Working together
with the community
Documentation on
Protecting the Lives of Pregnant Women in Africa– Community-centered Sustainable Health Promotion Program

Japanese Organization for International Cooperation in Family Planning（JOICFP ）1-10 Ichigaya Tamachi, Shinjuku-ku, Tokyo 162- 0843, Japan
Tel：+81-3 -3268 -5875

Fax：+81-3 -3235 -9774

Mail：info@joicfp.or.jp

Web：www.joicfp.or.jp

December 2022

Acknowledgement
With the aim of contributing to the well-being of pregnant women

Ghana

and girls from marginalized groups in Ghana, Kenya, Tanzania and

Kenya

Zambia, the program “Protecting the lives of pregnant women in
Africa” was implemented by Japanese Organization for International
Cooperation in Family Planning (JOICFP) in collaboration withrespective governments and NGO partners of four African countries
from 2018 to 2022, with the support from the Takeda CSR Global
Program.

Tanzania
We extend our sincere gratitude to Takeda Pharmaceutical Company
for supporting JOICFP and this program for five years. We would
also like to thank all the stakeholders and implementing partners infour countries for the successful implementation, which came withmany achievements, lessons learned, and good practices. Special

Table of Contents

thanks go to the community people, including community healthvolunteers, youth volunteers, community health committee
members, health care workers, and government officials, for their

3 ……… Acknowledgement

Zambia

4 ……… Abbreviations

high commitment and ownership. Even when the COVID-19
pandemic disrupted access to health services from 2020 to 2021, allof the stakeholders made best of efforts to continue the project

4 ……… About the Program

activities and provide regular services while carefully preventing

6 ……… Achievements

infection. These efforts are very much appreciated. COVID-19 could

7 ……… Good practices

not stop us, but made us more resilient and creative.

Social and behaviour change communication
8 ……… BCC Ambassadors as key agents for reaching mass / Kenya
10 ……… Community dialogues on SRHR with film shows / Tanzania
12 ……… Male engagement through Male Champions / Tanzania
Quality SRH service delivery

This documentation was developed with two objectives: (1) tocompile good practices and lessons learned from the five years ofprogram implementation, which are the results of joint efforts ofmore than 4,500 change agents from communities, and (2) to sharethem with those who are interested in sustainable,community-centered health programs to promote sexual and14 ……… Partnering with OTCM sellers / Ghana

reproductive health and rights for all.

16 ……… 5S for advancing the quality of SRH care at the facility level / Ghana

18 ……… Increasing adolescent SRH service uptake through intersectoral collaboration / Tanzania

We sincerely hope that those who live in the communities will
embrace this program, continue activities that promote positive

Community-centered sustainable mechanism

change, and to even add new ideas that would make the program

20 ……… Local resource mobilization by community members/ Kenya

their own. Again, we would like to send our heartfelt appreciation to

22 ……… Supportive supervision mechanism for volunteers / Ghana
24 ……… Community ownership by CHC / Zambia

our partners for their strong collaboration, commitment, anddedication in promoting SRHR of women and girls in Africa.

26 ……… Participatory sustainability planning & testing / Tanzania

Cover photo : Kabatila Kavat, Youth Champion, Kenya

2

Mayumi Katsube
Executive Director
JOICFP

3

About the Program
Program purpose
Access to quality RH services (ANC, Facility-based delivery,
PNC, FP) for women in reproductive age (15-49) in the
project sites is increased in Ghana, Kenya, Tanzania andZambiaAbbreviations

Local government partners

5S : Sort, set, shine, standardize, sustain

Ghana: District / municipal health offices of Suhum, Kwahu

ANC : Ante-natal care

East, Birim North, Akyemansa, Upper Manya Krobo, Lower

BCC : Behaviour change communication

Manya Krobo, and Yilo Krobo, Easter Region

CHC : Community health committees
CHMC : Community health management committee
CHV : Community health volunteer
CHW : Community health workers
COVID : Coronavirus disease
DHMT : District health management team
DHO : District health office
EC : Emergency contraception

Kenya: Sub-county health offices of Makadara, Kamukunji
and Kibera, Nairobi County and Nyeri Central, Nyeri County
Tanzania: District health office of Bahi, Dodoma Region
Zambia: District health offices of Mpongwe, Masaiti, andLufwanyama, Copperbelt Province, and Kapiri Mposhi,
Central Province

FAQs : Frequently asked questions
FP : Family planning
HCW : Healthcare worker
HFMC : Health facility management committee
IGA : Income-generating activity
JOICFP : Japanese Organization for International
Cooperation in Family Planning
MWH : Maternity waiting house
OTCM : Over-the-counter medicine
PE : Peer educator
PNC : Post-natal care

Target areas and Population

Kenya: Total population: 981,416
Four sub-counties: Makadara, Kamukunji and Kibera,

YC : Youth Champion

1. Social andbehaviorchangecommunication• Media tools development
and utilization training• Increasing information
contact points incommunity• Skill improvement ofhealth care workers

2.Quality SRH
service delivery• Increasing access points
for SRH services

Community dialogues on SRHR
with film shows (Tanzania)

Male engagement through MaleChampions (Tanzania)

Partnering with OTCM sellers(Ghana)5S for advancing the quality of
SRH care at the facility level(Ghana)• Better work environment• Client friendly services

Zambia: Total population: 584,174

Increasing adolescent SRH service
uptake through intersectoralcollaboration (Tanzania)
Local resource mobilization bycommunity members (Kenya)

Nine sites in Mpongwe District, 11 sites in Masaiti District• Capacity enhancementof CHC/CHMC

and 3 sites in Lufwanyama District, Copperbelt Province
Three sites in Kapiri Mposhi District, Central Province

Takeda Global CSR program

BCC Ambassadors as key agentsfor reaching mass (Kenya)• Recruitment and trainingof community healthvolunteers• Health promotion
activities by community
health volunteers

Nairobi County and Nyeri Central, Nyeri County

Funded by

Good practices• Communication action
plan development

Manya Krobo, and Yilo Krobo

Twelve wards in Bahi District, Dodoma Region

TOT : Training of trainers• Obstacle-based message
creation

Birim North, Akyemansa, Upper Manya Krobo, Lower

Tanzania: Total population: 247,746

SSV : Supportive supervision

by increasing
access to quality RH
services (ANC,
facility-based
delivery, PNC, FP）
for women in
reproductive age(15-49) at the
project sites in
Ghana, Kenya,
Tanzania andZambia• Communication strategy
development bycommunity people

