Julie Solo, Cheikh Mbacké, and Steven Sinding

Mid-term Evaluation of Advance Family Planning: Advocacy That Works

Mid-term Evaluation of Advance Family Planning: Advocacy That Works

Julie Solo, Cheikh Mbacké, and Steven Sinding

Draft: November 16, 2011

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Table of Contents

Acknowledgments ..................................................................................................................................... 3 List of Acronyms ......................................................................................................................................... 4 I. Introduction .............................................................................................................................................. 6 II. Methodology ........................................................................................................................................... 6 III. Findings ................................................................................................................................................... 7

A. Achievements: “Advocacy that works” .................................................................................... 7

Objective One: Catalytic investments in three countries ............................................. 10 Objective Two: Technical assistance in six countries ................................................... 13 Objective Three: Voices from the South ............................................................................. 14

B. Keys to Success: “Demystifying advocacy” .......................................................................... 16

A is for Amplification, Ability, and Asks ............................................................................... 16 F is for Focus, Facilitation, and Flexibility .......................................................................... 17 P is for Partnership, Personal connections, and Pushing ............................................. 18

C. Challenges: “Too small and too short” ................................................................................... 20

Not enough time ............................................................................................................................. 20 Being a different kind of project ............................................................................................. 20 Communication .............................................................................................................................. 21

IV. Moving Forward ................................................................................................................................ 22

Conclusions ........................................................................................................................................... 22 Short term recommendations: remainder of project… ..................................................... 22 Longer-term recommendations: … and beyond ................................................................... 23

Appendix 1: Interview guide .............................................................................................................. 25 Appendix 2: List of Global Respondents ....................................................................................... 26 Appendix 3: Indonesia Country Report ......................................................................................... 27 Appendix 4: Tanzania Country Report .......................................................................................... 36 Appendix 5: Uganda Country Report .............................................................................................. 41

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Acknowledgments The evaluation team would like to thank the staff of AFP and its partner organizations for all their help in conducting this evaluation. In particular, Duff Gillespie, Beth Fredrick, Sabrina Karklins, Jennifer Carlin, and Naomi Johnson of AFP in Baltimore provided valuable guidance, input, and support along the way. AFP focuses on identifying ‘asks’ in their advocacy efforts, and so we thank them for responding to all of our ‘asks’ during the evaluation. AFP also acts as a facilitator, and their staff and partners did a great job in facilitating the evaluation process, from helping to arrange interviews to providing background information and handling all the logistical details of our field visits to Ghana, Indonesia, Tanzania, and Uganda. Mayun Pudja and Endang Saputra in Indonesia put together a comprehensive and informative itinerary, provided informative guidance throughout, and were excellent tour guides and translators. Halima Shariff in Tanzania was able to set up meetings that made a short trip extremely fruitful and exciting. In Uganda, Martin Ninsiima and Jotham Musinguzi arranged a week full of interesting meetings and were responsive to requests from the evaluation team, such as arranging a last-minute site visit. Sarah Mukasa, Joan Koomson, and Ony Nwaohuocha from AWDF graciously hosted a member of the evaluation team for a day at their office in Ghana, offering warm hospitality and interesting ideas and perspectives. AFP is a project guided by partnership, and we were impressed by the openness of all partners and their generosity with their time. We thank all of the people named in the appendices for sharing their experiences and ideas. We enjoyed learning about this project and look forward to hearing about its future accomplishments.

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List of Acronyms AFP Advance Family Planning AJAAT Association of Journalists Against AIDS in Tanzania ANAT Advocacy Network on HIV and AIDS in Tanzania APINDO Indonesian Employers Association AWDF African Women’s Development Fund AWLN Africa Women’s Leadership Network BKKBN Badan Koordinasi Keluarga Berencana Nasional (Indonesia’s national family

planning program) BMGF Bill & Melinda Gates Foundation CBD Community-Based Distribution CCP Center for Communication Programs CCPF Cara Cipta Padu Foundation CPR Contraceptive Prevalence Rate CSR Corporate Social Responsibility CWG Core Working Group DFID Department for International Development DHS Demographic and Health Survey EARHN Eastern Africa Reproductive Health Network EDL Essential Drugs List FP Family Planning GCG Global Consultative Group HDT Human Development Trust IUD Intrauterine Device IPPF International Planned Parenthood Federation IPPFAR International Planned Parenthood Federation Africa Regional Office JHSPH Johns Hopkins Bloomberg School of Public Health MDG Millennium Development Goal MoFEA Ministries of Finance and Economic Affairs MOH Ministry of Health MoHSW Ministry of Health and Social Welfare MOU Memorandum of Understanding MP Member of Parliament NGO Non-Governmental Organization NMS National Medical Stores OAFLA Organization of African First Ladies Against HIV/AIDS PAI Population Action International PFPC Parliamentary Family Planning Club POPSEC Population Secretariat PPD-ARO Partners in Population and Development Africa Regional Office RAPID Resources for the Awareness of Population Impacts on Development RHSC Reproductive Health Supplies Coalition RHU Reproductive Health Uganda RMA Resource Mobilization and Awareness RMAWG Resource Mobilization and Awareness Working Group RU Research Utilization

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TACAIDS Tanzania Commission for AIDS TAMA Tanzanian Midwives Association TNCM Tanzania National Coordinating Mechanism UFPC Ugandan Family Planning Coalition UFPC Uganda Family Planning Coalition UHMG Uganda Health Marketing Group USAID United States Agency for International Development

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I. Introduction Advocacy is a term that is used with great frequency but often with little clarity or specificity. And yet it is a fundamental factor in making programs and policies work. Creating broader understanding of what advocacy is and how to make it effective can benefit many social programs. There is a particular need for advocacy for family planning (FP) programs, which have experienced a loss of emphasis for several years due to many factors, including the global health community’s emphasis on HIV, a shift away from vertical programs to broader health systems strengthening, and the assault from the religious and political right. In the last few years there has been some positive momentum, partly due to impressive success in countries such as Rwanda, Malawi, and Ethiopia, making it an opportune time to build on this energy. There is also a growing need to strengthen national government capacity and commitment to ensure sustainable programs and progress. To this end, the Bill & Melinda Gates Foundation (BMGF) and the David and Lucile Packard Foundation have jointly conceived and funded a three-year project called Advance Family Planning (AFP). AFP is an advocacy initiative that strives to increase funding for family planning, ensure family planning funds are better spent, address policy barriers and increase the visibility of family planning among the world’s policy makers, especially in developing countries. Ultimately, it aims to ensure universal access to reproductive health (RH), Millennium Development Goal 5b. The $12 million project began in October 2009 with a planned end-date of October 31, 2012. This is a promising initiative, but is still in its very early stages. As we will show in this report, given the positive results so far, it would be wise to extend the project to better understand its potential and to better institutionalize its approach.

II. Methodology It was decided to conduct a mid-term evaluation of the AFP project. There were a number of encouraging stories of success in the three Tier 11

countries, and it was felt that an external evaluation could help improve understanding of what had been achieved and what were possible course corrections for the remainder of the project. In addition, an evaluation could help give suggestions for the future.

A three-person team conducted the evaluation between August and October 2011 through document review and interviews with AFP staff and partners. The team developed a short list of questions to guide these interviews (Appendix 1). We carried out interviews with 29 global partners and stakeholders, some of which were conducted in person and some by phone (Appendix 2). In addition, team members traveled to the three Tier 1 countries and

1 As will be described in greater detail later, AFP works in three focus, or Tier 1, countries, provides technical assistance in six others, and carries out certain global activities. Given the priority of the Tier 1 countries, the evaluation team decided to visit all three.

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interviewed 77 respondents: Indonesia (31); Tanzania (20); and Uganda (26). These trips also included visits to districts in Indonesia and Uganda to see AFP’s work beyond the national level. One team member also traveled to Ghana to meet with staff of the African Women’s Development Fund, one of the main partners of the project. It is important to keep in mind that it is early in a project for an evaluation and that work has been underway for less than a year for some components. That said, a good deal has happened in a short period of time, giving a sense of what is working, areas that could be improved, and suggestions for the longer term future.

III. Findings

A. Achievements: “Advocacy that works” AFP has helped to bring about a number of positive changes, in terms of increasing family planning budgets, bringing about policy changes to increase access, raising awareness around family planning, and building the capacity of local individuals and institutions to do this advocacy work. Catalyzing change in these areas meets important needs in the family planning field now. As USAID staff explained during our interview with them, to move family planning programs, one needs know-how, resources, and government commitment. The field has a good deal of know-how. Donor resources, while not plentiful, are in place. What is largely missing is government commitment and resources – exactly the areas that AFP is designed to address. ”We need more voices to move the government commitment along,” USAID staff concluded. Some people describe AFP’s efforts as a different and particularly effective kind of advocacy, “advocacy that works,” according to a Core Working Group member in Indonesia. Others see the work as not necessarily new, but as providing a needed push and energy to move things forward. Almost all AFP staff and partners were excited about the adaptation of the Spitfire Strategies™2

approach to developing and implementing advocacy strategies. “The way they spin it as something new energizes people,” explained one partner.

Another notable aspect of AFP’s approach is its emphasis on evidence-based advocacy. While not mentioned as often as Spitfire, several, including its staff, see this as a valuable aspect of AFP. Drawing on its affiliation with Johns Hopkins University Bloomberg School of Public Health (JHSPH), AFP has prepared a number of policy briefs that arm advocates with the kind of evidence they see as most likely to be persuasive to policy-makers. For example, in Indonesia, partners were enthusiastic about training they had received from AFP in the costing of reproductive health services, which provided them with economic evidence supporting the case for increased FP budgets. AFP’s achievements were significantly strengthened by the partners involved. In addition to JHSPH’s Bill and Melinda Gates Institute on Population and Reproductive Health and the Center for Communication Programs (CCP), the main partners include the African Women’s Development Fund, Partners in Population and Development’s Africa Regional Office (PPD-

2 Spitfire Strategies developed a tool called the Smart Chart, which guides users through six steps to develop a strategic communication plan. This tool was adapted- very successfully- for use in the AFP project.

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ARO), and Futures Group International (Futures). In addition, AFP assembled a Global Consultative Group (GCG) made up of 21 members, many of whom were interviewed for this evaluation. The GCG is an informal working group which is intended to provide strategic advice to AFP, identify promising advocacy opportunities, and exchange information. As we will describe later, AFP has not fully taken advantage of this resource. The project was guided by a ‘quick wins’ mentality, given its short time frame. Some felt that this strategy provided pressure that did accelerate quick results. For example, it prompted collaboration with the Resource Mobilization and Awareness (RMA) Working Group (WG) of the Reproductive Health Supplies Coalition (RHSC), which represented an already existing network of advocates. AFP was able to bring additional resources and new strategic ideas, and to help develop a coordinated and focused plan for the RMA WG to address commodity security issues. While there is much to be said for such collaboration, it can raise issues of attribution, as much of AFP’s work involves building on existing activities. While most respondents felt that AFP did a good job of sharing credit with its collaborators and partners, a few felt uncomfortable with how AFP claimed credit for certain outcomes. It is important to note that in addition to using its own resources, AFP has had some success in leveraging other resources. In year one of the project, almost $890,000 of non-project funds were leveraged for AFP activities (see table below). It is encouraging to note, for example, that BKKBN, the national family planning program in Indonesia, contributed its own resources to cover some of the costs of Spectrum training for its staff.

