# SERVICE DELIVERY IMPROVEMENT DIVISION {#service-delivery-improvement-division .unnumbered}

**STRATEGY ISSUES PAPER**

## DECEMBER 19, 2002 {#december-19-2002 .unnumbered}

**Joy Riggs-Perla**

**Nancy J. Piet-Pelon**

Service Delivery Improvement Division

**Strategy Issues Paper**

Table of Contents

Executive Summary

I. Introduction 1

-Purpose 1

-Key Strategic Questions 1

-Strategy Development Process 1

-Challenges and Changes in the Environment 2

II\. Key Areas for Technical Leadership for the Future 4

-Revitalizing Clinical FP/RH Services within Integrated Programs 5

-Appropriate Investments in Human Capacity Development/Training 7

-Maintaining Programmatic Focus within Health Sector Reform Programs 8

-Addressing FP/RH Programs in HIV/AIDS Endemic Environments 9

-Sustaining Programs 10

-Private and Commercial Sectors 10

-NGO/PVO Programs 11

-Contraceptive Security 11

III\. Programmatic Support to the Field 12

-Scope of Central Projects 12

-Providing Missions with Affordable Alternatives and Better
Accountability 13

-Improving Utilization of Best Practices and new Research Findings 13

-Improving Timely Support and Communications between Missions and
USAID/W 14

IV\. Existing Portfolio 15

-Current Portfolio 15

-Utilization of Central Projects 15

-Future Projects 16

V. Management and Funding Issues 17

-Future Global Funding Issues 17

-Agency Resource and Management Issues 17

VI\. Future Program Options 19

-Strategic Choices 19

\- Priorities for Core Financial and Human Resources 19

-Prioritizing Countries 20

-Future Needs 21

-Mission-Support Needs 23

-Performance Monitoring and Evaluation 24

VII\. Key Decisions and Follow-up Needed 24

Annexes (on the CD):

Annex I -- SOTA Consultations with PHN Officers

Annex II -- Synopsis of Interviews

Annex III -- Assessment of Alternative Mechanisms for Funding by Ken
Schofield

Annex IV -- Notes from Knowledge Sharing Meetings I-IV

Annex V -- SDI Strategy Development Team Meeting Notes

Annex VI -- Trends and Issues Affecting Service Delivery over the Next
Decade by The Policy Project, John Ross and John Stover

> Annex VII -- Red Dot Exercise notes
>
> Annex VIII -- Use of Bilateral Mechanisms for PHN Programming in the
> Field -- Susan Thollaug and Maria Mamlouk
>
> Annex IV -- List of evaluations -- Engender Health, JHPIEGO -- TRH,
> MAQ

SDI Strategy Issues Paper

Executive Summary

**Background**: The purpose of this strategy issues paper is to document
for the Service Delivery Improvement (SDI) Division a set of strategic
issues and directions to consider for shaping its work in the future in
the area of family planning and reproductive health (FP/RH) service
delivery. The paper outlines key areas identified by USAID staff and
stakeholders as important for the future of FP/RH service delivery, as
well as the current environment and USAID programmatic issues for FP/RH
at the field level. Suggestions are made for how the Division positions
its resources, both human and financial, to support the Office's
strategic objective as well as the related goal of the Agency.

**Where are we today?** USAID has been an integral part of a revolution
that has seen millions of couples benefit from FP/RH services. Yet the
need for family planning services will continue to increase rapidly in
the next decade. Growth rates are slowing but global population will not
level off until it has reached 11 billion in the last half of this
century. There are still millions of couples, particularly the poor, who
have not been reached and continue lives where their full potential is
compromised. At present there are approximately 488 million family
planning users but numbers will increase dramatically in the next
decade. Most population growth in the developing world will take place
in urban areas, especially in secondary cities, although currently
roughly 60% of the world's population is still rural. HIV/AIDS has
emerged as an international crisis and an urgent priority for the
countries with highest prevalence rates. FP/RH services in some
countries are not being given much priority as human and financial
resources are increasingly dealing with HIV/AIDS. Many countries are
also undergoing health sector reform, which is often accompanied by
profound changes in the way FP/RH and other health services are
organized and financed. Conflict and social upheaval are also common in
many parts of the world. Donor funding, however, for FP/RH programs is
declining and that decline is likely to continue. Clearly new strategies
are needed to ensure that the growing needs are met in affordable and
sustainable ways. Many are looking to USAID for the necessary
leadership.

**Where does SDI need to be?** The mandate of the Bureau for Global
Health (GH) is to support the field, provide global technical
leadership, and undertake research on behalf of the Agency. SDI's
mandate is to support field missions with the full range of technical
services necessary to improve the delivery of family planning and
reproductive health services. These include programmatic areas that
USAID has been working in for years including scaling up private and
public services and supplies, increasing access to quality services,
improving the method mix and informed choice, ensuring appropriately
skilled providers, assuring a steady supply of contraceptives and
essential drugs and ensuring the sustainability of programs. The results
of technical and programmatic innovation must be effectively
mainstreamed and scaled up in country programs. In order to serve the
field appropriately, SDI must design FP/RH programs that are flexible,
respond to a variety of different needs, and provide the technical depth
and specialization in certain topics that field missions need to enhance
their programs. Central mechanisms must also provide optimal support to
field staff. In keeping with the Administrator's policy to shift more
responsibility and resources to the field, Missions with bilateral
population projects must have Agency resources to support their efforts.
SDI needs to improve ways of providing technical support to bilateral
programs as well as finding appropriate mechanisms to program field
support funds. While not a problem unique to SDI, the Division is having
difficulty managing large projects, making judicious use of core
resources, and, at the same time, providing timely strategic and
technical support to field missions. Competing priorities are diluting
the opportunity to have a major impact.

**What are SDI's strategic priorities**? As result of reviewing
strategic options, the Division sees the following priorities for use of
SDI's core [financial]{.underline} resources: (1) advocacy for, and
adoption of, best practices for family planning and reproductive health
service delivery in collaboration with field missions and with external
partners and, (2) application of core resources to complement mission
efforts to strengthen institutions and local capacity at the country
level. The highest priority for use of SDI [human resources]{.underline}
is to provide the field missions with the technical expertise and
strategic assistance they need to strengthen their FP/RH service
delivery programs. At the same time, SDI must manage the current and
future portfolio in ways that meet mission needs and provide the support
that missions have come to expect from the Bureau. For the most part,
the technologies and best practices to strengthen service delivery
programs already exist and need to be applied and scaled up.

##  {#section .unnumbered}

## Focusing resources on fewer countries to achieve impact is an important objective. A potential model of categorizing countries into three groups: pre-transition countries, transition countries and low fertility countries, was thought to be useful in terms of prioritizing the types of assistance they may require rather than as a way of choosing countries with which to work. For instance, in pre-transition countries, SDI's assistance would be for strengthening health systems geared to expanding access and quality of services particularly when utilization rates are very low. In transition countries, increasing method mix and helping find ways to scale up programs might be the focus. In low fertility countries, primary attention could be on policy and issues related to sustaining programs over the long run. Other options for categorizing and prioritizing country work, and for assisting field missions on strategy development, have been vetted. The concept of segmenting the population by wealth quintiles to identify those in greatest need, to appropriately target programs, as well as to identify those who can afford to pay for services or use private and commercial sources, is useful. Another potentially useful model is looking at the "systems" issues that affect service delivery. Given the profound impact of changes in the organization and financing of health services on field programs, field missions may need help in devising strategies to keep focused on outcomes and work constructively to strengthen health systems, both public and private. {#focusing-resources-on-fewer-countries-to-achieve-impact-is-an-important-objective.-a-potential-model-of-categorizing-countries-into-three-groups-pre-transition-countries-transition-countries-and-low-fertility-countries-was-thought-to-be-useful-in-terms-of-prioritizing-the-types-of-assistance-they-may-require-rather-than-as-a-way-of-choosing-countries-with-which-to-work.-for-instance-in-pre-transition-countries-sdis-assistance-would-be-for-strengthening-health-systems-geared-to-expanding-access-and-quality-of-services-particularly-when-utilization-rates-are-very-low.-in-transition-countries-increasing-method-mix-and-helping-find-ways-to-scale-up-programs-might-be-the-focus.-in-low-fertility-countries-primary-attention-could-be-on-policy-and-issues-related-to-sustaining-programs-over-the-long-run.-other-options-for-categorizing-and-prioritizing-country-work-and-for-assisting-field-missions-on-strategy-development-have-been-vetted.-the-concept-of-segmenting-the-population-by-wealth-quintiles-to-identify-those-in-greatest-need-to-appropriately-target-programs-as-well-as-to-identify-those-who-can-afford-to-pay-for-services-or-use-private-and-commercial-sources-is-useful.-another-potentially-useful-model-is-looking-at-the-systems-issues-that-affect-service-delivery.-given-the-profound-impact-of-changes-in-the-organization-and-financing-of-health-services-on-field-programs-field-missions-may-need-help-in-devising-strategies-to-keep-focused-on-outcomes-and-work-constructively-to-strengthen-health-systems-both-public-and-private. .unnumbered}

Taking advantage of existing mechanisms across the GH Bureau is an
important strategy for reducing the number of projects, costs, and the
management burden. New initiatives are needed in some areas. (1)
Strengthening clinical family planning services is needed to
re-invigorate clinical family planning and related services. The primary
focus should be clinical family planning services because expertise in
this area is not readily available through the existing mechanisms. The
new activity does need to be able to address related clinical services
as well including PAC, STI counseling and treatment, maternal health
services and HIV/AIDS services where appropriate. (2) A new integrated
human capacity development and training program is needed to provide GH
and field missions with strategic advice and technical assistance
related to human capacity development in all GH technical areas. The
human resources constraints related to improving worker performance such
as manpower planning, personnel deployment, compensation, accreditation,
and pre-service training are critical across all of the PHN areas and
should be dealt with more strategically.