Seven districts in Eastern Region: Suhum, Kwahu East,

PPAZ : Planned Parenthood Association of Zambia

SRHR : Sexual and reproductive health and rights

Protecting
the lives ofpregnant
women in
AfricaActions

Ghana: Total population: 718,263

SMAG : Safe Motherhood Action GroupSRH : Sexual and reproductive healthApproaches

3.Communitycenteredsustainablemechanism• Income-generating
activities / local
resource mobilization• Supportive supervision
for community healthvolunteers

Supportive supervision
mechanism for volunteers (Ghana)Community ownership by CHC(Zambia)

Participatory sustainability
planning & testing (Tanzania)

45

Achievements

Good practices
Social and behavior change communication

4

16

1,038

3,695

1,138,737

African countries
worked inDistricts/Sub-counties
worked with

Health workers
trainedVolunteers
trainedCommunity people
reached

Ghana

Kenya

Tanzania

Zambia7 districts
Baseline 2018
Achievements as of
September 2022*

Baseline 2018
Achievement as ofJune 2022

Baseline 2018
Achievement as ofMarch 2022

7 sitesBaseline 2018
Achievement as of
September 2022

• Partnering with OTCM sellers / Ghana

30.7% → 102%

15% → 48.2%• Increasing adolescent SRH service uptake through intersectoral collaboration / Tanzania

Note

150

ANC+4 visit

70.6% → 83.4%
90

Adolescents
accessing FP
services

90

120
90

120
90

60

60

60

30

30

30

0
150

0
150

0

43.6% → 50.9%
9064.2% → 111%
120

• Male engagement through Male Champions / Tanzania

Quality SRH service delivery• 5S for advancing the quality of SRH care at the facility level / Ghana

90

061.4% → 99%
120
90

19.4% → 39.6%
120
90

60

60

60

60

30

30

30

30

0

0

0

0

51.1% → 55.2%
9073.8% → 98%
120
90

45% → 99%120
9019.1% → 37.2%
90

60

60

60

30

30

30

30

0

0

0

0

24.3% → 37.6%
9066.9% → 94%
120
90

66.7% → 69%
120
90

120
90

60

60

60

30

30

30

30

0

0

0

4.8% → 7.3%
90

17.9% → 79%• Supportive supervision mechanism for volunteers / Ghana• Participatory sustainability planning & testing / Tanzania

0

120
90

• Local resource mobilization by community members / Kenya• Community ownership by CHC / Zambia

74% → 99.7%

60

120

Community-centered sustainable mechanism

120

60

120

FP uptake

120

30

120

PNC uptake

52.5% → 102%

60

120

Facility-basedskilled deliveries• Community dialogues on SRHR with film shows / Tanzania

150

120

6

• BCC Ambassadors as key agents for reaching mass / Kenya

380 → 950
1200

NA →

48,544

900

60

60

600

30

30

300

0

0

0

No. of trained
volunteers

1,430

799

394

1,072

No. of trained healthcare workers

873

83

44

38

No. of community
people reached withhealth information

274,797

282,980

376,288

204,672

No. of community
people who received
FP and ASRH service

50,288

168,432

142,084

48,638* Baseline data for the newly joined 6 districts are based on the data of 2020.

67

KenyaSocial and behaviour change communication

BCC ambassadors as key agents for reaching mass
Most significant change

Sustainability

1. With the participation of the BCC Ambassadors, the▪ A kind of teamwork was established within thenumber of people who received SRH information

community, consisting of sub-county health officers,

increased from 30,686 in 2019 to 52,952 in 2020 evenfacility officers, CHVs, YCs, BCC Ambassadors, etc. under

under various restrictions in health education sessions

the community health committee (CHC). The community

during the COVID-19 pandemic.

became self-standing without any outside support.

2. Incorporating religious leaders as part of the BCC▪ Close cooperation between the sub-county team andAmbassadors was one of the core strategies under thisother stakeholders, including BCC Ambassadors, CHVs,

intervention. One of the most significant changes wasand YCs made it easy in handing over the project’s

the training of one of the Muslim religious leaders from

activities to the community.

a mosque at the project site. Since the training he hascontinued passing the key messages by incorporatingthem in the Ijumaa teachings (Friday prayer teachings)
as well as Madrasa teachings (Islamic religious
teachings). This was a win because the project gained
entry to disseminating correct SRHR information to the▪ Being recognized as a part of the sub-county healthpromotion team is a motivation for the BCC
Ambassadors.
▪ The activities of BCC Ambassadors do not require extra
funds except for initial training and BCC tools.

Muslim community in their natural setup. Juma (theBackground & context

Implementation details▪ In the early stages of the project,

1. CHVs and YCs together with county health officers went to thecommunity health volunteers (CHVs) andcommunity to identify candidates for “Behaviour Change

Youth Champions (YCs) developed

Communication (BCC) Ambassadors”. Those selected werecommunication strategies and messages

schoolteachers, religious leaders, youth leaders, Nyumba kumi (tento effectively deliver sexual andhouseholds) leaders, police, chiefs, and sellers (e.g., vegetable sellers

reproductive health and rights (SRHR)

in the market, etc.) who do have the information routes in their works.

messages to community people.
▪ Due to COVID-19, home visits and groupthrough a 5-day training. They were provided with basic knowledge

discussions by CHVs and YCs became

about the project, SRHR, key messages to disseminate, and their roles.

impossible.

communication strategy, the project teamfound it necessary to strengthen the massuseful tools produced by the project together with the community

approach. The project team decided to findpeople in a participatory way.

persons who have already establishedtheir information routes to access mass
targets in the community.
▪ Support from influential members of thecommunity was also necessary, but they
could not be reached by the CHVs and YCs.

the community to relevant health services.

Other effects
The number of referrals under the project was low when it

Tips for future programs▪ With the engagement of community members who have
fixed routes to disseminate information, SRHR messages
could reach a wider audience. This approach can apply
to other areas.

was just the YCs and CHVs offering referrals. Eight months
after the BCC Ambassadors were trained, referral cases
increased from an average of 25% to an average of 60% of
the number of people reached with correct information.

