...... - .. j .-.. .. f 4 ; .gI." •
-?O.k1ATION/..MILYPL.NNING SUPPORT PROJECT, PHASE . USAID/MOROCCO
608-0133 -' ___ , The project aims to establish and demonsE-ra-e-w'ithin'_ oth 'e bt i a- . private saccors a capability to plan, implement, and evaluate cost-effective family planning programs. The project contains a variety of subactivities (12 separate activities) designed to promote the use of modern contraceptives among the target popuiation; raise the levels of awareness of population problems and commitment to
_.$ugus-23...._ ,887,0001787S 608-84-04 January 17, 1984 7 at-ar (Somc1t/) 3 .1797 ,887,- "i 'ut- .
I Ursula Nadolny 1Robert C. Chase i ission Director TrTinal _-gvauation _ _ Officer______I_____
IE+C programs and increased availability of services. The subactivities include
education, referral services, informational materials design, training, commodity support, and some data gathering/analysis/dissemination.
This was the final evaluation of this project and its 12 inter-related sub-activities, prior to the commencement of "Phase III" activities. The general objectives of the evaluation were to determine the progress of the project and of the 12 component sub activities; review the status of the family planning/health/nutrition services provided; I and suggest future directions for family planning activities and funding within the GOM, and potential spheres of cooperation with other ministries and agencies and with individuals outside the formal public health system.
Family planning activities in Morocco have progressed substantially during the past 5 years of project activity. Contraceptive Prevalence (CP) estimates indicate that the nationwide CP has more than dbubled from 12% (1978) to 27% (1983). In the 3 provinces , receiving home distribution of contraceptive methods since 1982, prevalence is irr the range of 41% to 53%.
USAID funding and technical support have been pivotal in assisting the MOH in its service expansion. Following initial delays in planning and facility constructiou, most of the 12 subprojects are now firmly under way. Two exceptions are the construction I of Family Planning Referral Centers (only 7 of the 10 planned are completed to date), and the commercial distribution of contraceptives (considered a risky activity, given the strong reservations of the medical establishment about the delivery of FP services by anyone except health professionals).
..ecific remarks on major sub-activities were as follows: 1) VDMS (Household Distribution) - Approximately 40% c-' the Moroccan population will be-covered by early 1984. Early service statistics indicate substantial client acceptance of all available methods. Provincial management, training and supervisory capabilities appear good. 2) National Sraining Center fur Reproductive Health - In operation since 1982. The Center provides ! 30-bed in-patient facility for referred obstetrical and gynecological cases, and pzrovides training for physicians in tubal ligation. 3) IE+C - Materials have been produced , both the MOE and the local IPPF affiliate. Materials include printed matter and radio and television productions. 4) Training - U.S., in-councry, and third country training .as been provided for medical students, physicians, nurses, educators, administrators, and statisticians/demographers. These training efforts have been essential to the * successful implementation of the project. 3) Other - During the project there has been a contraceptive prevalence survey in 3 VDMS provinces and field work for a second national CPS is currently underwair. The final report of che National Fertility Surrey was ,renared n..late 1983. • ' NEAR EAST EVALUATION ABSTRACT CONTiNUATION SHEET
Page 2 of 2 Pages
Key findings and observations by the evaluation team included support for the planned extension of VDMS and other project activities, but coupled with improved monitoring and evaluation of this activity via streamlined data collection and analysis at the local, provincial and national levels. Physician training in sterilization should be increased, and training of IUD insertion should continue, especially in rural areas and peri-urban slums. There is a need for clearer IE+C objectives, and for pre-testing and evaluacion of IE+C materials being produced.
Continued efforts to increase collaboration with other government ministries in the promotion and delivery of family planning should be encouraged. Finally, during the coming project period, thought should be given to mechanisms for increasing the self-financing capabilities of family planning activities in Morocco. In summary the evaluation found the project to be generally successful and a good example of productive cooperation and discussion between the GOM/MOH and USAID.
LESSONS LERNED (from evaluation report)
1) The implementation of strong, practical family planning programs need not necessarily be proceeded by promulgation of major population policy statements by the Government of Morocco. In this culture lack of overt discussion should not necessarily be construed as an.indication of lack of interest or concern regarding a given issue. 2) The provision of family planning via the existing health structure is more likely to ensure the long term availability and coverage of such services. 3) Home visits for family planning setrice delivery, by male and female health workers, are acceptable in Moroccan society. .; f-.OC.CTL VAL.UA.-ION . ,A %Y (FES) - PART I .,;.-.i Sym l-. ! 608-0153' USAID/MOROCCO SUPPORT, Ii A-ZVY LUAT .1 Ue.'ZA (E f.- --. ,ma,-,in:'.; r Ponn|kriovi.POPLATION/F.AILY im: PLA NING sT-L".aozr-IN-un., s.., Cauntry or AI=Af - ,.oe, F.I Yr,.SilJ No. . .NzI,,,nl1 "' FY) 84-04
LI, REGULAR EVALUATION C3 SPECIAL EVALUATION
-. Y ?FOJC.T IMLEMS.T.TION MATES r.- ESTIMATED PROJECT I 7. PERIOD COVERED- BY EVAtUATION A*,. -- I' M- C. oralaFlnai P.., FUND ING Fra (,.,,. ,) October, 1978 35 P;;o. or Cbicin Input A. 'ra-i s ,00 .000 T~i(ord. December, 1983 EuL4f axI~___ 0118 12000,000. T1 (o~yJDcme,18 F_ ,y __ aS.U $1,00S iow Iir:Iofn January, 1984 . ACTION DECISIONS APRCVED BY MISSION OR AIO/W OFFICE DIRECTOR
A. L h elilaImanfd/or unresolved tIavs; cite hua kam deing fur"rmray. 3NE 5Or DATE ACTION (NOTE: Mlmon ,islJims which a tki;wt AIO/W or rwgion-a ol,,Iea b-tlon should S RESPONSIaLOFFICER E C OMPLETEDLTEBe @aP=y ?VP 01 du:.-..n1, 9.6.. alrram, SPAR, PIO wh:c will prrm deta.led queer.) FOR ACTION
1. The proJect has been successful and should be MOH.AMPF/ continued 'and expanded.. USAID New Project 2. Information which documents public acceptability of 'and demand f6r (ontraceptive services should be made available on a regular basis to senior Govern mental leaders to encourage political and material .support for population and F.P. programs. MOH/AMPF Ongoing 3. Encourage use of up-dated RAPID presentation to senior GOM officials. MOH/USAID 06/84 4. Encourage AMLPF and MOH to develop compatible methods of collecting F.P. statistics; Determine TA require ments for data collection and management for both C ATF and MOH. USAID/AMPF/MOH 06-84 5. Establish system to determine acceptability and/or effectiveness of health interventions included in the VDMS package. USAID/MOH .06-85 6. In order to attempt to meet the demand, training of physicians in sterilization techniques should focus on HDs who do not have extensive administrative O i duties. MOH Ongoing 7. Standard criteria for the provision of tubal ligations should be dewveloped and uniformily used throughout the country.
I (Continued) S S. INVENlTORY OF DOCUMENTS TO SE REVISED PR AaOVE DECISIONS 10. AL.T ERNATIVE DECISIONS ON FUTUR IOF PRO0JECT PmIlct Paper lImplarrnton PlnOther (Specify) A. E C~antinue Proje=WItmou. aangs 4~., CI Network 1"
E] 2napneWa Plan PI017 -______8 Chwa Projoc: u. r~o
Li ga. mF~ra P10/C Other (Spi ly I Ch.angs Implarnti.natinPlan Prepare new Lr "Okcainu ProjecT PojA,.nn ,P"Project Paper ii. PROJ5T OFFICER AND HOST C:UNTRY OR OTHER RANKING PARTICIPANTS 12. M;on/AO,/W Offca 0lt:' .r A mr-o's- AS APPROPRIATE (?Jan- and Ties) Gerard R. Bowers, Population Officer B. Eilene Oldwine, Assistant Population Officer Tye "s
,Ursla Nadolny, Evaluation Officer Ty Nm,, . Robert C. Chase Onto JA N 2
4"D~~", .1015(1-3 PROJECT EVALUATION SU5ARY (PES) Continuation Sheet page 2
8. Establish a system for periodic review and revision of training anuals and provincial level supervisory responsibilities. MOH 06/84 9. Provide TA to the MOH to assist in IE+C materials development. USAID/MOH 08/84 10. Encourage the improvement of F.P. services provided by the private sector through the development of promotional training and information materials for pharmacies and their staffs. MOH/USAID On-going 11. Continue to develop the linkages between the HOH and other GOM ministries and private organizations to promote F.P. activities. USAID/MOH On-going ACKNOWLEDGEMEN TS
The evaluation team would like to express its appreciation for the administrative and logistic support provided by the MIOH and the staff of USAID/Rabat, and the openess and candor with which the family planning project vas discussed vith the team. The evaluation .as further assisted by the extensive efforts of the MOH, APPF, and USAID to provide all relevant project documentation. We would also like to acknowledge the generous hospitality of the provincial medical -staff in Casablanca, Kenitra, Beni Mellal, and Marrakech. TABLE OF CONTENTS
TEAM COMPOSITION------3 I. SUMMARY ------4 II. RECOMMENDATIONS ------7 III. PURPOSE OF EVALUATION------13 IV. EVALUATION METHODOLOGY ------14 V. EXTERNAL FACTORS------15 INPUTS------' 16 VII.VI. OUTPUTS ------
1. Marrakech Pilot Project ------17 2. Visite a Domicile de Motivation Systematique (VDMS) Program------.------19 3. 10 Reference Centers ------23 4. Training ------24 5. FP Services ------26 6. Commercial.Retail Sales ------27 7. IE+C------28 8. World Fertility Survey ------30 9. Contraceptive Prevalence Survey (CPS)------31 10. National Training Center for Reproductive Health (NTCRH) ------32 11. INTRAH------ 12. RAPID ------35 VIII. GOAL------IX. PURPOSE------36 X. BENEFICIARIES ------36 XI. UNPLANNED EFFECTS ------36 XII. LESSONS LEARNED------36 XIII. SPECIAL COMMENTS/REMARKS------38 XIV. ACTIONS TAKEN SINCE LAST MAJOR EVALUATION------47 XV. APPENDICES 1. Contraceptive Prevalence in Morocco ------48 2. Documents Reviewed------53 3. List of Persons Contacted ------55 4.. Sites Visited ------57 5. Forms - Stock Control and Services------58 6. Sample of Press Clippings------. .. ----- 61 3
TEAM COPCSITICN:
duiiana weissman, Populaton Officer Near East Bureau, AID Washington, D.C.
