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) Good afternoon, I am Heidi Schroffel from CARE and I am presenting on behalf of my colleague Jimmy Nzau. Today I would like to tell you a story about how a small pilot project of only two refugee camp health facilities ended up improving access to FP planning and PAC all across Djibouti. This was only possible through a strong partnership with Djibouti’s Ministry of Health, I am therefore really excited that Dr. Traore from Djibouti’s Maternal and Child Directorate is here with me to give his perspective on this journey.

Djibouti Population < 0.9 million Total Fertility Rate 3.5% Maternal Mortality Rate 229 per 100K Modern Contraceptive Prevalence 19% Unmet need for Family Planning 22% So Djibouti is a challenging context. It’s a small country in the horn of Africa with limited resources and a protracted refugee crisis. The country hosts about 18,000 Somalis in the two refugee camps of Ali Addeh and Holl Holl, often for decades. Reproductive health indicators are poor. Sources: World Bank, WHO (2013-2015)

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)

CARE in Djibouti: The Timeline… 2012 2013 2014 2015 SAFPAC EXPANSION 10 health facilities (2 camps & 8 MoH facilities) 173 new FP users/month SCALE UP CARE supports MoH 22 govt. health facilities nationwide >900 new FP users/month CARE HEALTH PROGRAM 2 refugee camps 2 health facilities 21 new FP clients/month 2012 program: maternal health, very poor FP services 2013: SAFPAC started as a pilot. Expansion, made transition from 2 refugee camp health facilities to include another 8 HF serving the general population. LARC utilization around 11% of new users. CARE office closes. SAFPAC PILOT 2 refugee camps 2 health facilities 37 new FP clients/month Started introducing LARC/PAC CARE Office Closes

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 So what we are seeing is an evolution of the partnership. We provided incremental support to the MoH as we moved from more basic service provision to capacity building among providers as well as MOH staff, who were trained as clinical supervisor. In 2014, the MoH took over monthly supervision visits and clinical skills assessment and adopted our M&E approach and tools nationwide. Then in 2015, here is how we had to figure out how to handover the project to MCH Directorate, how to continue procuring supplies and support them remotely to expand the programming from 10 to 22 HF. Now it is the MOH who does all the work and CARE staff goes out for regular supervision visits and provides feedback on their findings. Issues that we found during supervision visit have varied from infection prevention issues to slow uptake of LARCs to husbands complaining about their wives getting contraceptives without their consent, and those issues have for the most part been effectively improved by the MoH.

Evolution of a Partnership II Before: With CARE Now: 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 Here are the elements of the before and after of the transition. I am not going to go over these in detail, but it shows how things evolved in terms of security, finances, staffing and programming. Overall the system has become much more cost-effective. What is really noticeable here is that the SAFPAC package on interventions went from 2 health facilities to 22 and more than quadrupled the number of users since the pilot and serving 45 times as many users as before the very beginning of the intervention. Logistics: driver, car, insurance, maintenance. Now for TA visit use MoH vehicle, occasional car rental Financial: MoH follows CARE processes, e.g. to submit quotes for TA/workshop costs to CARE so that CARE staff can get travel advance With CARE, we had : Geographic limitation and security considerations Salaries and benefits Indirect costs and other cost related to general administration -Basically, potential questions that could be posed SSS = Selective Service System, now can just email travel dates and security questions to UNFPA and they will tell you Finance still operates entirely under CARE policies but we just explain it to MOH Our role changed from using our staff to MOH supervising to the opposite way We have changed logistically to a more cost-effective way Before, CARE could only access the capital and one region. Now, MOH can access all areas and make services 100% available. -If we have to travel there for training purposes or other reasons, we let them know and they give us a budget and we use cash.

The Ingredients in this Special Sauce… Investment Mutual Accountability Trust $$$ Technical Support This is the formula for why the system for Djibouti works. CARE is investing much more than money in Djibouti, other elements are proving much more important. The majority of our investment is trust and accountability, which is a foundation CARE always aims to builds on. We also provide a lot of continuing technical support using the tools that we made and were adopted by the MOH. PARTNERSHIP & SCALE UP

The Equation Outcomes CARE Increased coverage Better access Trusted brand Capacity building M&E systems Technical assistance Advocacy/Influence Outcomes Increased coverage Better access Decreased costs Accountability Sustainability Greater impact Government Stability Security Reach Buy-in from the MOH Ownership These are the particular elements that each partner brought to the table, along with this mutual trust and accountability. If these are combined in the right way, we believe we can achieve outcomes at an entirely different scale and have overall much 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 In addition to analyzing routine monitoring data we used a participatory, qualitative process to obtain input from stakeholders: community leaders, providers, MOH, UNHCR to find out about the impact observed at several levels. 9

# of New FP and LARC Users by Month 2013 2014 2015 Commodity stock-outs due to unexpected high demand # FP Users In terms of uptake of FP users and the proportion of LARCs the results have been dramatic. Here is a visual of how together we are doing more with less. While in 2014, when CARE implements the SAFPAC project, uptake increases significantly, in 2015 - after the our CARE office closes and the MOH expands the scale of the intervention- is when the results really take off. # LARC Users 10

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. FP 2020: advocate with Djibouti government to have budget line for commodities, task-shifting. RH law: content needs to align with international standards and reflect realities on the ground. Big thing is to change the National FP policy to a national RH law -Take lessons learned from other models and apply it to this one -The Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa, better known as the Maputo Protocol, guarantees comprehensive rights to women including the right to take part in the political process, to social and political equality with men, to control of their reproductive health, and an end to female genital mutilation – which is still a huge problem in Africa -So a lot of policy change/advocacy and further testing in other countries/environments are next steps 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) The issue of sustainability needs to be further explored. While the overall system has been strengthened and the country now has a solid system for monitoring FP /PAC services, there remains the reliance on commodities which are currently being purchased by CARE. And then there is an exciting new initiative funded by FP2020, aimed at supporting the Ministry in its next steps. Here is where I would like to hand it over to our colleague from the Ministry of Health to talk about this more from his perspective.