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Attachment I:

POLICY Core Packages: Report on Progress and Results Through July 6, 2002

Contents

POLICY Core Packages...... 2

Romania...... 5

Ukraine...... 7

Nigeria...... 10

Mexico...... 11

Jamaica...... 13

Guatemala...... 15

South Africa...... 17

Philippines...... 19

RH GOALS Model...... 21

Peru...... 23

Kenya...... 26

Malawi...... 28

Assessment and Issues...... 29 POLICY Core Packages: Report on Progress and Results Through July 6, 2002

Overview of POLICY Core Packages

Rationale

In general, POLICY uses core funds to undertake specific activities that need to be carried out in order to advance technical progress globally, or achieve short-term objectives mutually agreed to with GH/POP/P&E. In addition, there are core-funded technical areas that warrant special attention such as HIV/AIDS, maternal health, and the project’s three crosscutting issues (adolescents, gender, and human rights). The history of core-funded population activities in the policy area over the last two decades shows that they consist primarily of single, often standalone activities often carried out in the U.S. Such activities have included special studies, model development, policy briefs, specialized program support such as NGO networks, improving advocacy training manuals, and special meetings on financing.

The underlying assumption with this approach has been that many of these core-funded activities will be picked up by country programs, and that assumption has been largely correct. However, the amount of time that it takes for some policy tools to be tested in the field and diffused can be lengthy. Some of them may not even reach the testing stage, or staff may not be able to find the ideal application for the policy tool. In addition, developing policy tools and approaches in isolation of a country setting does not necessarily inform the project and its clients (counterparts, USAID, NGOs, donors, communities) about the policy impacts of the approach, and how specific issues can be addressed in the field.

Therefore, POLICY has developed the strategy of using a portion of its core funds to test new policy approaches in POLICY countries. The strategy involves developing and implementing an integrated program called “POLICY packages.” We label these packages as ‘integrated’ because we combine some of the technical approaches of the different POLICY intermediate results (IRs) in designing them. In implementing the project generally, the IRs and their associated activities tend to merge. Technical advances, research, and experimentation ultimately involve more than just one IR, especially if they are aimed at obtaining meaningful results. Since the majority of our work is field-based, we can realize significant gains in efficiency and effectiveness for USAID’s global objectives through direct application of core funds to field packages.

The purpose of the POLICY package, therefore, is to advance USAID and its partners’ technical knowledge, demonstrate or test new or innovative approaches in the field, or provide additional resources that would shed light on a critical global policy issue that a Mission might not otherwise fund.

Description of Core Packages

What is a POLICY package?

The POLICY package is a combination of technical and financial resources that are usually applied at the country level. The package can include a mix of U.S.-based staff, country staff, consultants, and collaborating institutions as well as direct financing of specific activities such as studies and workshops. The contents of a POLICY package will depend on the opportunities offered in a particular country, and

2 USAID’s global objective in the policy area. However, the packages we have proposed and are contemplating focus mainly on IR1 and IR2—advocacy and planning and finance—and their synergies, and on the underlying crosscutting issues of gender, human rights, and adolescents. The duration of POLICY packages is roughly 12–18 months; however, successful packages, or ones showing great promise, can be continued for a full second year. Once developed or tested in the field, the products of such work will be applied in other settings and countries.

What are the technical emphases of the POLICY core packages?

GH/POP/P&E wishes POLICY II to achieve strategic objective (SO) results in 10 countries under the basic award, and IR1 and IR2 results in at least 20 countries. Both the SO and IR2 are heavily dependent on achieving results in planning and finance areas such as targeting resources, involving the private sector, spending money more efficiently, and increasing funding for FP/RH services. These are technical areas that are generally not adequately funded by USAID Missions (as opposed to advocacy and policy dialogue, which tend to receive more Mission support). Therefore, to achieve the results expected from GH/POP/P&E for the SO and IR2, we place a premium on POLICY packages that produce transferable techniques related to planning and finance including operational policies. Packages may also be directed to POLICY’s three crosscutting issues of gender, adolescents, and human rights.

In addition, as the project is doing more work in HIV/AIDS policy, core funds from the HIV/AIDS Office will be directed to core packages as well for the same overall objective of advancing global knowledge of key policy issues. The two technical areas that have emerged for HIV/AIDS core package funding currently are policies affecting stigma and discrimination, and financing.

Because packages are meant to provide knowledge and experiences with global relevance, packages also have an emphasis on documenting the activity and results. Only through clear documentation can the lessons and experiences be transferred to the wider community.

Where are POLICY core packages offered?

Core packages involve intensive application of POLICY’s human and financial resources and require a combination of IRs, so it is only possible to focus on four to six countries or packages each year. In this manner, it may be possible to apply packages in as many as 12 to 15 countries over the life of the project. Countries are selected based on specific criteria including POLICY’s in-country presence, Mission receptivity, the technical opportunity available, the prospects for success and replication, and the potential impact on achieving the project’s SO and IRs.

Core Package Status by Country

Since the first core package on contraceptive security in Romania began in March 2001, six additional packages have been designed, processed, and approved and are now underway. POLICY began core package work in Ukraine, Nigeria, and Mexico in 2001, and in Jamaica, South Africa, and Guatemala in 2002. In addition, two other core package proposals were approved in the second quarter of this calendar year. USAID approved a package on safe motherhood in Peru that will get underway by POLICY this summer, and a package to develop a resource allocation model for reproductive health based on the principles of the HIV/AIDS GOALS model.

Table 1 lists core package countries by thematic area and provides the start and end dates, as well as financial information. The following sections contain country-specific detail on each of the core packages.

3 Table 1. Core Packages by Theme, Status, and Budget Expenditures CTO Approval Mission Expected Country Thematic Area Obligation and Accruals Pipeline Date Approval End Date as of June 30 Contraceptive Romania Mar. 2001 March 2001 July 2002 $442,396 $394,349 $48,047 Security

RH Operational Ukraine July 2001 July 2001 Dec. 2002 $393,538 $246,433 $147,125 Policies

Adolescent Nigeria Sept. 2001 Oct. 2001 March 2003 $260,000 $75,253 $184,747 FP/RH

Stigma and Mexico Dec. 2001 Dec. 2001 Dec. 2002 $125,000 $20,482 $104,518 Discrimination FP/RH and Jamaica HIV/AIDS Dec. 2001 Dec. 2001 April 2003 $435,348 $34,215 $401,133 Integration RH Operational Guatemala Nov. 2001 Dec. 2001 June 2003 $163,568 $18,557 $145,011 Policies

Stigma and South Africa Feb. 2002 March 2002 Jan. 2003 $125,000 $6,091 $118,909 Discrimination

Contraceptive Not Philippines May 2002 July 2003 $398,758 N/A N/A Security Approved

RH GOALS TBD July 2002 N/A July 2003 $260,000 Model

Safe Peru June 2002 June 2002 Dec. 2003 $245,409 Motherhood

FP Operational Pending Kenya June 2002 Feb. 2004 $400,000 policies Approval

FP Operational In Malawi June 2003 policies development

4 Romania Core Package: “Eliminating Operational Policy Barriers to Contraceptive Security in Romania”

Background

The purpose of the core package in Romania is to help the government of Romania (GOR) Ministry of Health and Family (MOHF) identify and eliminate operational constraints to implementing recently approved national contraceptive security policies. These policies aim to allocate government resources for contraceptive procurement, channel free contraceptives to disadvantaged segments of the population, create contraceptive revolving funds at the district level, and ensure access in rural areas.