Jay Friedman, Program Analyst Division of Reproductive Health Centers for Disease Control, Atlanta
Maria Wawer, MD, Assistant Professor, Department of Population Dynamics, Johns Hopkins School of Hygiene and Public Health Baltimore, Maryland 4
I SU;.674ARY: Family Planning activities in ,orocco have prcgressed substantially during the past five years. Based on contraceptive prevalence (CP) estimates, naticnwide CP has more than doubled frcm 12% in 1978 to 27% in 1983. In the three prcvinces receiving horme distribution of contraceptive methods since lEl ('CiELV.S* program), prevalence is in the range of 41% to 53%.
These dramatic changes have cccurred largely as a result of public sector activities, particularly programs within the Ministry of Health (MOH) of the Government of iiorccco (GOM). Since 1978, the hinistry has been allocating ever greater support for family planning as a key component of reproductive and maternal child health. In addition, the MOH Five Year (1981-1985) Health Development Plan includes a goal of 24% contraceptive prevalence among NWRA by 1985, a goal vhich given all current indications, has already been surpassed. Both the substantial family planning gains and the Ministry commitment have evolved despite the absence of a population policy in the National 1981-1985 Development Plan.
USAID funding and technical support have been pivotal in assisting the MOH in its service expansion. Following initial delays in planning and facility construction, most of the 12 subprojects found in USAID Population/Family Planning Support II (Project 608-0155; 1978-1983, extended to March 31, 1984) are now firmly under way. The two exceptions are the construction of Family Planning Referral Centers and the commercial distribution of contrace'ptives. As a result of initial construction delays it appears that only 7 (of the 10 planned) centers will be completed by the PACO March 31, 1984. Given the success of home distribution by MOH nurses and a move away .froim service provision in relatively expensive fixed facilities, the rationale for building additional provincial reference centers has diminished; current USAID/Rabat plans do not call for additional expenditures for this activity. Concerning the second activity (commercial distribution) the Comiti Technique of the Ministry of Health has consistently shown great reluctance to embark on a activity it considers risky. (The medical "establishment" in Morocco outside of the MOH still has reservations about the delivery of FP services by anyone except health professionals). With respect to the other subprojects, the Evaluation Team noted the following salient points:
Visites a Domicile de Motivation Systimatique. Evaluation Team estimate based on logistics and survey data - The VDMS expansion to 13 provinces is proceeding as planried. The expansion has taken place in t,o ohases (3 provinces launched in 1982 and an additional 10 launched in l583)** and will cover approximately 40% of the lkoroccan population by the time field visits are extended throughout all 13 provinces in early 10.84. Early service statistics indicate substantial client acceptance of all available methods (pill, condom, referral for IUD and sterilization). Evaluation Team field trips to three VONS provinces suggest that in most cases management, training and supervisory capabilities are good The National Training Center for Reproductive Health has been in operation 3ince I62. The center provides a 30 ted in patient facility for referred obstetrical and gynecological cases, and has provided training for 26 physicians in tubal ligation. The NTCRH has also been designated by JHPIEGO as an international training facility for persons from other francophone/arabic speaking countries in the region.
IE+C materials have been produced by both the MOH Service de Traucation Sanitaire, and by the AMPF (l'Association Marocaine de Planification Familiale - Moroccan Family ?lanning Association), an IPPF affiliate. Materials include printed matter, and radio and television productions.
Training (U.S., in-country and third country) has been provided for medical students, physicians, ntirses, educators, administrators, and statistician/demographers. These training efforts have been essential to the successful implementation of the project (see Outputs), particularly the VCMS effort.
During the life of the project there has been a contraceptive prevalence survey in three VDMS provinces, and field work for a second, national CPS was underway during the evaluation team's visit. The final report of the National Fertility Survey (the Moroccan portion of the World Fertility Survey - WFS) vas received by USAID in December, 1983. The Evaluation Team formulated recommendations regarding many of the above activities, and has made more detailed observations regarding all 12 subprojects. The most important findings of the evaluation team were:
* Following a pilot project in Marrakech province *which ended in 1980, the project subsequently expended to three new provinces. Currently, expansion is taking place in 8 additional provinces (including, once again, Marrakech). Of these 8 latter provinces, two have recently been subdivided, resulting in 10 provinces, for a total of 13. 6
a. USAID has noted its intention to expand VE!S assistance to 9ive additional provinces, beyond the 13 Provinces now covered. Given the success of VD:S thus far, the evaluation team believes that this proposed expansion is highly warranted. in oroer to monitor and evaluate the VDIIS project progress, additional efforts are needed to streamline data collection and analysis a- the local, provincial and national levels. Indeed, there is a need for the timely flow of pertinent, essential data for purposes of analysis, process evaluation and planning for all Family planning activities in Morocco.
Data can be gathered via zervice statistics, surveys and special studies. The evaluation team noted a tendency to try to gather too much detailed data through zervice statistics. There is an immediate need for a standard periodic report combining VDMS and fixed center family planning activities. Training and supervision activities %sithin VDMS will also require ongoing evaluation and adjustment, particularly at the field level, including worker/client contact.
b. Given the success of home distribution and the move away from service provision in fixed centers, the evaluation team agrees that additional Reference Centers are unnecessary at this time. Training and clinical activities planned for the centers can be accomodated in existing provincial facilities. c. Given the high level of client demand for female sterilization reported to the evaluation team by provincial health personril in the provinces visited, it is important that the National Training Center train physicians as quickly as possible. Physician training capabilities should be increased with at least one other center or subcenter being established in Casablanca, to service the medical school of that city. d. The training of personnel in IUD insertion should also continue, particularly for those levels of workers (infirmiers brevetis) who are most likely to work in remote rural areas and peri-urban slums. e. There is a need for clearer IE+C objectives, and the pre-testing for and evaluation of IE+C activities and materials being produced both by the MOH and the AMPF. The comprehensability, acceptability and impact of existing materials is unclear. f. Continued efforts to increase collaboration between other government ministries (Jeunesse et Sport, Agriculture) and the MOH in the promotion and delivery of family planning should be explored and encouraged. g. Finally, during the coming project period, thought should be given to mechanisms for Increasing the self financing capabilities of family planning activities in Morocco. Various methods of improving program self reliance may be tested in pilot studies. The AIPF Is already examining the effects of charging clients small sums for contraceptives. Such pilot studies might be incorporated into the activities of the VDMS and 2.OH fixed facilities. Cooperation with traditional birthi attendants ano other groups not funded by the .CH, as vell as IE+C courses for pharmacists, may provide additional mechanisms for relatively inexpensive service delivery and client motivation. In aadition, information regaraing private sector utilization should be gathered during VC.N S home visits and special surveys.
In summary, project 608-C15F has generally proven to be very successful, and speaks well of the level of cooperation and discussion between the GO/MOH and USAID/Rabat. Specific observation and lessons learned will be of use not only to Morocco, but may also serve as an example to similar endeavours in other countries.
SI. RECOM,ENDATIOS
The evaluation team reccrmends that the evaluation reports be shared with MOH officials at the national and provincial levels.
1. Policy
Public support for family planning efforts in Morocco has increased significantly during the past two years. (See table of outputs). The Ministry of Health and AMPF should continue to encourage support from political leaders and policy makers through the publication of information which documents the widespread public demand for, and acceptance of, all modern family planning methods. This information should be made available on a regular basis to the Prime Minister and Cabinet to encourage their political and material support of family planning programs as an important ccntribution to the improvement of family health. Demographic data should be used to reinforce this effort.
2. Trainira
The accomplishments of this project in training, particularly at the service delivery level, have been truly impressive. The evaluation team identified several areas %hich will need further attention is family planning services are expanded.
Long term participant training has not been used in this project, and in fact, the evaluation team could not identify any shortcomings which were the direct result of not providing this kind of training; Short term training i.,hich is designed to develop specific skills has been used effectively. These efforts should be continued.
Each province has developed its own training manual for VDMS workers, and while all include the basic information needed for VOMS training, there is naturally some variation in quality. A periodic review and revision of training manuals at the central level is reccmmended so that all of the provinces will benefit from the strong points of each. 8
Supervision occurs at many levels in the VCiS system and includes the monitoring of field visits as well as a qualitative assessment of the itinerant's efforts. Supervisory responsibilities and activities need to be more clearly defined and incorporated into training for '/CMS supervisors. Use of a routine checklist, as well as systematic periodic field observation of VDUiS orker skills, should be considered. Additional training in data gathering and principles of data management at the national and provincial levels could provide the MOH with the ability to generate only that information which vould be useful at all levels of the health system. The provincial level econcme-administrateurs could be trained in handling service statistics, to do mini-surveys and random sample record searches, and to collect and aggregate data from operations research activities which could provide information for national level planning and administration efforts. The VOMS workers could profit from further on-the-job training or a regular review of procedures at the field level in the use of the VDMS client record form (FICHE).
Communications training was identified as a weak spot in every VDMS province visited. The didactic training currently being provided does not necessarily need to be expanded, but should be reinforced by practical field level training. This should be included and planned for in every VDMS training course. Training of nurses in IUD insertions has been successfully -instituted and should continue to be emphasized to ensure the widespread availbility of this service, the training of physicians in IUD insertions should continue but not at the expense of training nurses. The results of this program should be carefully monitored for early indentification of problems with expulsion or perforations which may indicate a need for additional training and/cr supervision.
Training of physicians in tubal ligation is not proceeding at a pace which responds to the current demand for this service. Training of physicians should focus on MD's who have time to perform tubal ligations, not those who have extensive administrative responsibilities. Training in the mini-lap procedure should be included because it requires less equipment than laparoscopy. Further training in the use of local anesthesia in tubal ligation procedures should be provided to encourage the use of this less complicated procedure. Criteria for the provision of tubal ligations are not uniformly applied at the provincial level. The evaluation team found that local criteria tended to be more conservative than national guidelines. MD's and nurses who most frequently cited the age of women (40-45 years) and parity (3-7 children with both sexes represented) as the criteria for a tubal ligation. Only one physician suggested that medical, 9
financial and social considerations, as vell as the desire of the wcmen, should be evaluated, and that it may at times be desirable to perform tubal ligations on ,.omen with less than 3 children. In order to avoid the imposition oF subjective individual judgments by heaith personnel, further emphasis on the guidelines developed at the national lvei shculd be made during training. These guidelines, which irclude medical and social factors, age of the women and parity, should be reviewed regularly r.ith health personnel to ensure their appropriateness in the Moroccan context and their consistent application. It was also recommended that the 1428 collect data on the characteristics of women who have requested a tubal ligation but v,ho were denied this procedure in order to gain a better understanding of the demand for sterilization.
3. Data Management Computerization of VOMS and other family planning data needs to be carefully planned to avoid overloading the system with data which will never be used. Provincial and national level program planners and managers will need to work closely with the computer specialists in the MOH and consider carefully their reccmmer.datons to ensure the most profitable exploitation of data.