Improving support to Missions for strategic planning, performance
monitoring, and information management is also needed. To extend SDI's
capacity, a stable of technical experts with field experience is needed
to assist missions with program development. These experts should
maintain working relationships with GH technical counterparts in order
to be as connected as possible to the Agency's perspective on a
particular topic. The recent increase in SDI staff should also expand
its capacity to engage proactively with field programs and to provide
the technical backstopping in many areas of service delivery improvement
that many missions need and want.

For the most part, the service delivery challenges in the field are
applying and scaling up known technologies and best practices rather
than creating new ones. Too often the emphasis is on creating new
technologies and strategies rather than optimizing the use of exiting
ones. There is also fairly universal dissatisfaction with the current
procedures for ensuring that the information generated from research and
the development of best practices are mainstreamed or scaled up in
country programs. As mentioned in Section III, substantial resources are
spent on developing and distributing technical information that is not
being used effectively because people do not have the information in
digestible form at a time when they need it. Thousands of hard copies of
documents are distributed in Washington and to field missions and dozens
of project websites offer similar information but substantial
re-thinking needs to occur about how to make this kind of information
practical and useful for field mission staff.

There are several needs that are already well-recognized by the Bureau.
(1) The volume of technical reports needs to be reduced and
rationalized, (2) the technical information coming from several sources
needs to be synthesized and packaged appropriately and (3) a process
needs to be established to facilitate the state-of-the-art and best
practices information being incorporated into field programs. One step
to address the last issue has been taken. PHNI will be developing and
managing the internal USAID PHN website to provide (and update) this
kind of information for use by field and Washington staff.

Substantial re-thinking needs to occur, however, about how to make
information on best practices and state-of-the-art available in ways
that are practical and useful for field mission staff.

SDI Strategy Issues Paper

# Introduction

## Purpose  {#purpose .unnumbered}

The purpose of this paper is to document for the SDI Division in the
Population and Reproductive Health Office a set of strategic issues and
directions to consider for shaping its work in the future in the area of
family planning and reproductive health (FP/RH) service delivery. The
paper outlines key areas identified by USAID staff and stakeholders as
important for the future of FP/RH service delivery, as well as the
working environment and program management issues for FP/RH programs
within USAID at the field level. Issues related to defining the mandate
of the Service Delivery Improvement (SDI) Division are raised and
suggestions made for how the Division positions its resources, both
human and financial, to support the Office's strategic objective as well
as the related goal of the Agency.

## Key Strategic Questions {#key-strategic-questions .unnumbered}

Making choices about future directions requires the SDI Division to look
critically at its [mandate]{.underline} for the next ten years. The
questions are:

-   What are the changes in environment in which FP/RH service delivery
    operates in the developing world and how can SDI best provide the
    strategic and technical support that missions need?

-   Given the Agency's policy of pushing more staffing and resources to
    field missions, what is SDI's "value-added" to achieve the Agency's
    objectives in FP/RH? In what ways should its role change in future
    years?

-   Funding constraints are likely to continue. How can SDI make the
    most strategic use of its core resources?

-   How can the SDI Division support the Global Health Bureau to help
    "re-position" population to make it a more compelling investment for
    countries and donors. How can GH exercise more effective global
    leadership that is so badly needed at this juncture, for which many
    donors are looking to USAID?

##  {#section-1 .unnumbered}

## Strategy Development Process  {#strategy-development-process .unnumbered}

Over the past four months, the SDI Division engaged in a number of
preparatory activities for developing this strategy paper. These
included:

-   extensive consultations with PHN officers from field missions, most
    recently during the Africa and ANE/E&E State-of-the-Art (SOTA)
    meetings in June and October respectively, consultations with
    individual PHN officers over the summer, and focus group sessions
    with groups (Annex 1),

-   a wide range of interviews with various stakeholders including CA
    partners, foundations, other donors, senior USAID staff, and USAID
    project managers to collect their views about the future on FP/RH
    issues (Annex 2),

-   a review of the advantages and disadvantages of alternative
    procurement instruments (both acquisition and assistance) available
    to the Bureau to meet GH mandates (Annex 3).

-   a set of four "Knowledge Sharing Meetings" designed to explore in
    greater depth some of the more critical technical and strategic
    issues facing field programs (Annex 4),

-   a review of the existing SDI portfolio to determine the areas of
    overlap and the gaps ("Red Dot" exercise), and an analysis of trends
    in the use of bilateral vs central projects (Annex 5),

-   an analysis by the Policy Project entitled "Trends and Issues
    Affecting Service Delivery Over the Next Decade" (Annex 6),

-   A review of the "Use of Bilateral Mechanisms for PHN Programming in
    the Field" by Susan Thollaug and Maria Mamlouk (Annex 7), and

-   external evaluations of the Engender Health and JHPIEGO projects,
    both of which are ending in September 2003, and an external
    evaluation of the MAQ Initiative (Annex 8).

The objective of these preparatory activities, guided by an SDI Strategy
Development Team, was to gain a better understanding of the challenges
facing FP/RH field programs, particularly because much has changed since
the last strategy document prepared ten years ago.[^1]

## Challenges and Changes in the Environment {#challenges-and-changes-in-the-environment .unnumbered}

The following are some of the important background facts that should be
taken into consideration in looking at FP/RH programs for the future:

-   The need for family planning services will continue to increase
    rapidly in the next decade. Growth rates are slowing but the
    population will not level off until it has reached 11 billion
    sometime in the last half of this century. Especially in Africa the
    increases are surprisingly large: where there are 100 women in union
    now, there will be 115 by 2005 and 133 by 2010. In Asia, the
    subcontinent countries of India, Pakistan, and Bangladesh will add
    36 million women of childbearing age from 2000 to 2005 and another
    34 million by 2010. Population momentum will also affect the need
    for family planning services. How will countries and donors deal
    with this increasing need for FP/RH services?

-   Urbanization is an increasingly important phenomenon through out the
    developing world. Urban populations will grow from 1.9 billion in
    2000 to 3.9 billion in 2030. Most population growth in the
    developing world will take place in urban areas, especially in
    secondary cities, except in Africa where most of the growth will
    occur in rural areas. However, it is important to remember that
    currently the majority of the world's population is still rural
    (roughly 60%).

-   Fertility declines have been impressive. However, these declines are
    geographically uneven and tend to be slowest in the least developed
    countries. Furthermore, there are substantial differences in access
    to and utilization of FP/RH services among various wealth quintiles
    within countries with the poorest segments of the population being
    at a significant disadvantage.

-   Contraceptive security is not assured. Programs will need an
    increasing number of methods to maintain current use and to provide
    for new acceptors. Insufficient funds are available globally to meet
    this challenge, unless private sector resources are mobilized to
    fill the gap. Clearly, more will be required from recipient
    governments, and hopefully more from donors.

-   The private sector will have to play a significant role in FP/RH in
    the future. Public sector programs have been very important in the
    past but increasingly clients in developing countries are seeking
    health care from private providers. USAID, while ahead of many other
    donors in working with the private sector in FP/RH, needs to focus a
    great deal more attention in the future on private and commercial
    sources of contraceptives as well as services.

-   HIV/AIDS has emerged as an international priority and an immediate
    and urgent priority for the countries with highest prevalence rates.
    Family planning and other reproductive health services in some
    countries are not being given much priority as both human and
    financial resources are increasingly directed to dealing with the
    HIV/AIDS epidemic. In some countries in Sub-Saharan Africa, life
    expectancy and population growth have been severely affected by the
    epidemic. Meeting the needs of clients for HIV/AIDS services is, and
    will continue, to severely tax the available health services and
    limit the ability of the health services to meet other requirements
    for services like family planning.

-   Many developing countries are undergoing health sector reform. These
    programs are often accompanied by profound changes in the way FP/RH
    and other health services are organized and financed.
    Decentralization has fundamentally changed the way programs are
    planned and managed. In some countries ministry of health mandates
    are changing and attempts are being made to include private sector
    and NGOs in national health programs. These important changes must
    be taken into consideration for strengthening systems that deliver
    FP/RH services in the future.