3. Various SRH tools including the message pad, flip charts, and JOICFPAprons（an apron with a clear pocket for flip charts) were provided to
BCC Ambassadors. The obstacle-based Message Pad was one of the▪ During an exercise to review the8

2. Two hundred and ten candidates were trained as BCC Ambassadors

Muslim religious leader) passes key messages and links

4. After the training, BCC Ambassadors started passing the key
messages to the community in their workplaces. Ambassadors also
referred individuals to health facilities.
5. They report directly to the link health facilities or through CHVs in a
simple reporting format including referral slips on a monthly basis.

9Tanzania

Social and behaviour change communication

Community dialogues on SRHR with film shows
Implementation details

Most significant change

Sustainability

1. Film shows were planned and organized by a

As a result of the film shows, two villages began building

We started developing a sustainability plan to hand over thefacilitation team of community leaders,

health centers by themselves.

film show activity to Bahi District in August 2021. Since

government officials, teachers, and various

For example, in one village, there was a screening of a film

facilitation skills are critical for this activity, JOICFP teamexperts such as paralegals and healthcare

on teenage pregnancy. After watching the film, themembers transferred them. Also, a facilitation guide for film

workers.

facilitator asked the audience “why did this happen in ourshows and community dialogue was developed.

2. To attract as many people as possible:▪ Chose places where people usually gather (e.g.,schools, market centers, and recreation centers);▪ Planned shows at times men were more likely togather after work (e.g., evening time like 19h to
21h);▪ Created a program with entertainment,
recreation, energizer, film shows, and discussion;andBackground & context▪ Bahi District, the project area, had the highest teenage
pregnancy and maternal mortality rates in the country. In regard
to SRHR, many people still believe rumors and superstitions.
Many pregnant women choose to give birth at home without any
prenatal checkups. Sexual and reproductive health and rights(SRHR) is more of a "women's matter," and few people know thatmen can receive medical advice and care.
▪ Project members, including community health volunteers andpeople from the communities, developed messages aimed at
deconstructing cultural habits, practices, and attitudes thatprevent women from accessing Sexual and Reproductive Health(SRH) services. SRH topics were taboo in the Bahi District, and it
was difficult to talk about such issues openly.
▪ By showing films related to SRHR topics, and discussing themafterward, villagers can think and talk about themselves
objectively. Even issues such as gender-based violence andviolence against children can be discussed with the support ofneutral facilitators.
▪ Such opportunities helped create an environment where SRHR
issues could be discussed openly. Organizing film shows inrural villages where entertainment is scarce is an effective way
to attract and gather many people (150 to 300 people at a time).

10▪ Promoted shows in advance with the help ofcommunity health volunteers, peer educators,
Male Champions, health staff, and local
government officials (ward executive officer,
village executive officer, and village/street
chairperson). The team used the publicannouncement system to notify everybody one
hour ahead of the show.

community?” People said their opinions such as “the girls
could not complete their education,” “there are no basic
health services in our village,” and “health facilities are too
far away.”
The community decided to collect money and in-kind
donations to build a health center.

Other effects
The film shows increased the visibility of the project to thecommunity. The after-the-show dialogue helped makematernal health and SRHR become community agendas.

Tips for future programs▪ Strong facilitation skills for community dialogues after
watching films are the key to promoting positive change.
The facilitator needs to control the discussion, where
different perspectives come up, encourage all groups toparticipate, talk about sensitive issues, and appreciate
everyone’s opinions.
▪ The films need to cover various topics and otherpriorities of the community such as policies and laws
related to SRHR, parenting, child protection, governance,and social accountability.

3. To address “taboo” topics:▪ Topics were decided in consultation with theward and village executive offices, health staff,
and community volunteers, considering thesituation of each village. Examples of the topics
were: danger signs during pregnancy, sexuallytransmitted diseases, teenage pregnancy,
parenting and family care, drugs and substanceabuse, gender-based violence, and violenceagainst children. Films with educational andentertainment elements were chosen.
▪ After showing films, participants talked first toraise questions. Then the experts answered thequestions and provided information. After that,
there was some time for participants to share
their opinions and issues in the community tothink together.
▪ Some issues, especially gender issues, weresensitive. Creating a friendly and safe
environment for the participants to speak theirminds freely without fear of conflict was very
important.

11

Tanzania

Social and behaviour change communication

Male engagement through Male Champions
Implementation details
1. The project team shared the idea of recruiting
Male Champions with the Bahi District healthoffice, and it was agreed to start advocating

Sustainability

toward the community leaders to obtain theirunderstanding of SRHR issues.
2. The project team and the Bahi District healthto the Male Champions continued after the end of theoffice had many discussions with various

project. Monthly follow-up meetings, regular supervisioncommunity leaders to deepen theirunderstanding of SRHR and to overcome their

Most significant change

shyness to talk about SRHR issues openly in

1. The number of men reached by the Male Champions

public.
3. The project team and Bahi District healthoffice discussed and developed the selection
criteria of the Male Champions.
4. The community leaders nominated MaleChampions together. One hundred and nine
Male Champions were selected. Among theMale Champions were teachers, religious
leaders, traditional leaders, civil servants,
bodaboda drivers (motorcycle taxi drivers),

Background & context▪ Among most families in Tanzania, men are the decision-makers.
Even if women and girls understand the importance of their own
health, they may not be able to access sexual and reproductive
health (SRH) services against their fathers’ or husbands’ decisions.
Men still decide many important family issues like the economy,
health, education, etc. Men in Tanzania, especially in rural areas,
would only listen to the opinions of influential men. There was aneed to find male influencers to successfully raise awarenessamong men on SRH issues.
▪ The baseline study conducted by the project found that men werereluctant of having their wives use family planning services. Also,men were not aware of their sexual and reproductive health andrights (SRHR) needs.
▪ Focusing only on women and girls cannot change the situation. The
project took an approach to promote male engagement by reaching
25,000 male adults through SRHR and gender-related sessions.