The evaluation team noted the general enthusiasm at the national and provincial levels for monitoring of project progress through data gathering activ.ities. Some excellent finnovations (e.g. tracking private sector acceptors in Marrakech) are resulting from the provincial level efforts, and these should be enccuraged'. At. the snrne time, the principles of summarization of data as they move from local to provincial to national level, and differentiation between da'a which need be collected frequently on a routine basis, since it may change quickly over a short time period, and data #hich can be collected less frequently by special studies or surveys needs to be stressed. This would avoid overloading the system with unnecessary detail. Further reinforcement of the training of VDINS workers in the use of the client form is reccmmended (see training). More detailed recommendations on the design of the VOMS client form and bi-monthly report are contained in section VII of this report.
4. Information, Education and Communication Public and private sector goals in information, education and communication should be consistent and mutually reinforcing.
Communications training for family planning workers and trainers has been extensive in this project, as previously mentioned.
The pre-testing and evaluation in the field of other IE+C materials (pamphlets, posters, films) has been inadequate, and as a result, it is impossible to know whether these materials are appropriate and will make a positive contribution to overall IE+C goals. 10
The evaluation team recommends that USAID voithhola funding for IE print materials unless the 1!-0H/A,;P"F present ar accompanying plan fcr field-testing these materials pricr to their producticr; ar.d that USAID support for production costs be contingent upon the satisfactory completion of such field tests. Nor5over, respondants/test subjects should be representative of the client populations.
5. VOMS
The data available from the VDNS provinces indicated that this is a highly effective method of delivering family planning services. The statistics which are currently available do not provide very much information about the acceptability and/or effectiveness of the other health interventions which are included in,the VDO:S program.
The usefulness of these services could be documented through a series of special studies or mini-surveys which could be implemented in a limited number of provinces. For example:
- ORT: test the ability of women to mix the solution correctly 2-3 weeks after a demonstration has been given. Test the ability of communications materials to reinforce her knowledge. Investigate the extent to which people keep IE+C material to serve as a reference. Add to other surveys a question regarding the number of women whose children have had diarrhea who have used oral rehydration therapy. 4 - Iron and folic ac d supplements: Test acceptability. Question a sample of women to see if they do or don't actually use it. Examine their supplies.
- Actamine V and promotion of breastfeeding: review the selection of beneficiaries for Actamine V and test acceptability and actual use. Question women to determine their understanding of the advantages of breastfeeding.
- Immunization referrals: research should be done to evaluate the efficacy of the VDNS vaccination referral system. This should be done in cooperation with personnel of the Expanded Programme on Immunizations (EPI, or programme Elargi de Vaccination - PEV).
6. Fixed Centers, Reference Centers
The notable success of the VDMS activity serves to underline the need for a review of the activities of the fixed centers in the provision of family planning/family health services. Training and supervision of personnel in the fixed centers should not be neglected, and provision of services should be consistent with VOMS. For example, some centers give only one cycle of pills, while the VOMS programs gives three. Service statistics on family planning activities in fixed centers should be combined with VDMS service statistics. II
The physicial layout of the reference centers will make provision of services on a large scale difficult. The centers may be more profitably used as training and referral centers. There does not appear to be a need to build more reference cerzers.
7. National training tenter for Reproductive .alth, Activities a, the National Training Center Fcr Reproductive Health are progressing very well since the Center's inauguration in November, 1982. The caution of the directorship, in proceeding slowly with careful training of highly qualified personnel, is probably warrafted, given the conservative attitudes of the Moroccan medical establishment.
Plans currently being considered to expand the flexibility and efficiency of Moroccan tubal ligation activities should be encouraged. These are: Include mini-lap training in the sterilization training for physicians/in addition to laparoscopic sterilization since it requires a less complex technology. Initiate training for aneasthetists in both general and local anaesthesia. Such training will further enhance client safety, and in the case of local anaesthesia, further simplify the technical demands of tubal ligation. The Center's cautious approach in testing the latter approach in order to ensure iLs' acceptance by the medical profession appears appropriate. Collect cost information regarding the different methods of sterilization (training costs, equipment, etc...) which will provide valuable information for future planning.
- Re-examine client selection criteria, mhich currently require that women have four or more children (of which at least one is a male), and minimum age of 25-3'. Medical criteria can override the criteria of age and parity. The Center can serve a valuable role in collecting data regarding tlhe characteristics of women requesting'the procedure (both those who receive it and those who do not) in order to evaluate and adjust the criteria if appropriate. Sach criteria can then be discussed and suggested (although not imposed) at the provincial level.
- Expand training activities to cover as wida a range of medical students in Morocco as possible. 12
8. - Association M0!arocaine de Planification Familiale Service statistics should be gathered in a manner which makes it possible to combine and compare the public and private sector achievements in a periodic, joirtly sponsored A4PF-MGH report. Further development of !E+C materials should be based on scientific market research efforts, adequate fiald testing of materials ard post-production field evaluations of results, as recommended in the section on IE+C.
9. - Alternative Methods of Service Pro,-ision (Commercial Retail) The original project paper and project agreement provided for the development of a commercial retail sales program. The evaluation team confirmed the serious reservation on the part of key MOH officials which prevented the initiation of this particular activity, but would like to suggest some alternative ways to work in the public and private sectors in Morocco. The Ministry of Health has already made plans to train traditional birth attendants in order to upgrade their obstetrical skills. The use of these women as providors of family planning referrals and services could also be tested, with the understanding that their status as private sector service providers vould not change.
Fee for services within the MOh program should continue to be discussed as a means to alleviate the financial burden of this. major program. The collection of information on private sector users of family planning services and trends over time could be helpful in planning for the future use of MIOH resources. Experience in other countries indicates that urban dwellers are more likely to shift to use of the private sector for family planning supplies, w.hile residents of rural areas tend to remain dependant on the public health system.
The MOH could contribute to an improvement in the quality of services provided by 'he private sector pharmacies and increase their interest in the promotion and sale of contraceptives through the development of promotional training and information materials for the pharmacies and their staffs. The linkages between the MOH field workers and field workers from other ministries (Social Affairs, Agriculture) have not yet been fully exploited. Continuing efforts, including seminars and simple brochures which describe the services provided through the VONS program could help to raise the awareness of these other workers as to the availability of this integrated package of health and family planning services and increase promotion/referral activities, especially in rural areas. 13
III. PURPOSE OF EVALUATION:
The Population/Family Planning Support Project (608-0155), was authorized in August, 1978, as a five year (1978-1983) project, and was subsequently extended to March 31, 1984. The life of project cost is now $11,887,000 (Including AID/Washington centrally funded activities and contraceptives ($7,182,000) and bilateral costs. ($4,705,000).
The current evaluation serves as the final evaluation of the project, and of its 12 interrelated subprojects, prior to the commencement of phase III activities. The subprojects in question are: 1. VDMS Marrakech Province Pilot Project 2. VDMS Expansion to 10* Additional Provinces 3. Construction and Equipping of Family Planning Referral Centers 4. Training (U.S., In-Country, Third Country) 5. Improved Family Planning Services Commodity Support 6. Commercial Distribution System of Contraceptives 7. Information, Education and Communication (IE+C) Programs 8. National Fertility Survey - Moroccan Portion of the WFS 9. Contraceptive Prevalence Survey 10. National Training Center for Reproductive Health 11. INTRAH 12. RAPID
The general objectives of the evaluation were to:
- Determine the progress of the project and of the 12 component subprojects, including the magnitude and direction of family planning activities in project provinces.
- Review the status of the family planning/health/nutrition services provided.
- Suggest future directions for family planning activities and funding within the GOM; potential spheres of cooperation with other ministries and agencies, and with individuals outside the formal public health system.
* Later increased to 13 provinces following the sub-division of Meknes, Kenitra and Oujda provinces. 14
IV. EVALUATION METHOOOLCGY: Evaluation findings are based on: 1. In-country discussions with representatives of the GOH, Ministry of Health (MOH) and USAID Rabat; and of other agencies and organizations involved in health and/or family planning activities in Morocco: the APF,**UNFPA, UNICEF and MSH (Management Sciences for Health).
2. Review of existing documents, including current and previous project papers and evaluations, training manuals, etc...
3. Travel to discuss and observe project activities of sites in the urban areas of Rabat, Salg and Casablanca, and in three VDMS provinces (Kenitra, Beni Mellal and Marrakech). The evaluation team subsequently discussed all major findings and recommendations with the MOH and with USAYD/Rabat, and incorporated their suggestions where appropriate.
ihe Moroccan Family Planning Association (IPPF affiliate). EXTERAL FACTORS:
Sackcround
1. Given the perception, by personnel in the. 1OH and in the GCM in general, that family planning may represent a very controversial activity within a conservative Mioslem society, early efforts in this field were slow and hesitant. As late as 1976, evaluators of the USAID/Rabat population project found no reference for family planning within health policy. Today, the NOH has accepted family planning as an important measure to ensure the health of vomen and children. The 1981-85 Five Year Development Plan of the MOH has set a target of 24% contraceptive prevalence among Married Women of Reproductive Age (MWRA) by 1985. At this time, the statement is the only one referring to family planning, or population within the GOM National Five Year Development Plan. Nonetheless, increasing interest in family planning at the national level is indicated by the King's selection of population, along with food and water, as one of three items for discussion of the Royal Academy Meetings of May and December in 1982; the issue of a family planning postage stamp the same year; and leading articles in conservative news papers in 1983 which discussed the negative consequences of rapid population growth. (1983 PES, Part 1)
From the political viewpoint, experience accrued during the Marrakech Pilot Project of 1978-60, and subsequent VOMS activities in 3 provinces (1981 onward), have proven to be a positive factor in encouraging future family planning activities. Client and health worker acceptance has been high, while negative religious or political repercussions have not materialized. For example, during the Marrakech VOMS pilot, contraceptive prevalence rose to 43% for MWRA from a pre-project level of 18%.
External social factors and client demand can thus be expected to spur on future related activities within the MOH, with or without an immediate national population policy statement. The one area where a national policy may potentially have an impact at this time would be in encouraging greater family planning activities in other ministries, such as the Ministire de la Jeunesse et des Sports, Ministire de l'Agriculture, etc... It is probable, however, that such activities are more likely to occur as a result of interministerial discussion and cooperation with the MOH, if the latter ministry demonstrates an interest in such collaboration. (The AMPF has already initiated some collaborative activities. See Outputs).
2. Integration with Health:
Firm ccmmitment to integrated health care by the MOH has resulted in the provision of family planning within the context of other health interventions. The VOMS family planning/health package is delivered by intinirant/brevet6 nurses within the NiOH structure. Although there was concern that family planning would be swallowed 16
by the other activities, the judicious selection of a well defined, manageable service package appears to have had overall positive effects: in particular, all the service activities, and certainly family planning, are now firmly entrenched within the existing infrastructure. (See Lessons Learned).
3. Transoortation: UFPA Provision of ioueds The VDMS program could not have been achieved without the provision of approximately' 800-mopeds for rural itinerant workers and for their supervisors. -The mopeds were made available by the U?1FPA. The important role of the UNFPA in this regard must be acknowledged; however, delays in provision for sufficient numbers of vehicles resulted in a half year delay in project expansion to rural areas. The additional time was used to improve pre-project planning, including the creation of training materials.
