From Pilot to Nationwide Scale Up: Increasing Access to FP and PAC in Djibouti Jimmy Nzau, MD (CARE) Amadou Traore, MD (MoH Djibouti) Heidi Schroffel, MPH (CARE)

Djibouti Population< 0.9 million Total Fertility Rate3.5% Maternal Mortality Rate 229 per 100K Modern Contraceptive Prevalence 19% Unmet need for Family Planning 22% Sources: World Bank, WHO ( ) 2

CARE’s SAFPAC Project SAFPAC: Supporting Access to FP & PAC Since 2011 in 5 countries: Chad, DRC, Mali, Pakistan & Djibouti Quality FP & PAC services through:  Clinical Training  Engagement with community and partners  M&E system  Logistics & Supply Chain Management (including provision of supplies) 3

CARE in Djibouti: The Timeline… CARE HEALTH PROGRAM 2 refugee camps o 2 health facilities o 21 new FP clients/month SAFPAC PILOT 2 refugee camps o 2 health facilities o 37 new FP clients/month o Started introducing LARC/PAC SAFPAC EXPANSION o 10 health facilities (2 camps & 8 MoH facilities) o 173 new FP users/month CARE Office Closes SCALE UP CARE supports MoH o 22 govt. health facilities nationwide o >900 new FP users/month 4

Evolution of a Partnership I 2013 Resource Mobilization Service provision in refugee camps only 2014 Capacity building and procurement Partnering with communities; M&E Engaging MoH and transferring skills 2015 Handover to MoH: Procurement, remote TA and quarterly supervision visits: - M&E - Cross-learning - Documentation 5

Evolution of a Partnership II Before: With CARENow: Without CARE Security 100% reliance on CARE Security & Safety System 100% reliance on UNDSS, UNFPA and our Regional Focal Point Finances & Compliance 100% CARE policies MOH follows CARE policies where applicable Staff 6 CARE staff Salaries & benefits MoH supervises CARE activities MoH personnel MoH implementation CARE USA supervises MoH activities Logistics 100% CARE Substantial cost 75% MOH Low cost for CARE Program: Coverage Budget Outcomes Geographic limitations: 1 region / 10 HFs $109K per year 173 new FP users/month Nationwide: all regions, 22 HFs $50K per year (CARE costs) >900 new FP user/months Ownership Potential for sustainability 6

The Ingredients in this Special Sauce… 7 Investment Mutual Accountability Trust $$$ Technical Support PARTNERSHIP & SCALE UP

The Equation CARE Trusted brand Capacity building M&E systems Technical assistance Advocacy/Influence Government Stability Security Reach Buy-in from the MOH Ownership Outcomes Increased coverage Better access Decreased costs Accountability Sustainability Greater impact 8

What Do our Partners Think? At the Community Level Increased awareness about FP and PAC Perceived decrease of unwanted pregnancy & abortion-related complications At the Healthcare Level Improved provider attitudes Improved quality of services LARCs available nationwide Increased demand for modern FP Lower hospital referral rates PAC services capacity at all health centers At the Government Level Improved supervision & evaluation Strengthened SRH system Strengthened commitment to service quality Deeper understanding of needs for quality SRH services > agreement to revise FP policy and guidelines 9

# of New FP and LARC Users by Month # FP Users # LARC Users 10 Commodity stock-outs due to unexpected high demand

What Makes it Possible? Strong results convinced MoH of the value of the intervention. Trust and accountability leveraged our partnership to go to scale. Scale-Up and transition requires a stable, motivated government. An NGO that can innovate and is willing to take risk. 11

What’s Next? Sustainability: reliance on commodities purchased by CARE > exploring other options New initiative funded by FP 2020 for $90,000:  Support the MoH to revise national FP policies and guidelines  Support the MoH and local stakeholders to adapt the national RH Law  Support the MoH to establish capacity building (TOT/Training Manuals) 12