The package includes three policy analyses to identify operational barriers to contraceptive security: (1) public sector funding for contraceptive procurement; (2) contraceptive market segmentation; and (3) implementation of the new contraceptive security policies. Research results will contribute to development of recommendations for policy action. The recommendations will drive the design of a pilot project to test new national policies designed to remove operational barriers to contraceptive security.

The package also includes assistance to form and strengthen local advocacy networks in three USAID priority judets (districts). These networks advocate for access to contraceptive services and commodities, especially among the most vulnerable segments of the population. Together with the national Reproductive Health Coalition of Romania, POLICY supports the judet networks in their efforts to advocate for final approval of revised contraceptive security policies by high-level decision makers and subsequent nationwide implementation.

Status and Achievements

The Romania package was developed by US-based POLICY staff in close consultation with Romanian staff and the MOHF. POLICY’s CTO approved the proposal in February 2001, and USAID/Bucharest approved the proposal in March 2001. Work began immediately, coincident with field support. Under the leadership of Country Manager Imelda Feranil, the Romania team of local consultants and US-based staff implemented the scope of work as specified in the proposal on schedule and within budget.

Technical assistance through the package helped achieve the following results:

 Three RH advocacy networks were formed in the USAID priority judets of Constanta, Iasi and Cluj.  The multisectoral judet networks include women’s groups, NGOs involved in FP/RH/AIDS, youth groups, human rights groups, faith-based organizations, and ethnic minority alliances.  The MOHF used POLICY data and analyses in the Minister’s Memorandum to the Committee on Transparency (composed of MOHF Board members, College of Physician representatives and National Health Insurance House officials) arguing for the inclusion of generic formularies of contraceptives in the list of drugs that should be covered under health insurance.  Also as a result of the core package and the technical assistance provided through it, the Romanian government approved several policies that directly increase resources for contraceptives:

5 o In late September 2001, the MOHF added 4 billion lei to the initial outlay of 7 billion lei for contraceptives for the year (an addition of approximately $125,000, resulting in a total outlay of $350,000). o The Law on Public Health Financing (Government Decision 41/17 of January 2002) approved procurement of contraceptives for free distribution for 2002. The MOHF subsequently approved an allocation of 10 billion lei for free contraceptives for 2002 (approximately $333,000 compared to $250,000 initially allocated in 2001). o The National Health Insurance House (NHIH) approved the inclusion of oral contraceptives and injectables in the list of generic formularies for drugs that will be covered under health insurance (NHIH Order No. 44/8, February 2002).

The three policy analyses on public sector funding for contraceptive procurement, contraceptive market segmentation, and case study of implementation of the new contraceptive security policies were helpful to Romanian partners and stakeholders who attended the October 2001 policy dialogue forum. The papers had, for the first time, provided concrete analysis and policy options based on hard data instead of anecdotal evidence. Also, USAID/Bucharest was particularly impressed with local consultant Mrs. Erhan’s paper, which laid out the flow of funds and processes related to the Romanian government’s budget for family planning.

The policy papers helped partners and stakeholders to better understand what policy analysis is. Stakeholders were most concerned about the need to improve efficiency in using scarce government funds for national and local procurement and distribution and in targeting such resources to the most disadvantaged. To ease the process of certifying eligibility for free contraceptives, participants proposed self-declaration of income instead of the current onerous process of obtaining certification of poverty status (requirements include notarized or field verification of tax status and mayoral approval). The MOHF is currently meeting with the Ministry of Finance about self-certification approval. The MOHF would subsequently develop guidelines for use in self-certification in the field. Another issue raised was the need to improve national and local procurement guidelines to ensure value for money. The MOHF and the national procurement agency for contraceptives are reviewing operational procedures in this regard. Contrary to the initial intention of drafting and pilot testing policies to remove operational policy barriers to contraceptive security, the MOHF instead moved directly ahead with policy changes at the national level because they felt the pilot test was unnecessary.

In the final months of the core package (January–June 2002), activities have focused on monitoring government action after the October 2001 multisectoral forum and on training and assisting three judet advocacy networks prepare for advocacy campaigns on related key issues. The government and the MOHF still need to act on several policy recommendations from the forum and the policy research, but POLICY has already accomplished many high-level results in Romania under the core package. Without further funding, POLICY will terminate project activities in July and close its Bucharest office.

The policy research methodology used in Romania is already being adapted for use in other countries. For example, the Romania market segmentation report was recently used to finalize the Philippine market segmentation analysis. Also, POLICY/Philippines staff are examining lessons learned through Romania core package technical assistance and experiences, particularly related to targeting and coverage under health insurance for long-term sustainability, as they gear up for a program that will address the gradual phaseout of USAID contraceptive donations starting in 2003.

6 Ukraine Core Package: “Translating Ukraine’s National Reproductive Health Program 2001- 2005 into Action – Eliminating Operational Policy Barriers, Setting Priorities, and Improving Efficiency of Resource Use at the Local Level”

Background

The Ukraine core package is designed to help implement the National Reproductive Health Program (NRHP) 2001–2005 by eliminating operational policy barriers and strengthening the government’s capacity to set reproductive health (RH) program priorities and more effectively allocate resources at the local level.

The package includes two main components. The first is collecting and analyzing data on specific barriers impeding the efficiency with which RH services are delivered in two typical Ukrainian cities – Kamianets-Podilsky and Svitlovodsk. The findings will be presented in policy papers and used in dialogue among city health administrators and local leaders to promote local reforms. Also, the Policy Development Group (PDG), a national-level, multisectoral group of RH stakeholders, will use the findings to develop recommendations and detailed guidelines for approval by the Cabinet of Ministers.

The second, priority-setting component involves introducing and applying an adaptation of the Columbia Framework model for priority-setting in Kamianets-Podilsky. The framework considers six criteria for setting priorities including: (1) magnitude of the RH problem, (2) efficacy of RH interventions, (3) cost of RH interventions, (4) program requirements, (5) capacity of the health system, and (6) cultural and social acceptability of RH interventions. The main objectives of this component of the package are to:

 Determine program priorities based on relevant information;  Build local capacity to use the priorities to develop a RH implementation plan; and  Allocate local resources to fund priorities.

The priority-setting exercise requires relevant information to inform decision-making; cost information for each RH intervention is a key component. POLICY is currently conducting a costing study in conjunction with local subcontractors and consultants.

Expected Results of Core Package and Continuing Field-supported Work

 Measures that encourage efficient resource allocation and use adopted or approved; and guidelines or mechanisms for efficient and/or equitable resource allocation presented for approval. The PDG will use findings of the efficiency studies to draft recommendations to the Cabinet of Ministers to remove Ministry of Health (MOH) norms that restrict more efficient use of resources. POLICY will provide technical assistance to the PDG to develop these recommendations and guidelines for implementation. POLICY anticipates that the Cabinet of Ministers will approve these recommendations.

7  Policies or plans used information produced with POLICY support. In addition, the city administrations in Kamianets-Podilsky and Svitlovodsk will use results of the efficiency studies to draft their proposal to the Cabinet of Ministers for a pilot project to operate without the influence of these MOH norms.  New policies, plans, and programs adopted at national, oblast, or local levels. The city of Kamianets-Podilsky expects to receive approval to conduct a pilot project to use resources more efficiently in Fall 2002. POLICY plans to assist the city to prepare an implementation and evaluation plan for this pilot project.  Public official/NGO support for health initiatives increased. The Mayor of Kamianets-Podilsky has publicly expressed support for reproductive health and health care reform.  New financing mechanism identified and tested.  Plans or policies that promote increased resources for FP/RH presented for approval.