Leveraged Support in Year One of AFP Donor Purpose Amount BMGF Funding to Gates Institute $225,881 Hewlett Foundation Funding to PPD-ARO $160,242 IPPF Funding for African Women’s

Leadership Network (AWLN) $250,000

BKKBN Spectrum training $195,000 USAID Indonesia assessment $58,000 Visits to the three Tier 1 countries showed the evaluation team the important contribution AFP had made to a number of advocacy successes. The following table summarizes the main achievements of AFP in its first 18 months. It is followed by a discussion of how well AFP has met each of its three main objectives thus far.

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Advance Family Planning Successes, 2010-11

Global/Regional Indonesia Tanzania Uganda Increased funding

• Strategic planning assistance to Hand-to-Hand campaign to rally global resources for FP

• Increased resource allocation in Bandung and Pontianak districts

• Created allocation of village budget for FP funding in Bandung district, an innovation that will be replicated

• Advocating with Pertamina (govt-owned oil company) to include FP support in Corporate Social Responsibility (CSR) budget

• Increase in government funding for FP from 0.5 billion Tanzanian shillings in 2010/11 to 1.2 billion for 2011/12

• AFP facilitated partnership between Barclays Bank and the Tanzania Midwives Association (TAMA) for the latter to access resources from the Bank

• Increased national budget for FP more than fivefold, from 1.5 to 8 billion Ugandan shillings

• Inclusion of funding for contraceptives in Global Fund proposal

• Significant allocation of World Bank loan for FP/RH

Changed policy

• FP included in the G8 Muskoka Declaration

• FP indicators included in the accountability mechanisms for the Global Strategy on Women and Children’s Health

• FP evidence included in the World Bank’s World Development Report which focused on gender

• FP included in Jampersal, a government program to provide free maternal care services for women without other coverage, and districts encouraged to support Jampersal

• MOU between BKKBN and APINDO (Indonesian Employers Association) to create workplace FP program

• Working to change policy that restricts access to female sterilization by requiring involvement of an anesthesiologist

• Policy approved to allow community health workers to provide injectable contraceptives

• Commodity security improved by creating a new vote so that funds go directly to NMS rather than passing through MOH

• Norigynon added to essential medicines list

Raised profile of FP

• African women’s voices heard in funding decisions through AWLN

• AWDF includes FP/RH in its grant-making

• District Working Groups have strengthened focus on FP

• Establishment of Parliamentary Family Planning Club (PFPC)

• Greater commitment of Parliamentarians to support FP/RH

• Supportive statements from President Museveni and the First Lady

Built capacity

• Bringing southern participation and strategic focus to RMA Working Group of RHSC

• Launch of AWLN • More than 400

people received

• Local entity identified and strengthened to coordinate advocacy efforts

• People trained in Spitfire, RH Costing, SPECTRUM

• Local entity identified and strengthened to coordinate advocacy efforts

• People trained in Spitfire

• Local family

• Local entity identified and strengthened to coordinate advocacy efforts

• People trained in Spitfire

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advocacy, Spectrum, RAPID and/or other trainings

• Incorporation of AFP advocacy approach in national BKKBN training

planning coalition revitalized

Objective One: Catalytic investments in three countries

Mobilize and strengthen sustainable FP/RH advocacy with catalytic investments in 3 countries with potential for wider replication in other developing countries (Tier 1: Tanzania, Uganda, and Indonesia)

The Tier 1 countries have been a major focus of AFP in its first 18 months, and there has been impressive success at the country level in Indonesia, Tanzania, and Uganda, as shown in the previous table. Detailed country reports are included as appendices to this report (see Appendices 3, 4 and 5), but below we summarize the general stories in each country. In all countries, work began with a landscape assessment. The Center for Communications Programs was a key partner on the ground, as its field staff helped to recruit AFP coordinators with knowledge of family planning and the policy making environment. Progress has been slower in Tanzania due to a more difficult environment with a less-developed advocacy base to build on, the longer-than-anticipated time to identify appropriate local partners, and the late recruitment of the AFP coordinator. An important aspect of the Tier 1 work has been the creation of Local Advisory and Core Working Groups and the identification of local entities in each country to take over coordination of AFP activities and technical and financial support to advocacy. Building the capacity of local organizations is essential given the importance of local ownership and the ongoing need for advocacy. The investment in each of the Tier 1 countries was viewed as catalytic, with each country chosen for different catalytic characteristics. Lessons from Indonesia can shed light on how to raise the profile of family planning in a decentralized system, an important issue in many countries. As the table below shows, when decision-making power is moved to lower levels of government, the number of policy makers to target with advocacy increases significantly. In Uganda, HIV/AIDS has dominated the landscape to the detriment of family planning and reproductive health. In addition, there has been minimal political leadership to raise the profile of family planning. Tanzania is similar to Uganda in terms of grappling with the HIV/AIDS epidemic. It is also a country where many policies exist in support of family planning, but they have not been fully translated into effective programmatic actions.

Decentralization and the increasing numbers of local government units

Country Year of Independence

Administrative Territories 2011 Administrative Territories

Indonesia 1945 8 provinces (1945) 30 provinces; 2 special regions; and 1 special district -subdivided into 405 districts and 97 municipalities

India 1947 14 states; 8 union territories (1956)

28 states & 7 union territories -subdivided into 640 districts

Nigeria 1960 12 states (1967) 36 states and Abuja, the federal capital territory

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-subdivided into 774 local government areas

Tanzania 1964 12 provinces (1964) reorganized into 20 regions (1966)

26 regions -subdivided into 99 districts

Uganda 1962 17 districts (1962) 4 regions -subdivided into 112 districts

Indonesia $1,555,607 to date Indonesia’s history of success and emphasis on family planning has been challenged by decentralization, which began ten years ago. This process has resulted in policy makers in over 500 local governments tending to emphasize infrastructure projects over preventive health services like family planning. Could AFP help to address this so that family planning received attention again, even down to the village level? An initial landscaping process conducted in early 2010 led to a strategic focus on increasing use of long-term methods, and framing this as an essential part of meeting the Millennium Development Goals (MDGs). Staff members of CCP’s Indonesia office were instrumental in getting the program started in early 2010, and continue to provide support. A Chief for the Secretariat was hired in November 2010, based at a local NGO, the Cara Cipta Padu Foundation (CCPF), with a second full-time staff member hired in August 2011. The work is mostly implemented through a central level Core Working Group in Jakarta, and District Working Groups in two districts, Bandung and Pontianak. These Working Groups have enthusiastically embraced both the Spitfire approach and Reproductive Health costing to help them advocate successfully for increased budgets in family planning. Since the launch of AFP activities, there has been an increase in the number of new acceptors for IUDs, implants, and male sterilization in Bandung District (see below). Although it is not possible to say that this is due to AFP directly, it is an encouraging trend.

Family planning new acceptors – Bandung District, 2010-2011

Data source: Distirct MOH Service Statistics

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AFP has played an important role in getting family planning back on the local program agenda and into district health budgets. “Family planning in Indonesia would be languishing without AFP,” explained an AFP partner. What is needed now is to continue support to institutionalize the approach and to expand to other districts. “I hope AFP will be continued because it is very important for the family planning program in Indonesia… It has helped to solve the problem with decentralization and the model from AFP may be very beneficial to implement more widely at the district level,” states the head of BKKBN, the national family planning program. Uganda $1,185,156 to date Uganda struggles with a lack of high-level support for FP. There are some indications that this is shifting, so can AFP take advantage of this opportunity to build more support for FP? CCP hired a staff member in 2010 to work full-time coordinating AFP efforts. PPD-ARO has played a central role in conducting high-level policy activities and in informing advocacy strategy development. In July 2011, Reproductive Health Uganda (RHU) received a sub-agreement from AFP as the local partner to coordinate activities. While Indonesia has focused on district level work, Uganda’s focus has been at the national level, with more recent efforts in two districts. The partners in Uganda have had impressive success in increasing the budget allocations for FP, in making money flow more efficiently, particularly to the National Medical Stores, and in facilitating important policy changes, such as allowing community-based distribution of injectables and adding Norigynon to the essential medicines list. At the 2009 International Family Planning Conference in Kampala, and subsequently, there have been encouraging signs of support for FP from high levels of government. AFP has taken advantage of the momentum leading up to and following that conference. By working with strong partners and building on important work in recent years, AFP has helped to catalyze significant changes in funding and policies to support increased access to FP. This work needs to continue and to expand now to the district level, perhaps applying lessons from some of the efforts in Indonesia. Tanzania $1,237,115 to date Tanzania’s contraceptive prevalence rate (CPR) growth has stagnated, in spite of a generally supportive policy environment. Could AFP help to revitalize family planning? AFP’s work in Tanzania is spearheaded by a group of four local NGOs: the Human Development Trust (HDT) is the lead coordinating organization, with three local NGOs sub-contracted as implementing partners, each with its comparative advantage and area of focus. In addition, there is a Local Advisory Group composed of eight high profile and well-connected Tanzanians. The Family Planning Coalition of Tanzania, made up of 14 NGOs, provides a strong base for amplifying and sustaining AFP’s advocacy work. The formation of these partnerships is an important achievement to move forward the advocacy agenda in the absence of high-level champions for family planning. In addition,

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AFP has helped establish a Parliamentary Family Planning Club, and the parliament has already voted to increase government funding for FP. As with the other countries, Spitfire has been widely embraced and will help guide strategy and action. Partly as a result of Tanzania’s weaker advocacy environment, AFP’s work in Tanzania took longer to get started than that in Indonesia or Uganda, but the partnerships that have been built show great promise in pushing Tanzania past its plateau in FP progress. And as in the other countries, the work will need to move to the district level if AFP is continued beyond its three-year duration.

Objective Two: Technical assistance in six countries

Strengthen existing FP/RH advocacy investments in 6 foundation (BMGF and Packard) priority program countries by providing cutting edge and highly specialized technical assistance (Tier 2: India, Pakistan, Ethiopia, Kenya, Nigeria, and Senegal)3

This has been a challenging area for AFP. The idea was to expand the impact of AFP’s approach, and it was hoped that targeted technical assistance could prove helpful in priority countries of the BMGF and the Packard Foundation. There have been some accomplishments (see table below), but it took much longer than anticipated to develop and move forward with advocacy partnerships and strategies.

Advocacy activities in Tier 2 countries Country Activity Partner(s) Resources Kenya Advocacy to expand access to

injectables via CBD JHPIEGO $150,000+

Nigeria RAPID development and launch Advocacy Nigeria $100,000+ Senegal Spitfire training, translation of

resource pack into French IntraHealth $40,000+

India Spitfire training and development of advocacy plans in Bihar and Uttar Pradesh

Population Foundation of India

$50,000+

Pakistan Spitfire facilitation to guide policy regarding community midwives’ activities

Pathfinder $40,000

One of the problems was that resources were limited for this work. Staff of the project and the Foundations funding it agree that some of the assumptions of this approach proved to be wrong, particularly that the amount of funding was adequate. “$40,000 was pretty ridiculous. It didn’t generate interest. There was a faulty original assumption about how they could make a difference with that amount of funding,” stated one donor. Generally, respondents believed AFP should have had more resources and more time because it takes time to build understanding of the AFP approach and foster relationships and trust. AFP

3 Ethiopia was subsequently dropped from the list when it was decided that there was already significant momentum for FP in the country.

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spent a lot of time and effort on the Tier 1 countries and simply has not had enough of either to devote to Tier 2 relationships. Partners had a number of suggestions for alternatives to the Tier 2 country approach. The most frequently mentioned idea was that instead of prescribed countries, there be a flexible pool of resources to be more opportunistic. Some respondents felt that with more flexibility AFP could respond with more agility as opportunities arise. On the other hand, a donor pointed out that there has to be a balance between holding to specific goals and being opportunistic; “the nine country parameter isn’t that restrictive.” Others suggested more strengthening and use of regional entities to expand the impact of AFP’s work. Another idea was to have a small grants mechanism to support advocacy activities, taking advantage of the African Women’s Development Fund’s skills as a grant-making institution.