VI. INPUTS AID inputs have been committed to this project on a timely basis. Commodities, technical services, and training opportunities have been made available to the GOM, often well in advance of actual use. The original project implementation plan could not forsee the delays in implementation which would result from the year-long debate within the Ministry concerning the expanded VDMS service package, or the six month -delay in the delivery of the mopeds provided by UNFPA ' for rural VDMIS workers. The slow initial progress of this project has been documented in the Annual Project Evaluation Summaries (1981 and 1983) and In the mid-project evaluation (December 1981). Local currency obligations were made well in advance of actual expenditures; and contraceptive commodity orders were adjusted downward in 1981 to reflect slow project implementation. The acceleration in project implementation can be illustrated most easily by a comparison of the expenditure rate for the VDOMS program $211,000 in 1982, and $1,750,000 in 1983, when expansion from 3 to 11 (now 13) provinces took place. Additions to the original list of project inputs include the RAPID presentation; the 1982 and 1983 national contraceptive prevalence surveys; population communications activities; provision of IUD-insertion training and equipment (an addition of major importance, since it made possible a significant increase in the availability of this contraceptive method at the lowest levels of the MOH service system); and renovation/equipment at the National Training Center for Reproductive Health. 17
TABLE OF OUTPUTS, OUTPUT INDICATORS, PROGRESS, STATUS
Outputs Magnitude of Outputs Progress/Current StLatus Expected Dates Courents/Prolleiiis/iiuses
1. Marrakech VDMS success fully completed
- 2 home visits, No. of intin~rants Completed in 1980. Conceived late Tte alrrakech P*!S pilot conducted by brevetes: 179 In October 1903, 1976. represented a single intin~rant-brevet~s tarrakech province service (family planning nurses for delivering No. of households became one of the Implemented only) delivery proqram, f.p. visited: 150,000 (38% 13 provinces in the late 1977. based oni 2 hooe visits tc urban and 62% rural) new integrated VDMS each I .WIlA. ClieiiL - Pre survey in urban expansion. Completed in 19810. acceptance of the + rural areas. Percentage of MWRA appro:Ih fac i tated visited tho accepted later VIlS expasioji. - Post survey in family planning urban area only Urban: 67% Rural: 56%
C.P.R. for visited women before VDMS: 25% (49% urban 11I%rural)
F llowing VilS: (65% urban 45% rural)*
* Minist~re de la Sant4 Sumiary Document 18
VDIMS Marrakech:
The objective of the V'D.,S M,arrakech Pilot Project was to study the feasibility of delivering family planning information and services for households. The project utilized the existing ,,ICH system of itinerant nurses: two visits were conducted for each accessible household in urban and rural areas of Marrakech Province. The Project results indicated that
- home visits, by either male or female initerant;workers, for delivery of family planning information and services is acceptable in tMorocco.
- With proper training, itinerant workers can safely supply and resupply oral contraceptives.
- Such activities enhance the availability and use of family planning services.
(From Lecomte, J. et al, An Evaluation of the Population and FamTTy7lanning Support Project in Morocco, i982). 19
TABLE OF OUTPUTS, OUTPUT INDICATORS. PROGRESS, STATUS
Outputs Magnitude of Outputs Progress/Current Status Expected Dates Coumients/Problems/Causi
2. VDMS-services* extended to 13 populous provinces
Trained intin~rant Number of itin~rants Program acceptability 3 provinces began field activities to brevet6 nurses make trained: 2300. appears high in VDMS in May 1982. date are progressing 5 yearly household provinces. well. visits to deliver Number of mopeds made 10* Provinces VDMS services available by UNFPA: Estiia.tes of contraceptive begun in late 1983 Evaluation a'nd reasses.s (family planning: 800. prevalence in the original ment of training and orals, condoms. three provinces (Meknes, Rural Implement- supervisory method referral for IUD, Number of dispensaries/ Beni ellal, El Jadida ation delayed due ologies/inistruments sterilization health centers out of suggest overall prevalence to U1IFPA inability should be an ongoing information; ORT; which VDMS operates: rose from approximately to provide mopeds activity: the quality referral for 455 25% to a range of 40-50% on a timely basis. between provinces is iimwnunization; (depending on the province) Mopeds arrived somethat uneven. iron folates; Percentage of Moroccan in just over I year of VDMS September 1983. weaning food). NWRA covered: 40% once service delivery Rural VDI4S began Datia collection flow, rural deployment is (May 1982-Fall 1983). October 1983. and analysis, from the Home visits are completed in early 1984 field 'level upwards, a! backed up by trained The goal of 25% CPR among all well as to the the fiel brevet( nurses F.P. stock readily Moroccan MWRA by 1985 will requires simplificatio within dispensaries, available at the probably be surpassed. greater timeliness and national, provincial a clearer definition ol and local levels essential infor;iation needs. 20
VDMS - EXPAISION TO 13 PROVIICES*
The existing VODIS program, with its current expansion, appears to be proceeding vary well. ndeed, dramatic progress has occurrd since early 1-82. Approximately 401 of tha KorocCan OcpuIation will be covered when services are extended to all the rural zones of the last 10 provinces involved in this phase of activities. V'IMS appears to be well accepted by all levels 0f the public heal th sector and by potential clients. As indicated in chart n.'umber 2, contraceptiie acceptance rates and prevalence rates, where availabie, suggest a fairly rapid increase of the use of contraception in the target population, once the services are made avaiiable.
Trainijg for the VDO.S itinerants was conducted at the provincial leve1, ased on training materials prepared by the MOH in Rabat. The majority of the provinces subsequently used the mate:-ials to elaborate their own training manuals. Provincial trainers, usually the animiteurs de SIAAP, traveled to Rabat for a VDMS orientation and an introduction to active training methodologies. Training courses for the field level itinerants in the provinces lasted 5 to 7 days, of which 1 day on the average was devoted to "communication skills." The quality of training received by the itin4rants has generally been high. However, some uneveness exists between provinces. In addition, a number of provincial health personnel indicated to the Evaluation Team that workers tended to experience problems in specific areas, in.particular use of the VOMS client record form (VOMS fiche) and in communication. A number of provinces are planning field observation/supervision to identify the problems more clearly, with subsequent retraining at the local level to fill existing gaps. One midecin chef noted that any additional "communications training" should be carried out in the field: additiondl didactic classroom lessons were not warranted. The Evalup.tion Team felt that the training activities/manuals in all the provinces should be reviewed centrally, possibly with the assistance of an outside consultant. Provincial trriners should subsequently be brought to a meeting in Rabat to discuss lessons learned, future strategies, and to incorporate elements from the strongest training materials into their own programs.
Mechanisms for field supervision vary between provinces. Although field level data are collected in all the provinces, the information gathered and particularly the subsequent analyses, differ between regions. In addition, some, but not all provinces have established mechanisms and instruments to conduct direct supervision during worker/cl lent contacts.
* Expansion originally occurred in the three provinces of Beni Mellal, El Jadida and Meknes. Expansion was then planned for 8 additional provinces, of which two have recently been subdivided, yielding 10. 21
As in the case of training, there is a nee. for I,0H/Rabit-level discussion with field-level supervisors, including ?.'a,ors de SIAAP. Majors de Conscription and Chefs .e Secteur, and ot'er individuals involved in supervision to ensure tnet supervision does nct consi.'.t solely of records review. Regular field level observation is essential. Criteria should be established by the pro'%inces setting forth a minimum, cumber of supervisory visits per year for eac category of supervisor. An observational checklist, such as the one currently being used in 3eni ;,ellal, could be adopted to other provinces. Discrepancies in provincia-ievel record keeping aid data analysis are discussed later in this si.tion: these .bservations. apply closely to VOMS.
VDMS workers deliver a carefully selected service mix: activities offered include family planning (pills, condoms, referral and information regarding the IUD, and tubal ligation, oral rehydration, referral for vaccination, weaning food and iron-folate). lmne current service mix does not appear to overburden the worker. It should be noted that VOMS workers conduct an average of 5 ainual visits per household. USAID/Rabat funds service provision equivalent to two of these visits. The additional client-worker contacts are carrie.I out with MOH funding. The MOH has used VDMS as an opportunity to systematize its own service delivery activities. It appears that the combination of F.P. and selected services, using the government infrastructure has resulted in a well functioning system which is now Pirmly embedded within the MOH. A few points should nonetheless be considered:
The MOH and provincial midecins chefs have idd.id a nunmber of VOMS activities to that proportion of visits whic., is "non VOMS." Although this is certainly not a problem in itself, it will be important for the MOH to monitor worker activities to ensure that the non VOMS duties do not dilute the very important VOMS F.P./health services. This is particularly true in those in those areas where 'VDS workers are !.king up to 20-25 home visits per day (VD,!S reccmmends 10 for rur.,!. 11' for urban workers). The provision of 5 very short visits per household per year is not necessarily superior to 2 longer visits With ,espt.ct to client comprehension and motivation. The impact of iron-folate ar.d weaning food (Actamine 5) should be evaluated. Data from other countries suggest client compliance with the for,mer is low because of ;unserious but irritating side effects; and that the provision of weaning supplements alone may have minira, heal th/nutritional effect.
If any new activities are to be added in the future, a ccnsiderition of resources and benefits is needed to ensure optimal service:: .re selected, and potentially less effective current services dropped. VDMS workers are linked to by a system of dispensaries. C..;'v"s de Santi (health centers), and, less directly, Centres de lifer.nc. ';'S activities are having an impact on the uti ilza::on pateFies ,', 22 these fixed facilities. Althojich it was re-uorted to the Evaluation Team that dispersary and health center utilization has increased for immunizatici, very possibly as a result of "O'D;IS referral, utilization for family planning is decreasing (and may do .o for treatment of diarrhea if the field lev-i. ORT program is successful. In the reference centers in particular, .he number of F.P. clients h Fallen to approximately 30% of previous l,-v.;is, due to VOMS fieli ',ork. IUD insertion in lower level dispensaries: Utilization trends will need to be monitored since use of fixe%, centers will increase for IUD insertions a! a result of VI&MS client referrals. The roles and staffing levels fixed cz:nters may r eed to be mo"Ified with time.
Inaddition, practices in the field (VM.IS and in the fixed centers) should be harmonized. In some dispensaries and health centers, workers give out only one cycle of pills at a time, as compared to VDMIS workers, who distribute 3 cycles. Such inconsistencies may be confusing for clients and produce unnecessary uncertainty about pill safety and the quality of VDMS service delivery.