The Ukraine package experience and the tools developed through the package have potential application for both scaling-up in Ukraine and in other country settings.

Status and Accomplishments

The core package proposal development process was highly participatory, involving POLICY staff economists, technical directors, and CEDPA subcontractors. Ukrainian partners, including the PDG, MOH, and Mission, were consulted early on in the proposal writing process to determine their potential interest. The proposal was approved by POLICY’s CTO in late March 2001 and subsequently submitted to USAID/Kyiv for final approval, which was granted in July 2001. USAID/Kyiv’s delayed approval of the core package combined with last summer’s holiday season in Ukraine resulted in a September 2001 start-up date.

Implementation has taken longer than anticipated because of the needed capacity building for local subcontractor Medical Management and Audit (MEDMA) and local POLICY consultants, as well as the fleshing out of the complexities of the Ukrainian health system pertaining to the local RH environment. TA from US-based staff has been required to strengthen capacity of local consultants and the subcontractor to conduct the research and policy analysis. As a result, additional funding of approximately $50K is required to complete the package by December 2002. However, notable progress and accomplishments have been achieved in the first six months of the package.

Efficiency Component. In July 2001, POLICY executed a subcontract with MEDMA, a burgeoning local medical research organization that had prior experience and credible standing with officials in Kamianets-Podilsky and Svitlovodsk, where the studies are taking place. Between September 2001 and April 2002, POLICY worked closely with MEDMA to design a study protocol that included seven modules: (1) time motion assessment, (2) provider survey on time utilization, (3) bed utilization assessment, (4) length of hospital stay assessment, (5) input assessment, (6) patient exit interview, and (7) a facility management survey on financial decision making. POLICY also helped develop the instruments and data analysis plans. The development of survey instruments was designed to be a participatory process because creating local ownership is a vital aspect of the core package. It involved pilot testing and careful refinement to ensure that all the data collected would serve the intended purpose: to inform policy dialogue and facilitate operational policy reforms. MEDMA conducted the field work and processed the data from December 2001 to June 2002 and is currently analyzing findings.

Preliminary findings confirm inefficiencies otherwise discounted as anecdotal. For example, the time motion assessment shows that nurses and midwives are spending little time with clients and, in general,

8 are spending their time inefficiently. In many clinics and hospitals in Ukraine, nurses and midwives are tasked with completing administrative journals and registers. While some of these registers are important data collection tools, many have little purpose and are easily falsified. The burden of completing these journals and then reviewing the journals to ensure they have been completed provides little opportunity for nurses and midwives to provide clinical care. As a result, doctors are providing services that could be provided by midwives and nurses, and midwives and nurses are unable to use their clinical training. One of the policy roots of this problem is that there are no concrete job descriptions for midwives and nurses. While a job description alone will not improve the efficiency with which medical personnel work, it is an important first step.

The length of hospital stay assessment has also provided useful results. It has long been acknowledged by health reform proponents that inpatient facilities in Ukraine provide care that could and should be provided in outpatient settings. For example, in the gynecological ward in Svitlovodsk, 70 percent of the cases reviewed were diagnosed in the hospital after admission. In addition, discharge from the gynecological ward of the hospitals in Svitlovodsk and Kamianets-Podilsky was delayed in 63 percent of all cases that were reviewed. This resulted in 391 wasted bed-days – over 40 percent of the total number of bed-days assessed in the gynecological ward.

Such evidence-based information plays an essential role in any serious dialogue on reforms at the local and national levels. MEDMA has presented some preliminary findings to the PDG and will present final study results to the PDG at the end of September. The PDG will use findings of the efficiency studies to provide evidence and support their proposals to remove MOH norms that restrict more efficient use of resources.

Priority-setting Component. POLICY conducted an introductory workshop on priority-setting in Kamianets-Podilsky in November 2001. Partners selected six RH problem areas and identified interventions to address them. Partners became and remain fully engaged by making themselves available for various aspects of data collection required for the initiative. One of the most important and labor- intensive parts of this component is data collection on the direct recurrent costs and medical equipment costs related to the priority interventions. POLICY, MEDMA, and a local consultant are conducting a costing analysis of priority RH interventions. In the last few months, POLICY helped to develop and pretest expert focus group instruments for data collection and prepared spreadsheets for data processing and analysis. MEDMA and the local consultant have recently completed data collection and are currently processing the data. Analysis will be completed in July 2002 and will be packaged for discussion in a workshop scheduled for September 2002. It is anticipated that the September workshop will result in concrete recommendations on investing local resources for RH, including measures to streamline inefficiencies.

Overall, the Ukraine core package is proceeding well. Interest of host-country counterparts remains high and prospects for measurable reform are in reach. The momentum of interest related to conducting the policy research has, in turn, sparked a keen interest on the part of the Mayor of Kamianets-Podilsky. The mayor has publicly stated his intention at local press conferences to include RH as a line item in the city budget. He has endorsed POLICY’s initiative by ensuring participation from appropriate health sector professionals in both components of the package. He is also pursuing policy dialogue with his political peers to implement a local pilot project. This pilot project would allow the city to operate without the influence of MOH norms that currently restrict cities from allocating and using health care resources efficiently. Two other cities in Ukraine – Svitlovodsk and Komsomolsk – have also expressed interest in participating in such a pilot project. The cities plan to use results of the efficiency studies in their proposal to the Cabinet of Ministers to grant the cities pilot project status.

9 Nigeria Core Package: “Development of Advocacy for a Young Adult Reproductive Health Strategy in Edo State, Nigeria”

Background

The purpose of the Nigeria core package is to use a full range of POLICY tools and strategies in a single state in Nigeria to develop a statewide youth and adolescent reproductive health (YARH) strategic plan and increased funding for such programs in the state. The strategic plan will outline interventions that target specific YARH problems and subpopulations and specify resource requirements and a detailed budget. The plan will also include a monitoring and evaluation plan that will guide progress. In the course of establishing the plan, a youth advocacy network will be formed to participate in the plan’s development, garner political and budgetary support for the strategy, and provide ongoing support for other YARH issues. Activities include carrying out a situation analysis, forming an NGO network, advocacy training, developing a state-level YARH strategic plan, applying the NewGen Model, and carrying out an advocacy campaign. This initiative has strong potential for replication throughout Nigeria.

Status and Achievements

The core package proposal for Nigeria was prepared by a team of POLICY staff in Nigeria and the United States. POLICY CTOs approved the proposal in April 2001, which was then submitted to USAID/Abuja for final approval and approved in May 2001. Heavy workloads, competing demands, and summer schedules prohibited start-up before the fall. Under the leadership of Core Package Manager Scott Moreland, the POLICY Nigeria team launched the core package in September 2001.

An essential aspect of launching this initiative was identifying appropriate local partners and a favorable environment. After considering several states and potential NGO collaborators, POLICY decided to work in Edo State with the Women’s Health and Action Research Center (WHARC), which has excellent research and clinical capabilities as well as good advocacy and political skills. In December 2001, POLICY signed a subcontract with WHARC, and in January 2002, the project launch took place. WHARC and POLICY convened a multisectoral stakeholders meeting and a meeting of members of 30+ NGOs from Edo State. Consensus emerged for developing a state-level YARH plan and for forming an NGO network.