Objective Three: Voices from the South

Leverage voices of Global South champions regionally and globally to demand revitalization of the FP/RH agenda to achieve MDG 5b4

and to create a platform for greater South-to-South cooperation

The third objective is somewhat less concrete than the others, but it presents exciting opportunities. “The emphasis on voices from the South is a very good opportunity for a shift in how we do the work that we do and where the focus should be. That’s what was new about AFP. I would like to see that continue,” stated staff from the African Women’s Development Fund (AWDF), a Ghana-based grant-making organization and one of AFP’s main project partners. One such opportunity is the African Women’s Leadership Network (AWLN). Made up of 35 women from 15 countries, AWLN was launched in July 2010 and met for its first planning meeting in October 2010. It was a slow and challenging start, but there are recent promising efforts that must be given time to evolve, as AWLN works to “find ways in which we can bring voices of women to bear on policymakers to ensure more resources and commodity security.” A member of the evaluation team met with staff from AWDF to learn more about the experiences thus far with AWLN. A large part of the slow start of AWLN had to do with how the network came into being. AFP had planned to create a network of African women leaders, an effort that was to be coordinated by AWDF. Around the same time, the Packard Foundation’s regional office in Africa had given a grant to the International Planned Parenthood Federation’s Africa Regional (IPPFAR) office in Nairobi to set up a similar type of network. AWDF and IPPFAR decided that the two initiatives to create networks should be combined into one to avoid duplication of effort, and this joint effort became AWLN. The coordinator is based at IPPFAR in Nairobi. The functioning of AWLN is complicated by the fact that AWDF and IPPFAR both support AWLN but with different donors and therefore different

4 Millennium Development Goal 5 calls for improving women’s health by reducing maternal mortality. There are two targets: 5a (“reduce the maternal mortality ratio by three-quarters”) and 5b (“achieve universal access to reproductive health”).

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requirements. With support from AFP, AWDF brought a communications officer on board in June 2011 to help with coordination and communication for AWLN. They hope to improve the relationship moving forward, as AWDF and IPPF bring complementary skills and expertise to the network, and both are interested in a rights-based perspective; “it wouldn’t be good to split our energies,” stated AWDF staff. Given the rights-based perspective of many of the members of AWLN, there was some discomfort with the narrow focus on FP rather than a broader focus on sexual and reproductive health and rights, but AWDF staff explain that “we all recognize [the importance of reducing] high maternal mortality so our engagement with this issue is to mobilize the women’s rights constituency around helping to reposition family planning as a means to address high maternal mortality.” Interestingly, as a result of its involvement with AFP, AWDF now includes FP in its grant-making, which it did not do before, thus expanding AFP’s impact to a range of AWDF grantees. This engagement of African organizations helps bring home the message that family planning is not an imposition from the West, but is supported by African women. AWLN has advocated with global entities to increase efforts in FP/RH. AFP has facilitated greater access to partners and information, including a useful link to the international YWCA in a 2011 meeting in Geneva. AWLN members also visited the State Department and USAID in Washington, D.C. In addition, AWLN has undertaken concrete country-level work, referred to as policy engagements, in Ghana, Kenya, and Nigeria. These were based on the outcomes of analyses it carried out to determine strategies and areas of focus, and included meetings by AWLN members and other local champions with high-level officials and site visits. The first took place in Nigeria in June 2011, the second in Kenya in August with a focus on youth-friendly services, and the third in Ghana in October, which focused on increasing government resources for commodity security. It will be important to ensure follow-up on these events, and to assess their utility in bringing about change. With each engagement, AWDF staff explains, “we have a number of asks and we want to track them.” Two of the three focus countries are Tier 2 countries for AFP, and these engagements are possibly another alternative to the Tier 2 approach to expanding AFP’s reach.

Little innovations can go a long way: “small inputs, high impact”

AWDF staff told a story of how something small can lead to big changes, in part through the power of a network. A woman from a small organization call Nana Yaa Memorial Trust developed a maternal health booklet for pregnant women to record vital information as a way to improve maternal care. She was motivated by the desire to ensure that others did not suffer the fate of her daughter, who had died in childbirth. This tool has now been adopted into national policy in Ghana and it includes a section on family planning. Recently, the First Lady of Eketi State in Nigeria, an AWLN member, adopted it for use there and launched it in June, with plans to distribute it more widely and monitor its impact on practice and on the population. Most of our respondents feel that this component of the AFP project – North-South linkages – needs to be built up further, with more effort to activate voices from the South to influence decision-making in the North, as has been done with the Resource Mobilization and Advocacy Working Group of the Reproductive Health Supplies Coalition

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(RHSC). One partner explained how AFP has infused new energy into RMA and brought national perspectives to that group by “bringing in truth from the ground.” AFP has also begun to be strongly involved with the Hand-to-Hand campaign, a global effort led by RHSC to mobilize resources and support to meet the goal of 100 million new users of modern contraception by 2015. In particular, AFP is helping to make the coordinated effort of RMA members more strategic and to dedicate resources to involvement of Voices from the South. RHSC feels that this effort to rally the global community is exactly the type of initiative where AFP can be of great help. This initiative, and AFP’s contribution, is too new to evaluate, but it holds great potential for country and global impact. In addition to its role at the country level in Uganda, PPD-ARO has contributed to regional efforts and strengthening South-to-South communication and connections. In particular, PPD-ARO has worked with the Eastern Africa Reproductive Health Network (EARHN) helping to organize meetings on repositioning family planning. Individuals from the six EARHN member countries (Burundi, Ethiopia, Kenya, Rwanda, Tanzania, and Uganda) also traveled to Ethiopia for a PPD-ARO organized study tour to see the Health Extension program to learn lessons for their own programs.

B. Keys to Success: “Demystifying advocacy” A number of words recurred during the interviews that describe AFP’s approach and way of working. The words are organized by the letters of the project – AFP – and highlight the themes of the work and the reasons for successful outcomes.

A is for Amplification, Ability, and Asks Amplify these voices. One of AFP’s strengths is how it amplifies a message by bringing many voices together. Voices are there, but how does one make sure they are heard and lead to action? AFP provides a space in which a range of voices can be amplified, from the senior level to community leaders. The project has done this by helping to set up or strengthen working groups, in most cases bringing together people who did not regularly meet prior to AFP’s involvement. Staff from Pontianak’s District Health Office in Indonesia explain that if they convey the message to local government from the health office, they can be ignored, but if someone else amplifies that voice it is a stronger trigger for decision-makers to pay attention to it. It is also important to have multiple voices supporting advocacy, and USAID staff spoke of the importance of having a voice other than USAID behind the advocacy. Enable others. From day one, AFP has sought to build capacity such that there is local ability and ownership, at national and district levels, to carry on the advocacy efforts. “We don’t see ourselves as an organization. We are a project enabling other groups.”

“Their focus on capacity building for advocacy is what sets AFP apart from most others and I am convinced that it is the right approach. The longer I am in this field the more I have come to realize that the only way to make progress is if local people ask for what they want and need.” (An IPPF respondent)

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The “ask”. “You don’t have advocacy if you don’t have ‘the ask’,” explains a BMGF staffer. The Spitfire approach, addressed in more detail below, is what helps focus in on the all-important “ask”. It was encouraging to hear how often partners in Tier 1 countries used the language of ‘the ask,’ and, more importantly, could describe concrete examples of this approach and how it had been helpful.

F is for Focus, Facilitation, and Flexibility Spitfire catches fire. Perhaps the most important reason for AFP’s success is its commitment to being focused – focused on advocacy, focused on family planning, and guided by a focused approach. “AFP provides a good model for our field where advocacy work is often too diffuse and unfocused,” says one member of the GCG. This focus, and the Spitfire approach, has led to concrete actions and concrete results. As one advocacy expert explained, Spitfire has “demystified advocacy.” Spitfire has been an important model to help people focus in quickly on “the ask” and that provides a lot of momentum: “Light bulbs go off in people’s heads and they see advocacy in a different way,” stated one donor. The quotes below capture some of the enthusiasm that the evaluation team heard:

“The Spitfire methodology has made their advocacy work more effective than the rather diffuse efforts we usually associate with advocacy.” “They bring a very needed sense of strategy and focus.” “We can get lost in the clouds, but using Spitfire allows people to focus on a specific ask.”

Perhaps most importantly, Spitfire helps move people away from a focus on tactics or activities – such as a sensitization meeting or a press release – to a focus on a goal and how best to reach it. AFP staff describe the “gravitational pull” to start with an activity rather than an objective, but see Spitfire as a powerful force against that pull. “So much advocacy is about raising awareness rather than what to do with that information, what they want to change.” Seeing is believing. AFP aims to facilitate, to catalyze and to mobilize. An important way AFP has managed to do this is through the use of site visits and study tours. The site visit by Ministry of Health staff in Uganda to Nakaseke to see the community-based distribution (CBD) of injectables project first-hand was instrumental in leading to a policy change that allowed community health workers to provide this service. A visit organized for members of EARHN to Ethiopia to see the Health Extension Program, mentioned earlier, has also born fruit, leading to proposals by district health teams in Uganda to replicate what they saw.

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Flexibility. AFP promotes an approach that focuses on concrete outcomes that are specific to different contexts, so it is flexible to adapt to different and changing situations. Within an overarching framework of increasing budgets for FP/RH, countries and districts can tailor their advocacy efforts to address their most pressing needs. This is important to ensure that the decision on specific ‘asks’ is made at the local level rather than imposed from the top. It was encouraging to see how the approach played out differently in the two focus districts in Indonesia, adapting to the local needs. In Bandung, a more rural district, the focus was on village level implementation and funding, while in Pontianak, which is more urban, there was particular interest in working with the private sector to create employment-based family planning.