Efforts are needed to ensure some level of family planning delivery to that proportion of th,.= population not currently covered by VDMS nor the projected Phase 3 expansion (some 25% will remain uncovered after phase 3). The MOH is discussing various ccmbirations of mobile and fixed service delivery, po':tentially with fewer annual worker/client contacts. 23
TABLE OF OUTPUTS, OUTPUT INDICATORS, PROGRESS, STATUS
Outputs Magnitude of Outputs Progress/Current Status Expected )ates Coimnents/Problems/Causes
3. Construction 7 Centers completed 5 sites have been Completion All 10 centers are and equipping of 10 3 centers currently visited by USAID. expected early expected to be completet FP Reference under construction S will be visited in 1984. by March 31, 1984. At Centers January January 1984 the two RlPference visit to Nador Center cotistruction and Oujda is sites visited by the anticipated evaluation team, buildings were 90% completed. Financi ng of ih,. f.enl:ers %,as a probleri because the FAR system is inconsistent with GOM fiscal procedures. (The GOM was unable to begin construction without an advance). USAID modified the FAR thru a PIL to advance 25% of construction costs. The design of the centers does not allow for efficient flow of patients. Wfhile AID engineers did review plans and construction for structual soundness, a further review by someone familiar with the particular needs of a health facility would have been beneficial. TABLE OF OUTPUTS, OUTPUT INDICATORS, PROGRESS, STATUS
Outputs Magnitude of Outputs Progress/Current Status Expected Dates Commients Problews/Causes
4. Special training programs cmiipleted for:
400 physicfans HO: The training component of 5000 pararhiedicals -Approximately 6 physicians the project has been very 30 administrators trained in reproductive health very sluccessful. Ongoing 10 statisticians/ yearly in Baltimore or Tunis; training evaluation and dewiographers 26 have received infertility or retraining are be.,ig 5 i-C specialists administrative training by discussed at the 1Oll and 10 policy makers and JIIPIEGO. Activity started at the provincial level. opinion leaders -44 short term participants in 1980 ongoing have received training in various aspects of family pl anning programis. Nursing: -63 senior FIOPII nurses trained Activity started in or trainers regarding I1ID 1983. Ongoing insertion. -600 nurses trained to insert IUD's. -Coimiuiications module (MO)i/ Iti[RAIl) beiu introduced into 30 nursing schools. VDHS: -164 VDI.IS trainers and 2129 Activity started in field level itin6rants 1981, training of brevet6s trained itinerants in the 13 Managers: VDMS provinces was -12 mid level wormen managers completed in March, in MOPII trained. 1983 IE-C: -see IIITRAII outputs. Policy Makers: -see RAPID output. TABLE OF OUTPUTS, OUTPUT INDICATORS. PROGRESS. STATUS
Outputs Magnitude of Outputs Progress/Current Status Expected Dates Coiients/lProbl ems/rmses
7. A national IE+C progran establ ished in the private sector. -Weekly radio program Audio-visual studio Sunmer, 1984 Famiily. planning material: as part of the equipment ordered devel oped hy AliPF and the scheduled "naa El frolllSony Corp, Japan MOlI radio and television Ousra" - family as well as brochures, planning spots on TV suffer from a lack at irregular of field testing during intervals, their conception and pos -50 newspaper articles production evaluation,. -3 regional family lo date it has not been planning exhibits possible to convince -35 nurses and social officials responsihle fo workers from 35 these activities that factories in the these materials Imust be Casablanca area tested on the public at trained and providing large. IISAII) has pills and condoms at the decliled to slpport work pl ace further produc ti oi -2 seminars held in costs of AMPF print collaboration with the materials until these Ministry of Youth and shortcomings are Sport (50 young people addressed. attended each seminar) lhe AIIPF seminar/ -80 directors and monitors training workshop of the Promotion Feminine series has beeni very Program attended a seminar successful in reaching on the medical-social- public groups and non economic aspects of MOll agencies. family planning -2 family planning songs produced; one is on the radio, the other will be soon. -10,000 AMPF brochures printed. -100 women trained as family planning motivators from the Ministry of Agriculture "Service de Vulgarisation" -50 journalists attended I day seminar on Family Planning and communication in the Arab World. -30 Inspectors General of the Ministry of Education attended 4 day workshop. -40 Red Crescent clinicians trained as FP service providors at R.C. facilities in the Casablanca area. TABLE OF OUTPUTS, OUTPUT INDICATORS, PROGRESS, STATUS
Outputs Magnitude of Outputs Progress/Current Status Expected Dates Comments/Problems/Causes
8. A National Fertility and FP Survey completed and analyzed Nation-wide survey of Report received by USAID Contraceptive prevalence 17,125 households early December, 1983 in 1980 nation-wide was 19%. NFS workshop planned for sulimier 1984. 31
TABLE OF OUTPUTS, OUTPUT INDICATORS, PROGRESS. STATUS
Outputs Magnitude of Outputs Progress/Current Status Expected Dates Coimients/Problems/Causes
9. Contraceptive Prevalence Surveys
- Three-Province 1. Household based Report Issued January, Contraceptive Prevalence Survey, 1982 survey in 3 original 1983 was found to be 25.1% VDMS provinces of Beni Hellal, El Jadida and Meknes 1,176 women inter viewed
- National Survey, 2. Nationwide Fieldwork presently Field work to be 1983 household-based underway completed early survey of 1984. Report late women 84/early 85 TABLE OF OUTPUTS, OUTPUT INDICATORS, PROGRESS, STATUS
Outputs Magnitude of Outputs Progress/Current Status Expected Dates Comments/Problems/Causes
10. National Training Center opened Center for November, 1982 Reproductive lcal th
The Center serves as 1. Approx. 200-250 Activity Nos. 1-4 at the Future plan include 1) a nucleus for 1) medical students NTCRH progressing well training sessions for training of medical per year: 75% of naesthetists in the use students in family these are fourth of general and local planning. 2) training year, and 25% sixth knaesthesia for in family planning for year students ;teril ization patients 3 levels of nursing receiving final !) an increased erphasis students - brevet~s practical training, in miinilap during tit) -diploi,6s d'6tat 2. Several hundred raining courses. to Cairistes. -1)A center students yearly )ermit greater choice for the training of 3. 30 Physicians (27) )f sterilization physicians in tubal Moroccan, 3 z.echniques at the ligation, via an foreign) trained local level agreement with since center 'laparoscopic training JIIPIEGO. 4) Training opened. Emphasis 'ill of course continue center for nurse currently on o be important).. trainers in IUD .laparoscopic insertion. 5) Training-training. center for 4. 65 trainers anaesthetist,:, trained. 5. To begin Activity No. 5 to 6) Collaborating in 1984. begin in 1984 center for WHO 6. Increased interest activities in in research, Activity No. 6 Family Planning. including progressing well epidemological research and studies related to adolescent fertility. In 1983, over 800 tubal ligations, 2000 IUD insertions, 10,000 new pill users and 5,000 condoms users were served at the center.
N TABLE OF OUTPUTS, OUTPUT INDICATORS, PROGRESS, STATUS
Outputs Magnitude of Outputs Progress/Current Status Expected Dates Coimuents/Problems/Causes
12. RAPID -Computer package USAID has received Initial location of ibis presented to the MOlt an updated ,APID program project activity in Ibe in 1980 from the Futures Group M011, wh4ich focuses oi -RAPID report (November, 1983) health services, rather distributed to the than in the Ministry Ministry of Plan, uf Plan, which concerns MohainnecI V itself with natiornal University, the development planning or Maghreb Population INSEA (National Institute Association for the analysis of -RAPID presentation to Economic Statistics) the Prime Minister delayed the presentation and the Cabinet in to the approprial.e February, 1983 national leaders because -1 Moroccan technician of MOII reluctance to trained to make RAPID "pioliticize" family presentation planning. T-his was -Full press coverage eventualy overcome; the of presentation to the activity has been moved P.M. and Cabinet 2/10/83 to INSEA, which is a more appropriate location, and a Mioroccan has been trained to give the presenitation. 36
VIII. GOAL: Unchanged. iX. PURPOSE: The project's purpose (to establish and to demonstrata within both the public and private sectors a capability to plan, implement and evaluate cost-effective family planning programs) has largely been achieved. The considerable ihvestment of resources in the public sector has been supplemented by small-scale but broad-based efforts in the private sector in the areas servedby the AMPF, which reported approximately 47,000 acceptor in 1982 in clinical and corrmunity-based distribution programs. Late in 1983, more than one million women in both public and private sector were using a modern contraceptive method. This exceeds the target established in the original project paper under subpurpose 1. Subpurpose 2, to raise levels of awareness of population problems and a commitment to solve, has also been achieved (see External Factors). Subpurpose 3, to foster new demand for family planning services through inproved IE+C programs and increase availability of services, has been achieved, alth,.ugh IE+C materials produced have not been adequately field tested (See Outputs). X. BENEFICIARIES: Unchanged.
XI. UNPLANNED EFFECTS: None.
XII. LESSONS LEARNED: Project 608-0155 has provided both the MOH and USAID with a wide range of experience. Among the most important lessons learned are: 1. In the 1970's and as late as 1981, neither active discussion nor a strong commitment to family planning by MOH professionals and other personnel were readily apparent. Despite disappointments, USAID/Rabat adopted a position of "supportive patience" and continued to negotiate for the need for family planning both as a health and a population measure.
The long term effect of the judicious approach adopted has been the implementation of strong, practical family planning programs providing wider population coverage. The changes have taken place without the promulgation of major population policy statements by either the GCM or the MOH. Indeed, despite the apparent lack of overt discussion regarding family planning in previous years, it is now obvious that substantial internal consideration was being given to these services by MOH officials. This internal review, and AID encouragement, enabled the program to evolve without major verbal pronouncements to this effect. 'yp 37
A recent paper by the Moroccan sociologist Fatima Mernissi notes that such a phenomenon may be in keeping with J,oroccan cultural patterns of d-al in7 -with social change. The lack of overt discussion ;,nuld thus not necessarily be construed as an indication of lack of interest or concern regarding a given issue. Indeed, to have wai ted for, or insisted upon a national population policy would have led to substantial delays and may even have resulted in a counter productive political backlash in the current Moroccan context. In the future, a clear national policy statement may ensure a long term commitment as well as GOM funding for population activities; in the short run, the lack of such a statement does not appear to directly affect service provision by the MOH. The Moroccan lesson may be of use for other national programs as well.
2. The major Moroccan Family Planning delivery system - VOMS - is designed as an integrated health services program: offering contraceptives; ORT; vaccination referral, iron-folic acid for pregnant/lactating women; and a weaning supplement (Actamine V). Original Ministry plans had included a far longer list of health interventions, whereas USAID was concerned that the linking of contraceptive services with multiple health interventions could dilute family planning efforts. The compromise which was struck appears to have been positive from many points of view. The number of services finally agreed upon has apparently not overburdened field workers nor their supervisors, and family planning activities continue to receive considerable attention. The provision of family planning via the existing health structure is more likely to ensure the long term availability of such services, and is ensuring their expansion to most parts of the country covered by the health system (over 75% of the population). Finally, the health system itself has benefitted: government health workers (itindrants brevet~s) had previously carried out home visits, but it was with the advent of the VOMS family planning/health package, and the additional training and supervision which occurred as a result of the package, that home visits for multiple services were optimized throughout the major parts of the country. From the viewpoint of the client, who now has systematic access to a few, carefully selected family planning/health services, the changes have been very positive. It should be noted that the success of VOMS has occurred due to careful avoidance of overloading the system. If, in the future, other activities are to be added, time and support factors will have to be considered. 3. As has frequently been discussed, the VOMS experience demonstrates that home visits/family planning service delivery are acceptable in Moroccan society. The original Marrakech project successfully used male and female workers, as do the urban components of the current VDMS project. 4. Client demand for all family planning methods (including IUD and tubal ligation) appears to be substantially increasing in Morocco. It would appear that religious/political constraints at the local level are minimal at this time.
