5 factsheets, in English and Swahili, 1,000 copies each)

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Frequently Asked Questions on Abortion as Allowed by the Constitution (2-sided A4 brief, in English and Swahili, 1,500 copies each) Turning Down the Wick (documentary video; 250 color jackets, CD labels, and discussion guide inserts)

The RHRA Board endorsed the communication strategy during its annual planning retreat. To implement the strategy, RHRA has set up a Communications Committee to review planned activities and provide technical guidance, hired a communication officer, and developed a one-year work plan to implement the communication strategy. RHRA has worked closely with 12 journalists, orienting them on key topics and providing background materials. In September 2012, RHRA launched a media campaign to increase public awareness of the abortion issue, with a focus on medical and legal professionals, young people, and health officials. Articles on this topic have been published in The People, NationMedia.com, Africa Science News, Xinhua News Service, and online blogs. RHRA has distributed bulk copies of the CDs and print materials to its six member organizations as well as the two ministries of health. Tanzania RAPIDWomen Advocacy and Outreach The project in Tanzania was designed to highlight the importance of family planning to womens empowerment. To create an evidence base for advocacy, Futures Group adapted the RAPIDWomen model to Tanzania and disseminated various materials at the national and district levels. Our Tanzania partner agency was Wanawake na Maendeleo (WAMA), an NGO founded and chaired by the First Lady, Mama Salma Kikwete. First, the project team did the data analysis to set up the model. This work entailed obtaining recent national data on educational attainment and economics, as well as the usual demographic and health indicators, including the 2010 Demographic and Health Survey data. Based on the model results, the project team prepared a PPT presentation highlighting the findings and explaining their relevance to Tanzania and translated it into Swahili. Then the team worked closely with a Task Force of Tanzanian health, education, and womens rights experts to discuss the storyline and refine the messages and visuals. Representatives from the Ministry of Health and Social Welfare, Ministry of Education and Vocational Training, and the Ministry of Community Development, Gender, and Children participated in the review group and drafted three policy briefs on womens health, girls education, and gender norms. Based on the groups feedback, we amended the education data in the model and changed some text and photos. The local team then pretested the PPT with 36 district council members and youth in Kisarawe District. Based on the pretest, we revised the Swahili PPT and replicated the changes in the English PPT. The highlight of the project was the national launch by the First Lady, Mama Salma Kikwete, held in Dar es Salaam on August 24, 2012. About 250 people attended the launch including high-level women leaders, cabinet ministers, parliamentarians, senior government officials, representatives of womens groups, media representatives, ambassadors, and development partners. In her first major speech on family planning, the First Lady stated that research findings show that women do not use family planning because they fear being divorced or beaten by their spouses. They should not fear. Before the national launch, WAMA organized a one-day orientation session for 15 media representatives in Dar es Salaam to provide them with detailed information on the RAPIDWomen model and the three themes (family planning, girls education, and gender norms). Several of the journalists who attended this briefing have written several articles on these topics. The national

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First Lady Mama Salma Kikwete greets attendees at the launch of RAPIDWomen in Dar es Salaam. In the photo from left to right are: the Minister for Education, the Minister for Community Development, Gender and Children, Mama Kikwete, and the UN Special Envoy for AIDS in Africa. Photo credit: Humphleahs International Limited.

launch received prominent coverage by the major local media outlets, including NIPASHE, IPP Media, In2East Africa, Jambo Leo, and the Daily News. The project team distributed a colorful two-page flyer with the key messages of the PPT and made video clips of the national launch, covering the presentation by the First Lady as well as interviews with women leaders and youth. After the national launch, the project team concentrated on disseminating the RAPIDWomen messages at the district level, since district officials make funding decisions on family planning. We prepared a second PPT that explained the importance of family planning and its benefits for individuals, families, and the community. Based on recommendations from the review group, we revised the district-level PPT and four briefs and prepared final versions in Swahili and English. During OctoberNovember 2012, WAMA, three national NGOs, and their local partners launched an intensive public education campaign in three regionsTemeke, Morogoro, and Dodoma. The key audiences were District Councilors, district officials responsible for planning and budgeting, and community members. The three NGOs also trained local government officials, members of civil society organizations (CSOs), health providers, and teachers to present the RAPIDWomen materials in their communities. Following are the highlights of the district activities: In Mvomero District of Morogoro region, UMATI (Chama Cha Uzazi na Malezi Bora Tanzania), the national FP association, disseminated the RAPIDWomen materials, reaching 22 district councilors and 23 district leaders, health officials, heads of departments, and teachers. UMATI also trained 24 representatives of CSOs and community health service providers to present the PPT and materials to diverse audiences. UMATI also organized a large community event during market day, using traditional dance, entertainment, and group discussion to engage the public in the key messages. During this event, UMATI provided

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information about sexual and reproductive health and HIV to 394 people, delivered family planning services and counseling to 41 people, and gave out 290 condoms. In Temeke, a suburb of Dar es Salaam, SOS Childrens Villages presented the model and materials to 26 district councilors and 16 district officials working in social welfare, health, administration, planning and statistics, community development, and law and protection. SOS Childrens Villages also trained 17 people, including local officials, members of CSOs, ward representatives, teachers, and a religious leader in RAPIDWomen. An all-day community event reached some 700 adults and 200 youth with the three RAPIDWomen themes reflected in music, art, plays, and acrobatic performances. In Dodoma urban district, the Medical Women Association of Tanzania (MEWATA) presented the PPT and materials to 30 district councilors and 18 district officials covering finances, agriculture, community development, social welfare, youth, medicine, education, and reproductive and child health. In addition, MEWATA trained 30 people from CSOs, faith-based organizations, teachers, and healthcare providers. It also organized a large public rally attended by about 200 community members, with the key messages conveyed through short plays presented by a drama group and entertainment by local traditional dancers.