-   In the post ICPD period, government policies and national health
    programs have changed to reflect the need to deal with reproductive
    health in a more integrated and client-oriented fashion. As FP/RH
    services have become more integrated, providing high quality
    services has become more complex than in the old-style vertical
    programs. Family planning services, in particular, are sometimes
    eclipsed by a myriad of other services. In service delivery systems
    that are integrated, front line health workers must have skills in a
    number of programs areas including management of common childhood
    illnesses, maternal health, providing immunizations, counseling on
    nutrition and so on as well as providing family planning services.
    This fact has implications for human resources and skills
    development.

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-   Armed conflict, political instability and the movement of refugee
    groups often cause women and children to become more vulnerable to
    violence and abuse. Increasingly, FP/RH services must be offered
    within an environment of tremendous social and political upheaval.
    Most often the countries affected by political instability are those
    in the "pre-transition" demographic stage with high unmet need, high
    fertility, low contraceptive prevalence and very weak service
    delivery structures. Social change in many countries linked with
    globalization presents new opportunities but also dangers. Economic
    changes can create new job opportunities for women but these changes
    may also widen the divide between rich and poor. Programs must take
    these factors into consideration.

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-   The presence of USAID programs in various countries changes
    depending on geo political and other factors. As USAID withdraws its
    support for programs in a particular country, how will family
    planning gains in contraceptive prevalence be sustained in these
    environments? How will new acceptors be informed and served?

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-   Financial resources for FP/RH have not kept up with need. Many
    external factors as well as internal bureaucratic constraints affect
    USAID's ability to allocate resources to the countries that need
    them the most. Furthermore, the Administrator has stated a desire to
    push more staff and resources to field missions given that USAID's
    comparative advantage as a donor has traditionally been with its
    decentralized structure and its technical capacity resident at the
    country level. If more resources go to the field, presumably fewer
    remain with central Bureaus. The GH Bureau must establish priorities
    in terms of both the countries and the activities it supports.

# Key Areas for Technical Leadership for the Future

Extensive consultations with field missions and CA partners who have
been on the front lines of implementing USAID's FP/RH programs have
revealed that there are still significant challenges in maintaining the
"bread and butter" FP/RH programs as well as dealing with the new
challenges. These are described in a paper recently completed by the
Policy Project.[^2] The authors identify some things that will not
change. For instance, it is unlikely that contraceptive technology will
change dramatically and therefore contraceptive choices will remain the
same. The pillars of good programs will continue to be increased access
to quality service delivery, a focus on informed choice, appropriately
skilled providers, and a steady and assured supply of contraceptives and
essential drugs. Developing and strengthening sustainable service
delivery systems at the country level will continue to be at the core of
USAID's programs, although the nature of the inputs from USAID should
depend on the level of development and capacity of the host country.

The following are key strategic and technical areas that many
stakeholders felt were important for FP/RH service delivery in the
future. These were gleaned from the field staff consultations,
stakeholder interviews, knowledge sharing meetings, as well as the
Policy Project Trends and Issues paper. This is not to suggest that new
projects are needed in each of these areas but rather, addressing these
issues through existing projects, or new ones where needed, must be
considered because they are critical to FP/RH service delivery in the
current global environment.

##  {#section-2 .unnumbered}

## Revitalizing Clinical FP/RH Services within Integrated Programs {#revitalizing-clinical-fprh-services-within-integrated-programs .unnumbered}

A balanced FP/RH program, where all contraceptive methods are available
at different program levels, is a critical ingredient to success of
family planning in the next decade. Appropriate contraceptive delivery
systems, where volunterism and informed choice are assured and quality
is uncompromised, have to be developed in some countries and nurtured in
those where the services already exist. A balanced program has
community- based distribution (CBD) at the community level provided by
frontline workers and clinical methods at all clinics, offered by
skilled providers. Clinical methods should include sterilization, IUD,
injectables and also Norplant where appropriate. Some clinics within
national systems should provide PAC, including family planning
counseling and services. This full-service approach will require a
review of national programs FP/RH delivery systems and provider
in-service training to ensure that each element of the balanced program
is in place.

The preparatory activities highlighted a key issue facing USAID and its
country partners in the coming decade, i.e., revitalizing clinical
family planning services. While CBD programs, which are less complex to
initiate than clinical services, are making progress in re-supply
methods, clinical family planning services have languished. The
disturbing worldwide trends demonstrate that clinical method use is flat
or declining, while the demand for smaller families is quite large and
increasing. Clearly greater attention needs to be given to clinical
methods, especially to long-term methods, as well as to continue the
on-going and planned efforts in commercial and social marketing of short
term methods. Increasing method mix is also an important service
delivery issue. The following are some key points made by USAID
stakeholders.

Clinical contraception, offering long-term and permanent protection from
unwanted fertility, deserves high priority in the future. IUD and
sterilization are excellent methods -- safe, convenient and
cost-effective- but these have been neglected, and have a poor
reputation. As a result these are underutilized. There are many clients
who indicate they would like a long-term or permanent method but their
need for these services is not being met. Consequently there is still
considerable unrealized potential and unmet demand for clinical
contraception services. The determinants of demand for family planning
services are not always well understood in particular country situations
suggesting the need for specific analytic work in this area to devise
more effective programming strategies. This is particularly important in
countries that are at the transition stage where unmet need is high.

In addition to improving clinical service delivery, demand creation
i.e., promoting the image of both sterilization and IUD is important.
Programs have to educate potential acceptors on health benefits derived
from accepting a long-term clinical method. Provider, program, and
facility biases need to be addressed. Systems need to be strengthened to
provide effective clinical services and follow up of clients. The policy
and legal/regulatory environment must also support the efficient
provision of services.

In many country programs there is still problems with contraceptive
services and supplies. Restricted method availability is one of the
greatest shortfalls of current programs. A number of countries still
rely primary on just one method. The lack of access to modern
contraceptives is still a major obstacle to their use in many countries.
This is a critical quality of care issue. When clients have limited
access to a range of choice in methods, the quality of the care they are
provided is compromised.

Post Abortion Care (PAC) and postpartum care are two services that fall
within clinical FP/RH services. Thirty seven percent of all pregnancies
end in spontaneous or induced abortions or still-births.[^3] Abortion is
one of the most frequently performed medical procedures in the world.
Globally, there are an estimated 50 million abortions every year, 20
million of which are classified as unsafe; thus, approximately 38 women
undergo an unsafe abortion every minute of the day.[^4] There needs to
be a concerted effort to expand PAC, and especially to ensure that
family planning counseling and service provision are an essential
element. Postpartum family planning services should be available at all
sites where delivery occurs. There should also be greater efforts to
reach women who deliver at home with family planning information and
services.

There are several critical issues that USAID must track more
effectively. 1) Projects need to continue to develop a more efficient
and systematic approach for quantifying achievements to show results of
activities and tools over time. 2) Improving the quality of services is
a high priority. 3) Worldwide experience in identifying approaches to
ensure the sustainability of programs needs to be shared and given
increased emphasis.

4\) Sustained improvements in clinical family planning require ongoing
and long-term system strengthening efforts.

Family planning services are likely to be faced with several integration
challenges. There has always been some integration of family planning
and safe motherhood at the clinic level. In the future more emphasis may
be needed on developing linkages between family planning and pre-and
postnatal care, post abortion services and programs to prevent
mother-to-child transmission of HIV. Current evidence shows the
significant health benefits of a three to five-year birth spacing
interval[^5] means that child survival as well as family planning
programs must ensure the availability of this birth spacing information
and the related services.

## Appropriate Investments in Human Capacity Development/Training {#appropriate-investments-in-human-capacity-developmenttraining .unnumbered}

Health worker performance improvement is an essential ingredient to
enhancing the quality of FP/RH services, and should continue to be a
pillar of future USAID programming. Within this context, pre and
in-service training are equally important investments in improving
clinical and counseling skills and ultimately the quality of care
provided. However, done in isolation or without attention to system
issues that directly determine the value of training, it can also be a
tremendous waste of resources. The Knowledge Sharing meeting on this
subject pointed out some important lessons to keep in mind for the
design of any follow on training activities.

Training should flow from national guidelines on service delivery.
Curricula should be built from these guidelines. In all training
programs, the "content is king" so time and attention must be devoted to
the development of the most up-to-date and appropriate training
materials and training techniques. Pre-service education must be aligned
with national policy, service delivery guidelines, and the job
requirements graduates are expected to meet. Attention should be focused
on strengthening clinical training sites reinforcing linkages between
clinical training and service delivery.

Attention must also be directed toward opportunities to work with
stakeholders to strengthen graduation requirements, accreditation of
pre-service education and clinical practice sites, licensure, deployment
of trained graduates and their periodic re-certification. Training
initiatives provide opportunities for partnering. USAID does not have to
take it all on but can provide the technical expertise while funding is
provided by the World Bank, DFID, or other donors.