5. Although original VOMS planning occurred at the central MCH level in Rabat, the individual VDMS provinces have subsequently produced their own training manuals, supervisory schedules and information gathering systems, based on prototypes developed in Rabat. This decentralization has certain advantages, in that it has probably produced a greater understanding of, and commitment to, the program among provincial middle level managers. However, the quality of the materials produced, although not poor, has been uneven, and it is important to continue to have central level review of inputs into these provincial activities. Such input can ensure standards of quality control, result in useful data for national level analysis, and provide provinces with information regarding the latest developments.
6. The VDMS project could not have been implemented and institutionalized in the current number of provinces without the provision of a means of transportation (mopeds) for field level personnel and supervisors. Adequate transportation is the backbone of this program, particularly in rural areas. 7. Morocco's mix of family planning/reproductive health activities, and the means by Wiich the' are delivered, serve as a useful model for other Moslem countries embarking upon such programs.
XIII. SPECIAL COMMENTS/REMARKS A. INFORMATION SYSTEMS I. Records-Keeping and Service Statistics a. GENERAL Records-keeping systems and the service statistics they generate, whether for fixed facilities or VOMS activities, should have the following characteristics: 1. They must be of immediate management use for evaluation and feed-back.
2. All data must be :ollected in a standard format at all program levels throughout Morocco, for purposes of easily preparing summary reports, for enab ing of comparison between provinces, for the preparation of national level reports and for eventual computeri zati on. 3. Records and reports must nbt overburden personnel at the lowest level who provide service delivery by being unduly complicated, by being time-consuming to prepare, or by requirements that reports be prepared more often than necessary for irmediate management purposes. This is particularly true for data which do not change -) greatly within short periods of time. 39
Data which are deemed necessary but which do not meet the above criteria, particularly data which do not change greatly over a short period of time, in almost all cases can be gathered from outside the service statistics system; by specific annual studies or mini-surveys (enquites ou 6tudes ponctuelles) or by large scale surveys such as a Contraceptive Prevalence Survey every two to five years. b. VOMS
FICHE O'ACTIVITES VDNS EXTENSION The VOMS program uses as a basic record for each women in a household the "FICHE D'ACTIVITES VDOS EXTENSION" (Exhibit 1). This form is being successfully used by VOMS itinerants.
The evaluation team was told in Beni Mellal Province, where VDMS activities began in May, 1982 that in some cases the VOMS itinerants initially had difficulties filling out the form, but that these were resolved within the first few months of operations. In Marrakech Province, where operations began in October 1983, the team was told there are similar problems. Although this type of problem should be quickly resolved in each province as itinerants become
accustomed to the form, as was the case in Beni Mellal, the evaluation team suggests the following simple modifications be discussed by the Population Division for possible implementation. 40
Under category B. Vaccination: NBRE D'ENF. REF. POUR (Number of Children referred for). Polio 0T COQ (OPT) Rougeol e (Measles) BCG Autre (Other) The different types of vaccinations for which children are referred should not be totalled, since the essential information is that the children have been referred for vaccination. Detailed information is only essential for the actual vaccinations given. Section B. Vaccination would then appear as:
1. NBRE D'ENF. REF. POUR VACCINATION: (Number of Children referred for Vaccination) SUITE A LA DERNIERE VISITE: (Follow-up to the last visit) 2. NBRE D'ENF VACCINES: (Number of Children Vaccinated) Polio DT COQ (OPT) Rougeole (Measles) BCG Autre (Other) This modification is desirable since the decision as to which vaccination a child actually needs is made by the personnel at the health facility who actually administer the vaccination under the EPI program. b. As more and more oral contraceptives are provided through the private sector, it would be useful to show the number of women obtaining pills in the private sector, and who are therefore not using the contraceptive services of the VMIS program. This can be shown on the form as it exists under: A. PLANIFICATION FAMILIALE, as follows: 3. UTICATRICE, Autre (Preciser) by marking (Users, other (Specify)
"Priv6" in the proper box. (Private Sector) 2. PERIODIC REPORT - VDMS and Family Planning in Fixed Health Facilities -54, 41
At the present time the VDMS program does not require that secteurs, circonscriptions and provinces provide a perioaic report in a szancaraized format which could be used at all program levels, including the national level.
The evaluation team reviewed the SOUS SYSTE ,-E D'EVALUATION (sub-system) presently under study by the Division de la Population. The team concluded that the data to be gathered are useful. However many of the detailed categories are not of immediate management use and could be gathered at less frequenz intervals than bi-monthlv. Or better still, could be gathered by surveys rather than periodic service statistics reports. The detailed age categories are an example of data which do not need to be gathered bi-monthly.
At the provincial level the evaluation team found that provincial staff were enthusiastic about providing detailed data on the obviously successful implementation of the VDMS program, but in most cases the data were much too detailed and did not meet the criteria mentioned earlier. For example, VDMS data were presented to the evaluation team on the proportion of all women visited who accepted contraception as representing contraceptive prevalence, whereas this term should only be applied to the proportion of all women in a population. The evaluation team therefore recommends that a standard bi-monthly or even tri-monthly report be adopted for all provinces which would provide only the information gathered on the FICHE (form) D'ACTIVITES, which would facilitate preparation of such a report. This would also provide a standard format utilizing already-existing information which is of immediate management use. This type of report could also be easily computerized. As was recommended in the 1981 evaluation, it is also suggested that this report include, in addition, the information gathered on form PF/2a COMPTE RENDU MENSUEL D'ACTIVITES (summary of activities for the month) which reports fixed health facility family planning activities at the circonscription level, and is informally used in a few provinces at the provincial level. This proposed form could be called VOMS-PF/2 RECAPITULATIF BIMENSUEL* O'ACTIVITES VOMS - PLANIFICATION FAMILIALE. (Bimonthly resume) A suggested format for this combined periodic report is in exhi-bit 2. or TRIMESTRIEL (Quartery) )1 42
3. SURVEYS AND SPECIAL REPORTS
The following information to be gathered by the SOUS-SYSTEIIIE D'EVALUATION could be gathered annually througn a randcm sampie records search of ten percent of FICHE DACTIVITES which could be dorne by the Administrateur-Econome in each province and/or cinconscription:
a. Place of residence and Age breakdown of women and children visited for each intervention. b. The number of women continuing contraceptive use for six months or more. The following information could be provided through a special annual report: a. Donn~es de Base - Foyers Existants, etc. (Basic data - households, etc.) b. Infrastructure - Iombre d'agents, velomoteurs, journies de travail totalis~es, etc. (MumLer of workers, mopeds, total number of days worked).
All other information on family planning use and other health interventions, including disease morbidity and mortality can be gathered from household based contraceptive prevalence type surveys every 2-5 years.
Before a standardized data system is Implemented there shouid be a short training course in its use for administrateurs-economes. This could be a joint effort of the Service de Mecanographique (date-processing) and a consultant.
II.Logistics The evaluation team reviewed the logistics system for contraceptive and other VDMS supplies at all levels, including the Casablanca warehouse, and the procedure used to schedule shipments for the national level to provinces. As was found during the 1981 evaluation the logistics system is working well; supplies are reaching peripheral areas and stock outs are not uccuring. Supplies are now shipped by the Service de Planification Familiale every six months instead of three months as previously. This makes for easier management of distribution and insures that larger quantities are on hand at the provincial level. 43 Approximately 12 months of supply were found to be on hand at the national level and 12 month's supply was also found in the three provinces the team visited. As the VOMS program expands, a 12 month supply, which is the minimum amount which should be kept at these levels will come to reoresent larger amounts. Additional warehouse space is to be constructed in Casablanca. Provinces must also ensure that there is a adequate storage facility to store increased amounts of supplies.
A minor problem occuring at the national level which was also discussed in the 1981 evaluation is that provinces do not regularly report the stock on hand in provincial level warehouses, only the stock in circonscription level warehouses. Since shipments from the national level are to rovinces, this causes problems for the personnel in the Service de Planification Familiale responsible for shipments. The evaluation therefore recommends that the person responsible 'or shipments in the provinces prepare a simple six-monthly report which could be entitled VDMS-PF.3. ETAT SEMESTRIEL DU STOCK DES PRODUITS CONTRACEPTIFS AU NIVEAU DE PROVTNCE, (semi-annual report or contraceptive stock at the provincial level) as shown in Exhibit 3. The format is identical with the supplies section of the circomscription report PF/2a. This report could be sent every six months to the Service de Planification Familiale as part of the suggested VDMS-PF/2 RECAPITULATIF BIMENSUEL D'ACTIVITES VOMS - PLANIFICATION FAMILIALE/
B. CONTRACEPTIVE PREVALENCE AND DEMOGRAPHIC GOALS
There are no specific demographic goals in the Health portion of the current GOM 5 Year Plan (1981-85). However, a target of 24% contraceptive prevalence among MWRA by 1985 has been established. Present indications are that this target will be surpassed
Nevertheless, significant changes in the birth rate cannot occur until prevalence is still higher; for example, it is estimated that the crude birth rate will remain above 30/1000 until nationwide contraceptive prevalence reaches 40% of MWRA. (See Bowers Memo of December 27, 1983).
The present project will reach approximately 40% of the population of Morocco in the 13 provinces included in the project area where VOMS house visits will take place. If it is assumed that contraceptive prevalence will be on the order of 50% in provinces with VOMS visits and 25% in other areas, as per present estimates (See Appendix I),once the VDMS program is fully operational in these 13 provinces, nation-wide prevalence will be approximately 35., as per the following calculations:
,/, 44
Users
I. Total MWRA - 3,461,500 x 60, x 25% - 519,225 2. Total MWRA - 3,461 ,500 x 40%. x 507 - 692,300 3. 1,21T,2
4. 1,211,525 divided by 3,461,500 - 35% Prevalence
At this point it might be expected that the crude birth rate would be about 32/1000. (As per Dorothy ,ortman linear .,regression method).