P is for Partnership, Personal connections, and Pushing This collaborative style. AFP held extensive consultations in the beginning of the project, including meetings in London, New York, and Washington D.C. in February and March, 2010. All of their work has involved developing collaborative relationships with a wide range of partners. “Working with others rather than going it alone – that’s a real difference from most advocacy initiatives,” explained staff from DFID. “AFP has acted as an honest broker – a breath of fresh air in our unusually fragmented, bickering field,” stated another European partner. Establishing, maintaining and effectively using broad partnerships is not only a factor in success, but it is also an important achievement, even if it is not a tangible success like a budget increase or a policy change. A district partner in Indonesia highlighted this strengthening of communication and collaboration as a change that was very important to her. Through the District Working Groups, partners working on FP/RH had begun to meet frequently and regularly, which they had not done before. Such familiarity meant that rather than only interacting on an event basis, their communication was more continuous and their activities better integrated. CCP has played a critical role at the country level, with staff from CCP country offices in the three Tier 1 countries helping to start up programs and guide implementation. This made identification of and access to local players much easier. The Futures Group has contributed significantly to capacity building through leading training efforts in the Spectrum Policy Modeling System and RAPID. For example, BKKBN staff from Indonesia traveled to Futures in Washington D.C. for a week-long Spectrum training, and these participants returned to Indonesia and organized large-scale district workshops to share what they had learned. Futures and AFP also jointly plan their advocacy activities in Tanzania and Nigeria to avoid duplication of effort. In Tanzania, AFP and Pathfinder International have signed a memorandum of understanding that charts their joint efforts in pursuit of common interests. For example, the two organizations are working closely together to facilitate and support country efforts to mobilize additional funds for family planning through the round 11 proposal to the Global Fund. AFP has also been good at taking advantage of a partner’s skills rather than duplicating existing capacity. For example, AFP gave Population Action International (PAI) resources and responsibility to organize visits when field leaders came to Washington to make sure

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the time there was used well. PAI staff appreciated that AFP didn’t take the organizing of the visits on themselves, instead taking advantage of PAI’s own skills and relationships. In addition, when AFP decided to work on the supplies issue, they were careful in how they handled entering what was already a well-established community; “Their foray into supplies was handled responsibly and respectfully,” according to PAI staff. Many praise AFP’s efforts at engaging regional partners, which are often not on the radar of funders; “a forgotten zone,” according to one donor. Respondents were “thrilled” that AFP is working with existing networks, like PPD-ARO and EARHN, and see this approach as a “smart strategic move. “ Many also see this as an area for increased emphasis: “I really admire this collaborative style and think it’s absolutely appropriate at the country level, but I sometimes wonder whether AFP might not be a bit more assertive at the regional or global level where local advocacy groups cannot be as effective,” stated a respondent from IPPF. It’s who you know. Much of AFP’s success is also due to strong personal connections, globally and at country level. Many felt that Duff Gillespie’s leadership is critical to AFP. “It’s hard to distinguish AFP as an organization from Duff Gillespie as an individual. AFP without Duff would be far less effective,” states one partner. AFP staff echoed this, “Duff’s contacts and reach made a big difference in our ability to make rapid progress.” Partners also had high praise for Beth Fredrick as Deputy Director, seeing her as a great complement to Duff. That catalytic push. Several respondents mentioned AFP’s catalytic role – entering the fray at just the right moment to help push an initiative over the top. “The pump was primed,” in Uganda, for example, regarding community based distribution of injectables, “and AFP came in and gave a little push,” according to a respondent from PAI. AFP’s role is to “keep up the interest,” AFP’s coordinator in Indonesia explains. “We push but make it seem like we’re not pushing.” AFP’s advocacy approach, with an emphasis on evidence-based advocacy, has proven to be an effective way to put knowledge into practice. The experience with changing the policy to allow CBD agents to provide injectables in Uganda shows how effective this can be (see below). Considering the mixed results in ensuring use of available evidence in FP/RH programs, this could fill a significant gap in the field.

Evidence-based advocacy is an effective way to put knowledge into practice Sometimes advocacy success is about being in the right place at the right time. After a successful pilot study was completed in 2005 on the safety and effectiveness of having CBD agents provide injectables, efforts to change the policy kept hitting a wall. “You don’t just get evidence and apply it,” explained Angela Akol, the Country Director for FHI 360 in Uganda. “We did advocacy, but didn’t get anywhere.” AFP came in at a good time and was able to provide a needed push. Most importantly, with a core group of partners, they facilitated a field visit for key MOH staff to see the program firsthand, which seemed to be the turning point in getting the policy approved. In December 2010, the Ugandan MOH issued new policy guidelines for community based distribution of injectables. This success was due to the extensive groundwork already done by multiple partners and also showed the catalyzing potential of AFP’s approach, as the Spitfire exercise

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identified the key person to target to change the policy. This advocacy approach could go a long way in helping to put important evidence into practice, as it did in Uganda.

C. Challenges: “Too small and too short”

Not enough time It was striking to the evaluation team how many interviews began with respondents questioning the short duration of the project. Three years, it was almost universally felt, was simply too short a period of time for this work to show results, particularly with its focus on building capacity. The following quotes from U.S. and European partners are indicative of this widespread sentiment:

“What were they thinking? This is a great concept, but it is designed too small and too short.” “I’ve never really understood why you would undertake a project like this and restrict it to three years.” “Taking on the world in three years is not feasible.”

While the short-term nature of the project can work in terms of the “quick wins” or “low-hanging fruit,” this is not the case for harder to reach fruit or for capacity building and putting in place something sustainable. The short duration is particularly problematic for capacity building, which takes time to take hold. And it should be pointed out that these capacity building efforts are taking place not only at national levels, but also with district level partners. Project staff admit they underestimated the time for start-up and for identifying local partners with the capacity to coordinate advocacy efforts. In addition, as described earlier, the project is complex in terms of the number of countries and partners, yet it operates with a small central core of staff. It took a fair amount of time to sort out roles and relationships among so many partners and for the two tiers of countries, as well as to create a sense of common purpose.

Being a different kind of project What is exciting about AFP is that it promotes a different approach and is structured in a different way from many development projects. AFP is “getting a buzz, getting momentum going, rather than doing things the same way,” according to CCP staff. However, this also has presented a challenge, as it takes time for people and partners to understand exactly what AFP is, and in turn, what it isn’t. In visits to Tier 1 countries, the evaluation team heard local partners ask for funding for implementation of services from AFP, such as support for clinical training, infrastructure, or supplies. This is something many partners are used to in development projects, but is not how AFP functions. Breaking this pattern and doing something new takes time to be understood, which can be a problem in such a short project. There is a tendency to go back to what is comfortable, such as general

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awareness building, but what makes AFP different is its policy-maker focus and its commitment to specific “asks” and specific targets. Institutionalizing this new approach, rather than doing things the old way, will still take more time.

Communication While many praise AFP’s open communication, there have been some challenges, both externally and internally, that should be addressed. Many members of the GCG were not familiar with specific achievements of AFP. European partners had comments such as “I have struggled to understand exactly what AFP is,” and “I’m not sure what AFP is.” Staff at most USAID Missions in countries visited by the evaluation team feel that they don’t know what AFP is doing and perhaps partly as a result of this, it was sometimes difficult for the evaluation team to arrange meetings with USAID mission staff. Even a donor to the project said she needs to see a more systematic summation of what AFP has accomplished, rather than “getting pieces here and there.” It is always difficult for a project like AFP to communicate effectively with all interested parties, particularly with a very small staff. This limits AFP’s impact, and leads to missed opportunities, for example with the GCG, to better engage this group of highly placed individuals who have influence both within their organizations and broadly in the field. Even those who praise AFP’s information sharing wonder about the burden this places on staff. A PAI staffer says “AFP’s public face and willingness to share is great, but how much energy does that take up? Is it worth it? There is a need to make sure the balance of your efforts is right.” It is not necessarily a question of spending more time on communicating, but possibly more on changing what is communicated. One respondent felt that the e-newsletter currently focuses too much on describing events and should, instead, include more information on how AFP is contributing, such as linkages between southern and northern advocacy efforts. A donor said they were interested in case studies, which AFP has been slow to produce. AFP has a lot to share and could do more on this front. Writing up stories while they are fresh is important and partners feel that it would be great to have some lessons disseminated at this stage. Yet, given staffing constraints, such work is probably best undertaken by well-chosen consultants. As with most global projects, internal communication could also be improved, with better sharing of information and lessons among countries. One example is strengthening support for family planning in decentralized systems, where Indonesia has significantly more experience than Uganda or Tanzania. Given the theme of South-to-South cooperation, such information sharing should be strengthened. Internal communication is important to share successes, but also to strengthen morale among partners so that they don’t feel alone in the challenges they are facing. For example, AWDF says that they don’t know if partners have similar challenges to those they have faced.

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IV. Moving Forward

Conclusions AFP should be seen as a pilot, not a full-blown intervention. The timeframe (three years) was too short and the money ($12 million) too little to do more than test a concept and a set of hypotheses about how to build local capacity to carry out effective advocacy for family planning in developing countries. The project appears (as far as one can see on the basis of less than two years’ activity) to be off to a promising start. There is evidence from each of the Tier 1 countries of positive movement on family planning as the result of some good advocacy work done by the partners in the project. On the basis of that general finding, we believe AFP should be extended and gradually expanded by the addition of funding and staff so that it can work in more countries and expand its impact. When considering the return on investment, it is clear that the return will be greater if more time is given to build capacity, expand activities, and share lessons learned to catalyze broader change. As USAID/Washington staff stated it, AFP is “a program that needs to be built bigger, longer, and with greater flexibility.”

Short term recommendations: remainder of project… Between now and the end of the current 3-year project, if no new funding is forthcoming, the project should stick with the three Tier 1 countries and not expend significant effort in additional (Tier 2) countries. However, AFP could continue to strengthen regional entities and initiatives as a way to reach more countries. In terms of work in the three Tier 1 countries, recommendations for this phase must take into account the different levels of progress observed in the three countries.

1. Continue focus on Tier 1 countries. While in Uganda it will be critical to push forward the emerging work/pilot at district level, the Tanzania program will gain in continuing its focus at the national level. This would allow Tanzanian partners to consolidate the small gains that were obtained but also to address more effectively the absence of high-level champions, particularly in government. The recommendation in Indonesia would be to scale up by expanding to more districts, and possibly engaging more at the national level to help facilitate and accelerate district level changes. For all three countries, additional time is needed to build the capacity of local entities to continue effective advocacy work.

2. Document the district approach for mainstreaming family planning into all

development sectors and the effort to prioritize and increase resources allocated to family planning. This should be done for both Indonesia and Uganda where work at district level has started. Tanzania can learn from this experience.

3. Share lessons internally and beyond. Bring together Tier 1 countries (or at least

Uganda and Tanzania) once a year to foster coordination and exchange of experience. This could help spin a regional movement with greater potential for

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impact if tied to the EARHN and be an excellent way of broadening impact. Tier 1 investments have been called ‘catalytic,’ but they will only be so if the time is given to use the experience to mobilize others. Tier 1 experiences should be shared using regional meetings and other forums to encourage other countries to adopt successful strategies and approaches.

4. Be more proactive in developing capacity of regional networks. In order to

effectively share lessons, as described above, AFP should continue its work with regional networks and proactively develop their capacity and engage them in advocacy opportunities.

5. Look into different ways of engaging the Global Consultative Group. In

interviews, many of the GCG members felt that they could not speak about details of AFP’s work, even when they had taken part in phone calls and meetings. This is a resource for AFP that could do more, so AFP should consider different ways of engaging these experts, including, for example: a) site visits, if any members happen to be in Tier 1 countries; b) better use of case studies and stories to share information; or c) creating a mechanism for GCG members to suggest advocacy opportunities.

6. Help countries move from broad statements of regional and international

agreements to concrete actions. Some partners saw opportunities around the Maputo Plan of Action, and thought that along with helping to make actions concrete and specific, AFP and its partners, particularly PPD-ARO, could help with tracking and thereby increase attention. This could be part of the mandate of some of the regional entities.

7. Facilitate ways that each partner can use the expertise of others. For example,

AWDF would like to work more with PPD-ARO. Both organizations have a pan-African mandate with a potential to amplify AFP’s impact well beyond the project’s target countries.

8. Bring on board additional donors. There are few donors supporting advocacy

work. AFP’s experience provides evidence that the approach is working and could be useful in convincing other donors to support this type of advocacy work.

Longer-term recommendations: … and beyond Looking to the future – and a future where AFP is extended – AFP should look at ways to further institutionalize its approach, as well as achieving wider uptake and broader impact.

1. AFP, along with its home institution, the Gates Institute, should position itself as an important resource for institution building, especially in Africa, perhaps in partnership with the Reproductive Health Alliance.5

5 The Alliance includes the U.S. Agency for International Development (USAID), the UK Department for International Development (DFID), The Australian Agency for International Development (AusAID), and the Bill & Melinda Gates Foundation

The track record of the Gates Institute, as well as AFP's very promising start, suggest that the sunk

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investment of the Gates and Packard Foundations should be capitalized on by the larger community of like-minded donors to sustain and expand the very important and promising institution- and capacity-building work they are doing. It would be tragically short-sighted to terminate either of these important programs now or in the immediate future. Building capacity, especially institutional capacity, takes time and patience. The 15-year investment the Gates Foundation has made in the Gates Institute shows what a sound design, good people and consistency over an extended period can do.