Presently field missions under-invest in pre-service training in favor
of in-service training. Yet, both are important and a more balanced
approach to funding these training activities is necessary in the next
decade. Future training projects should include all health and family
planning areas. As many countries now try to deliver an essential
service package (ESP) that incorporates several primary health services,
training programs will have to be designed to meet integrated service
delivery needs.

Distance learning and e-learning techniques are new areas that can be
incorporated into training programs, if these address a particular need.
The technology should not drive the decisions but rather objectives of
the training should determine the most appropriate technology.
E-learning and distance learning requires excellent training materials
and learner support. There is a role for both, however, in situations
where learners are unable to attend regular training courses away from
their places of work.

The JHPIEGO external evaluation also recommended a continuing need for
strengthening pre- and in-service training, including broadening the
focus beyond FP/RH given that health workers need more than just FP/RH
skills and it may be cost-effective to include other areas. The
evaluation suggested orienting PHN officers about the importance and
value of pre-service training; continuing core investments in
pre-service education, materials development, dissemination and trainer
networks; strengthening pre-service education with concurrent
development of clinical training sites, and increasing efficiency of
in-service training systems.

**Maintaining Programmatic Focus within Health Sector Reform Programs**

At a Knowledge Sharing meeting on this subject, participants agreed that
USAID and its partners cannot afford to be on the sidelines of health
reform. USAID has much to offer by way of keeping the reform process
focused on improving sustainable program outcomes that are, after all,
the underlying rationale for reform. Helping USAID field missions who
are on the front lines of this process at the country level, engage
productively, and at an early stage, in health reform is an important
part of Global Health's responsibility in family planning and
reproductive health as well as the other PHN program areas. The new
FP/RH service delivery strategy must take into consideration this
important contextual reality in almost every country where USAID is
present and provide for technical and strategic leadership, both to
assist field missions and in coordinating with other donors at the
global level.

Health sector reform is a relatively young process. There is little hard
evidence to date to demonstrate its successes. Many mistakes have been
made in the process of learning what works. The complexity and
difficulty of the process has also been seriously under-estimated by
donors. Collecting data on health program changes resulting from reform
is a very important area that needs more attention and one in which
USAID could make a major contribution. In some countries, SWAps provide
an opportunity for donors to coordinate their activities at the country
level. They may, but do not necessarily, include pooled funding
arrangements. The most important part of SWAps is the coordinated
planning and monitoring process in which USAID can be an important
partner even if it does not participate in pooled funding arrangements.

There are other areas where USAID missions can engage to ensure that the
health reform process does not undermine FP/RH outcomes. The lack of
adequate procurement capacity at the country level, for instance, has
been one of the most difficult problems to overcome but it is an area
where USAID has much to offer. The emphasis, however, needs to be on
developing and institutionalizing the host country's procurement system,
thereby having one national system that all partners utilize. The
mechanism for financial flow is another important area in the reform
process. National health accounts help to understand funding flows but
they tend to be too aggregate. More detail is needed to track
expenditures for specialized areas such as family planning and
reproductive health. USAID can make a significant contribution to the
reform process by using tools such as the DHS (with the poverty quintile
index) to map service utilization, track those who do and do not benefit
from reform and determine whether the poor are being reached.

Decentralization, which often accompanies health reform, has
fundamentally changed the way programs are introduced and scaled up,
primarily because the initiative and funding may no longer come from the
central MOH. The process has been most successful where there was
considerable attention to capacity development. Community involvement
and generating the demand for services at the client level are key
issues in facilitating and strengthening decentralization.
Decentralization and integration go together. Defining the essential
service package (including FP/RH services) is a good organizing
principle for decentralization. Building capacity for decentralized
management of integrated programs is sometime complicated by USAID's
funding categories.

USAID PHN officers and their implementing partners need technical
information and training in the area of health reform to enable them to
become full partners in the process. GH needs to find a way to convey
technical information in ways that can be readily used by field
personnel and support their efforts once they are at the table with
other donors on health reform.

## Addressing FP/RH Programs in HIV/AIDS Endemic Environments {#addressing-fprh-programs-in-hivaids-endemic-environments .unnumbered}

In HIV/AIDS endemic environments, and even in low prevalence situations,
FP/RH programs are affected by the impact that HIV/AIDS has on the
service delivery system. In Africa, the shift of attention to HIV/AIDS
-- both staff time and political pressure -- has minimized the focus on
population and family planning. Missions say that they need more
guidance on how to manage this situation.

It is critical to keep family planning on the agenda in countries where
decision-makers are beginning to overlook family planning because of
more pressing health problems such as HIV/AIDS. FP/RH services and
HIV/AIDS prevention programs must be linked and must reinforce each
other. For instance, in VCT and MTCT programs, family planning
counseling and service delivery are essential, not only for programmatic
but also ethical reasons. This is difficult in environments where the
basic health care systems are overwhelmed by the cost and the direct
human resource losses caused by HIV/AIDS. Huge increases in external
funding for HIV/AIDS and the vertical funding streams through mechanisms
such as the Global Fund also risk dwarfing and sidelining other
essential health programs and diverting scarce human resources.

USAID can play an important role in assisting countries to use
additional HIV/AIDS, TB and malaria resources to help protect or
strengthen the basic health care system, draw in private providers and
NGOs, and educate people directly about behavior changes necessary to
curb those diseases as well as improve their reproductive health
practices in general.

GH has an important role to play in providing practical programmatic and
technical guidance to Missions, sharing best practices, undertaking
needed applied and operations research and representing USAID in global
fora where these issues are being discussed. The field technical
guidance to be issued this year on FP/HIV Integration is a good example
of the kinds of guidance needed by the field missions. Such guidance
must also be accompanied when requested by staff who can work with
missions to help operationalize the guidance, given how stretched many
field staff have become in recent years. Future FP/RH service delivery
activities will need to include staff with expertise and recent field
experience in this area given the magnitude of the problem, particularly
in southern and eastern Africa.

## Sustaining Programs  {#sustaining-programs .unnumbered}

##  {#section-3 .unnumbered}

-   **Private and Commercial Sectors**

The public sector is critical for reaching the poor, but in many
countries, both poor and rich alike are heavy users of private sector
services and rely on commercial outlets for contraceptive supplies as
well as drugs. Private practitioners will become an increasingly
important provider of FP/RH services over the next ten years and in many
countries are seen as important partners in meeting national demand for
services. They can help fill a resource gap that the public sector
cannot meet on its own. Studies show that many clients can afford and
indeed are willing to pay for health services. Public sector programs
need to make sure that they are targeting unmet need among the poorest
groups but are not destroying incentives for the private sector to serve
those who can afford to pay. Government services have not been
particularly good at targeting the poor and have often benefited higher
income groups disproportionately. Contraceptive prevalence rates, as
well as knowledge and attitudes about family planning, are all
consistently lowest among the poorest population quintiles in most
countries.[^6] It is important that GH makes much greater efforts to
think creatively and work more actively with private and commercial
entities in the future. Expanding quality of care initiatives must
involve private providers as well as government ones in order to reach
the populations needing FP/RH services. Given that most population
growth in the developing world will occur in urban areas, USAID will
need to strengthen approaches that work well in urban settings. These
approaches certainly include social marketing and other private sector
strategies.

In recognition of these facts, a new Commercial and Private Sector
strategy is currently under development in GH. While this is an
important effort, private sector strategies also need to be part of
other GH programs in FP/RH such as strengthening clinical services or
training. Working closely with the Policy and PHRplus projects also
provides a good way to understand the broader aspects of the
organization and financing of services at the country level and ensuring
that changes brought on by health reform support FP/RH outcomes.

##  {#section-4 .unnumbered}

-   **NGO/PVO Programs**

GH has also recognized the unique role that NGOs and US-PVOs play in
FP/RH programs, including developing an "Action Plan" in July 2002 for
future work with these organizations. As stated in this plan, PVOs and
NGOs have unique skills in the development arena that are generally not
found among other USAID partner organizations. PVOs and NGOs know how to
organize and mobilize communities, reach into households to change
behavior, work with socially or geographically marginalized groups and
help empower those who would otherwise not be able to access modern
health care, including FP/RH services. The SDI Division will be working
with selected Missions beginning in FY 03 on a new PVO/NGO Initiative
geared to developing and scaling up non-government programs in FP/RH.
[^7]

## Contraceptive Security 

In their "Trends and Issues" paper, Ross and Stover state "The
tremendous growth in the number of family planning users in the future
will require changes in the way family planning services are offered.
Growth in the absolute number of contraceptive users reflects results
from growth in the percentage of couples using a method, compounded with
growth in the number of couples. Both have been sharply upward since the
mid-1960s, and a brief calculation suggests the implications for
services, for contraceptive commodities, and for related personnel
(principally in the public sector). From 1965 to 2000, a period of 35
years, the number of women in union in the developing world (including
China) more than doubled, from 342 million to 813 million. There was
also a rise in the percentage using a contraceptive method, from about
10% to about 60% now. Putting these two changes together yields the
historic increase from only 34 million users to about 488 million. That
gain reflects a revolution in reproductive behavior, and in the service
institutions that have emerged to support it." (p 28)