Between January and April 2002, POLICY worked with WHARC to design the situation analysis – a multifaceted approach to gathering essential information through focus groups and key informant studies among service providers, religious leaders, youth, and others. Guidance for structuring interviews is complete. POLICY also assisted WHARC in preparing for data processing and developing a data analysis plan. WHARC commenced field work in May, which is expected to be completed in June/July. In June, POLICY conducted a network building skills workshop for the burgeoning NGO network, which includes the 30+ NGOs that participated in the initial stakeholders meeting.

The core package is well underway, and the design has thus far proven sound and appropriate. Careful selection of the project site as well as local subcontractor partners provides a strong foundation for success. WHARC faces competing demands for staff time and will likely require more time for data processing. Subsequent activities rely on this data and information. Therefore, the pace of activities has been slower than initially planned. Work is expected to be completed in March 2003.

10 Mexico Core Package: “Measuring Stigma and Discrimination to Improve Program Approaches to HIV/AIDS Care and Prevention in Mexico”

Background

The purpose of the Mexico core package is to demonstrate how HIV/AIDS-related stigma and discrimination can be reduced through careful analysis and replicable interventions. The focus of the package will be on a concentrated epidemic, more specifically on men who have sex with men. The package emphasizes the empowerment of people living with HIV/AIDS (PLWAs) to be more open about their status and more proactive about tackling both the internal and external manifestations of stigma and discrimination. It also seeks to help health care providers and PLWAs to better understand how stigma adversely affects the delivery of services and the types of national and operational policies that can be adopted to reduce service-related stigma. The package will also show how public perception of PLWAs, as influenced by media images, can be improved and thus contribute to eliminating stigma and discrimination. The approaches to address these focal areas include the following four package components:

 Research to design a survey and indicators on stigma and discrimination and capacity building for PLWA organizations.  Research on barriers to access to and use of services in health care, welfare, employment, and legal support; development of policy dialogue materials in these areas; and development and pilot testing of a training program for health care providers.  Review of legislation, policies, and norms related to stigma and discrimination particularly in the workplace, combined with advocacy and policy dialogue to reduce discrimination in the workplace.  Development and testing of a media training and sensitization program, including involvement of PLWA and creation of a photojournal on PLWA.

Status and Achievements

Development of the core package proposal was led by US-based POLICY staff in collaboration with Mexico-based staff. Having been approved by the Office of HIV/AIDS and POLICY CTOs in November 2001, the proposal was submitted to the Mission for final approval, which was granted in December 2001. Initial start-up of the core package was delayed to enable host-country partners to become more actively engaged in the execution of the project because of its broad implications for programmatic considerations in Mexico’s AIDS Control Program. Under the leadership of the Core Package Manager Mary Kinkaid, the POLICY/Mexico team launched the initiative and regained the confidence of local partners that would play an essential role in the implementation of the activities.

To ensure local ownership, POLICY helped to form a Comite Directivo (Advisory Board) in Mexico to oversee all technical issues related to package implementation. It comprises representatives from CENSIDA, the National Institute for Public Health, academia, PLWA organizations, and POLICY. By

11 April 2001, the Comite Directivo was incredibly supportive and actively involved all aspects of the core package work.

In the past few months, activities began with a meeting of the local project coordinator with key counterparts to develop workplans and budgets for the various components. Plans are in place for the media and legal/regulatory policies package components and corresponding subcontracts with Letra S were executed in April 2002. The final configuration of the baseline/indicators component and the barriers to access to services component are still being negotiated, pending the outcome of discussions with the Measure Project and the National Institute for Public Health in Mexico.

Also, POLICY formed a three-person consulting team, including a lawyer, PLWA activist, and human rights activist, that is now poised to launch the third component – legal analysis, drafting of legal proposals, and advocacy for changes in laws to address stigma and discrimination issues in the target states. In collaboration with the National Institute for Public Health in Mexico, we are preparing for an international expert group meeting on August 21–23, 2002 to identify the indicators and move the baseline survey ahead. The POLICY team involved in implementation of the South Africa package will participate in this meeting.

Due to sensitivities of local counterparts who prefer to be involved in technical design and approval of all activities, activities are being implemented at a slower than expected pace although they have not been modified in any significant way. The revised completion date is March 2004.

12 Jamaica Core Package: “Addressing Operational Policy Barriers to Facilitate Integration of RH/STI/HIV/AIDS Services at the Parish Level in Portland, Jamaica”

Background

The Jamaica core package is designed to help the MOH delineate the extent, feasibility, and potential scope of integration in FP/MCH and STI/HIV/AIDS services. POLICY activities will include studies of selected service delivery activities identified in the MOH’s 2000-2005 Strategic Framework for Reproductive Health. Following the analysis, POLICY will help develop a plan that addresses operational policy barriers that may impede integration at a parish level. POLICY will conduct a regional workshop (with national representation) to identify potential models of integration for the parish of Portland and the urban area of St. Ann’s Bay in St. Ann Parish. The experience gleaned from the parish level will be used to guide integration approaches for other parishes and will be useful to donors and program managers in other countries as they make decisions on integration of RH services.

Expected results include:

 Financially feasible implementation plan for integration of RH/FP/STI/HIV/AIDS services is approved.  New/revised national operational policies to reduce or eliminate barriers to integration are approved.  Local policy champions are identified and trained in advocacy.  Local policy champions participate in process of formulating implementation plan for integration.  POLICY-supported policy champions advocate for integrating FP/MCH and STD/HIV/AIDS services.  Plans for efficient use of resources are drafted and submitted for approval.  Revised or new national operational policies for reducing barriers to FP/MCH and STI/HIV/AIDS are drafted and submitted for approval.

Status and Achievements

The Jamaica core package proposal was drafted primarily by US-based staff and approved by POLICY CTOs and USAID/Kingston in December 2001. Under the leadership of Core Package Manager, Karen Hardee, the initiative was quickly launched in January 2002. During the final approval stage in Jamaica and in the start-up, some Jamaican partners expressed concern about not being sufficiently involved in the package’s development. Consequently, greater effort is being made to build ownership of core package activities.

To lay the foundation for collaboration, POLICY held a series of meetings in January with the MOH Tripartite Committee on RH and with the North East Regional Health Authority (NERHA) office to agree on the scope of work for the package. The MOH wanted NERHA to take ownership of the activities outlined in the core package so that the findings from the feasibility studies will actually be used in that

13 region, and potentially in others. However, leadership changes at NERHA1 have delayed the implementation of the kick-off workshop to determine which models of integration to test.

The workshop scheduled for June has been postponed until July or September at the request of the new NERHA RTD. This postponement also accommodates the schedule of the new Chief Medical Officer (CMO) of the Ministry of Health, who is interested in integration activities but could not participate in the June meeting. In the meantime, data are being collected on the existing FP and STI/HIV/AIDS services in Portland Parish and St. Ann’s Bay.

As a result of these initial delays, the package completion date is projected for June 2003.

1 The regional technical director (RTD) who had originally approved the package activities left in April and the new RTD started in May

14 Guatemala Core Package: “Removing Reproductive Health Operational Policy Barriers in Guatemala”

Background

The purpose of the Guatemala core package is to help develop and put in place operational policies to reduce barriers to family planning (FP) and support implementation of the recently restored national RH program. The package builds on an assessment of medical and institutional barriers that was conducted in 1999 with field support funds. This package will identify, study, and address through policy change the higher-level operational policies, laws, and regulations that are at the root of medical and institutional barriers identified during the 1999 survey. Since the three primary institutional FP providers (MOH, IGSS, APROFAM) have already taken measures to reduce operational barriers identified in the 1999 study, this package has the added advantage of expanding the analysis of operational policies to those that might hinder those institutional measures, some of which are policy actions.