12▪ Supportive supervision and monitoring by local partners

etc.
5. They were trained on sexuality, gender issues,
SRH services, voluntarism, the importance ofmale engagement, male SRH needs, etc. in a
5-day training course. Communication tools
such as brochures, a message list andguidebooks were provided.

increased dramatically. In the initial half of FY2019, only
7,776 male adults were reached by community healthvolunteers (CHVs), but in the latter half of the year,
28,700 males were reached by the Male Champions.
2. Men understand more of the importance of maleinformation on film shows and outreachclinics to the community, especially to men.
7. The Male Champions kept track of theiractivities and submitted monthly reports tohealth facilities. They also participated in themonthly meetings at nearby health facilities
as part of the CHV team, health facilities aspart of the CHV team.

activities of the Male Champions.
▪ The Tanzanian government is now focusing on making
male engagement a national standard for reproductive,
maternal, newborn, child, and adolescent healthpromotion. A member of the project team joined theMinistry of Health to develop the Male Engagement
National Training Package.

involvement in SRH and maternal health. They became
more supportive of their wives and daughters receiving
services. It has become common for males toaccompany their wives to visit health facilities forantenatal care (ANC) resulting in more facility
deliveries. Changes in men's behavior were also
observed in childcare. More men are bringing theirchildren to clinics.
3. Previously men were reluctant to visit health facilities toreceive sexually transmitted infections treatment andother SRH services. But now the community at large andmen think it is normal for men to go to the healthfacilities to receive SRH services.

6. After the training, the Male Champions
conducted group sessions. They also provided

visits, phone calls, etc. are made to ensure the continued

Other effects▪ Men realized they had SRH needs.
▪ Some Male Champions gained further trust from
community members. They were selected as leaders of
the community.
▪ Some Male Champions were promoted to community

Tips for future programs▪ It is essential to first have numerous discussions with
community leaders to have a common understandingthat SRH issues are not just women's issues, but men
themselves, and that men's understanding andengagement are critical to tackling the SRH issues in thecommunity.
▪ It is crucial to select Male Champions from Influential
men by their community members under the supervisionof local government leaders following the recommended
criteria.
▪ In order to reach more men in the community, groupsessions by Influential men as Male Champions at places
where men gather daily are effective to disseminate
information and influence their mindsets and attitudes
among men about SRH-related issues.
▪ Close support and supervision for Male Champions byhealth care workers, community health management
team, project staff, and community leaders arehealth workers, a position to support local healthnecessary to keep motivating Male Champions andinitiatives under the Ministry of Health.

sustaining their activities.

13

GhanaQuality SRH service delivery

Partnering with OTCM sellers
Implementation details
1. Engaged association leaders: OTCM sellers have a union of sellers. The
group was identified and adopted to support the project.
2. Meetings were organized to reorient the association leaders on the
project and reactivate their interest in the roles they have been
assigned.

Most significant change

Sustainability

the training of OTCM sellers in each district. They are the district public

1. The number of people who accessed SRHR services▪ Current contraceptive use, update on standard operating

health nurse, the health promotion officer, and the health information(contraceptive distribution, medication, etc.) atprocedures related to drugs regulations, and the need to

officer.

community pharmacies almost doubled from 876 inrefer clients in need to health facilities were shared

September 2021 to 1,628 in September 2022.

among the OTCM sellers at association meetings.

3. Three trainers, who were key players in the project, were assigned for

4. Training of Trainers (TOT): The project conducted a training/workshop
for three trainers per district) by five facilitators including the regional

2. The number of people who received SRHR information▪ The government and health facilities welcomedat community pharmacies (consultation, distribution ofcollaboration with OTCM sellers since they can provide

pamphlets and brochures, etc.) soared from 7,219 inservices during the pandemic and collect more detailed

manager and a district health office director, visited the sites to

September 2021 to 15,979 in September 2022. The OTCM

data on contraceptive distribution in communities.

provide the necessary support to the trainers during the step-downsellers are on board and are now discouraging the use

training for OTCM sellers. A 3-day training on SRHR and 2-day trainingof EC as a regular family planning method. The family

on Infection prevention and control were provided.

planning acceptance rate also went up following thehealth facilities during the COVID-19 pandemic.

The 64 licensed OTCM sellers were trained for the six districts. The

involvement of the OTCM sellers.

▪ Over-the-counter medicines (OTCM) sellers are

information and services and to provide data in line with project

Background & context▪ Difficulty of in-person communication by
volunteers to provide information and services
during the COVID-19 pandemic.
▪ Difficulty and fear for community people to visit

5. Training of OTCM sellers: A floating monitoring team led by the project

sellers agreed to collaborate with the project to disseminate SRHR

frequently the first point of call for people in need

output indicators. They were all connected to health facilities in theirof health services. Community-based small

respective communities.

pharmacies can serve as service points,
especially in rural areas, where the healthfacilities are far from home.
▪ OTCM sellers have strong patronage and are
relied on by community people as the first pointof call.
▪ If the OTCM sellers are equipped with sexual,
reproductive, health, and rights (SRHR)
knowledge, information, supplies, and skills toprevent infections, and learn control protocols,
they can be easy-to-access service points linked
with health facilities.
▪ OTCM sellers’ service statistics were not captured

6. Tools: The project provided OTCM sellers with various behavior
change communication (BCC) tools including Message Pads, FAQs, flip
charts, etc. as well as simple reporting tools such as referral slips,
with orientation on how to use them.
7. The trained OTCM sellers provided SRHR messages and counseling totheir customers and sold medicines and contraceptives. They also

3. The OTCM sellers became a bridge between thecustomers and health facilities. They have a good
relationship with young girls especially, through sellingECs. The OTCM sellers referred them to health facilities
to encourage the use of contraceptives.
4. The sellers’ motivation originally came from a businessperspective. But through this project, they recognized
themselves as part of the community that contributes tothe development of adolescents and young people.

communication skills and SRHR information allowed the sellers tocommunicate better with customers and won their trust.
8. Public health officers conducted quarterly supportive supervisory
visits with relevant officers and the JOICFP team to the OTCM sellers.
9. The OTCM sellers also participated in quarterly facility-based meetings
10. The OTCM sellers sent monthly reports by reporting tools on thenumber of contraceptives, counseling, and referrals done to the link

emergency contraception, condoms distributed,

facilities.

▪ Stakeholders such as the coordinating directors andleadership of the OTCM seller union of each district
committed to playing their roles with no equivocation.
▪ The program is to be incorporated into the routine Ghana
Health Service program of the respective districts toguarantee the sustainability of the project.