They refer to the fact that in April 2001 in Istanbul, donors met to
talk about "Meeting the Challenge: Securing Contraceptive Supplies," to
draw the world's attention to an incipient crisis in contraceptive
security. "As prevalence of use has risen, compounded with growing
populations, the numbers of users needing contraceptives has grown
rapidly... The UNFPA estimates that the amount required for
contraceptives alone is US\$572 million in 2000."(p16)

Expanding access to family planning is meaningless unless it is
accompanied by the continued availability, either through public or
private channels, of contraceptive supplies. Many missions are
struggling with this issue, particularly where USAID has been a major
supplier for government programs. Over the coming decade, missions will
need help from GH to identify affordable alternative sources for
financing contraceptive commodities as well as working with other major
donors globally to find solutions. Making longer-term methods more
readily available is also part of the solution. USAID's Contraceptive
Security team has a number of activities already underway to look at
issues such as analysis of lessons learned, looking at market
segmentation issues to identify population groups needing subsidized
supplies as well as those who can afford to pay, communications with
other donors, advocacy and awareness building efforts related to
contraceptive security and so on. These efforts are particularly
important in light of health reform efforts, poverty reduction
strategies and other changes that might have a profound effect on the
availability of contraceptives. This is an area where a global
partnership that includes substantial resources for the poorer countries
is probably warranted.

# Programmatic Support to the Field

The consultations with PHN Officers in the field missions also revealed
important programmatic and management issues that must influence the SDI
strategy as much as the technical ones. Field missions have very diverse
needs ranging from the need for limited technical assistance in selected
areas of their portfolios to complete reliance on central mechanisms for
implementation of their programs. Needs change over time depending on
circumstances within the countries. These include factors such as
mission staffing, preferences of the host government or USAID mission
leadership, funding levels, changing program requirements, and so on. In
order to serve the field appropriately, SDI must design programs that
are flexible, respond to a variety of different needs, but also that
provide the technical depth and specialization in certain topics that
field missions need to enhance their programs. These central mechanisms
must also provide optimal support to field staff who are often very
stretched from the managerial side. The substantial increase in
technical staff in SDI bodes well for meeting the expressed needs from
the field missions. The SDI staff can assist the field with both
technical and management support. The following are key points generated
from extensive consultations on field programmatic needs.

**Scope of Central Projects**

One consistent message from consulting with field PHN officers is that
simplifying management is paramount. In general missions are
understaffed and PHN staff, in particular, are seriously over-extended.
Central projects that help ease their management burden while providing
needed technical support are valued. Those that create new management
burdens or result in a fragmentation of the Mission's portfolio are not
attractive. Many Missions are choosing to develop bilateral projects and
procurement mechanisms, which are directly responsible to the Mission,
involve fewer global "hotel" costs, and provide a consolidated
management unit for a broad range of activities. These missions may
supplement their bilateral projects with use of technically specialized
central projects for particular aspects of their program. Other Missions
are choosing to run their programs largely through field support in
order to avoid the complications of doing their own procurements and to
lighten their management loads. A few Missions (such as India) have
local restrictions on direct TA contracts that make use of central
projects the only practical way of getting the specialized assistance
they need to support their bilateral programs.

Feedback from field officers on the scope of central projects was varied
depending on their own needs and circumstances. The Africa SOTA session
indicated that some people felt that large, general projects that
provided "one-stop shopping" were not desirable because their technical
depth was limited. These officers wanted more specialized projects that
could supplement their own bilateral programs in areas in which they
needed special assistance, which could explain why Advance Africa is
currently under utilized .

Other officers felt that broader, more comprehensive projects were
important because the USAID/Washington mechanisms needed to be able to
provide a variety of technical assistance to integrated programs under
one umbrella CA without having to resort to having multiple CAs, each
providing different kinds of expertise. The issue is sometimes related
to the fact that a Mission has a productive working relationship with
one or more of the CAs that they wish to continue and broaden into
various other elements of their programs rather than seeking multiple
partners.

**Providing missions with affordable alternatives and better
accountability.**

Missions are clearly sensitive to the cost of central projects which are
viewed as being more expensive than bilateral contracts or agreements
because Missions have to pay for part of the "hotel costs" associated
with keeping a stable of subject matter specialists available to respond
to a variety of needs across many missions. One of the reasons that IQCs
(like TASC) and Leader/Associate Contracts (like EHP) have become
increasingly popular is because Missions have the ability to develop
scopes of work for country specific activities and pay only for the task
order involved without having to go through a lengthy procurement
process of their own.

Mission PHN Officers also complained about the lack of prompt financial
reporting on central projects, which sometimes compromises their ability
to manage the financial aspects of their activities. Central Cooperative
Agreements (in contrast to contracts) cannot be required to provide
country-by-country financial or programmatic reporting. Doing so
certainly adds to the cost and complexity of their program.
Nevertheless, many CAs attempt to provide timely programmatic and
financial reporting because they do understand why Missions need this
information.

**Improving the utilization of best practices and new research
findings**

There seems to be fairly universal consensus that USAID and its partners
do a terrible job of disseminating important technical and programmatic
information in ways that are cost-effective and useful for the field.
Copious technical reports are generated by each project and sent to
Missions world-wide in hopes that the research findings or best
practices will find their way into new and on-going programs. Developing
best practices, after all, is a pointless exercise unless they find
their way into on-going development programs in the field. Valiant
attempts have been made to summarize and otherwise make the volumes of
information more user-friendly and practical. Unfortunately, most of
these attempts have not succeeded in making this kind of information
available [in a form]{.underline} and [at a time]{.underline} when the
field officers need it for decision making. Again, over burdened mission
staff do not have the time to wade through long documents looking for
the specific pieces of information they need at the right time.

A web-site providing state-of-the-art technical information and research
across all PHN programmatic areas and indexed for easy access by field
staff, might be a good first step. Some efforts on specific topics have
been taken in this regard but they are so far limited in scope.
Websites, however, are only a partial answer. They require frequent
attention to updates and also to ensure that the highest quality
materials are available on the site. GH could do much more to bring new
technologies and program innovations to scale. This will require
concerted efforts at inter-office collaboration within GH, something
that has been traditionally difficult and a great deal more direct and
frequent communication with the field.

**Improving timely support and communications between missions and
USAID/W**

Missions that have the capability to enter into and manage bilateral
population projects, and choose to do so, must have Agency resources to
support their efforts in keeping with the Administrator's desire to see
more responsibility and resources shifted to the field. GH needs to
conceptualize new ways of providing technical support to field bilateral
programs as well as providing appropriate mechanisms to program field
support funds. This critical issue was emphasized by field officers
during consultations on the SDI strategy. Field missions want GH to be
supportive of their bilateral work. More attention is needed to
determine the most effective mechanisms to support the field.

There is a tremendous desire on all sides for more frequent
consultations among Missions and between Missions and Washington. A
study in August of this year on the Use of Bilateral Mechanisms[^8]
pointed out that Washington operates in an information vacuum when it
comes to bilateral PHN projects (other than the knowledge individuals
have as a result of personal experience with the mission). Travel funds
are limited and therefore Washington staff, especially seasoned direct
hire staff who know the mission environments, cannot visit missions to
assist very often. It is very difficult for Washington to provide timely
and relevant help to field missions when there is so little information
and limited contact. Senior staff in Washington are over-extended and
are too seldom available to travel to missions to provide strategic and
policy-related advice and yet, these are the very people who can and
should have biggest influence on field programs. SOTA meetings, which
are highly valued by both the field and Washington, are very infrequent
and not a good substitute for more frequent communications. Some CTOs in
Washington, it was noted, dislike doing the managerial tasks or
financial management that is needed most by Missions and prefer to
engage in more interesting technical work or travel.

At the ANE/E&E SOTA meeting, field staff suggested that more frequent
sub-regional meetings (attended by Washington senior staff) would be
very helpful and a cost-effective way of sharing best practices and
discussing problems. A good model cited was the regional biannual
meeting of the southern Africa PHN Officers.