The strategy consists primarily of analyzing the legal and policy framework and its impacts on the delivery of family planning services, conducting interviews with key informants to obtain additional information, and preparing proposed operational policy changes linked to barriers. POLICY expects to achieve several results:

 National operational policies to reduce or eliminate barriers to FP service delivery and access are approved.  NGO networks participate in analysis and formulation of recommendations for new/revised policies.  Local advocacy networks advocate for implementation of operational policies.  Documents of MOH, IGSS, and APROFAM identify different barriers to FP.  MOH, IGSS, and APROFAM use POLICY-supported data to propose reduction of barriers to FP.  Networks use POLICY-supported data to promote policies that reduce barriers to FP.

Status and Achievements

The Guatemala core package was jointly designed by POLICY staff in Guatemala and the United States, with input from local partners and USAID/Guatemala City. The POLICY/Guatemala Country Manager Lucia Merino first developed a concept paper to show how the core package study would complement ongoing field support efforts. The Mission and local partners were supportive of the potential initiative. The proposal, approved by POLICY’s CTO in September 2001, was subsequently submitted to USAID/Guatemala City for final approval, which was granted in November 2001.

As a starting point in January 2002, under the leadership of Core Package Manager Norine Jewell, the POLICY/Guatemala team conducted a workshop to present the objectives and strategies of the core package to partners, obtain their input and create local ownership. POLICY also studied relevant documents to illuminate the operational policies affecting Guatemala’s FP services and hired a consultant

15 to analyze the legal and policy framework for family planning. The consultant’s report will be finalized by the end of June.

In June, POLICY organized another workshop to expand understanding of the concept of operational policies by sharing POLICY’s occasional paper on operational policies and presenting case studies of operational policies in Guatemala. Participants discussed operational policies that may be causing the barriers identified in the medical barriers study and that require further examination during the next phase of work. POLICY also presented a report on the legal framework on FP and gained consensus for the next phase of work. Also in June, POLICY hired a second consultant to assist in the next phase of the project, and finalized the methodology and instruments for further data collection and analysis.

The Guatemala core package has been underway for six months. Activities thus far are on target and expenditures are in line with the proposed budget.

16 South Africa Core Package: “Measuring Stigma and Discrimination to Improve Program Approaches to HIV/AIDS Care and Prevention in South Africa”

Background

The purpose of the South Africa core package is to demonstrate how HIV/AIDS-related stigma and discrimination can be reduced through careful analysis and replicable interventions. The focus of the package will be on a generalized epidemic. It aims to identify, review, and document best practice activities and interventions (including appropriate indicators) in three sectors, all of which aim to reduce HIV/AIDS-related stigma and discrimination.

The core package will achieve its objectives by (1) working with a group of PLWAs to show how public perceptions of PLWAs, as influenced by powerful media images, can be improved and thus contribute to eliminating stigma and discrimination; (2) working with representatives from selected national government departments to examine how HIV/AIDS policies and programs are able to improve the workplace environment for those living with HIV/AIDS to enable them to access the necessary support services; and (3) highlighting models of best practice that help faith-based leaders to better understand stigma and how it adversely affects the availability and accessibility of their services.

The approach involves baseline data collection and analysis to generate information for all three components of the package in addition to training and multisectoral policy dialogue. For the media component, training in how to work with the media is expected to build capacity among PLWA to sustain a proactive dialogue with the press. It will create new leadership among PLWA in nine provinces and the increased positive coverage and reporting of PLWA in the community will send messages to the community that will reduce stigma and discrimination.

For the national government department component, consultative meetings with key heads of departments set the stage for examining the HIV/AIDS policy environment in the workplace within the context of international human rights charters. Focus groups and key informant interviews in 10 national departments are planned to identify key practices in the workplace and develop a set of guidelines and recommendations that will serve as an example for creating a supportive non-discriminatory environment.

For the faith-based community component, the package supports a dialogue between faith-based leaders around interventions that have reduced stigma. It also seeks to increase support for PLWA in particular communities.

Status and Achievements

The initial idea for the South Africa core package proposal was developed alongside the Mexico core package thus creating a critical link between the two packages. Based on an idea emanating from the POLICY Human Rights Working Group, POLICY technical directors developed the proposal in conjunction with USAID/South Africa, the HIV/AIDS and TB Chief Directorate at the National Department of Health, and other relevant stakeholders (including the National Association of People Living with HIV/AIDS).

17 Approval for the core package was given by the POLICY CTO in March 2002, including the HIV/AIDS Office at USAID/Washington. USAID/South Africa and the HIV/AIDS and TB Chief Directorate at the National Department of Health approved the proposal in April 2002. The Centre for Study of AIDS at the University of Pretoria will manage the core package, and POLICY/South Africa is in the process of recruiting a full time staff member to manage it.

To create local ownership of the core package, POLICY immediately began negotiating with key stakeholders for permission to undertake the research in the three components. Supportive stakeholders include the Chief Directorate: HIV/AIDS and TB; the National Department of Health; the Interdepartmental Committee on HIV/AIDS; and the National Association of People Living with HIV/AIDS.

Recently, a subcontract was executed with the Centre for Study of AIDS, University of Pretoria to undertake the research. Preliminary work has begun to develop protocols, survey instruments, and other related materials. POLICY’s Country Manager began recruiting for a full-time staff member to work on the core package.

18 Philippines Core Package: “Developing Sustainable Solutions to Family Planning Program Needs at the Local Government Level in the Philippines”

Background

(Note: Not approved by the Mission but included here because POLICY spent some modest resources on its development and it illustrates our interest in addressing key financial issues around family planning financing.)

The purpose of the Philippine package is to assist local government units (LGUs) develop a sustainable strategy to meet FP needs in a decentralized setting within the context of health sector reform. The theme of the package is contraceptive security. In the Philippines, most contraceptive supplies are still donor- funded and distributed through the Department of Health (DOH) network. However, donor phaseout is on the horizon. With devolution mandated under the 1991 Local Government Code, LGUs will need to take on more responsibility for various development programs, including FP. One potential advantage to the decentralized administrative environment is greater fiscal and administrative flexibility. This increased flexibility will enable LGUs to develop innovative financing schemes, such as user fees in public outlets, localized community insurance schemes covering health services, and other modes of public–private partnerships not feasible at the national level. This package is designed to help LGUs develop innovative strategic plan that will address planning and financing for FP in the context of health sector reform. It is envisaged that a prototype planning process will be developed for replication in other LGUs in the Philippines and in other country contexts where decentralization is underway or has already taken place. Through the core package, the prototype planning process will be developed in two culturally diverse provinces selected from the eight provinces currently engaged in the health sector reform planning process.

Several measurable results are expected under the core package:

 Local plans to meet family planning needs in two LGUs including financing are approved by local authorities (Governor, Provincial Planning Development Office, and Provincial Health Office);  NGOs participate in the formulation of the local plans to meet family planning needs in two LGUs;  Guidelines for a targeting strategy are submitted and approved by local authorities (Governor, Provincial Planning Development Office, and Provincial Health Office);  POLICY-supported market segmentation study is used in designing strategies for the targeting strategy and public-private collaboration;  Individuals trained in the strategic planning process develop prototype of the planning process for replication in other LGUs.

