1. 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.

2. 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 ( )

3. 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)

4. 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

5. 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.

6. 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: 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 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.

7. 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

8. 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

9. 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

10. # 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 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

11. 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

12. 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.