# IV. Existing Portfolio {#iv.-existing-portfolio .unnumbered}

## Current Portfolio: The current set of projects cover the full range of technical areas needed for enhancing FP/RH service delivery. Strengthening clinical FP/RH services and related pre and in-service training are provided by EngenderHealth and TRH/JHPIEGO. Improving the performance of frontline health workers including skills development, on-the-job training, and changing provider behavior are the main focus areas of PRIME II. The Management and Leadership (M&L) project aims to improve leadership and management skills as a way of ensuring the effectiveness and sustainability of services. The NGO Networks for Health, CARE/MORR and CEDPA-Enable activities will be ending soon. A new NGO/PVO Initiative to partner with selected missions on NGO/PVO programs will begin this fiscal year to utilize the special skills that those organizations bring to FP/RH programs. Advance Africa and Catalyst are FP/RH service delivery projects that are designed to respond to a broad variety of mission needs as well as develop best practices in improving access and quality of care. The Commercial Marketing Services (CMS) Project is coming to an end; as mentioned earlier, a new strategy and procurement for working with the private and commercial sectors is currently under design. Working with youth and adolescents is also an important priority for strengthening FP/RH services and an area needing the exploration of best practices given the sensitivity and difficulty in many countries of working with youth. The current YouthNet project, in collaboration with the HIV/AIDS Office, works on that issue.  {#current-portfolio-the-current-set-of-projects-cover-the-full-range-of-technical-areas-needed-for-enhancing-fprh-service-delivery.-strengthening-clinical-fprh-services-and-related-pre-and-in-service-training-are-provided-by-engenderhealth-and-trhjhpiego.-improving-the-performance-of-frontline-health-workers-including-skills-development-on-the-job-training-and-changing-provider-behavior-are-the-main-focus-areas-of-prime-ii.-the-management-and-leadership-ml-project-aims-to-improve-leadership-and-management-skills-as-a-way-of-ensuring-the-effectiveness-and-sustainability-of-services.-the-ngo-networks-for-health-caremorr-and-cedpa-enable-activities-will-be-ending-soon.-a-new-ngopvo-initiative-to-partner-with-selected-missions-on-ngopvo-programs-will-begin-this-fiscal-year-to-utilize-the-special-skills-that-those-organizations-bring-to-fprh-programs.-advance-africa-and-catalyst-are-fprh-service-delivery-projects-that-are-designed-to-respond-to-a-broad-variety-of-mission-needs-as-well-as-develop-best-practices-in-improving-access-and-quality-of-care.-the-commercial-marketing-services-cms-project-is-coming-to-an-end-as-mentioned-earlier-a-new-strategy-and-procurement-for-working-with-the-private-and-commercial-sectors-is-currently-under-design.-working-with-youth-and-adolescents-is-also-an-important-priority-for-strengthening-fprh-services-and-an-area-needing-the-exploration-of-best-practices-given-the-sensitivity-and-difficulty-in-many-countries-of-working-with-youth.-the-current-youthnet-project-in-collaboration-with-the-hivaids-office-works-on-that-issue. .unnumbered}

This is a fairly comprehensive portfolio that does provide expertise in
a wide-range of FP/RH service delivery expertise and a large variety of
choices to the missions. The question is: how can on-going projects and
new activities be shaped to have greater strategic impact? What
value-added do they bring to mission programs and how can core resources
to these activities be allocated in the most cost-effective way
possible?

**Utilization of Central Projects**: Given the technical and
programmatic needs identified by the wide range of stakeholders, it is
important to look at the current portfolio to identify the nature of new
activities needed. An analysis was conducted earlier this year, the
purpose of which was to identify technical mandates of projects within
the SDI Division; describe current activities; recognize overlap and
duplication, if any; suggest options for management efficiencies and
technical synergy; identify management and programmatic implications of
suggested options. Some of the observations of this exercise are noted
below.

-   The analysis revealed that there were some areas of overlap among
    the major service delivery CAs with both positive and negative
    implications. Overlap in technical areas may even be beneficial as
    it can contribute to impact, more holistic programming, and a
    greater choice of CAs for missions. However, overlapping mandates
    may mean that CAs become competitive and behave in ways that detract
    from functioning as a team at the field level. For future
    procurements, it may be advisable to define a sharper technical
    focus and rely on competitive procurement to award agreements or
    contracts whose mandates are clearly distinct.

-   Most importantly, however, overlapping mandates raise serious
    questions about the efficient use of resources. Developing capacity
    in US institutions to provide specialized assistance to the
    developing world has been an important USAID contribution but it is
    expensive and must be weighed against the benefit of those resources
    being allocated directly to country programs. The cost of
    maintaining these major central projects is substantial and needs to
    be [minimized]{.underline} to provide only (1) the support needed by
    field missions and (2) the technical innovation and leadership
    functions that are important GH mandates. This is a critical issue
    for future designs.

-   Missions [do want]{.underline} GH programs to be able to provide
    specialized technical assistance in areas that require innovation
    and leadership. A leader/associate mechanism might offer some
    advantages not available in the Cooperative Agreements and Contracts
    currently most widely used. Missions have responded well to a
    leader/associate type contracting mechanism, for instance, because
    it allows them to pay only for activities within their own countries
    but has the advantages of a centralized technical capacity and the
    ability to take field support funds in a task order managed by GH.

-   For existing central projects that are highly under-subscribed from
    field support, it may be necessary to cut back on central staffing
    and administration to save on hotel costs and refocus activity on
    the countries that are interested and on core-funded activities that
    related to GH mandates.

## Future Projects: The most important question to ask is: are new activities needed or can the same results be achieved by the strategic placement of core funds in existing mechanisms. Given that the EngenderHealth and JHPIEGO projects are coming to an end in September 2003, and given the priority for continued work in the areas of clinical family planning development and training, new activities in these areas may be needed. The evaluations of both projects have provided very useful guidance about adjustments needed in both the structure and the content of these kinds of projects. SDI will continue to have the responsibility to provide technical leadership in all dimensions of service delivery through centrally managed projects as well as to provide vehicles, when requested by field missions, for the implementation of bilateral programs. {#future-projects-the-most-important-question-to-ask-is-are-new-activities-needed-or-can-the-same-results-be-achieved-by-the-strategic-placement-of-core-funds-in-existing-mechanisms.-given-that-the-engenderhealth-and-jhpiego-projects-are-coming-to-an-end-in-september-2003-and-given-the-priority-for-continued-work-in-the-areas-of-clinical-family-planning-development-and-training-new-activities-in-these-areas-may-be-needed.-the-evaluations-of-both-projects-have-provided-very-useful-guidance-about-adjustments-needed-in-both-the-structure-and-the-content-of-these-kinds-of-projects.-sdi-will-continue-to-have-the-responsibility-to-provide-technical-leadership-in-all-dimensions-of-service-delivery-through-centrally-managed-projects-as-well-as-to-provide-vehicles-when-requested-by-field-missions-for-the-implementation-of-bilateral-programs. .unnumbered}

There are also projects that may need to be amended, and their total
size decreased to reflect lower than anticipated field support funding
from field missions. It is important to avoid wasting scarce Agency
resources on maintaining large technical staffs within projects that are
not operating at the scale hoped for in the design process. A careful
analysis needs to be performed to determine whether Advance Africa is
appropriately staffed relative to the activity underway and whether the
costs are in line with the anticipated outcomes.

# V. Management and funding issues {#v.-management-and-funding-issues .unnumbered}

##  {#section-5 .unnumbered}

## Future Global Funding Issues {#future-global-funding-issues .unnumbered}

The Policy Project paper on Trends and Issues points out that a most
compelling concern is the tremendous growth in the number of family
planning users in the future that will require changes in the way family
planning services are offered. Some have suggested that most organized
family planning programs will almost certainly disappear by the middle
of the century as programs become institutionalized within existing
health systems.[^9] But in the meantime, these programs have a
critically important role to play and require huge resources, including
continuing subsidization, especially of programs in the pre-transition
countries. Donor funding for these programs is already declining and
that decline is likely to continue. And yet the use of contraception
will need to increase significantly and current acceptors need to be
maintained and served. Clearly new strategies are needed to ensure that
these growing needs are met in affordable and sustainable ways.

Resources should be made available by GH to support important global
partnerships with other donors, foundations, field missions and
international organizations in the area of FP/RH. Human resources, as
well as financial ones, need to be devoted to ensuring that USAID is an
important player in these multilateral efforts. These are efforts that
cannot be supported on an individual country level. Field missions
expressed a need for GH to provide more leadership in several areas of
FP/RH. USAID, for instance, should be an important player in policy
reform efforts that affect how health and family planning services are
organized and financed. Joining multilateral efforts will help USAID
have a bigger voice and ability to influence important international
developments in the sector. Interviews with other donors and foundations
suggested that USAID's voice on population issues is important and that
more visible leadership would be welcomed.

## Agency Resource and Management Issues {#agency-resource-and-management-issues .unnumbered}

USAID operates on annual appropriations but generally works on projects
and procurement mechanisms of five years. Funding for PHN programs come
through four streams of money (Child Survival including maternal health,
HIV/AIDS, Population and Infectious Disease.) Guidelines for proper use
of each type of these allocations pose challenges for programming in a
field environment where most services are integrated. The annual
allocations of each category of money changes from year to year further
complicating funding, especially for field missions who may not get the
kind of money they need for the nature of their programs. Considering
the political environment for the Agency, these constraints are unlikely
to change dramatically in the near future, although the importance of
building support for these programs in Congress has never been more
important.

Finding ways to reduce the management burden associated with USAID's
complicated funding mechanisms is crucial, especially for field
missions, many of which have suffered substantial staffing cut backs
during the past decade. Management considerations are paramount in the
choices Missions make about the mechanisms they will use to implement
their programs. Missions may well forego the opportunity to draw on
central projects, despite the expertise and additional funding they
bring, if it means that they have to work with additional management
units or find the field support funding system too cumbersome.