Status and Achievements

The core package proposal for the Philippines was developed through a collaborative and iterative process involving POLICY Country Director Aurora Perez and local consultants. USAID/Manila and the

19 Secretary of Health were consulted on the concepts and preliminary design of the package early on and both expressed keen interest. In April 2002, POLICY’s CTO approved the proposal, which was subsequently submitted to USAID/Manila for final approval. The core package was still under review at the Mission as of June 15, though approval seems imminent. In the future, continuously updating the Mission throughout development of the proposal might help to expedite the approval process.

20 RH GOALS Model Core Package: “Reproductive Health Resource Allocation Model with Country Application”

Background

The purpose of this core package is to develop a model to assist countries to develop comprehensive reproductive health action plans (RHAP), and to achieve greater efficiency in the use of available funds. The model is intended to improve resource allocation both within and across the components of reproductive health programs. It will facilitate policy dialogue among all concerned stakeholders about feasible goals, the cost of achieving those goals, and the impact of alternate ways of allocating available resources.

In many cases, national reproductive health action plans set goals for the various components of the plan (family planning, safe motherhood, HIV/AIDS, adolescents, etc.) but the goals are not linked to funding requirements and may not even be feasible given available resources. This core package will produce a resource allocation model that will assist countries to develop feasible goals and understand the funding required and the benefits that can be achieved from additional funding.

Use of this model, as part of the priority-setting dialogue, will lead to two key outcomes:

1. Improved reproductive health action plans, with increased efficiency in the use of funding resources; 2. Better dialogue between all stakeholders regarding reproductive health priorities.

Innovative Approach. Planning for comprehensive reproductive health programs has been hampered by a lack of tools to relate program actions to goals. Family planning has had such tools for a long time. It is relatively easy to relate increases in contraception services to reductions in fertility and unwanted births. In the fields of safe motherhood, HIV/AIDS and adolescents it has not been possible to relate expansion of services to key outcomes such as reductions in maternal mortality or HIV incidence. This lack has made it impossible to allocate resources and set goals for comprehensive reproductive health programs.

Recent work by the POLICY Project has made it possible to establish these linkages for safe motherhood and HIV/AIDS. This activity proposes to combine these new approaches into an integrated planning tool to facilitate goal-setting, priority-setting and resource allocation.

This package offers a new mechanism whereby planners can examine various action programs within a single framework, and manipulate the input assumptions to explore alternative uses of resources. It promises an analytic tool to the field that has not been available. As a by-product, its application within a country will bring together data on various programs for joint examination and use, something that is often not done even within Ministries of Health

Potential for Wider Impact. Most countries are developing or have developed reproductive health action plans as a result of agreements made at the ICPD and ICPD+5 conferences. This model could potentially contribute to better programs in most of these countries. In many countries allocation of health resources is done at the district or state level. Uganda, Ethiopia, Kenya and India have all expressed an interest in

21 tools that can assist in resource allocation decisions at the sub-national level. As a result, the potential applications of this model are large.

Approach. Most countries have developed or are developing reproductive health action plans (RHAP). There are many challenges to this work. Some of the biggest challenges are how to answer the following questions:

 How much funding is required to achieve the goals of the RHAP?  What goals are feasible (for indicators such as unwanted pregnancies, maternal mortality ratio, number of HIV infections)?  How should we allocate the available resources to best achieve these goals?

This model will assist in answering these questions by linking funding to program activities and linking program activities to outcome indicators. A major problem facing policy makers is resource allocation; how best to allocate available resources to achieve the desired goals? This is difficult because of the lack of good costing information on many components, the lack of any way to relate funding on specific program activities (such as counseling and testing) to outcome indicators (such as HIV incidence) and the multiplicity of goals. While it would be possible to develop a model that would optimize resource allocation, we do not propose to do so. Optimization would require that all goals be expressed in a common term, such as disability-adjusted life years. Such an approach would lead to the conclusion that the most cost-effective interventions should be funded fully while the least cost-effective should receive no funding. In reality, policy makers need to balance a variety of concerns in addition to cost- effectiveness. These include issues of equity, social values, political support and existing programs.

Therefore, this model aims to improve priority-setting and resource allocation by clearly showing the consequences of resource allocation decisions on a variety of outcome measures. The model will calculate the consequences of policy decisions on these outcome measures while the participants in the planning process will decide how much importance to give to achieving these various goals. The outcome measures in the model will include such high level indicators as unwanted pregnancies, maternal deaths and new HIV infections as well as intermediate indicators such as family planning users, people receiving advanced treatment for HIV-related complications and access to emergency obstetric care,

The participants in the policy dialogue process should represent all the stakeholders interested in quality reproductive health programs. Once the final plan is developed, different stakeholders can undertake dissemination and advocacy programs to support the effective implementation of the plan.

After POLICY develops the model schedule for the end of 2002, then we will field test in it a country. Jordan and India are currently under consideration.

Status and Achievements

POLICY will begin work on this package in July 2002.

22 Peru Core Package: “Overcoming Operational Barriers to the Provision of Services Essential to Safe Motherhood in Five Low-income Departments in Peru”

Background

This core-funded component of the Peru Workplan will help to develop and put in place policy solutions to reduce operational barriers that impede client access to and utilization of services essential to reducing maternal mortality and ensuring safe motherhood in low-income areas. The barriers to access and use may exist at the household, community, or service-delivery level. Although this package may identify the barriers at the household and community levels, the focus will be on operational barriers at the service- delivery level. Operational barriers at the service-delivery level are often symptomatic of inappropriate and/or outdated operational policies2 and regulations at different levels of the health system. This package proposes to identify and study such policies and address through policy change operational policies that are at the root of these barriers.

Specifically, the package will

 Conduct an in-depth analysis of the underlying policy causes of existing access barriers that are identified;  Improve understanding of the difference between utilization of prenatal services and utilization of delivery care services; and  Help formulate new and/or revised operational policies to remove these barriers.

This package will not only provide actionable information and policy analysis for Peru, but will also have global implications. Numerous countries suffer from similar barriers to good maternal health outcomes, and could learn much from this proposed methodology for improving operational policies.

There are many hypotheses and questions surrounding the fact that poor pregnant women opt not to use free delivery care services, putting themselves at risk by delivering without the assistance of a professional caregiver, such as a professional midwife or doctor. A thorough analysis of these hypotheses is a critical step toward identifying and addressing the barriers that stand in the way of access to and use of safe delivery care by low-income women. Reducing or eliminating such barriers in parts of Peru where the MMR is higher is an essential means of saving women’s lives.

Approach. The package will begin with the selection of five departments (rural, low-income, high maternal mortality, high number of unassisted deliveries) as study sites for the package. As mentioned previously, Peru is a very heterogeneous country and maternal health problems and profiles differ from one department to another. In selecting the five study sites, POLICY will group Peru’s 24 departments by

2 Operational policies are the rules, regulations, guidelines, operating procedures, and administrative norms that governments use to translate national laws and policies into programs and services. These policies may pose barriers to service delivery due to misguided design of the policy or misguided implementation of an appropriate policy.

23 maternal health profile and pick one department from each group for study, thus ensuring that policy recommendations and changes instituted in each department type will be relevant for others in the group.