2. Consider alternatives to the Tier 2 approach in order to expand impact. For

example, a) flexible resources to respond to opportunities; b) expanding on the policy engagement model implemented by AWLN; c) greater use of regional networks (e.g. replicating the model of the study tour for EARHN members to Ethiopia, with follow-up). This would require that there be at least 2-3 years added to the project.

3. Expand staffing. If AFP continues, and especially if it grows, it will need more staff. The evaluation team agrees with the statement of an AFP partner: “They are lean, but maybe too lean.”

4. Expand to Francophone West Africa. If there is more time, AFP should add a

French speaker to take advantage of opportunities arising in Francophone West Africa, a region with the highest fertility and lowest contraceptive use in the world. This could be done in partnership with the Gates Institute and PPD-ARO, both of which are considering opportunities to expand their work to Francophone Africa.

5. Apply lessons to maternal health. One of the reasons for AFP’s success is its focus

on family planning, but AFP’s experience has broader applicability. The lessons from AFP’s advocacy approach should be shared with the broader maternal health community, given the linkages between these areas and the possible synergies between FP and MCH players and programs.

6. Begin to think about succession planning. Given Duff Gillespie’s importance to

the success of AFP, it is critical to be sure either that Duff is prepared to continue in a leadership role in any extension of the project or that a leader of comparable experience, breadth and skill is identified to replace him, ideally over a transitional period.

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Appendix 1: Interview guide

Advance Family Planning Mid-term evaluation question guide for partners

1. How have you worked with/interacted with AFP?

2. What do you see as key achievements/successes of AFP?

3. What were key factors that contributed to these successes?

4. Is there anything about AFP’s approach to advocacy that is different from other advocacy work that you know about? If so, what is different?

5. What would you suggest that AFP could do differently to increase its impact?

6. What suggestions do you have for the remaining 18 months of AFP?

7. Should AFP continue beyond the initially planned three-year duration of the project? If yes, what are your suggestions for a continuation? (changes in how they work, where they work, specific issues to focus on, etc.)

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Appendix 2: List of Global Respondents Name Organization 1. Duff Gillespie Advance Family Planning (AFP) 2. Beth Fredrick AFP 3. Sabrina Karklins AFP 4. Michelle Hindin AFP 5. Amy Tsui Gates Institute 6. Scott Radloff United States Agency for International Development

(USAID) 7. Carmen Tull USAID 8. Alex Todd-Lippock USAID 9. Jose Oying Rimon Bill & Melinda Gates Foundation 10. Jen Daves Bill & Melinda Gates Foundation 11. Lana Dakan David and Lucile Packard Foundation 12. Suzanne Ehlers Population Action International (PAI) 13. Wendy Turnbull PAI 14. Elisha Dunn-Georgiou PAI 15. Sarah Clark Futures Group 16. Priya Emmart Futures Group 17. Susan Krenn Center for Communication Programs (CCP), JHU 18. Alice Payne Merritt CCP 19. Jennifer Boyle CCP 20. Julia Bunting DFID 21. Neil Datta Inter-European Parliamentary Forum on Population and

Development 22. Musimbi Kanyoro Global Fund for Women 23. John Skibiak Reproductive Health Supplies Coalition 24. Ann Starrs Family Care International 25. Vicky Claeys IPPF, European Network 26. John Worley IPPF 27. Sarah Mukasa African Women’s Development Fund (AWDF) 28. Joan Koomson AWDF 29. Abigail Ony Nwaohuocha AWDF

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Appendix 3: Indonesia Country Report

Advance Family Planning in Indonesia: Amplification, Focus, Partnership

Notes from field visit, September 4-14, 2011 Introduction Indonesia is widely regarded as a model of family planning success. But in the last ten years, as the country has pursued decentralization, family planning has struggled to receive the same attention as it did in the past. Being the fourth most populous nation in the world, what happens in Indonesia is significant not only for its own people but also for the global population. In addition, Indonesia is still battling relatively high maternal mortality, and its contraceptive method mix is highly skewed towards injectables and pills, with limited use of long-term methods. In light of these reasons, Advance Family Planning (AFP) selected Indonesia as one of its Tier 1 focus countries. What has been achieved? In its first 18 months, AFP has made significant progress, and achieved a number of ‘quick wins.’ An initial landscaping process conducted in early 2010 led to a strategic focus on increasing use of long-term methods, and framing this as an essential part of meeting the Millennium Development Goals (MDGs). AFP supports a different kind of advocacy, explains a member of the Core Working Group in Jakarta, “advocacy that works.” And it has provided a much-needed push, according to respondents, in a country where family planning has lost its priority status. Professor Toening (Sri Moertiningsih Adioetomo) of the University of Indonesia explained how “this is the real thing… So many papers have been produced on how to revitalize family planning, and people say government commitment is important, but they don’t explain how to do it.” AFP, she went on, shows how to make this commitment real and meaningful. AFP has achieved successes with limited staff. Staff members of the Center for Communication Programs (CCP) Indonesia office were instrumental in getting the program started in early 2010, and continue to provide support. A Chief for the Secretariat, Mayun Pudja, was hired in November 2010, based at the local NGO Cara Cipta Padu Foundation. A second full-time staff member was hired in August 2011. The work is mostly implemented through a central level Core Working Group in Jakarta, and District Working Groups in two districts, Bandung and Pontianak. The main achievements have been the following: Inclusion of family planning in Jampersal, a government program to provide free

maternal care services for women without other coverage. This approach uses maternity service as a stepping-stone to increase use of long-term methods through post-partum contraception. This has been a concrete way for the National Population

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and Family Planning Board (BKKBN) and the Ministry of Health (MOH) to work together. There has been an issue around involving private midwives, as the program does not reimburse at a rate that matched their fee. The Mayor in Bandung created a subsidy fund to cover this additional cost and the midwives joined the program. Through advocacy, including sharing the document about the Bandung subsidy, the Mayor in Pontianak recently agreed to do the same.

MOU between BKKBN and APINDO (Indonesian Employers Association) for

workplace family planning, which has begun to spread to the district level. The head of APINDO in Pontianak stated that he is ready to apply that MOU into programs, and there are plans to hold a meeting in October to move forward (partners note that implementation has been delayed due to Ramadan). He praised AFP’s role is bringing about the MOU and facilitating the meeting between APINDO and BKKBN Pontianak. He felt that members would be interested if it’s framed as showing that FP in the workplace is a way to benefit both the employee and the company. He has shared this information and idea with the provincial level and he hopes they will share with other districts.

Increases in local budgets for family planning, in part through use of the RH costing

skills from AFP training. Of particular note was the innovation of allocation of the village family planning funding in Bandung district, described below.

There have been concrete changes in the two focus districts of Bandung and Pontianak. The Head of the Social Planning Sector of the Bandung District Planning Board explained how AFP had helped him see family planning as a critical component of family welfare and national development. The inclusion of MDG goals into the local government plan, explained Mr. Indra, is due to AFP. The District Working Group in Bandung came up with a unique idea- to take budget for FP from the village budget. This “indigenous strategy” had never been done before, and “without AFP, this wouldn’t have happened.” Before there was a vague allocation for family welfare, but now there is specific funding for FP. As of 2011, 60% of villages have included this allocation and it is expected to reach 100% in 2012. There is strong potential for expansion. For example, the BKKBN central office sent people to learn about village-based FP budget in Bandung. A key to making this happen was the diverse composition of the working group, with the idea coming from a person from the village development group and then fleshed out by the group. It was also possible because of the openness to creativity in the leadership. Pontianak provides a different working environment compared with Bandung- it is a municipality of roughly 300,000, and so is a more urban setting compared with the rural villages of Bandung. As such, there has been more interest in private sector linkages. They have seen an increase in budget allocated for FP from 2010 to 2011. Members of the District Working Group praise the RH costing training for helping to make this happen by giving them stronger skills in costing out the program; they then argued strongly for increased resources. AFP has also helped increase awareness of Jampersal among service providers- it is now being implemented in all 23 health centers. According to the district health office, the number of FP acceptors post-partum has doubled. The focus has been on FP, but partners are using what they’ve learned for other areas, for example applying the RH costing method to other health areas. Mr. Indra of the Bandung District Planning Board wants to apply AFP methods in other development plans- he is now

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working on the poverty reduction strategy and what AFP has done so far- such as the costing and Spitfire approach- will be applied in that strategy development. The timeline below shows the process of making these changes happen, highlighting illustrative activities and successes. It calls attention to the time needed to bring about change and shows how early it is in the project for an evaluation.

AFP in Indonesia: a timeline of the first 18 months Date Jakarta Bandung Pontianak 2010 March • Landscaping done through

desk review and informant interviews (Mar-May)

April May • Consultative meeting with

FP champions- decided to have 2 groups: an Advisory Group and a Core Working Group (CWG)

June • CWG established • Launch of AFP at meeting

with over 200 participants, opened by Minister of Health

July • Net Map training for 10 CWG members

August • District selection September • Development of workplan October • Spitfire training for CWG

• Training on Spectrum by Futures Group in Washington DC for 7 BKKBN staff (cost-shared by BKKBN)

• Development of workplan

November • Chief of AFP Secretariat hired

• Spitfire and RH Costing training for District Working Group

• Spitfire and RH Costing training for District Working Group

December 2011 January • BKKBN and APINDO sign

MOU to develop a workplace FP program

February • Jampersal coordination meeting hosted by MOH to help define roles of different implementing units

Finalization of workplan and costing

March • Advocay meeting with BKKBN and APINDO to define implemention of MOU

• Meeting with Pertamina (govt-owned oil company) to advocate for contribution to FP from CSR budget

Finalization of workplan and costing

April • Jampersal program begins, with inclusion of family planning in its coverage of

• Round table discussion, hosted by the Mayor and facilitated by AFP to

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maternity services • Follow-up meeting with

Pertamina, with additional follow-up planned for Oct.

increase local budget for FP particularly for better access to LAPM

May • Meeting with Jampersal program management and service providers to raise awareness and discuss implementation

June • Proposal writing training for CWG members

• Spitfire and RH costing training for Aisyiyah

• Round table discussion hosted by the Mayor and facilitated by AFP to increase local budget for FP particularly for better access to LAPM

• Meeting with Jampersal program management and service providers to raise awareness and discuss implementation

July • Meeting held to share lessons on Jampersal implementation- UNFPA to use AFP methodology for larger study in 10 districts

• Advocacy to Village Leaders Association (APDESI) to allocate special budget for field FP activity from 2012 village budget- successfully obtained commitment- IDR 2.5 million per village, for 270 villages (roughly $75,000)

August Mayor agrees to create subsidy fund so private midwives will participate in Jampersal

It Takes a Village: Listening to the Leaders of Bandasari The tangible and concrete meaning of AFP’s work came through in a visit to the village of Bandasari in the district of Bandung. The village of 7,923 inhabitants is led by Agus Salim, such a strong supporter of family planning that he proudly told the group about his vasectomy and his desire to “lead by example.” He saw support to FP decreasing, people being transferred to other areas, and so he was concerned that population growth would increase and impact negatively on the village. He wanted to rebuild the FP human resource infrastructure. He described the allocation of village funds to family planning, and suggested that there be a FP orientation meeting of village leaders to share experiences. Village midwives also talked about implementing Jampersal and the need to change community attitudes to continue to increase use of long-term methods. To this end, they suggested advocating with the government to pay more attention to the cadre of the community mobilization team.