Mission OYBs currently account for 64 % of all PHN funding, with about
half in field support and the rest in bilateral projects. The remaining
36% is programmed by GH largely for state-of-the-art, field-based
activities and for support to international organizations. As noted
earlier, currently little is known in USAID/W about the details of
bilaterals, their successes or even their primary focus. Given the
magnitude of PHN resources programs through bilateral projects, GH needs
to better informed about them and be in a position to assist missions as
needed in implementing these programs. For field missions, the ease of
program management becomes an issue in selecting a funding mechanism.
The Thollaug/Mamlouk report states that "...the reasons cited for
choosing a centrally managed instrument over a bilateral approach or
vice versa did not seem to be rooted mainly in technical considerations.
...concerns about program manageability tend to overshadow the objective
of applying the best technical solution to the health issue at hand." (p
20) Furthermore, the authors conclude that the "lack of systematic
information about field based programming in GH is one manifestation of
the current relationship between Washington and the field. The quality,
quantity, and consistency of interaction are limited by inadequate
staffing and excessive management burden both in missions and
Washington. A greater emphasis on developing country-specific expertise
among GH staff, plus strengthening the country team system, could make
the field-GH connection more consistent, productive, and adaptive to the
myriad realities faced in USAID's field missions." (p 21)

There are also staff management issues in USAID/Washington that are
broader than just the SDI Division but affect the Division in terms of
getting the most 'mileage' out of limited human resources. The
bureaucratic culture in Washington encourages large numbers of staff to
attend lengthy technical meetings and presentations that may be related
only tangentially to their primary work objectives. Too many meetings
are held simply to share information rather than make important
decisions. There is not enough attention paid to limiting meeting
participants to only those who must attend to achieve the stated
objectives of the meeting, using other media for information
dissemination and holding staff accountable for how they spend their
time. Part of the problem may relate to a lack of clarity among staff
about the mandate of central offices and insufficient guidance from
supervisors on how staff should spend their time.

> **VI. Future Program Options**

## Strategic Choices {#strategic-choices .unnumbered}

Given all of the information summarized in sections I -- V, how can the
SDI strategy best support the Office of Population and Reproductive
Health in carrying out its strategic objective. GH itself needs to take
a fresh look at its mandates and the vehicles it uses for working in
global health in general. The "value-added" of central projects and the
functions that distinguish them from bilateral programs, should guide
the nature of the activities that are designed. These mandates clearly
must include providing technically specialized assistance to the field,
global leadership and research.

[]{.mark}

The recently revised Strategic Objective is to: [advance and support
voluntary FP/RH programs worldwide to reduce unintended pregnancy and
foster improved RH practices]{.underline}.

One of the most crucial roles for the GH Bureau to attain this objective
is continuing [advocacy]{.underline} for FP/RH programs. Other partners
clearly want USAID to exercise this kind of global leadership in the
population field. Some feel that renewed enthusiasm and greater support
for population programs will require a new vision, which in simple but
compelling language (perhaps tied to ethical and humanitarian concerns)
helps people understand its global importance. There also needs to be a
realignment of senior staff time on activities related to building
global partnerships, working with other donors to address key global
issues facing FP/RH programs and on global advocacy efforts.

Relative to other activities in the office and in its role with field
missions, SDI itself must shape its mandate and programs to get the best
value for the Agency as a whole within the available human and financial
resources. Furthermore, it must monitor and evaluate the investments
being made in order to determine whether they are making the intended
contribution over time.

Various approaches to improving the impact of core human and financial
resources were discussed at an SDI Strategy Team meeting on December 3,
during which the following agreements were reached.

## Priorities for Core Financial and Human Resources {#priorities-for-core-financial-and-human-resources .unnumbered}

[]{.mark}

While not a problem unique to SDI, the Division is having difficulty
managing large projects, making judicious use of resources, and, at the
same time, providing the strategic and technical support to field
missions that is so badly needed and wanted. Competing priorities are
diluting the opportunity to have a major impact. SDI's vision should
include providing missions with the skills and supplementary resources
needed to ensure that its FP/RH programs are scaled up to have
significant impact as well as being as evidence-based and
technically-sound as possible. This vision, would, over time, suggest
that SDI manage fewer projects and make its technical staff more readily
available to missions to support field activities. With the increase in
SDI technical staff, it should be possible to meet the objective of
making technical expertise more available to the field.

A related point is that, in order for core resources to make a
difference, they cannot be sprinkled in small amounts across the entire
USAID world. Difficult but necessary choices need to be made about
selecting countries and programs where a substantial infusion of core
money is likely to have a major impact by bringing programs to scale.
Again, because not all countries require the same kind of assistance,
some categorization of countries, may facilitate critical thinking about
the use of resources.

At the December 3^rd^ meeting, priorities for use of SDI's core
[financial]{.underline} resources were identified as (1) advocacy for,
and adoption of, best practices for family planning and reproductive
health service delivery in collaboration with field missions and with
external partners and, (2) application of core resources to complement
mission efforts to strengthen institutions and local capacity at the
country level. The highest priority for use of SDI [human
resources]{.underline} was to provide the field missions with the
technical expertise and strategic assistance they require to strengthen
their FP/RH service delivery programs. If this priority for staff is to
have meaning, performance evaluations and determining how staff spend
their time must be measured by how well missions are served. In addition
to these priorities, the management of current and future programs is a
critical role for SDI staff. It is particularly important to reduce the
management burden of the field Missions through programs that are
focused and well-managed by SDI.

## Prioritizing Countries {#prioritizing-countries .unnumbered}

The model suggested by Ross and Stover, of categorizing countries into
three groups: pre-transition countries, transition countries and low
fertility countries, was thought to be useful in terms of prioritizing
the **types of assistance** they may require rather than as a way of
choosing countries with which to work. Geopolitical and other country
selection factors would make anything else impractical. For instance, in
pre-transition countries, SDI's assistance would be strengthening health
systems geared to expanding access and quality of services particularly
when utilization rates are very low. In transition countries, increasing
method mix and helping find ways to scale up programs might be the
focus. In low fertility countries, primary attention could be on policy
and issues related to sustaining programs over the long run.

Other options for categorizing and prioritizing country work were
discussed, particularly in relation to assisting field missions on
strategy development. The concept of segmenting the population by wealth
quintiles to identify those in greatest need, to appropriately target
programs, as well as to identify those who can afford to pay for
services or use private and commercial sources, is useful. As mentioned
earlier in the paper, the poorest quintiles in all countries show the
lowest utilization of family planning as well as most other health
services, and are often paying a much greater proportion of their
incomes for health care than the general population. This kind of market
segmentation can help SDI and GH play an important role to test ways of
targeting programs more effectively for reaching the poorest as well as
finding ways of serving those who can afford to pay. This also enhances
USAID's ability work in concert with other donors and host countries on
specific poverty reduction strategies. As mentioned in Section II, the
DHS and other surveys can help USAID, and all of its partners, map
service utilization and to track those who do and do not benefit.

Another potentially useful way of categorizing countries and assisting
field missions is by looking at the health "systems" issues that affect
service delivery. Given the profound impact that changes in the way
health services are organized and financed are having on field programs,
and because there is enormous variation in the challenges the programs
face, field missions may need help in devising strategies to keep
focused on outcomes and work constructively with the change process.
Service delivery improvement is, after all, a systems strengthening
effort. It is crucial that SDI is able to draw on specialized technical
expertise resident in existing mechanisms such as PHRplus and Policy to
provide the assistance the field requires, using SDI core resources and
technical expertise within the Division.

## Future Needs {#future-needs .unnumbered}

Section II of this paper outlines areas that many of USAID's staff and
stakeholders believe to be important topics for which GH needs to
provide leadership, direction and support to the field. Few of these
topics require the development of new projects. Many existing projects
in others divisions and offices, as well as on-going projects in SDI,
provide mechanisms through which these priorities should be addressed
[if core resources were allocated more strategically.]{.underline} Work
on strengthening FP/RH programs within reformed/decentralized systems
can be undertaken through both Policy and PHRplus. Advance Africa and
Catalyst, working with the IMPACT project in the HIV/AIDS Office, can
offer best practices for FP/RH service delivery in HIV/AIDS endemic
environments. The SDI Division has recognized the importance to working
with private and commercial entities on FP/RH services and commodities
and is moving forward with a new strategy. The non-profit sector will be
addressed through the new NGO/PVO Initiative. This paper suggests that
new activities may be needed to strengthen clinical FP services and to
take a new, more consolidated approach to strengthening human capacity
development.