Tips for future programs▪ OTCM sellers can extend their scope of services andbusiness, improve their expertise and get support andadvice from health experts. It became a win-win
partnership.
▪ Integrating OTCM sellers in the health delivery systemreferred their customers to health facilities. Training on

in official statistics before (e.g., numbers of pills,
and counseling provided).

14

director of public health, and the regional maternal health coordinator.

Other effects▪ The sensitized OTCM sellers counsel young people
against the use of ECs, resulting in a decrease in theiruse of ECs and an increase in contraceptive use.
▪ A strong collaboration between the OTCM sellers and the
district health offices.
▪ The OTCM sellers boost referrals of clients to healthfacilities, which results in increased service uptake.

ensures that the health facilities can get service
statistics from OTCM sellers and increase referrals fromthe communities.
▪ It is better to train two persons per store if the owners
are not usually at the store.
▪ Electronic technology should be introduced forcollecting data from the OTCM sellers since both thehealth staff and the OTCM sellers are hard-pressed withtime. Paper-based reporting may be highly ineffective.

15

GhanaQuality SRH service delivery

5S for advancing the quality of SRH care at the facility level
Implementation details

Most significant change

1. One-day 5S overview and implementation

1. There is orderliness at the facilities for easy operation i.e.,

training were organized for frontline

labeling, numbering, zoning, and taping. things are put inhealthcare workers including sub-districtboxes with labels to show what is inside. There areleaders.

protocols/guidelines/standard operating procedures to

2. One-day 5S monitoring and supervision
training was organized for selected staff

2. Whenever a new staff member is assigned to a healthincluding some district and sub-district

facility, other staff members will conduct training on 5S

heads.

to maintain an organized environment.

3. Facility heads organized a step-down training

creative and took initiative. For example, some staff madesupervise and monitor 5S implementation atdust-bin boxes from cardboard, another made an activity

the facility level. Regular supervision of 5Sclock from cardboard, etc.

ensured.
4. Facility heads submitted the collated results
to the District Health Information Officer▪ The following conditions were commonly seen at the health facilities

quarterly.
5. Sub-district heads conducted quarterly

4. High standards of cleanliness are maintained at thehealth facilities.
5. The healthcare workers embraced the concept of 5S that‘it is NOT a cleaning campaign but quality improvement
and a basis of organization management’. It became
easier and faster to find things. As a result, the waitingin the project area before the project:peer-review evaluation exercises within theirtime of clients decreased. The clients’ flow in health▪ Low acknowledgment of the importance of client-centered services
among health service providers

localities and collated records, using the 5S

facilities was improved. It makes it easier to check the

spider score sheet.

stock status and can prevent inadvertent stock out. First▪ Inadequate management of medical consumables and medicinesthat takes time to find things and sometimes causes stock out.

6. A team from the district health office▪ Inadequate management of client files. It took more than 15 minutes
to find a folder of a client since there was no tracking system.

facilities and compiled results.

▪ Lack of orderliness in the workplace. Even the corridor was litteredwith things.
▪ The project introduced the 5S (sort, set, shine, standardize, sustain)
approach and exercises to improve the attitudes and behavior ofhealthcare workers in the area of work environment improvement.
▪ 5S is a good entry point to realize the importance of improving theworking environment. By reducing wastage, overburden, andinconsistencies, 5S results in immediate and visible effects.
▪ It can also motivate staff members to be self-aware of the efficiency
and efficacy of their work. It becomes the first step to improving thequality of services by reviewing one’s way of working including
relationships with clients.

16

3. The staff members of the health facilities became

for their staff. An officer was designated to

implementation at the facility level was

Background & context

maintain the work environment in the same manner.

conducted routine evaluations at all the

7. An award system was instituted to reward
high-performing facilities to motivate staff toimprove service delivery. At the annual review

Expired, First Out (FEFO) is applied on medicines andsome non-medicine consumables so as to avoid expiry.

Other effects▪ Discipline among health workers on how to organize
themselves improved and they are “keepers” of eachother.
▪ Competition among facilities becomes one motivation tokeep conducting 5S.
▪ The orderliness and cleanliness in some facilities attract
more clients.

Sustainability▪ Regular quarterly monitoring with a checklist▪ Annual performance review to award top three facilities▪ On-the-job training for the new staff members

meeting of the district health office, the top

Tips for future programs

three facilities are awarded for their high

The most important points for sustainable 5S and quality

performance on 5S.

improvement are the following

8. A WhatsApp platform was created, and▪ Make it a discipline for all the staff of a health facility

regular updates were shared among the▪ Regular support and contact by the head of a healthfacility

monitoring team.
9. One year after the initial training, the trainees
received a refresher training to update andadvance the 5S activities.

▪ Commitment of the leaders▪ To consider 5S not as an additional task, but as one ofthe original duties which benefits to reduce the burdenof the worktheir works

17

Tanzania

Quality SRH service delivery

Increasing adolescent SRH service uptake through intersectoral collaboration
Implementation details▪

1. Before starting health education at schools, HCWs and school
professionals discussed adolescent health issues including
adolescent pregnancy. Discussions were also held with thestudents’ parents to create awareness and reach a

Sustainability

consensus.

▪ At schools, peer educators and schoolteachers developed a

2. HCWs were trained to provide adolescent-friendly

sustainability plan to continue health education sessions. Peer

reproductive services. The trained health staff regularly went

educators continued to organize group and one-on-one sessions

to schools to provide health education sessions in their free

under the supervision of school health teachers.

time in coordination with schoolteachers. At schools, HCWs
can only conduct awareness activities, according to the
Ministry of Education’s guidelines. So, they provided
information to students about which SRH services areavailable at healthcare facilities so that students can visit

Background & context▪ Teenage pregnancy and maternal mortality rates are thehighest in the country in Bahi District. Because of thestigma against young people when they accessed sexual

the target number (30,000).

adolescents, which makes it easy for adolescents to go tohealth facilities to consult with HCWs.
3. The health facilities were open when students could easily
on Fridays and 16:30 to 17:30 on weekends.