As part of the training-of-trainers sessions in the three districts, participants prepared district action plans outlining future initiatives. After discussing the issues raised by the RAPIDWomen materials, the group identified key actions to be done, including those that would need funds from the district budget. In this process, district leaders committed themselves to implement some actions and allocate the necessary funds in district plans and budgets for 2013/2014. The main priorities in the Action Plans are summarized in Table 1.
Table 1. Priorities in the District Action Plans
Actor/Decisionmaker District Government Key Actions

Youth in Mvomero district, Morogoro region, read the RAPIDWomen flyer. Photo credit: UMATI/Tanzania

Empower girls to attend schools Allocate funds for girls dormitories Increase budget for FP and ensure access to various FP methods Design women- and girl-centered programs Disseminate the model to members of the ward planning committee Integrate issues identified in the RAPIDWomen presentation in village and ward plans Increase awareness to the community on gender-based violence (GBV) and family planning Prepare a bylaw to address early marriage Use mass community education to address social cultural norms affecting GBV

Local Government and Civil Society Organizations

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Local leaders in Temeke district develop action plans to address early pregnancy and gender discrimination. Photo credit: SOS Childrens Villages

Our activities under this grant entailed several innovations: Our RAPID analysis for West Africa used the goal of meeting all unmet need for family planning by 2030, whereas other RAPID applications had been based on national goals for fertility levels or population size. The model on Climate Change, Food Security, and Population is more sophisticated than the traditional RAPID Model because it is based on interactions among multiple variables and can adapt to nonlinear relationships. RAPIDWomen is also more complex than the traditional RAPID Model because it calculates the effects of three interventions on a composite variable (the Human Development Index). Typically, we focus on FP advocacy at the national level, but in this work, we also tailored messages and materials for use in regional and district advocacy. This approach helped us to refine the messages to appeal to policymakers at various levels. While we have worked on many controversial issues such as stigma against people who are HIV positive, we have not been involved in the abortion issue. In Kenya, we helped our colleagues frame the issue in a sensitive way and make better use of new media to connect with youtha key audience and a potential force for social change.

Our work has covered many diverse issues related to family planning, including the contribution that voluntary family planning can make to slowing population growth; factors affecting food security; womens empowerment, their physical and mental health, and rights; early marriage and childbearing; decisions regarding the timing and number of children; girls education; cultural norms, religious dictates, and the role of men in family decision making. By raising these issues, we generated thoughtful discussions and debates and led many people to think of family planning in a new light.

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Challenges/Lessons Learned
The two new models were effective in making the case for family planning as a key intervention to address the effects of climate change and population pressures on food supplies (in Ethiopia) and as a means of empowering women while accelerating national socio-economic development (in Tanzania). The three interventions highlighted in the RAPIDWomen Modelfamily planning, girls education, and gender-based violencewere chosen partly for their statistical power, but they proved to be highly relevant to Tanzania and appealed to broader audiences than a narrow family planning message. In all venues, the project materials generated a lot of discussion and interest. Audiences such as national leaders as well as local officials appreciated that the materials are based on data and research studies. They found the materials to be user-friendly, colorful, and succinct (especially the flyers and briefs). In Tanzania, forming a Task Force to participate in the design of the presentation (the data, story, and outline) had the added advantage of involving key ministries in the work and promoting multisectoral collaboration. The process of identifying an ask (specific item to be done) is a new concept for advocates. While it takes time to work through the various priorities, having a concrete action gives them a focus and clarifies their target audiences and messages. Collaborating with high-profile CSOs such as WAMA entails a long negotiation and planning process, particularly if there are activities that will involve the active participation of a public figure, such as the First Lady. Nevertheless, such high-risk/high-gain ventures can be highly effective. In Tanzania, engaging well-established national NGOs in district dissemination worked out very well. They were enthusiastic partners and had close ties with local groups.

Plans for Dissemination/Follow-up

Additional work on all four project components will be done with funds from other donors: In West Africa, the Ougadougou Partnership, a network of country-level planning teams, is collaborating with multiple donors to strengthen FP programs in all nine countries. In Ethiopia, dissemination of the Climate Change, Food Security, and Population model, presentation, and other materials began in September 2012 with funding from the USAIDfunded Health Policy Project. In Kenya, RHRA will continue its communication work with support from Planned Parenthood Federation of America Global. In Tanzania, the USAID | Health Policy Initiative Task Order 5, implemented by Futures Group, will continue to work with WAMA and to disseminate the RAPIDWomen materials more widely. The three NGO partners will incorporate the materials into their ongoing outreach activities.

Organizational Changes: None

Contact Us: Futures Group One Thomas Circle, NW, Suite 200 Washington, D.C. 20005 policyinfo@futuresgroup.com