Policy research and analysis will focus on the key question: what are the operational barriers that keep low-income women from seeking free delivery care at health facilities? The research will address the following questions:

 Are free services indeed free, or are women who deliver in government facilities required to pay for medicines, supplies, and other incidental costs, which may render facility-based care unaffordable to many?  Do some health facilities blatantly disregard government directives and charge women for delivery services (use of delivery room, medical personnel time, inpatient stay, etc.)?  Are reimbursements through the insurance system for delivery care at health facilities adequate to cover the actual costs of the services provided?  Do prevailing health facility norms and policies pertaining to delivery or ANC serve as barriers to women seeking delivery services?  Do pregnant women in remote rural areas receive adequate information about free delivery care services, and other characteristics of maternal health services, such as time schedules, type of available providers, home visits, and others? Are they aware of the needs of assistance when there are complications? Are they aware of the risk signals related to pregnancy complications?  How do cultural and social bias and tradition affect a woman’s decision whether to seek professional medical care at delivery? Are there opportunity costs related to costs incurred by women and their families to reach the health center/hospital that are deterrents to seeking services?

In order to answer these questions, in each department, POLICY will

 Analyze DHS and other secondary data. One such secondary data set is a POLICY-led health services survey conducted (using field support) in a sample of 135 hospitals and health centers belonging to 20 DISAs  Conduct individual interviews and focus group sessions with pregnant women and women who have recently given birth, both at their homes and at the health service delivery points.  Interview service providers.  Analyze existing hospital, DISA, and, where relevant, central MOH policies and norms that pertain to delivery care.  Review and analyze the rules and regulations of the integrated health insurance system, including its reimbursement policies.  Estimate the actual costs of providing delivery care services in a hospital in order to compare with reimbursement rates.

POLICY will organize and implement workshops for multisectoral groups of stakeholders, including civil society organizations, in each of the five departments to discuss findings, fill information gaps on policy roots, prioritize policies that need immediate attention, and identify/recommend policy solutions for reducing or eliminating the most harmful barriers. This same discussion will be fostered at the central level with the members of the Mesa Multisectorial por la Maternidad Saludable y Segura, which the MOH is promoting.

24 Using the recommendations that flow from the policy discussions, POLICY will assist hospitals and DISAs in the five departments to draft new and/or revised operational policies to address the identified barriers. These draft policies will once again be presented to a multisectoral group for final validation. POLICY will also work with the central MOH to reassess and, where necessary, revise existing guidelines on the insurance plan, particularly its reimbursement policy.

Status and Achievements

POLICY will begin work on this package in July 2002.

25 Kenya Core Package: “Improving Access to Family Planning Services in Public Sector Facilities for Poor/Underserved Populations in Kenya”

Background

(Note: This package has been approved by the USAID CTOs, but has not yet been approved by the Mission. We are anticipating Mission approval in August. It is included here because POLICY has spent modest resources on developing it.)

The overarching objective of this core package is to improve financial access to family planning (FP) services for the poor and other underserved groups. The proposed package intends to identify and resolve financial/ cost barriers to access to FP services for couples/ women who have very low incomes or are in other underserved groups. The package seeks to achieve the three following objectives:

 Enhance access to FP services amongst the poor and underserved by assuring that waivers and exemptions are appropriately applied to those who need them.  Assure that those revenues generated from FP-related fees are retained and used to improve the quality of FP/RH services.  Generate additional revenues to move the public sector toward eventual financial sustainability in the delivery of FP services, including especially management and logistics systems.

In its new National Condom Policy and Strategy,3 the GOK has made the long-term commitment to gradually introduce “fees for service” for all public sector health services, including FP in an effort to shore up the health system and expand access. At the same time, the GOK is committed to the effective application of a system of waivers and exemptions from fees for poor clients and other designated groups (e.g., youth, persons living with HIV/AIDS).

According to the MOH fee guidelines – last reviewed in 1994, MCH/FP, antenatal and postnatal services are to be provided free. In practice, however, public health facilities have put in place an “access fee” under the direction of the District Health Management Boards (DHMBs). It is highly likely that with increasing poverty levels, the poor and other underserved populations are being denied access to FP services on the basis of inability to pay. Against the background of government’s commitment to the “Poverty Reduction Strategy Process” (PRSP) and, in particular, strengthening the system of waivers and exemptions, it is critical to re-examine the levels of fees charged for FP services, and to put in place operational policies that provide a safety net to mitigate against the adverse effects of cost sharing.

3National Condom Policy and Strategy, 2001-2005, Republic of Kenya: Ministry of Health in collaboration with the National AIDS Control Council, September 2001, 23 p. The POLICY Project was the principal source of technical assistance to the Ministry of Health in the development and adoption of this national policy and strategy.

26 Approach. This package will apply elements of the POLICY Project’s framework for reforming operational policies4 through a participatory and mutually-supportive process to address the need to provide financial access to FP services for poor/ underserved populations in Kenya. We will study the following two operational policy areas and test various policy changes to see how access can be increased:

1. Fees, waivers, and exemptions for FP services 2. Targeting of services (e.g., targeted to low income households and other priority groups)

Potential Impacts and Expected Results. If successfully implemented, the core package will strengthen the development and implementation of FP operational policies/ guidelines and will improve provision and access to FP services, especially for the poor and vulnerable. The development of clear, transparent, and equitable fee, waiver and exemption guidelines will provide the poor and other vulnerable groups with much better access to quality FP services in the hospitals and other facilities in the four districts where we will implement core package activities while at the same time protecting them against the adverse impacts of cost sharing for FP and other health services. Through the development of a more responsive pro-poor fee structure, the poor and vulnerable will also have improved access to FP services at higher levels of the health care system. This will also improve the efficiency and effectiveness of the referral system/ structure with respect to FP/RH.

While providing free FP services to the very poor, it is likely that under new FP pricing guidelines, fees will continue to be charged for those who are able to pay for FP services. Also, by focusing on implementation of fees at the hospital level (outpatient and inpatient) and defining roles and responsibilities of the various entities in the process, the interventions will complement on-going MOH decentralization efforts. This will be essential for gaining ownership by MOH officials.

The proposed core package will also make important contributions to the PRSP. It also might promote better targeting FP funds from international donor organizations and others. Finally, the package will provide a strong leadership development component that will enhance capabilities of young health professionals involved in FP policy, services, and systems.

Status and Achievements

POLICY will begin work on this package when USAID/Nairobi approves it (expected August 2002).

4 Operational policies are the rules, regulations, codes, guidelines, plans, budgets, procedures, and administrative norms that governments use to translate national laws and policies into programs and services. See Harry Cross, Karen Hardee, and Norine Jewell, December 2001, Reforming Operational Policies: A Pathway to Improving Reproductive Health Programs, the POLICY Project.

27 Proposed Malawi Core Package Concept Paper: “Malawi: Removing Key Operational Policy Barriers that Limit Access to Family Planning”

Background

The best national and ministerial strategies and plans are not effective unless there is a positive operational policy environment to ensure the implementation of the larger goals and objectives. In fact, a poor operational policy environment can have an effect unintended by national policies and actually restrict access to services at the delivery point. The poor operational policies are all too obvious in the health system, which manifests the symptoms almost everywhere: lack of supplies, lack of personnel, misallocation of existing personnel, medical barriers, poor maintenance, lack of transportation, poor logistics, and so forth. One example is the fact that doctors trained at Malawian government expense are not required to remain in public service (apparently). Last year, only one of the 20 new doctors graduated in Malawi took up service with the government. A good example of a medical barrier in Malawi is the fact that HSAs (basic health workers) are not authorized to give injections of Depo-Provera even though they routinely give a number of other more complicated injections, such as immunizations.