Taking advantage of existing mechanisms across the GH Bureau is an
important strategy for reducing the number of projects and reducing
costs. Furthermore developing large central projects with large hotel
costs may not be a very cost-effective development investment at this
juncture. GH needs to find better ways of providing direct technical
support to field programs and strengthening Mission capacity to manage
programs. Fewer, more focused projects might better to able to address
the R&D, and technical innovation and leadership, functions in FP/RH. At
the same time, these activities do need to have the capacity to take
field support for missions who need that option or provide for
Mission-managed task orders in a variety of related program areas to
increase flexibility and usefulness of the projects to the missions. New
procurement mechanisms such as leader/associate contracts and
cooperative agreements offer flexible ways of supporting the field and
providing specialized technical assistance. SDI should also consider
whether the "bread and butter" FP/RH technical support available through
activities such as Catalyst and Advance Africa might in the future be
better offered through mechanisms such as TASC that give missions a
selection of pre-qualified firms with which to contract directly.

The following areas were identified during the December 3 meeting as
important because they represent future needs that cannot be met through
existing mechanisms.

**[Strengthening Clinical Family Planning Services:]{.underline}** To
re-invigorate clinical family planning and related services, a new
procurement should be considered. The primary focus should be clinical
family planning services because expertise in this area is not readily
available through the existing mechanisms other than Engender and
JHPIEGO, both of which are ending this fiscal year. Most national
programs need assistance to ensure that the quality of the clinical
services meets international standards and that all elements of a
clinical program are in place. Particular attention must be given to the
in-service training of providers and also to ensuring that informed
choice and volunterism are assured. Clinical family planning services
must be set within a system where all methods are provided at different
levels of the system and where couples are given the information they
require to make an informed choice. While the focus of the new activity
should be clinical family planning, other related clinical services
should also be included such as PAC, STI counseling and treatment,
maternal health services, and HIV/AIDS services where appropriate. The
establishment and training for clinical services requires a technical
approach that has been established over decades of work by the Agency
Optimal service for potential users will require a "contraceptive life"
approach -- providing the appropriate method for a client at each stage
of her reproductive life.

**[Human Capacity Development/Training]{.underline}:** Developing and
institutionalizing human capacity at the country level is an area
needing much more emphasis. Other donors have also recognized this need
and recently have been giving it more attention. GH needs a mechanism
whose mandate is to provide GH and field missions with strategic advice
and technical assistance related to human capacity development in family
planning, reproductive health, maternal and child health, HIV/AIDS and
infectious disease. The human resources constraints related to improving
worker performance such as personnel deployment, compensation,
accreditation and so on are critical across all of the PHN areas and
should be dealt with in a more strategic fashion than the current
fragmented approach would allow. This is also an area where working with
other donors would facilitate better impact of USAID's investments. Many
of the institutions conducting pre-service training (medical, nursing,
and midwifery schools) need and demand curriculum change in more than
just family planning. At the peripheral level, workers are providing an
integrated set of services, which also argues for a more comprehensive
approach. Currently a large variety of CAs work on issues related to
training and some elements of improving worker performance but without
much coordination, strategic direction or focus from an organization
with a broader view. Prime II, JHPIEGO, M&L and QAP all work on various
elements of human capacity development which ultimately, might be
streamlined under one overall approach. Because this would need to
involve all offices of the Bureau in consultation with regional PHN
staff, program development may take some time.

## Mission-Support Needs {#mission-support-needs .unnumbered}

**Supporting Missions for Strategic Planning/Performance Monitoring**:
USAID/Washington staff will never be able to provide all of the
strategic and technical help that missions request which is the
rationale for having mechanisms such as Synergy, MEDS and PopTech.
Consultants are fielded on request but much depends on their
availability at the time needed and they often are not well connected to
the issues that the Agency feels are paramount. There is a need to have
a stable core of technical experts to assist missions with strategy and
program development who are independent of the firms that will
eventually compete for the work. These experts need to be aware of the
latest state-of-the-art information available and maintain working
relationships with technical counterpart in the GH Bureau in order to be
as connected as possible to the Agency's perspective on a particular
topic. SDI staff need to work with these existing mechanisms more
systematically to establish a core group of strategy support consultants
who have country or regional expertise as well as technical credentials
in the areas needed by the missions. When missions have difficulties
funding such experts, SDI core resources should be used. Likewise,
Missions often want help establishing their performance monitoring
plans. On-going projects such as Measure, working with USAID and its
partners, can play an important role in establishing the monitoring and
evaluation framework, after which it can be maintained and used locally.
Finally, the same mechanism should also be used to improve
USAID/Washington's information about bilateral programs that does not
involve any additional reporting or documentation burdens on field
missions. SDI staff need to be able to identify service delivery
technical and programmatic issues with mission programs and to be able
to offer assistance and guidance when necessary.

**Information management**: For the most part, the service delivery
challenges in the field are applying and scaling up known technologies
and best practices rather than creating new ones. There is often too
much emphasis on creating new technologies and strategies rather than
optimizing the use of exiting ones. There is also fairly universal
dissatisfaction with the current procedures for ensuring that the
information generated from research and the development of best
practices are mainstreamed or scaled up in country programs. As
mentioned in Section III, substantial resources are spent on developing
and distributing technical information that is not being used
effectively because people do not have the information in digestible
form at a time when they need it. Thousands of hard copies of documents
are distributed in Washington and to field missions and dozens of
project websites offer similar information but substantial re-thinking
needs to occur about how to make this kind of information practical and
useful for field mission staff.

There are several needs that are already well-recognized by the Bureau.
(1) The volume of technical reports needs to be reduced and
rationalized, (2) the technical information coming from several sources
needs to be synthesized and packaged appropriately and (3) a process
needs to be established to facilitate the state-of-the-art and best
practices information being incorporated into field programs. One step
to address the last issue has been taken. PHNI will be developing and
managing the internal USAID PHN website to provide (and update) this
kind of information for use by field and Washington staff. Further work
is necessary, however, to address all three issues raised above.

###  {#section-6 .unnumbered}

##  {#section-7 .unnumbered}

## Performance Monitoring and Evaluation {#performance-monitoring-and-evaluation .unnumbered}

Developing reasonable M&E plans for strategic objectives as broad as
those in GH is always difficult. Substantial resources have been spent
by central projects on trying to measure outcomes that may be beyond
their manageable interests with disappointing results. There needs to be
a realistic approach to determining the outcome indicators that these
projects should be held accountable for, including an appropriate
allocation of resources for measuring those outcomes. Once decisions are
made on some of the issues, it is very important for SDI to have a good
performance monitoring plan and to report on performance at least
annually. This will enable senior staff to consider whether any
adjustments are needed in the strategy. The performance monitoring plan
will depend primarily on how SDI defines its mandate, both for
supporting the field and for global leadership on service delivery
issues. Indicators would then need to be developed that reflect the
added value SDI brings to field programs as well as the specific
achievements on broader global issues. Annually, the Office and SDI need
to assess the resources (human and financial) devoted to achieving the
specific benchmark indicators and make a judgment about whether the
level of resources are in line with actual outcomes.

# VII. Key Decisions and Follow-up Needed {#vii.-key-decisions-and-follow-up-needed .unnumbered}

-   Share revised paper with GH senior staff and obtain agreement to
    move forward with the activities outlined.

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-   Commission an analysis of Advance Africa to determine whether any
    amendments are needed is size and staffing. A reassessment of the
    likelihood of large field support commitments for projects such as
    YouthNet might also suggest the need to keep it as a smaller, more
    focused effort.

-   Move forward with new activity design for clinical family planning.
    Much useful information has been generated in the course of the
    knowledge sharing meetings, interviews, special analyses, focus
    groups and other preparatory work for this Paper that can be used by
    SDI to develop the authorization document and RFAs/RFPs for a new
    procurement. The design should be initiated as soon as possible in
    January.

-   A "human capacity development" working group already exists and
    should be commissioned by GH leadership to move forward with
    planning for a Bureau- wide Human Capacity Development activity.

[^1]: Destler, Liberi, Smith, Stover, "Preparing for the Twenty-First
    Century: Principles for Family Planning Service Delivery in the
    Nineties", Nov. 1990

[^2]: Ross, Stover, "Trends and Issues Affecting Service Delivery Over
    the Next Decade", Policy Project, Oct 2002.

[^3]: Cobb, Putney, Rochat, Solo, Buano, Dunlop, and Vandenbroucke,
    "Global Evaluation of USAID's Post Abortion Care Program, Oct 2001.

[^4]: IPAS, 2000

[^5]: "Birth Spacing: Three to Five Saves Lives", DHS Study, Johns
    Hopkins Population Information Program, Oct 2002

[^6]: PHNI Project analysis of Family Planning by Wealth Quintile (DHS)

[^7]: "Enhancing PVO and NGO Partnerships in Family Planning and
    Reproductive Health", Bureau for Global Health Action Plan, July
    2002.

[^8]: Thollaug, Mamlouk, "Use of Bilateral Mechanisms for PHN
    Programming in the Field" Aug 2002.

[^9]: Caldwell, Phillips, Barkat-e-Khuda, "The Future of Family Planning
    Programs", Studies in Family Planning, Volune 33, No. 1, March 2002.