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This is a village that has embraced the importance of family planning and of increasing use of long-term methods, and a village that continues to have ideas for advocacy needs. Advocacy is as much about listening as speaking, and AFP should continue to listen to these important voices and support them in their efforts. Keys to success Advance Family Planning is a different kind of project, both in terms of how it functions and how it approaches advocacy. AFP staff describe the need to explain advocacy- “it’s a new terminology in Indonesia- people mix it up with communication,” explains Mayun Pudja. The emphasis on evidence-based advocacy is also new. While BKKBN staff in Bandung had been involved in advocacy before, they felt that what is different about AFP is that the method is scientific-based and implemented systematically. The process of how AFP works is different from traditional projects, which provide funding and then the partner implements. What is new about AFP, according to Mayun Pudja, is that there is a shift from project implementation into being a catalyst, “so we don’t do the work, they do the work.” In meetings with partners, sometimes they would still ask for funding for implementing projects, showing the continuing confusion about AFP’s way of working. In interviews, three main themes emerged as keys to success for this advocacy approach: amplification, focus, and partnership. Amplification: “Advocacy needs amplification of sound.” A fundamental focus of AFP, globally and in Indonesia, is raising the profile of family planning, most importantly to increase resource allocation. AFP’s role is to “keep up the interest,” Mayun explains. “We push but make it seem like we’re not pushing.” This pushing and convening helps to amplify the sound, as one partner explained, thereby leading to increased budget and policy change. Staff from Pontianak’s District Health Office explain that if they convey the message to local government from the health office, they can be ignored, but if someone else amplifies that voice it is a stronger trigger for decision-makers to pay attention to it. Such amplification means building partnerships, described in more detail below. Focus: “Advocacy is not just blah, blah, blah. You have to have focus.” What truly distinguishes AFP’s approach is the specific focus of advocacy efforts. Rather than raising awareness generally, there is a focus on specific changes and who best to communicate with to make those changes. People credit Spitfire with bringing this message home. “It’s things we know and have done but not in a systematic way,” states Mayun Pudja. “It’s put in a more structured process- what is the message that we should tell to decision-makers, who will deliver it, and when? We’re not yet very strong in these things- too many messages so decision-makers don’t know what we’re after.” Professor Sri Moertiningsih Adioetomo emphasized the importance of this: “This focus is a key reason for the quick wins in Indonesia.” Partnership: “An advocacy team.”

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The formation of Working Groups is the foundation of AFP’s work, at both national and district levels. These partners “own the activity,” while AFP’s role is to provide training and technical assistance and help craft an evidence-based message, to “open the door.” AFP has engaged with a wide range of partners. Members of the Core Working Group in Jakarta spoke of how they had become “an advocacy team.” They work on a voluntary basis, but people were excited to be part of the group because FP had been neglected for several years and they wanted to address this and share ideas with each other. “After silence for over five years, it was exciting to hear about family planning again,” explained Fitri Putjuk from CCP. The Working Groups bring people together, leading to better integration and coordination of activities. Mrs. Darmanelly, the head of BKKBN in Pontianak District, spoke of the importance of the continuous communication, as compared with earlier communication only on an event basis, leading to closer and friendly interactions among family planning champions, thereby facilitating collaboration and change. Before, advocacy was event-based, and would end with conducting an event. But with the working group, FP has become an integral part of members’ programs so it will be implemented on a sustainable basis. The Head of APINDO in Pontianak also praised how AFP helped facilitate continuous communication between APINDO and BKKBN. BKKBN in Bandung talked about how AFP helped them strengthen the partnership network at the grassroots level, in particular advocating the Village Leader Association because it is at the village level that activities are taking place. Partnership is made stronger when there is something concrete on which to collaborate. For example, Jampersal gave BKKBN and the MOH a tangible way to collaborate. They agreed that Bandung and Pontianak would be test districts, to help present the scheme and see how it works. AFP then helped to evaluate the process, which pointed out some implementation challenges. They brought those findings to the MOH at a meeting where UNFPA also participated, and now UNFPA will evaluate Jampersal in 10 districts using the AFP evaluation method. AFP has a strong focus on capacity building with the goal of creating sustainable change. A key part of this is the training for all members of the working groups in RH costing and Spitfire. In addition, on a cost sharing basis with BKKBN, AFP supported training on Spectrum by the Futures Group in Washington D.C. with a five-day TOT attended by seven senior staff members from BKKBN. AFP has also provided support to the University of Indonesia to institutionalize advocacy training for graduate students, using the AFP approach of RH costing and Spitfire.

A Tale of Two Districts Visits to the two project districts highlighted the changes that AFP has helped bring about and what they mean to the people in those districts. The similarities and differences also call attention to two important factors: Leadership is critically important. In Bandung, a more aggressive and more

progressive leader has led to more quick wins; “he can catalyze and bring FP to the attention of local decision-makers.”

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Flexibility is essential. By training in an approach rather than pushing specific agenda items, local partners can identify advocacy needs that make sense in their context. For example, working with villages made sense in Bandung, while in a more urban setting like Pontianak, partners were interested in pursuing private sector FP involvement. This will be important as the approach is expanded more widely throughout Indonesia.

Moving forward In addition to continuing its current work, AFP plans to expand to three additional districts. While AFP has made progress and gained insight into revitalizing family planning with local governments, many see the scale as too small now and would like to see it expand to more districts; “otherwise it is a small drop of water in the ocean.” Several people want to see expansion to some of the more challenging districts in the country. Dr. Sugiri, the Head of BKKBN, was particularly interested in expanding to the eastern part of Indonesia. In talking about the possibility of expanding with AFP’s limited staff, Esty Febriani from CCP emphasized the structure of the program; “We can do it. We can use district people to do it. We don’t only depend on our staff.” Determining the best way forward is complicated by the short time frame of the project, and all staff and stakeholders hope that the project will be extended. Expand within borders In order to expand- which is widely and strongly desired by partners- AFP will need to develop and help facilitate systems for replication. In part, AFP can do this through convening meetings where ideas are shared, e.g. between village leaders, or heads of BKKBN district offices. Core Working Group (CWG) members also suggested more effort at the central level, particularly targeting the President and Vice-President, to facilitate district level support for FP. One member of the CWG offered to use his personal connection to the Vice-President, and knowing his background as an economist, recommended developing persuasive and relevant messages that would resonate with him. Even though there is no longer central control with a decentralized system, the center can still influence and facilitate district level actions, as seen with the MOU between APINDO and BKKBN. In order to expand the model, AFP will need to more clearly define and articulate what the model entails, and some feel it should be streamlined so that it can be more easily expanded. In order to do all of this, it is necessary to keep the CWG members interested. Clearly, most members of the working groups are committed, but they are also busy and scheduling is often challenging. Members had several suggestions: 1) add incentives to meeting attendance in the form of knowledge- identify people to make presentations, share best practices, etc. (e.g. not everyone knows details about Jampersal); 2) broaden the group and bring in fresh blood; 3) have specific tasks assigned to members; and 4) members should have an alternate from their organization, when possible, to ensure representation. Advocacy doesn’t end, but projects do. AFP should work towards achieving a tipping point in skills and awareness around advocacy, so that the work can continue with more limited assistance, and eventually on its own. Time is still needed- beyond the 1½ years remaining in the project- to build such capacity.

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Expand beyond borders Decentralization is an issue that challenges programs in many countries around the world, and lessons from Indonesia should be shared to inform efforts. Sharing lessons will make the investment mean more. Indonesia has traditionally been a source of learning in family planning, and could possibly be so again with important lessons about revitalizing family planning in decentralized systems.

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List of Respondents

Name Organization JAKARTA 1. Mayun Pudja Chief of Secretariat, Advance Family Planning, Cipta Cara

Padu Foundation 2. Endang Saputra Senior Program Officer, Advance Family Planning 3. Fitri Putjuk Senior Technical Advisor & Country Representative,

Center for Communication Programs (CCP) 4. Esty Febriani CCP/Advance Family Planning 5. Dr. Sugiri Syarief Head of BKKBN 6. Dr. Kasmiyati Deputy for Training, Research and Development, BKKBN 7. Dr. Theodora Pandjaitan Head, Division of Collaboration and Overseas Training,

BKKBN 8. Dr. Wicaksono BKKBN 9. Dr. Ahmad Rozali Director of FP Private Sector, BKKBN 10. Dr. Ina Agustina BKKBN 11. Mr. Muammar Executive Secretary of Indonesia Secure Contraceptive

Association 12. Kartono Mohammad 13. Inne Silvianne Executive Director, The Indonesian Planned Parenthood

Association 14. Dr. Rachmat Sentika Indonesian Medical Association Central Executive Board 15. Prof. Sri Moertiningsih

Adioetomo (Toening) Research Associate, Demographic Institute and Faculty of Economics and Business, University of Indonesia

16. Dr. Cut Idawani IFPPD BANDUNG

17. Aten Sonadi Bandung District Working Group Coordinator 18. Mrs. Grace Mediana Head of District BKKBN, Bandung District 19. Mr. M. Hairun Secretary of District BKKBN, Bandung District 20. Mr. Indra Head of Social Planning Sector, Bandung District Planning

Board (Bappeda) 21. Mr. Ahmad Kustijadi Head of District Health Office, Bandung District 22. Agus Salim Bandasari Village Leader, Cangkuang Sub-district 23. Mrs. Zaenab Bandasari Vilage Midwives PONTIANAK 24. Mrs. Darmanelly Head of Pontianak City BKKBN 25. Mrs. Arismawaty Pontianak City BKKBN 26. Mrs. Sri Murtini Pontianak City Health Office 27. Mr. Ibnu Masykur Pontianak City Religious Affairs Office 28. Mr. Abang Nurdin Pontianak City PKBI 29. Mrs. Marianai Pontianak City IBI (Midwives Association) 30. Mr. Andreas Acui APINDO 31. Mrs. Mayani Head of Pontianak City Sub-District Health Center

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Appendix 4: Tanzania Country Report

Advance Family Planning in Tanzania Notes from field visit, September 21-23, 2011

The Context During the last decade, Tanzania was unable to sustain the momentum of its family planning program that was very dynamic in the 1990s. This loss of dynamism is reflected in recent trends of contraceptive use. While the prevalence of modern contraceptive use among married women almost trebled between 1992 and 1999, increasing from 6.6% to 16.9%, its annual rate of increase was 3 times slower during the period 1999-2010 where modern CPR went from 16.9% to 27.4%. It is believed that Tanzania’s FP program lost steam partly because of diversion of resources towards competing health priorities such as Malaria, HIV/AIDS and tuberculosis. Additionally, myths and misconceptions about FP, and inadequate consideration of its relevance to national development planning, contribute to low visibility of FP. But there is also evidence that government interest is not strong and that the demand for big families remains relatively high by East African standards. The Demographic and Health Surveys of 2004-05 and 2009-10 show that couples still prefer big families especially in the rural areas. However, the proportion of married women who want no more children increased from 23% in 1992 to 30% in 1996 and remains at this level according to the 2010 DHS. My discussions with AFP stakeholders6

seem to suggest that things are turning around and that there is right now real potential to achieve great progress in raising the CPR. Some partners have suggested that the modern CPR shown by the 2010 DHS is artificially depressed because of endemic commodity stock-outs. But the medium term looks good as major new actors such as DFID and AusAID have demonstrated commitment to help address the problem of stock outs by pledging respectively $12.5m and $2.5m to this end. It would therefore appear that AFP was launched in a relatively conducive environment where quick wins are not out of reach.