Plans for the succeeding USAID project call for VOMS activities in 18 provinces, including the large urban areas of Casablanca, Rabat - Salg and Tangiers which would cover approximately 65% of Morocco's population. Once this project is well under way, using similar assumptions, contraceptive prevalence would be on the order of 41%, as per the following calculations: Users
1. Total M1WRA - 3,461,500 x 35% x 25' - 302,881 2. Total MWRA - 3,461,500 x 65% x 50c,0 - 1,124,988 3.
4. 1,427,869 divided by 3,461,500 - 410" prevalence. In order to bring the CBR below 30, it seems therefore that special efforts are needed not only to ensure that prevalence is raised above 50% in the VOMS provinces, but that it also be increased above 25,% in the provinces which will not be included in the succeeding project. In the latter case these efforts might include the reinforcement of family planning services in fixed health facilities and that all possibilities of utilizing alternative distribution systems (including commercial sales) are fully explored. A far more accurate picture of this situation will be availdble once nationwide CPS results become available in 1984. In addition, the inclusion of large urban areas in the succeeding project area where contraceptive prevalence is at least dou.*le the prevalence in rural areas (See 1982 CPS results) may mean that higher rates of prevalence than 50% could be assumed for future VDMS project areas in making these estimates. C. IE+C MATERiALS
IE+C print materials developed by the MO'H and the AMPF suffer from scme weakrassesi a tendency to use symbolism which may or may not be understood by the public; messages which require tremendous leaps in logic to interpret; and messages which are unclear. For example, a series of posters developed by the AMPF illustrate a family of four, with the women sitting by the feet of the man. The most common reaction to the poster has been, why is the women sitting at the feet of the man? Since the poster has not been field tested, no one knows what kind of message the poster is actually communicating to the public.
A series of pamphlets developed by the MOH on family planning and oral rehydration contain an extensive written text, although the illiteracy rate among Moroccan women is as high as 98% in some rural areas, and overall literacy is under 30%. According'to the MOH, the pamphlets are geared to people who have completed the fourth grade. The MOH anticipates that these pamphlets will be read to mothers by their children, husbands or neighbors. A questionnaire has been distributed to some health centers, in an attempt to field test a pamphlet entitled, "Why family Planning." The questions include "Does family planning protect the health of the mother and child?" Yes, or no are the possible answers. All of the questions which relate to the substanc:6 of the questionnaire are similarly phrased, so that it will not be possible to determine the respondent's level of acceptance and understanding of the message. A poster of a women breastfeeding her infant carries tie message, "Breast feed your child. Plan your family." The poster can thus be interpreted to mean that breastfeeding is the appropriate way to plan your family. Consultants have worked with the communications staff of the AMPF and MOH on various aspects of their IE and C activities. Further consultant assistance in the design of field testing efforts appears to be warrented. The desigi of interviews, questionnaires and surveys which can provide the information needed to determine the "real" message of IE+C materials is a highly specialized skill which may not be readily available to the Alk"F or the MOH. The evaluation team recommends that the use of shot term consultants for this purpose be discussed with both organiza'ions. 0. Cost Estimation Given the breadth and variety of this project's 12 sub-projects/outputs, it has not been possible to accurately determine the cost per user of family planning services in Morocco. As a very general measure, however, it is noted that the GOM, AID and the UN have together contributed some $35 million to this project ($18 million, $12 million and $5 million, respectively) over the period 1979-83. Total (public sector) users for each year during this period are estimated by USA'D t-o have been 180,000 in 1979; 320,000 in 1980; 400,000 in 1931; 530,000 in 1982; and 650,000 in 1983. This represents approximately 2,COOCO user-years of FP "protection" during 1979-83, or a per-user cost of roughly $17.00/year. The denominator for this estimate is or course, the financial value of all GOM and donor inputs, inciuding such non-service related elements as U.S. and third country training grants, technical assistance in data collection population education in-the schools, conferences, etc. At the other extreme of cost estimation, i.e., costs to AID for direct support of service delivery, the US cost for the VDMS project is about $150,000 per province per year, excluding contraceptives. With (public sector) contraceptive users in the three well-established VOMS provinces averaging 50,000 per province, the AID cost-per-acceptor year for the VDMS program would appear to be about $3.00. The MOPH retains detailed accounts of the operating costs of their FP program; and USAID expects to provide additional cost information in the financial analysis section of the new family planning project paper. The project pipeline is being drawn down at an accelerated rate now that project activities are under way in all 13 VOMS provinces.. UNFPA's delayed delivery of mopeds to 10 of these provinces did, however, push back the launch date of these 10 provinces about 5 months, until October, 1983. USAID estimates that the current project pipeline will be fully expended by the end of the current fiscal year (FY 84).
E. USAID Project Administration The Family Planning project has been directly administered by USAID/Rabat staff. The evaluation team remarked on the in-depth understanding of this project on the part of the two staff members primarily responsible for the project, and was favorably impressed by their relationship with GOM officials, their familiarity with field conditions (which is clearly the result of regular visits to the provinces), and their ability to address the many sensitive issues which have arisen over the life of the project. This method of project administration has clearly been effective in the Moroccan context. ACTIONS T.J'1E SINCE LAST MAJOR E'/ALUA I!N:
1. The National Center for Training in Reproductiv-s H.alth ;-as opened and is providing training in sterilization tec;nicues in Rabat. Similar training is not being provided in Casablanca, atlznough two physicians from Casablanca were trained by JHPIEGO. 2. Female sterilization is now part of family planning service. Tubal ligations are being performed in provincial hospitals. Demand is high. Statistics are being kept. 3. Nurses and physicians are being trained in providing IUD insertions, which are being done in all provinces, in many cases as low as the dispensary level. 4. The VDMS program has been extended to a total of 13 provinces, covering 40% of the population. The range of services offered, besides family planning, does not appear to overburden the house visitor. Those covering rural areas are equipped with mopeds. They are using as their basic recording form a client card designed by USAID and the MOH in collaboration with the 1981 evaluation team.
S. A 1980 National Fertility Survey, part of the World Fertility Survey, has been completed. Contraceptive prevalence was found to be 19%.
6. A 1982 Contraceptive Prevalence Survey of the three original VDMS provinces - Beni ellal, El Jadida and Meknes - has been completed and a report written. Prevalence was found to be 25%. It is now USAID/GOM policy to do a CPS every 2.5 years. A ,ational Contraceptive Prevalence Survey, with oversampling of the three original 'IDMS provinces, is presently in the fieldwork phase. 7. The Moroccan Family Planning Association (A'PF) is implementing a national IE+C program. 8. RAPID presentations have been made to senior officials of the GOM, including the Prime Minister and his Cabinet. An employee of the MOH has been trained to make the presentation.
9. Seven additional family planning reference centers are now under construction, with construction of three more to begin in January 1984. Their primary emphasis has changed from dealing with problem FP cases to being the site for training doctors and nurses in IUD insertions. The centers also provide the usual FP services. 10 A Family Planning goal of 24% contraceptive prevalence is mentioned in the 1981-85 Five Year Health Plan. There now seems to be a much greater acceptance of family planning activities by the GOM. 11 The "paramedicalization" of family planning services in Morocco is now complete. On the other hand, there may be a slowdown in training paramedics in FP techniques in the future because of increasing numbers of new medical graduates. APPENDIX I
Contraceptive Prevalence in Morocco
Contraceptive prevalence due to public sector service delivery and private sector procurement has been estimated in Morocco as follows:,
YEAR TOTAL PREVALENCE SOURCE 1978 12% USAID Service Statistics Estimate 1980 19% National Fertility Survey (WFS)
1981 21% Evaluation Team - Logistics Data 1982 25% Contraceptive Prevalence Survey (CPS) In 3 original VDMS Provinces 1983 27% Evaluation Team - Logistics Data, (41-53% in 3 Servi-ce Statistics, Survey Data original VDMS Provinces) 1984 (date expected late 1984) Nationwide CPS The 1983 estimate by the evaluation team was calculated as follows:
A. National Level 1. Shipments of oral contraceptives from national level to provinces January 1 - November 30, 1983 - 5,410,760 cycles
2. Extrapolation to 12 months 5,410,760 x 12:11- 5,902,647 cycles 3. Number of Public Sector Pill Users 5,902,647 divided by 13 cycles per year per user - 454,050 users
4. Number of Public Sector Users All Methods 454,050 divided by 0.75 as 1982 CPS found pill users represented 75% of all users 605,400 users
5. Number of Public and Private Sector Users, 605 ,400 divided by 0.65 as 1982 CPS found public sector served 65% of all users - 931,385 users
6. 1983 Population of Morocco (USAID) - 21,500,000 of whom 23% are women 15-49 (USAID) - 4,945,000 of whom 70% are married (USAID) - 3,461,500 MWRA (MWRA, Married Women of Reproductive Age)
7. 931,385 users divided by 3,461,500 MWRA - 27% estimated prevalence B. Beni Mellal Province 1. Oral Contraceptives Distributed January 1 - November 30, 1983 by VOMS Program - 332,595 cycles 2. Total Oral Contraceptives Distributed by Public Sector 332,595 divided by 0.7874 as Service Statistics State VOMS served 78.74% of Public Sector - 422,396 cycles
3. Total Oral Contraceptives Distributed Public and Private Sectors 422,396 divided by 0.76 as CPS found Public Sector served 76% of all users - 557,842 cycles 4. Extrapolated to 12 months 557,842 x 12:11 - 606,310 cycles
5. Number of Pill Users 708,916 divided by 13 cycles/year/ user 46,639 users 6. Number of Users all Methods 46639 divided by 0.831 as CPS found pills users 83.10 of all users - : 56,102 users
7. Population of Beni Mellal (1982) - 668,703 + 2.6% increase (census) 686,089 of whom 23% are women 15-49 (USAID 157,800 of whom 70% are married (USAID) - 110,460 MWRA
8. 56102 Users divided by 110,460 MWRA - 51% estimated prevalence C. El Jadida Province 1. Average Oral Contraceptive Distributed Per month January - June 1983 by VDMS Program 20,302 cycles 2. Extrapolated to one year - 1983 20,302 x 12 243,627 cycles 3. Total Oral Contraceptives Distributed By Public Sector 243.627 divided by 0.7764 as Service Statistics state VDMS served 77.64% of Public Sector 313,790 cycles
4. Number of Public Sector Pill Users 313,790 divided by 13 cycles/year/ ,user 24,138 users 5. Number of Public and Private Sector Pill Users 24,138 divided by 0.65 as CPS found public sector served 65% of all users 37,135 users
6. Number of Users All Methods 37,135 divided by 0.714 as CPS found pill users 71.4% of all users 52,010 users
7. Population of El Jadida (1982) 763,351 + 2.6% increase (Census) 783,198 of whom 23% are women 15-49 (USAID) 180,135 of whom 70% are married (USAID) 126,095 MWRA
8. 52,010 users divided by 126,095 MWRA 41.2% estimated prevalence D. Meknes Province 1. Shipment of Oral Contraceptives from national level to Meknes 1983 300,000 cycles 2. Number of Public Sector Pill Users 300,000 divided by 13 cycles/year/user 23,077 users
3. Number of Public and Private Sector Pill Users 23,077 divided by 0.59 as CPS found Public Sector served 59% of all users 39,113 users 4. Number of Users All Methods 39,113 divided by 0.707 as CPS found pill users 70.7% of all users 55,332 users 5. Population of Meknes (1982) 626,868 + 2.6% increase (Census) 643,166 of whom 23% are women 15-49 (USAID) 147,929 of whom 70% are married (USAID) 103,550 MWRA
6. 55,332 Users divided by 103,555 MWRA 53.4% estimated Prevalence APPENDIX 2 Documents Reviewed
An Evaluation of the Population .nd Family Planning Support Project in Morocco, Lecompte, J., et a]., APHA, Washington, D.C. 1982 Association Marocaine de Planification Familiale (AMPF) Management Audit Report, IPPF, 16-25 May, 198. Concept Paper, Pro.iect No. 608-0171, Population and Family Planning Support, Phase III, Morocco. USAID/Morocco, April 1983. Project Evaluation Summary, PES, Part 1, January 1982 - March 1983. Project No. 608-0155, USAID, Morocco. Training Materials: - Session aupris de Communication pour les Etudiant de 1'Ecole des Cadres. April 1982, 1983.