(HCWs) to conduct pregnancy tests and not for healtheducation and counseling because the needs were notknown. Schools were not aware of the gap between schools
and health facilities in terms of sexual and reproductive
health and rights (SRHR) service provision for adolescents

4. The project also trained adolescents both in and out of schoolas peer educators.
5. The school health teachers were trained on SRHR foradolescents and the necessity of education. They were also
trained as mentors to the peer educators who conducted
extracurricular SRHR sessions at schools.
6. In total, 47 youth clubs were established. Youth clubs at

2. Cases of sexual abuse and teenage
pregnancies at schools dropped, especially atmembers are being recruited with the support of school healthteachers.
▪ Health facilities also continue providing health education foradolescents and youth while blocking time at the clinic foradolescents.
▪ The government of Tanzania directed each school to conduct peerboarding schools. At one of the primary

reproductive health education sessions, sports, games, and folk

boarding schools within the project site boys

media as extra-curricular activities. This guidance is expected toused to ask girls sexual favors in exchange

encourage the continuity of the activities.

for meat for dinner. Through the project, thestudents learned that this was a kind of
sexual abuse, and this practice stopped. Afterinterventions by the project, no teenage
pregnancy cases were reported at the school.
3. Testimonies from teachers and HCWs at oneof the secondary schools and a dispensary

Tips for future programs▪ Developing a joint action plan by health workers andschoolteachers is the first important step in filling the adolescent
SRHR service gap between schools and health facilities.
▪ By setting up dedicated hours for adolescents and youth at clinics,

admitted that students became more open

young people can come to receive SRH services easily.

educators, who provided health education sessions to otherabout SRHR-related issues when talking tohealth activities. Intersectoral collaboration was necessaryteachers and HCWs. The number of students▪ Different strategies and approaches are necessary to target

students at the ex-curriculum time. The youth clubs also

to ensure information and services reached the youth andorganized sports events (football), games, and folk media

seeking family planning (FP) /SRH services

to meet the specific need of preventing pregnancies.

(drama and songs), inviting both children in and out of school

has increased at health facilities.

and did not have special programs on SRHR for students inschools were established by trained health teachers and peer

the Bahi district. Schools did not have enough budget for▪ The number of trained HCWs who can provide adolescentand youth-friendly reproductive health services wasseverely limited.
▪ The Ministry of Education in Tanzania did not allow

18

schools by HCWs help build trust between the HCWs and thehealth facilities. A youth-friendly environment for young▪ Before the project, schools only invited healthcare workers

1. A total of 48,544 adolescents used SRH
services at health facilities, which is 162% of

and reproductive health (SRH) services, they did not visit

seen by other adults was necessary.

Most significant change

clinics by themselves. Health education sessions held atvisit, and adults were not around. This was from 15:00 to 17:00

people where they can access SRH services without being▪ Peer educators also ran youth club activities at schools. New

to provide SRHR information.
7. Several youth clubs supported out-of-school youth throughincome-generating activities (IGA) such as agriculture, small
animal keeping, and tailoring.

in-school and out-of-school adolescents respectively to reduce
teenage pregnancy. The project proposed the Bahi Health Officestrengthen the collaboration between health facilities andcommunity structures, such as families and CHVs to approach

Other effects
One of the schools in the project area was aout-of-school adolescents.
▪ In addition to the SRHR education for out-of-school adolescents,

school for the deaf. Some of the students were

IGAs, skill development, a one-stop clinic day for adolescents that

pregnant adolescent girls to stay in schools until November

8. Film shows were conducted at schools. The project teamtrained as peer educators to conduct healthprovides reproductive and child health care and treatment clinic,

24, 2021. Preventing early-age pregnancy among female

sometimes asked teachers to stay in another room so

education sessions with their peers using signand other general health services, and entertainment programs are

students was critically important for girls to keep studying.

students could open up during discussions.

language.

to be provided to mobilize the youth to come for services.

19

KenyaCommunity-centered sustainable mechanism

Local resource mobilization by community members
Implementation details
1. The project manager first shared theconcept of local resource mobilization
among the project team, CHVs, and YCs andmotivated them by telling them “We can try!”
2. She shared this concept with government
partners. They first showed reluctant
reactions. She decided to include thesub-county officials in the training. The
training helped them understand theimportance of SRHR education and services,and how crucial resource mobilization is forsustainable projects.

Background & context▪ The necessity of local resource mobilization hit the heart of the project
manager when she visited Japan in 2018 to participate in the first joint
planning workshop under the Takeda Project. She learned fromexperiences in Japan and Sudan the importance of communities taking
the initiative in improving public health.
▪ As the project progressed, issues related to sexual and reproductive
health and rights (SRHR) that were not anticipated and budgeted
emerged. One of the reasons for teenage pregnancies among in-school
girls was due to the lack of money to purchase sanitary pads. Someadolescent girls sold sex for money. In addition to health education
activities, free sanitary pads were essential, so resources were needed.
▪ In order to sustain the activities, communities needed to find resources
locally without relying on external funding after the project ended. The
project manager anticipated that the key community agents, namely
community health volunteers (CHV), Youth Champions (YCs), andBehavior Change Communication (BCC) Ambassadors gain skills tomobilize resources by themselves, it will become a sustainablemechanism.

20

Most significant change

Sustainability

1. The trained youths in Kibera began a (sanitary) pad

The sanitary pad drive is still continuing and resource

3. The project manager looked for a consultant

drive aimed at mobilizing pads and funds to procure

mobilization for the maternity equipment happened in 2021

as a trainer on resource mobilization since itpads to distribute to adolescent girls in the slums toand 2022, or over one year since the training. The trainedneeds technical expertise like writing skills

reduce teenage pregnancy. YCs raised 53,000 Kenyan

teams were selected from government existing structuresof an effective proposal, etc. Together withshillings (approximately USD430) in mobile money bysuch as sub-county health management teams, healththe project team, the consultant developed ausing SMS (short message service). Attractive dancing

facility management teams, youth committees, andtraining program, especially for domestic

events and other entertaining events were organized forcommunity health structures hence resource mobilization

resource mobilization by the community.

sensitization and fundraising.

efforts will be carried on in their natural setups.

4. A total of 120 participants, community health

2. In Makadara Sub-County, CHC members successfullycommittee (CHC) members, YCs, andmobilized resources from local organizations,Tips for future programs

sub-county officials enrolled in a 4-day

foundations, and companies in the sub-county. The CHC

training. During the training, the participants

members negotiated and submitted a proposal to five

▪ The resource mobilization by CHC should be

developed action plans through group workorganizations and private companies to equip healthfor their local resource mobilization.

facilities with medical and office equipment. A printing

5. After this training, CHC members, and YCs
together with sub-county officials, started
approaching local industries, individual
donors, and private companies as‘community work.’machine, delivery beds, and other medical equipment
for a maternity ward were donated. Through CHC’s

mainstreamed in existing government and community
structures to ensure sustainability and ownership.
▪ The training should include youths as they are moreconversant with their needs.

lobbying, the Sportspesa foundation provided
equipment for the maternity ward with an equivalentworth 1.7 million Kenyan shillings (approximately 14,000
US Dollars).