Respondents concur however that advocacy for FP is very difficult in Tanzania with a notorious absence of real champions in government and parliament, at least until AFP entered the scene. Program structure and dynamics

6 Because of the similarity of individual responses to our interview guide and the limited time available for interviews, I chose to combine individual interviews with group meetings. These group meetings were extremely useful in helping understand the context and structure of the initiative, gauge the level of commitment of different stakeholders, and learn about group dynamics. I had group meetings with the National Family Planning Coalition and the Local Advisory Group. Group interviews were also conducted in each partner organization.

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The implementation of AFP in Tanzania is an excellent example of the use of partnerships to create a strong movement for policy change at country level. The work is spearheaded by a group of four local NGOs. A Tanzanian NGO, the Human Development Trust (HDT), is the lead implementing organization. HDT enjoys a good reputation and track record in policy analysis, dialogue and advocacy and has a solid experience in engaging policymakers. Three local NGOs are sub-contracted as implementing partners, each with their comparative advantage and area of focus. Each partner has terms of reference representing a specific portion of the overall AFP strategy and is responsible for conducting an assessment that will be critical to moving the overall strategy forward by providing the evidence needed for effective advocacy. These implementing organizations are at the heart of a larger coalition of 14 Tanzanian NGOs, the Family Planning Coalition of Tanzania, which provides a strong base for amplifying AFP’s advocacy work. A Local Advisory Group composed of eight high-profile and well connected Tanzanians, some working in government ministries, provides guidance and helps make the linkages needed for effective advocacy. This large coalition composed almost exclusively of Tanzanians works closely with the National Family Planning Working Group which includes 19 organizations working on FP comprising local and international NGOs, bilateral donors, and government. Government usually chairs Working Group meetings and the rotating secretariat is currently held by Pathfinder International. AFP has a memorandum of understanding with a number of these working group members. The establishment, maintenance and effective use of these broad partnerships is a major achievement that should not be dwarfed by the more concretely visible ones. According to most of our interviewees, AFP’s achievements in Tanzania were made possible by its all-embracing approach that focuses on adding value to what partners on the ground are already doing and its success in coalition building. Achievements AFP’s strategy in Tanzania focuses on strengthening efforts to sustain increased family planning funding through strong and continued policy commitment and action by the government with the aim to achieve three specific outcomes: • Increased commitments (from the national budget) toward the estimated 20bn

Tanzanian shillings required annually to address unmet need for family planning and reach the target CPR of 60% by 2015. The first step being an increase from 0.5bn in 2010/11 to 2bn by 2012/13.

• Timely disbursement of family planning funds by the Ministries of Finance and Economic Affairs (MoFEA), and Health and Social Welfare (MoHSW) by 2012/13.

• Government approves administration of injectable contraceptives (women’s preferred method) by community health workers by December 2012.

This strategy is based on the understanding that stock-outs and policy constraints limiting access to injectables are the main barriers to satisfying unmet need for family planning in

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Tanzania. The last outcome is probably the most challenging one given the strong resistance the idea stirs among some policymakers and health professionals. It is fair to say that AFP has been functional in Tanzania for about 1 year. The AFP coordinator, Halima Shariff was recruited and took office on September 1st , 2010 and the contract with the lead implementing partner (HDT) was signed only in April 2011and project funding was received in mid June 2011; which means that AFP has been fully functional in Tanzania only for four months. However, a number of start-up activities such as capacity and partnership building for strengthening FP advocacy were implemented through the AFP office in Tanzania between October 2010 and April 2011. Despite this short time span a number of notable successes have been achieved including:

• Establishment of the Parliamentary Family Planning Club (PFPC), which commits itself to repositioning family planning in Tanzania, helping close the shortfall in funding and reducing stock-outs by ensuring timely disbursement of earmarked funds. The club is refining its advocacy strategy in order to fully engage Parliament in the medium term.

• Tanzanian parliament voted an increase in government funding for FP from 0.5bn (2010/11) to 1.2bn Tanzanian shillings for fiscal year 2011/12. This is a small but considerable step toward reaching the goal of 2bn Tanzanian shillings by budget year 2012/13, as per AFP’s advocacy strategy.

• The Spitfire approach, which has been widely embraced, has completely transformed the way advocacy for family planning is done in Tanzania. There is not one single individual who was exposed to Spitfire who does not stress that it was a game changer. Almost everyone recommends large-scale training on Spitfire particularly in districts in order to influence resource allocation at that level.

The AFP coalition has initiated a series of activities aimed at achieving its strategic goals and the effort to increase resources for family planning is being pursued from different angles. The team is working hard to mobilize resources for family planning from the Global Fund by supporting the integration of family planning into the development of Tanzania’s round 11 proposal coordinated by the Tanzania National Coordinating Mechanism (TNCM) through the Tanzania Commission for AIDS (TACAIDS). One coalition member and implementing partner (UMATI) is about to complete its assessment of private sector companies’ social responsibility policies and interest in supporting family planning. Discussions are also ongoing with the Tanzania Midwives Association (TAMA) and Barclays Bank to see how the bank’s annual Step Ahead campaign, which focuses on MDGs 4 and 5 could be utilized to advance family planning in the coming years. Way forward Our respondents unanimously said that AFP is at early stages in Tanzania and that strategy implementation was on track. They found it therefore too early to think about course correction.

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AFP was able to create a strong movement for change and coalition members are all highly committed and excited to be involved in what they called a ground-breaking initiative that taught them already so much. They think that, while it makes sense to focus initially at the national level, AFP should consider building advocacy capacity at the district level to help mobilize district council members and ensure that FP is in their agenda. They think that, while increased funding for FP is laudable, it will not be enough to create the vibrant family program that is needed to achieve the country’s development goals. It will be important to remain vigilant and make sure that mobilized resources are effectively used to advance family planning. They also think that it will be important to have a strategy for increasing demand going forward. Although the Spitfire approach is very effective in reaching the individuals that count most and getting them to make the desired decisions, AFP should keep in mind that decisions made by individuals are easily reversed in the absence of broader support. A combined approach is therefore needed: target individuals but also help build consensus without which individuals making decisions are isolated. Many of our respondents thought that, as AFP activities develop and coalition membership grows, coordination is likely to become highly demanding and Halima will need additional support to keep the initiative’s momentum and ensure that nothing falls through the cracks. Finally, the consensus is that AFP should continue beyond the initial three years in order to make its philosophy, approach and impact sustainable. It should also consider innovative ways of addressing demand at the district level. However, in the short time remaining in this first phase, the advocacy work should continue to focus at the national level to consolidate the gains that are being made.

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List of respondents Name Organization 1. Ms. Halima Shariff Director, AFP Tanzania 2. Mr. Tim Manchester Senior RH/FP Advisor, USAID Tanzania 3. Dr. Peter Bujari Executive Director, Human Development Trust 4. Mr. James Mlali Senior Policy Advocacy Officer, Human Development Trust 5. Ms. Anne Marie Mpanda M & E Manager, Human Development Trust 6. Ms. Easter Mwanjesa AFP Implementing Partner, Project Officer Advocacy &

Resource Mobilization, UMATI 7. Mr. George Nyembela AFP Implementing Partner, Program Officer Association of

Journalists Against AIDS in Tanzania (AJAAT) 8. Mr. Bruno Ghumpi AFP Implementing Partner, Advocacy Network on HIV and

AIDS in Tanzania (ANAT) 9. Dr. Theopista Jacob Coalition member, Pediatric Association of Tanzania 10. Ms. Neema Duma Coalition member, Tanzanian Gender Networking Program 11. Dr. Calista Simbakalia Member, Local Advisory Group (Independent Consultant) 12. Dr. Marina Njelekela Member, Local Advisory Group (Head, Department of

Physiology, Muhimbili Univ. of Health $ Allied Sciences) 13. Mr. Simon Kivamwo Member, Local Advisory group (Senior media professional 14. Mr. Robert Masatu Member, Local Advisory group (Statistician, Planning

Commission, President’s Office) 15. Ms Millicent Obasso Country Director, Futures Group International 16. Mr. Gregory Kamugisha Senior Technical Advisor, Futures group International 17. Mr. Ezekiel Kalaule Deputy Director, Technical, Futures group International 18. Dr. Pasiens Mapunda Deputy Country Representative, Pathfinder International 19. Mr. Faustine Kimario Specialist, Project Coordinator, Pathfinder International 20. Mr. Cuthbert Maendaenda Member, Local Advisory Group (filled questionnaire)

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Appendix 5: Uganda Country Report

Advance Family Planning in Uganda: Spitfiring for Success

Notes from field visit, September 26-30, 2011 Introduction With close to 7 children per woman in 2006, Uganda has the highest total fertility rate in eastern Africa. This high fertility level has remained relatively unchanged between the last two Demographic and Health Surveys partly because of a floundering family program. The impressive increase in the use of modern contraceptives that was observed between 1989 and 2001 when it went from 2.5% to 18.2% was not sustained beyond 2001. In fact the prevalence rate stagnated at the 2001 level or even declined slightly reaching 17.9% in 2006. A significant decline from 11.3 to 7.2% was observed among the poorest and rural section of the population reflecting a major corrosion of access to contraceptives. It is not surprising then to see the unmet need for family planning shoot up from 35% in 2001 to 41% in 2006, the highest level ever recorded by the DHS system since it was launched. Among the poorest sections of the population, unmet need for family planning stood at an astounding 46.5% in 2006. In fact unmet need for family planning increased in all wealth quintiles suggesting that the program’s disruption was pervasive. The fact that this general program deterioration occurred despite the existence of a highly supportive policy framework is a testimony to the reality that these policies are not implemented effectively. The AFP Uganda landscape assessment conducted before the launch of AFP is right to the point: “Although there is no deliberate obstruction to family planning programs, inadequate political support has created an environment of malaise and fatigue among managers and policy makers”. AFP’s strategy to revitalize Uganda’s family planning program through increased resources, access and choice achieved a lot in a short time because it was able to turn the morose policy environment to its advantage. AFP began its work in Uganda in early 2010. The Center for Communication Programs (CCP) hired a dedicated staff member in February 2010 to coordinate efforts and undertake the landscape assessment mentioned above as a basis for strategy development. PPD-ARO became a key partner early on, and plays a central role in high-level activities, “for that heavy clout,” explains one partner. After a year, Reproductive Health Uganda (RHU) was identified as the local partner to coordinate AFP. RHU just received their subagreement in July 2011, so this transition is in the very early stages. AFP also has an advisory committee that helps to look at broad strategic directions.

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Achievements: “their voice has been heard” AFP has contributed to a number of concrete successes in Uganda. Below are the main achievements of AFP, organized by the objectives of the advocacy strategy. “They have been small, but their voice has been heard,” according to UNFPA staff. 1. Better resource allocation for FP/RH from Ugandan Government and donors Increased government budget line for RH more than fivefold, from roughly 1.5 to 8

billion Ugandan Shillings. It should be noted that this is the culmination of over 11 years of work, according to Parliamentarians, showing that even what appears to be a ‘quick win’ in reality might not have been so speedy.

Worked with Parliamentarians to approve the World Bank loan only when it included $30 million for RH- approved May 25, 2010, and Parliamentarians went further by insisting that 70% of maternal and RH funds be allocated to FP.

Getting contraceptives included in Round 10 Global Fund proposal. Although approved, the proposal remains unsigned as of November 16, 2011. Despite this, it was an achievement to get FP into the Global Fund framework, and they are starting earlier for the next round- RHU is an alternate member of the CCM, and it will likely be easier this time.