- Cours de Communication a l'Intention des Etudiants de l'Ecole des Cadres. S~minaire/Atelier & l'Intention des Enseignants des Ecoles des Infirmiers Brevetis. Report 8-10 November, 1983. Modules de cours de formation des formateurs (extension du VDMS). Module de cours de planification familiale de a l'usage du personnel infirmier responsable de la formation.
- Module de cours de formation pour midicins en techniques de stirilisation par laparoscopie.
- Module autodidactique a l'usage de l'infirmier itinirant (El Jadida).
- Module de cours de formation du personnel paramedical (Marrakech). - Modules d'entrainement de personnel paramedical (Beni Mellal) - Module de cours de planification familiale i l'usage du personnel paramedical - SIAAP, VOMS. (Kenitra).
- Module auto-didactiques a l'usage de l'infirmier itinirant, 1983. SIAAP - VDMS, (Kenitra). - Programme preparant au diplome d'Adjoint de Santi brevetS.
- Module de planification familiale 5 l'usage des enseignants des 1coles des infirmiers brevetis. - Guide a 1 'usage des enseignants des icoles de formation des cadre techniques.
- Guide des activitis de l'uniti itingrante des sorte familiale. Royaume du Maroc. Ministere de Sante Publique, Direction des Affairs Techniques, 1981. Enqaete Provinciale du Prevalence Contraceptifs 1981-1982. Royaume du Maroc, Minist.re de Sant6 Publique, Westinghouse Health Systems. Presentation de l 'Association Marocaine de Planification Familiale Draft tables, 1979 National Fertility Survey. Mernissi, Fatima. Unpublished article: "Why Moroccan Women Practice Family Planning". AMPF (Association Marocaine de Planification Familiale) Rapport Annuel, 1982. Jouhari, A. Santi Publique Apercu des Problimes socio-4conomiques et dimographiques et planficiation familiale au Maroc. OMS-FNUAP January - February, 1982. UNFPA Projects and Activities in Morocco, 1983.
Laaziri, Z. Plan de Developpement 1981-.85: Activitis d'Education Pour le Santi. Situation au 30 November, 1983.
In addition, the Ministry of Health, Family Planning Division, provided the Evaluation Team with approximately 25 handouts and short documents. \ APPENDIX 3 List of Persons Contacted
MOH: Dr. Rahal Rahhali, inistre, inistire de la Sant6 Publique. -Professor Moulay Tahar Alaoui, Directeur des Services Techniques. Dr. Jouhari, Chef de la DIvision de la Population. Dr. Zarouf, Special Assistant, Division de la Population. M. Hadj Mimoun Boukhrissi, Chef du Service de la Planification Familiale. Dr. Mechbal, Chef de la Division de l'Infrastructure. M. Laziri, Chef du Service de l'Evaluation. Mne. Laziri, Chef du Service de l'Education Sanitaire. Dr. Belhaj, Chef du Service de Nutrition et de le Protection de la Santi de la Mire et de l'Enfant. M. Ouakrim, Chef du Service d'Exploitation Mgcanographique.
AMPF: Moroccan Family Planning Association National Committee M. El Mehdi, Directeur Executif de 1'AMPF. M. Driouche Medjki Abdellatif, COntroleur Financier de.l'AMPF. M. Greiga, Directeur, !E+C.
MSH: Management Sciences for Health Dr. J. Wolff. Mr. R. Roberts, Chief of Party
UNFPA: United Nations Fund for Population Activities Dr. Sardari, UNFPA Coordinator.
UNICEF: United Nations Children Fund Mr. L. de Vos, UNICEF Representative.
USAID/Rabat: United States Agency for International Development
Mr. Robert C. Chase, Director. Mr. H. Petrequin, Deputy Director. Mr. G. Bowers, Health and Population Officer. Ms. B.E. Oldwine, Assistant Population Officer. Ms. U. Nadolny, Nutrition Officer 56 Casablanca
Dr. Akhmis, M4decin Chef de la Prefecture. M. Rhaddoui, Major de SIAAP. M. Fadi, Chef du Dipot Central, MOH. Kenitra
Dr. Azedinne, M4decin Chef de la Province. Dr. Ouziani, Midecin Chef de SIAAP. Mddecin Chef du Centre de Rifirence. Dr. A Jerrari, Midecin Chef de Circonscription, Lalla Mimounia. M. M. Dohmani, Majeur de Circonscription de Lalla Mimounia. Dr. Delsa Dispensaire Urbaine de Kenitra.
Beni Mellal
Dr. Oucharif, Midecin Chef de la Province. Dr. Jazdi, Midecin Chef de SIAAP. M. Boukdir, Major de SIAAP. Mme. Boukdir, Directeur, Centre de Formation des Infirmiers. M. Sairi, Administrateur Econome. M. Hamed Ilin, Animateur de VDMS. M. Seraraj Birgeru, Statistician. Mme. Haddad, Sage Femme, Centre de Reference.
Marrakech
Dr. El Mansour, Mgdecin Chef de la Province. Dr. Rachdi, Mldecin Chef de SIAAP. M. ANiba, Major de SIAAP. M. Hene, Animateur Provincial d'Education Sanitaire. M. Raja, Administrateur Econome de SIAAP. Dr. Ben Chaou, Midecin Chef de la Centre de Rifirence. Dr. Sletti, M~decin Chef de Circonscription; Mohammedia. Mme. Montaser, Animatrice de PSME. M. Senaoui, Major de Circonscription Mohammedia. M. Ait Maati, Chef de Secteur, Dispensaire de Tamauslat. APPENDIX 4 Sites Visited
Rabat/Sal i: MOH: Ministry of Health National Training Center for Reproductive Health Division de la Population Centre de Rifirence, Sali
AMPF: National Headquarters, Association Marocaine de la Planification Familiale
Casablanca: Prefecture Medical e Dpot Central Centre de Reference
Kenitra: Province M6dicale Centre de Reference Circonscription de Lalla Mimounia Dispersaire Rurale Dispensaire Urbaine de Kenitra Housevisitor (itinerant) in Rural Area
Beni Mellal: Province Mddicale Centre de Reference Fkih Ben Salah Centre de Santi Souk Had Bradia: Centre de Sante Rurale
Marrakech: - Province Midicale - Centre de Reference - Dispensaire Miixte (urbane - rurale) de Tamousclatite - Centre de Sante de Mohammedia - Itinerants in'urban area IN' %IMIE UL MAROC L4~*' . lIN -gTERKi,, . NTE P.LI,'QEU I /v'Z / FICHE D'ACT!VITES V.D.M.S. EXTENSION .- [
Province ou Prifectut : ...... - N' -nr,;istrsmen- / / / ' Circonscrip:ion M dicaie: ...... - Nom o ii Pem e ...... Formation Sanitairs ...... - Age n f annus
Aaess :......
Date.d sa visits (jour, mois, annitsi a 198 I s 198 -198 198*
o..,Rlire.ce I =- 77' ----."... '- I diii placc,____ uiL...
2. NoUvell Acc.lotrice
Pilule I I Condom _--'-- -'__ I______r'-
-~~~ ~Autre(Prissr) ______
3. Utilisetric ziPilule ... II
Condoms ,______Auu.o ( Preisor) jI
M" 4. Referee pour sterilisatvc. 5. Nbre do cycles ou pilces - donnees
Pilule .---
Condom ___ Autres Au- r ___ -- -- -
I. Nbre d'Enf.Ref. pour: . Polio __ __ OTCoq -'_--__ - Rouge-l--
8Co z Autr_ = Suite i Ia 0oerwfr visite < 2. Nbro C'Enf. vaccinis: z Polio -. O7Coq ...... < Rougqole *8CG Autre
1. Enf.actuararheocues:______
."Non "'- 2. Oimonstracion Oralyt. Non lC .- - i" i - l
3. Nbre do sachets donnos
1. Ac .mino : Otmonatration : r---___..._ _ _-- --
Non ____ ...... duarnt. donni 2. Fer:P OsAntity donnee pour - rolsss Allai:ement_ Autr s
Best Avi %W,:iFEIIL 111I, L4TPUBLIQUI ~ '~t~.i
- Provin.-i ou Frffc , ...... Cir:onwc' ; on Yiaicais ......
I ~ j Pre(Prd
5- 5- 5 - sQ:,IS-4-omi ic .w r
Asprz:cp %ww &-AN~f v
--. Nzre 5dt5 yil Piki ______
5 s~~Pz-s~s~~ ..5.i.S -,-.la--
Condom- - ______--S,
:i Autrut-- s
4 - -~ - . 5- - 4-~ 44p~~- ~ -~ p~IA~c
- s *-* r->~~i~-~______- ~ ------~~ ~i-- ~ - ~ ~ ~ - u ? c______5 -~--~-5----~~---~ ~ -,:--s 2Nuveiie~z c rcs ~ - ~ '~
------5-5e 1 -cs 5 It~-- fI c-., s r OX- - P~~e< ------'. do'~~cyc'4A5' cu :55- ss- S - S4.S4 5 - - Auti( ~ ~ S ~ 4 -. Sr- es--- 5 S- - 5
5'-pSSlf 5'cac SU' - . 5)5l~j
-~~~~ t d'Ef Pil do-ur+~-s - ,! 4 4 V* Cnos--- j . <. ~ - ~ - 2-4 No: d'-: -
5 -s--p_ --_ _ _--
- 53 i ' £ " - t. D i.o : ,:
F. Elat M ...- du stock des produils contraclils ou
~Type Tyod.do prmlW1traillIiuc lI'Iulem Condtuas
M~u~uvtmcnt~dui prae l (ellC.lCI) (on juIlcee)
S.Su...... tt -k an d thut d u lw otv ......
h - Qu ll rc durantlI ......
QuanIO diitribule pcadunt lojmn a ......
4-Stock A la fin duisrefm l..... K - Deriniere ciYmion [E~lE IIWJ~iflt)[E\EI1V~ Mink. flfodinrcu[anox___
~PI
L ~ .. '. - iil&.ii di*o f"P
; o joii 4m. ', TAL :13Z U r 1
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