6. Seventy-two CHC members were trained onmonitoring their resource mobilization
activities by the project team.
7. Soon after the training, the COVID-19
outbreak came. Resource mobilization had
to start on a small scale within thecommunity.

Other effects
Interventions were recognized by the National Council for
Population Development. This drew the interest of thedirector general of the council to visit the site and learn
more about the intervention and incorporate them into
national programs.

21

GhanaCommunity-centered sustainable mechanism

Supportive supervision mechanism for volunteers
Implementation details

Sustainability

1. In order to facilitate the regular▪ SSV for volunteers was integrated into sub-district

SSV activities, District Directors

routine quarterly SSVs.

of Health Service, JOICFP, and▪ SSV is implemented within the community and by thesome district health officers

community members, so extra costs, such as

developed a draft checklist as

transportation fees are unnecessary.

an SSV tool. The checklist▪ SSV of the CHVs became part of the performance

focused on the activity areas of
the CHVs. The list was intended

appraisal of health staff by the decision of the Suhum

to be used by the community

Health Directorate.

SSV teams consisting of 2

▪ Capacity building for CHMCs by the District Healthcommunity health management

Directorate is planned to keep them updated on newcommittee (CHMC) members

development.

and 1 health staff for each area.
2. The draft checklist was tested

Background & context▪ The following challenges emerged as the project progressed:▪ The high dropout rate among community health volunteers (CHVs), who were
the key actors in raising awareness and smooth referral of individuals tohealth services.
▪ Low rate of active CHVs
▪ The necessity of a mechanism to sustain CHVs’ motivations and activities▪ There was no support for CHVs from the District Health Directorates▪ The project introduced supportive supervision (SSV) as a systematic supportive
mechanism for CHVs. The expected effects of a systematic, community-based
SSV include the following:▪ By conducting the SSV within a compact area, monitoring and supervision areeasy to manage and health workers are encouraged to visit communities
regularly.
▪ By having supervision sessions regularly, local health administrations canaccumulate data.

22

on a small scale for selected

Most significant change

communities. After the test

1. CHVs welcomed stronger supervision. They felt

Tips for future programs▪ Extending supervision to CHVs helps to reduce theattrition rate and improves overall performance.

results were reflected in therecognized by the health staff and CHMC members anddraft checklist, it was finalized.

were motivated. As a result, the volunteers’ attrition▪ The checklist must go under periodic review, even afterrate declined. Through the SSV with questionnaires andthe project end. The district health offices should review

interviews, CHVs said that their ties with health staff

and revise the checklist to cater to needs that change atstrengthened because of increased communication.

the grassroots level.

3. The checklist was introduced toproject areas, and SSV teams (1health staff and 2 CHMC
members for each community)
were trained for regular SSVs
using the checklist.
4. The two CHMC members took
on the task of training other
CHMC members on how to use
the SSV tools including thechecklist.
5. The SSV teams visited CHVs on
a quarterly basis.

Health staff became more supportive towards CHVs
after making frequent regular visits with the checklist.

▪ It is cost-effective to work with CHMCs because they livein the communities and are in touch with volunteers.

2. CHVs’ activities increased from 38,750 in September
2021 to 46,142 in September 2022. This is almost a 120%
increase in one year. The number of people reached byvolunteers increased from 43,710 in September 2021 to68, 170 in September 2022, or almost a 160% increase in
one year.
3. Change in commitment and the way of oversight within
the health management structure advanced continuous
supervision.

6. Other project areas adopted thechecklist and received training.

Other effects▪ The CHVs will have more opportunities to receive refresher training as OJT(on-the-job training).

In Ghana, there was no system to manage CHVs. The SSV▪ Supervisory visits improve the relationship between health workers and CHVs
and tied them together.

by strengthening the capacities of CHVs to improve healthtool can be a game changer for the broader health systemdelivery at the community level.

23

Zambia

Community-centered sustainable mechanism

Community ownership by CHC
Implementation details

Most significant change

Sustainability

1. The project team and district officers selected target

1. Before the project started, target communities were

▪ In most of the project communities, CHCs are still functioning,communities that have high reproductive health needs, awaiting for help from the outside. But now they are

self-sustaining, and responsible for protecting the health ofcertain size of the population, existing Safe Motherhoodaware of their capabilities and are gradually becoming

the people, especially women, children, and adolescents.

Action Groups (SMAGs: community health volunteers), a

self-standing. For example, some communities built

high commitment of district health officers as well as thematernity waiting houses (MWHs) with their own funds

communities for health promotion activities and social

and labor. Funds were raised through income-generatingchange.

activities (IGAs), support from local companies

2. One of the key approaches to ensure sustainability was toengage all the stakeholders from the very beginning. The
project team organized CHCs for all the target communities.
The CHCs were based on neighborhood health committees,
which are operated under government policy.
3. The committee membership consists of traditional
community leaders, schoolteachers, health staff, etc. The
SMAGs and peer educators also became members of thisBackground & context▪ The Japanese Organization for International
Cooperation in Family Planning (JOICFP) and its
counterpart, the Planned Parenthood Association ofZambia (PPAZ), have been nurturing a long-standing,trusting relationship since 1987. Some PPAZ staff wellunderstand JOICFP’s community-centeredreproductive health approach to mobilize people andfacilitate engagement. This community healthapproach has been handed down within PPAZ by theparticipating communities were those with the highest
needs and will, the members’ ownership and commitment
were strong.

project by Takeda.
▪ There was plenty of accumulated knowledge andexperience including good practices obtained frompreceding projects.
▪ The approach was selected because the community
health committees (CHCs) would enhanceownership from the top level to ensure continuity ofactivities after the end of projects and programs.

