Scaling up an Innovation: Experience with the Standard Days Method® of Family Planning Institute for Reproductive Health Georgetown University

 DRC  Guatemala  India/Jharkhand  Mali  Rwanda Scaling up the Standard Days Method: 5-year prospective case study in using the ExpandNet model for planning, monitoring, research

Hypothesis: Applying the systems analysis framework and scaling-up principles articulated in the ExpandNet model to scaling up SDM in existing programs and services will lead to more sustainable, quality SDM services.

Scaling-up Strategy Process Conduct trainings Advocacy Supervision Outputs Providers trained Clinics offering SDM IEC activities Outcomes Provider competency Awareness and use Availability Supportive policies Inputs Staff Partners Funds CycleBeads Scale-up Logic Model Problem: Gap in availability & access to SDM services Impact: increased availability of SDM

Services Integration Political support & technical leadership Systems integration Norms & procedures Training curricula Supervision HIS Procurement & distribution Budget lines Provider training Availability of CycleBeads Supportive supervision IEC: new method as part of FP mix Scale-up: NOT just MORE of the SAME

Defining success in scale up Availability of SDM at national, sub- national, organizational level Availability of SDM at SDPsProvider capacity

Research questions: Scale-up outcomes Client What is the experience of women and men with SDM when scaled-up? (Knowledge, attitudes and use) Service provision Is SDM offered correctly by providers? How does SDM introduction influence quality, availability and use of overall family planning services? System integration To what extent has SDM been integrated into training, IEC, procurement and distribution, and HMIS? Is it included in norms, protocols and guidelines? Resource mobilization What is the level of resources dedicated to SDM?

Research questions: Scale-up process Resource team Do user organizations assume the roles, responsibilities and ownership of the resource team during scale-up process? Advocacy/ Dissemination What is the role of SDM champions? What strategies work best? Organizational choices Has SDM been offered outside traditional public sector service delivery?

Data sources Semi annual benchmark monitoring Most Significant Change (MSC) story collection (1-2 times) Individual interviews with stakeholders (1-3 times) Guided discussions with staff (quarterly) Event tracking (timelines) Community surveys & facility assessments (1-2 times) Evaluation

Scale Up in the state of Jharkhand, India A new state formed in million people with more than 90% in rural areas TFR = 3.3 CPR = 36%, spacing methods at 8% IMR - 49 and MMR % literacy rate Source for statistics: NFHS-3 ( ) Program goal: Scale Up SDM to full coverage in 11 out of 24 districts

Monitoring Performance Benchmarks – India, Jharkhand Selected Indicators (as of 6/09) No. of resource organizations2/8 SDM included in key policies, norms, protocols1/2 SDM in pre-service trainingIn process Commodities in logistics & procurement systemsPartially SDM in IE&C materials4/9 SDM in HMISIn process Proportion of SDPs with FAM in method mix22% FAM in surveys (DHS)No Funds leveraged for FAM$246,000 Providers trained3,100 / 15,000

Dynamic, requires flexibility in programming and M&E Supportive political environment influenced by results from pilots Health is a state subject, policy changes influenced by centre System requires substantial capacity building Low priority of FP, particularly birth spacing Naxalite affected areas Large cadre of community level providers (30,000 ASHAs & 34,000 AWWs) Environment

Should include multiple organizations Benefits  Credibility  Efficiency  Quality  Resource leveraging  Consistency Resource Team Challenges  Vertical programming  Competition for resources  Donor constraints

Government of Jharkhand User Organization Benefits  Financial resources (MOU, PIP)  Capacity  Integration into training, IEC, procurement, supervision Challenges  Involve central, district, block  Transitioning to member of resource team

Adapt to scale-up conditions Simplify/adapt/test training materials Develop/test approaches to facilitate ownership, sustainability and scalability  Community radio  Social marketing  Distance learning  magazine tear-outs  mHealth approaches (CycleTel) The Innovation

Supervision with structured tool Monthly/semi annual/ annual report Shared quarterly with stakeholders Data sources Process tracking tools MOH service statistics Training reports Follow-up visits with users September 2009 Government of Jharkhand signs MOU with IRH and commits $211,000 to SDM and LAM scale up January 2009 October 2008 February 2009 HLL Lifecare Limited becomes licensed manufacturer of CycleBeads June 2009 Comic books printed and CHW trainings begin in Jharkhand (paid by gov't) Debut of community radio programs in Gumla, Jharkhand March 2009 April 2009May 2009 SDM/LAM integration project initiated with UPVHA, an NGO in Allahabad, UP Filmed counseling video Household survey in Jharkhand scale- up districts conducted Facility level trainings begin in 3 districts in Jharkhand (paid by gov’t) Monitoring

Lessons Learned: Using research & evaluation methodologies have enabled IRH to:  measure scale-up progress,  identify needed adjustments,  involve stakeholders,  provide evidence for advocacy, and  maintain momentum & accountability Challenges facing scale-up are many (i.e. shifting policy and resource environments, large number of partners involved)

ExpandNet framework has contributed to sustainable, strategic and quality scale-up efforts