Focusing on access to family planning services, this core package will examine the key operational policies that may act as barriers to service provision. For 3–4 operational policies, the core package would develop a plan for reform, including gathering and presenting state-of-the-art information, international protocols and norms, and local experience; estimate the positive impacts of reforming the operational policies in terms of increased access; develop and implement a modest advocacy plan to stimulate/assist the MOH to change the policies; and assess the impacts one year after the policy change. The Mission is delighted with this potential activity.

Status

This concept is still at the pre-proposal stage. It is included here in companionship with the Kenya proposal to illustrate how core packages can be brought to bear on key operational issue that inhibit access to family planning by underserved groups in Africa.

28 Assessment and Issues

Assessment

The concept and application of core packages in the POLICY Project has been an interesting and useful experiment. Perhaps the most unexpected characteristic of the programmatic approach has been the difficulty of actually implementing them (see issues section below). That is, while the idea seems fairly straightforward on paper and makes good use of core funds, the processes to design packages, obtain approvals, and in some cases, implement them have been more of a challenge than anticipated by project management.

There is little doubt, however, about the content of the core packages and their potential importance for improving policies for FP/RH, safe motherhood, and HIV/AIDS. In our initial planning, we targeted some key areas that would yield important breakthroughs and results. These general issue areas included financial and resource aspects of FP/RH, maternal health, and HIV/AIDS as well as our three crosscutting themes (adolescents, gender, and human rights). The importance of the core packages is underscored by the fact that they all have regional or global significance. The audiences for the results will be much broader and wider that just the countries or agencies in which they are taking place.

Although the development and approval of core packages are subject to a number of unpredictable determinants, we have been able to focus a good portion of POLICY’s resources on several key issues. First, through the core packages in the Ukraine, Romania, Guatemala Kenya, and possibly Malawi, we are in the process of building experience and knowledge about key aspects of access to family planning and other essential RH services. In particular, we are addressing central issues of insufficient financial resources to meet basic FP needs, such as contraceptive supplies (the latter especially when donors no longer will provide them), and operational barriers that keep people, especially women, from accessing services. With our maternal health funds, we have employed the core package approach to design and obtain approval for the Peru core package that will explore policy barriers to women seeking maternal care.

With our HIV/AIDS funds, we have chosen to focus on stigma and discrimination because stigma is at the center of the spread of HIV/AIDS (and acknowledged by many experts as the single greatest cause of the spread of AIDS today). Yet, little is known about what it is, how it works, and its determinants much less about how to influence it.5 Our core package work in Mexico and South Africa will result in cutting- edge findings on how stigma functions. Our secondary focus with HIV/AIDS funds would be in the area of financial barriers to access to care (although the exact focus has not been determined at this writing).

Therefore, the finds that we are employing for core packages have the potential of making major contributions to some of the most pressing technical issues in this decade. Because these issues are not well understood, and/or because the interventions to identify and modify them are not well known (and for these reasons, Missions generally do not fund them), we believe core packages are playing a critical role in moving USAID’s assistance forward in the next years.

5 A Population Council/Horizons review of HIV/AIDS and stigma in 2001 came up with only 21 studies worldwide, eight of them in the U.S.

29 Finally, by concentrating our core package work on a few key issues, we will be able to combine the results with our other fieldwork and begin to build a literature of experience and knowledge around these issues. The proposed core packages in Kenya and Malawi, and possibly other African countries will combine with our USAID/GH and AFR Bureau initiative (and some country program work) to improve awareness and access to family planning in Africa. With another package or two on stigma and HIV/AIDS, this body of work could become one of the most important pieces of policy research we carrying out with respect to HIV/AIDS in POLICY II.

Issues

There have been several issues, both major and minor, with core packages. In this section, we will address only the major issues.

Not everyone understood the core package approach in the beginning. The concept of core packages was introduced in the fall of 2000. It took time to develop core package definitions, procedures, and management mechanisms. In addition, there was some confusion on the part of all parties (including Missions) about exactly how the funds could be used. It was important, for example, that Missions and staff understood that these funds are one-time allocations for specific program activities that are not supplements to the ongoing country programs. The intention was not to use these funds to replace field support. We were able to clear up these issues by preparing guidelines for core packages, educating staff and counterparts, and working closely with those preparing core package proposals. Because our staff is spread out over the world, and we work with so many Missions, getting everyone ‘on the same’ page with respect to core packages took some time. One of the most heavily attended sessions at TD Week in April 2002 was on the subject of core packages. We have now reached a stage where there is fundamental understanding among staff of the purpose and role of core packages.

The development of core package proposals must involve all stakeholders. In several cases, we had difficulty with the timing of sharing proposals with the stakeholders, thus causing some of them to feel left out of the proposal development. There are four main stakeholders in the development of a core package proposal: POLICY staff (U.S. and field), USAID/GH/POP, the USAID Mission, and counterpart agencies in the country. Part of this problem is because we must obtain approval from USAID/Washington before seeking Mission approval. While this sequence is entirely logical, it can result in the situation where the Mission feels it is being presented a proposal ‘thought up’ or imposed upon them by Washington, or where the Mission feels as if it did not have sufficient inputs into proposal development. In one case, the host-country government also felt that it was not involved in the proposal development. These issues have caused significant delays in obtaining approvals for core packages.

It would be ideal if we could develop a way of preparing proposals that could involve all stakeholders simultaneously. In this manner, all of those who need to approve the package would feel a part its development and implementation. This approach is probably not possible, however, because it could raise expectations with one stakeholder while another may not approve the concept or proposal. We would like to discuss this issue further with our CTOs to figure out how best to put in place procedures where all stakeholders feel involved and supportive of the core package in question. Better or clearer procedure here should speed up the preparation and approval process.

Internal management of the core package development and proposals needed to be clearer. Within the project, there are a number of people involved in the management of the core packages once the core package begins. These include project management (Director, Deputies, IR Directors), regional managers, country managers, and technical staff both here and overseas. In the first nine months of core package implementation, it became apparent that there was not a clear understanding of core package oversight and management once the package is underway. This understanding is critical because the core packages

30 require first rate technical oversight, and they also may require midterm adjustments. To make the management and oversight functions, and decision making crystal clear, we expanded our guidelines for core package management and specified the role of all participants: who makes what decisions, how and when technical reviews will take place, and so forth. At this writing, we believe that the entire staff now has a good understanding of roles and responsibilities, which will help to ensure smooth implementation (from an internal management perspective) in the future.

Staff capacity to implement core packages may not be sufficient. If the Kenya core package is approved by the Mission in August, POLICY will have 10 core packages underway. We are anticipating several more in the next 5 months. Of course, some core packages (e.g. Romania, Ukraine) will phase out. However, we still anticipate that there will be a considerable demand for highly qualified technical staff to work on core packages over the next three years. The technical issues that we deal with in core packages are cutting-edge, and some of the technical approaches proposed have not been attempted before. Given that POLICY’s overall rate of expenditures will be increasing thanks to greater funding levels in FY01 and FY02, we will need to keep improving our staff not only by adding more staff, but also by raising the skill levels of existing staff.

We need to shorten the time frame for core package proposals. The POLICY Project now has less than 36 months before it ends in July 2005. Given the amount of time it has taken for some proposals to be approved and the inevitable delays that can be encountered, we are going to consider requesting that all core package proposals have a time frame of about one year (12 months). Previously, we entertained core package proposals of up to 18 months duration, and even as much as 24 months in the case of the stigma and discrimination packages. In addition, we will need to establish a closing date for the submission and start-up of core packages due to the end of the POLICY contract, which likely to be around January 2004, or perhaps a little earlier.

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