2. Increased access and choice for family planning Getting Norigynon on the essential drugs list (EDL). RHU staff attribute the speed of

this change to the concrete steps of identifying key individuals to target, and so “in three weeks we had something done which could have taken three years.”

CBD Depo policy (see box). The next step is advocacy in the districts to implement the policy, which will begin in October. A challenge is that new Director General of the MOH has indicated that she does not support this policy. AFP and partners are already planning actions to advocate with her, including taking her on a site visit, but this shows that advocacy does not end, even after a successful outcome.

Evidence-based advocacy is an effective way to put knowledge into practice

Sometimes advocacy success is about being in the right place at the right time. After a successful pilot study was completed in 2005 on the safety and effectiveness of having CBD agents provide injectables, efforts to change the policy kept hitting a wall. “You don’t just get evidence and apply it,” explained Angela Akol, the Country Director for FHI 360 in Uganda. “We did advocacy, but didn’t get anywhere.” AFP came in at a good time and was able to provide a needed push. Most importantly, they facilitated a field visit for key MOH staff to see the program firsthand, which seemed to be the turning point in getting the policy approved. In December 2010, the Ugandan MOH issued new policy guidelines for community based distribution of injectables. This success was due to the extensive groundwork already done by multiple partners and also showed the catalyzing potential of AFP’s approach, as the Spitfire exercise identified the key person to target to change the policy. This advocacy approach could go a long way in helping to put important evidence into practice, as it did in Uganda.

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3. Improved coordination of procurement and reporting systems for public and private resources

Facilitating flow of commodities to the National Medical Stores (NMS). In noting

problems with commodity security, AFP and others questioned why the funds passed through the MOH before coming to NMS; “after doing some ‘Spitfiring’ we saw it should go directly to NMS.” There was some worry that the MOH would fight this change, but “we met with the President and he said he’d support it.” As a result of this change, whereas NMS used to be empty, now it’s full of drugs.

Helping create separate supply chain through the Uganda Health Marketing Group (UHMG) for NGOs which should improve access by private sector.

4. Strong, effective and well-resourced advocacy coalitions and networks for family

planning at national and district level Built Parliamentary leadership on FP. Members of Parliament (MPs) talked about

building momentum both within and outside of Parliament, creating more visibility of FP, in addition to the concrete budget increases described above. As an example, they cited the recent Women’s Day celebration on March 8, 2011, during which the President even mentioned family planning in a positive light. One MP talked about the challenge of getting attention on what is perceived as a women’s issue; “if the speed at which we handled the AIDS epidemic were the speed at which we handled maternal mortality, we’d have gone a long way.”

Ugandan Family Planning Coalition (UFPC) came together in 2009 around the issue of commodity security, but has now broadened its focus to also advocate on issues of common interest and coordinate provision of FP to avoid duplication of effort. AFP has become an active member. Some feel like this group could house a Secretariat for coordinating advocacy efforts- they even submitted a proposal to DFID to support that, but it was not funded.

Beginning to go beyond the national level. Most of AFP’s success in Uganda has been

at the national level, but “since service delivery happens at the sub-county level, we should do more advocacy at that level,” explains staff at the Population Secretariat (POPSEC). As of February 2011, AFP has begun work in two districts: Mukono and Mayuge, piloting prioritizing family planning in district planning and budgeting. Although FP is identified as a challenge in many districts, when identifying activities, district plans are often totally silent on FP. AFP is working with the Ministry of Local Government to try to ensure local ownership. In a visit to Mukono, the evaluation team saw positive steps, with district staff describing their new plan that mainstreamed and integrated FP into other sectors. They also appreciated support in resource mobilization to expand FP services through the Village Health Teams.

While not part of the Ugandan national advocacy strategy, AFP’s impact has spread

beyond national borders, particularly because of PPD-ARO’s regional focus. This includes work with groups such as the East African Reproductive Health Network (EARHN), SEAPACOH, and the Organization of Africa First Ladies against HIV/AIDS (OAFLA). The latter had been focused on HIV, but PPD-ARO influenced their agenda to be expanded to cover FP, a success achieved in one half-day meeting in July 2010.

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Keys to Success: “our business is advocacy every day” PPD-ARO staff describe AFP as a new way of doing advocacy, explaining that they have been “doing things which were new to us, holding us to a higher notch.” As with other countries, the AFP approach was initially confusing to partners who were used to having projects fund implementation; “First they looked at us like donors, bringing in more money, but we said no, we’re facilitating,” explain AFP staff. This is an ongoing challenge for an advocacy project, but over time, partners end up understanding what the project is, and isn’t. A focused project. There are few projects with a focus on advocacy. CCP staff

explain that AFP is “unique in that it’s purely advocacy, not mixed with service delivery. We can be focused- our business is advocacy every day.”

A focused approach. It is rare for so many people to agree on the importance of a tool, but it seems that Spitfire has truly caught fire among those who have used it. Almost all respondents mentioned how Spitfire had led to more focus and better strategic thinking, and often a surprisingly fast outcome. RHU staff raved about the approach: “using Spitfire, we know who to target at the right time… this one works so fast.” AFP’s coordinator likes how “you sit for 2-3 hours and come out with a plan.” The approach has been so popular that he receives requests for support from a wide range of groups. POPSEC staff describe how previously they did general advocacy which wasn’t targeted, but now they can focus on particular steps and specific people to influence. Spitfire has been an important part of building capacity.

Power of personal connections. “Sometimes we need to go a notch higher, for

example meet with the President,” explained an AFP partner. So much happens through who you know, and PPD-ARO has important personal connections, including with the President of Uganda. This makes it possible to “discuss at closer range, when all the doors are closed.” Partners praise AFP staff for being present at meetings and being vocal on the issues, pointing out the need in advocacy to be continually at the table.

Study tours can make a difference. AFP has a theme of South-to-South sharing

and learning. In addition to Spitfire training for EARHN, they also had a field visit to Ethiopia to see the Health Extension Program. Study tours need follow-up to have an impact. To that end, PPD-ARO is exploring opportunities to bring members together and train them in resource mobilization to try to replicate the lessons they learned. POPSEC followed up with the two districts that were part of the study tour by helping them develop proposals for having village health teams trained and empowered to move forward the districts’ new FP agenda.

Pressure of quick wins. Some AFP partners feel that the pressure of achieving

quick wins was good as it pushed them to get things done. And in some cases, Spitfire can greatly facilitate relatively fast success. But people acknowledge that in many cases these wins were quick because of all the prior work that had been done, and that in general, advocacy takes time.

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Way Forward The need for advocacy doesn’t end, particularly in an environment that is often hostile to family planning. Steps forward are often followed by steps back (e.g. CBD of Depo, Global Fund money not coming through in the end). You have to be there, to keep pushing, learning from past experience. Some of the suggestions for the remaining time of the project are described below. Go to the district level. “We have to move to the district if we want to make a

difference in this country.” If they are successful in the two districts, use as a model and spread to other districts. The District Health Officer in Mukono is already talking about having other districts come to learn from their efforts so that “it becomes a success story for Uganda.” AFP should coordinate efforts with DSW and possibly compare different models of building capacity at the district level.

Make sure the money is well spent. The budget for RH has increased, but the issue

now is effective utilization. Part of this will involve addressing demand to ensure that commodities do not go unused on NMS shelves. AFP should engage with groups working on that and “Spitfire them.” It would be great if AFP could create more excitement, using stories.

It’s not just about the money: gender bias in resource use

When we think about gender bias in FP, we often think about male opposition to FP use. But gender bias plays out in all sorts of ways, even affecting commodity security. The General Manager of the National Medical Stores explored this issue by looking at who was submitting the orders for medicines. Interestingly, when a woman filled out the form, contraceptives were included 100% of the time. When it was done by a man? Only 20% requested contraceptives.

Quick wins are satisfying, but AFP will need to move beyond the low-hanging fruit.

“Sometimes what needs to change is not low-hanging,” points out FHI 360 staff. Need to improve communication and collaboration with partners. Some partners

felt that they were not informed about plans, not included in planning, and that the process for choosing RHU was not transparent. Some felt that if it was coordinated better, they could do much more.

Institutionalize by continuing to build capacity. “They need to transfer that energy

to local institutions so they can carry the work forward,” explained a partner. This work is far from done, as one respondent stated; “I’m not sure we’ve given enough capacity to local entities to do their own resource mobilization.” Even if resource mobilization skills are there, it is unclear who will fund advocacy. RHU suggests building capacity in many more partners in Spitfire, even in the districts; “this would be the footprint AFP could leave behind.” One question is whether it is better to build up RHU or create a network that builds ownership from more organizations. RHU staff state that “this coalition we have formed- if AFP could take it on and strengthen it, it would be good- groups that would be competitors have come together and have a formidable voice, so they can’t take us lightly. Resource

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mobilization as a coalition would make a difference. You need some catalyzing resources to have a secretariat for a coalition.” Another partner states that “we need to stand together…. The machine is there, we need someone to help us drive.”

Identify other important research utilization (RU) possibilities. AFP’s advocacy

approach is an important complement to research efforts. Much RU work has only had limited success, but the example of CDB of Depo in Uganda shows the impact of the extra push, the power of personal relationships, and the usefulness of Spitfire.

When asked whether AFP should continue beyond the planned three years, all respondents said yes. “For me, it has just started,” RHU said. The main focus areas for an extension would include making sure that additional resources allocated for RH are well spent, capacity building to ensure sustainability, more work at the district level, and possibly strengthening community mobilization. In particular, there is a need for district ownership- “they look to development partners, but they should take charge,” stated one partner. In addition, DHS and Census data will become available in 2012, providing important opportunities for evidence-based advocacy. It would be a shame to not be able to take advantage of such opportunities. It is important to remember why this all matters. This photo is of a young woman waiting for family planning services at a health center in Mukono district. All the abstract discussion about advocacy is really all about making sure that all women, including this young woman, get the reproductive health services they need.

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List of Respondents Name Organization 1. Martin Ninsiima Program Officer, AFP, Center for Communication Programs (CCP) 2. Jotham Musinguzi Regional Director, Partners in Population and Development

Africa Regional Office (PPD ARO) 3. Abdelylah Lakssir International Programme Officer, PPD ARO 4. Diana Nambatya Programme Officer, PPD ARO 5. Patrick Mugirwa PPD ARO 6. Betty Kyaddondo Head, Family Health Department, Population Secretariat

(POPSEC) 7. Eva Nakimuli National Programme Officer, Family Health Dept, POPSEC 8. Hope Nzeire National Programme Officer, Family Health Dept, POPSEC 9. Sylvia Ssinabulya Member of Parliament 10. Rosemary Najjemba

Muyinda Member of Parliament

11. Jackson Chekweko Executive Director, Reproductive Health Uganda (RHU) 12. Hasifa Naluyiga RHU 13. Jennifer Wanyana RH Division, Ministry of Health 14. Wilfred Ochan Assistant Representative, UNFPA 15. Ismail Ndifuna Team Leader (RH), UNFPA 16. Jon Cooper Country Director, Marie Stopes Uganda 17. Julia Mayersohn External Relations Manager, Marie Stopes Uganda 18. Angela Akol FHI 360 19. Moses Kamabare General Manager, National Medical Stores 20. Luke L. L. Lokuda Chief Administrative Officer, Mukono District Local Government 21. Elly K. Tumushabe District Health Officer, Mukono District Local Government 22. Fred Katemba FP Coordinator, Mukono District 23. Samuel Baale Technical Assistance Officer, Euroleverage, German Foundation

for World Population (DSW) 24. Matthias Brucker EU Project Manager, DSW 25. Cheryl Lettenmaier Regional Representative, CCP 26. Moses Muwonge Health Logistics Consultant