2. Access of pregnant women to health care facilities was
improved with the introduction of MWHs. Pregnant
women can stay at an MWH four weeks prior to the
expected delivery date, which is located next to a clinic.
The fee to stay is free. Staying at the MWH is safer for
pregnant women as they would not have to walk long

39.4% of facility-based deliveries by the end of 2022, theto do, along with detailed planning. By choosing options

actual rate was 39.6% at the end of 2022.

and making decisions on their own, communities had

urgent matters.
6. Members have their own roles in the community. For
instance, teachers support peer educators in and out ofschool, and support sessions for youths.
7. The CHC members from new sites visited existing projectsites to learn from their experiences.
8. The district health officer regularly monitored the CHC’s
reporting including accounting for improved quality of
project documentation.

▪ The CHC recruits and replaces volunteers when thevolunteers relocate to other sites or cannot continue their▪ Close supervision and promoting networks with other sectors

The committee discussed specifically what kind of activities▪ The local leaders and local government officers at

reproductive health.

▪ Four communities have constructed MWHs throughcommunity-based initiatives so far.

skilled birth attendants increased. While the target wasmeeting to review the community action plan and discuss

SRHR activities, especially for adolescent sexual androles. The CHC gives initial training to volunteers. CHCs

discussed and decided on how to improve maternal health.

stronger ownership and commitment toward the project.

members, they have become strong supporters and promote▪ At another community, one company collected
donations to cover the construction fees of an MWH.

distances when in labor. Facility-based deliveries by

5. Members attend monthly meetings and an annual review

and its community approach and welcomed the new▪ In one community, the local government provided aflour mill for income generation.

4. The main objective was improving maternal health. The CHC

staff in charge of the PPAZ/JOICFP projects.

the project sites were well acquainted with JOICFP

24

committee after advice from the project team. Since the(money/in-kind), donations from individuals, etc.

▪ After the training of traditional leaders as part of the CHC

connect the community with healthcare facilities.

(department of agriculture etc.) help create a sustainable
environment.
▪ Through monitoring, the district office knows the details ofcommunities and can quickly provide support.
▪ Good teamwork: the close collaborative relationship between
health workers and the volunteers.

Tips for future programs▪ Use existing mechanisms like the neighborhood healthcommittee as CHCs rather than creating a new entity.

Other effects▪ Involve all the stakeholders from the onset of the project.

▪ Self-help movements led by CHC stimulated other▪ Engagement of experts to ensure IGAs are viable and running

communities to do a similar attempt.
▪ The Ministry of Health is considering this project as acommunity-operated model SMAG program in the
country.
▪ Endorsement by the local leadership improved resource
mobilization in the community▪ Inter-sectoral collaboration between health andagriculture was facilitated.
▪ The model of IGAs by CHCs was replicated in Ghana tostrengthen the sustainability of the project.

well in all project areas.
▪ Conduct more monitoring activities for better feedback from
beneficiaries.
▪ Support volunteer-led sensitization activities, and work
closely with traditional leaders to promote them.
▪ Spend more time with the volunteers in the community toprovide technical support and to ensure that community
sensitization is carried out accordingly.
▪ Appreciation and recognition of voluntary work by CHC arevery important.

25

Community-centered sustainable mechanism

Tanzania

Participatory sustainability planning & testing

Background & context

Implementation details▪ Even though sustainability

1. JOICFP staff held a series of discussions with the district health department andplans were discussed andcommunity health committees (CHCs) to develop a sustainability plan. The committee

developed in JOICFP projects,

members included village leaders, health care workers, volunteers trained by thethey were not always

project, community representatives, traditional leaders, religious leaders, teachers,

implemented after JOICFP left

and other members responsible for improving the health of the local people. What toand the impacts of thesustain beyond the project life was first discussed and agreed.

projects were often lost. Thistime, JOICFP decided to pilot asustainability plan during the
project period to determine
its feasibility and ensure thatit could be continued after
the end of the project without
JOICFP.
▪ The local government offices,
community health volunteers

steps.” The plan and implementation steps were developed by the Bahi Health Officewith support from JOICFP. Activities required to ensure the implementation ofsustainability plans were detailed in the “hand-over plan.” “Detailed Implementation
steps” and “flowchart of the detailed implementation steps” described what to do andwho would do it to continue activities after the end of the project.
3. A flowchart for each activity was printed and hung on the wall of activity sites, such asat the health facilities, schools, and the room of ward executive officers, so those whoare concerned can check the flow and assign persons.

(CHVs), community health

4. The members went over the question of “How much do we actually need to implement

committee (CHC) members,

this activity?” and more importantly, “Is there any way we can do it without a budget?”and other beneficiaries ofmany times to minimize the cost as much as possible to make the plans feasible.

Bahi District expressed theneed to continue the efforts.

26

2. The sustainability plan included a “handover plan” and its “detailed implementation

5. The process of testing the ideas, revising, and reworking the plan lasted more than six
months.

Most significant change

Sustainability

1. CHC integrated project activities into its action plan to sustain their▪ The JOICFP project team visited some of theimplementation at the community level after the project phase-out.

communities in the Bahi District after the

2. Bahi district council has integrated the project interventions into
comprehensive council health plans for budget reallocation andsustainability of the interventions.

end of the project. The team confirmed thatthe activities were handed over to the Bahi
Health District Office. Film shows,school-based education, adolescent and3. Multiple sectors including education, health, community

youth-friendly services, health education

development, planning, and the agricultural department,

sessions by volunteers, and monitoring andintegrated health-related interventions in routine activities.

supportive supervision of the volunteers by

4. Community development and agricultural department supported

health care workers were done properly.

income generation activities that allowed community health▪ Detailed implementation steps were

workers to provide reproductive, maternal, newborn, child, anddocumented so the plan would be

adolescent health interventions sustainably at the community

implemented even after personnel changes.

level.
5. Planning department at the district council level approved therequested funds by the district health department to support thesustainability of project-related activities.

Tips for future programs▪ The concept of sustainability should beshared from the beginning of the projectand put into practical terms.

Other effects▪ The strategy should be documented andBahi District was the first district to continue systematic

tested at various levels with district, ward,

6. Finally, an action plan was developed to ensure sustainability, and a “hand-overinterventions for sustainability under the JOICFP project. Theirand village level authorities, health careceremony” was held at the end of the project period for all to gain confidence andefforts served as a reference to other projects, such as Ghana,workers, and community volunteers.

boost motivation.

Zambia, and Burkina Faso.

27