World Neighbors in ACTION

World Neighbors IN ACTION Developing a Framework for Integrating Reproductive Health in Development Programs This issue describes a process for synthesizing lessons learned from program implementation in six countries and using those lessons learned to adapt a programmatic framework. The framework is intended to guide the development and implementation of reproductive health components in integrated programs in order to maximize their effectiveness. Background The key elements of the framework Since 2000, World Neighbors has developed in 2000 were: been using a framework for reproductive health components developed by 1) Integration Linkages: WN pro- 5) Action Learning: Action learn- international program staff during a grams are integrated development pro- ing is the systematic and participa- workshop. The framework was used grams. RH components are linked tory analysis, learning and documen- to guide the development of reproduc- with other activities identified as pri- tation of program need, context, pro- tive health components in the context orities by local communities. cess, outcomes and impact. Action learning is used to inform decision- of World Neighbors’ integrated pro- 2) Information and Counseling: making, improve programs and gramming. The accessibility of accurate RH in- widen impact. Integrated development programs, formation is seen as critical for the suc- such as those WN implements with cess of a RH component. 6) Gender: The WN program partners, are very complex and require strategy specifies that programs will 3) Quality Reproductive Health managers to balance a large number respond to community needs Services: Improving access where of activities and priorities. Thus, the through an empowering, gender- necessary and strengthening the link- framework has proved to be a useful sensitive and holistic development ages between community-based struc- tool in ensuring that key elements of an process. Gender issues are an im- tures and formal RH services is seen effective RH component are not over- portant consideration in the devel- as vital to the effectiveness of RH looked during the design, implementa- opment and implementation of ac- components. tion or evaluation of programs. tivities. 4) Community Local Capacity When the original framework was de- 7) Special Groups: This element Building: In all aspects of its work, veloped WN staff acknowledged that emphasizes addressing the needs of WN seeks to strengthen the capaci- the framework was dynamic and vulnerable groups such as adoles- ties of communities and local organi- should be refined and adapted as the cents, migrants and their families. RH components evolved. The frame- zations to determine their own devel- work had seven components. See box opment priorities and act on them. on right. The first part of the workshop included that there were significant differences Revising the Framework Based on presentations that incorporated recent in design of the programs and each pro- Program Learning evaluation results for six country program offered learning on reproductive At a recent meeting in February 2003, grams; India, Nepal, Bukina Faso, health in a unique context. World Neighbors’ staff and partners Kenya, Haiti and Ecuador. Each pre- Each of the six program presentations took the opportunity to review lessons sentation used the 2000 framework to used a common framework which fa- learned during the past three years and summarize their program approach, but cilitated analysis and synthesis across make changes as indicated to the also presented key lessons learned over the programs. framework. the past three years. It should be noted

WNIA SPRING/SUMMER 2003 SUBJECT: INTEGRATING REPRODUCTIVE HEALTH IN DEVELOPMENT PROGRAMS VOLUME 29, NO. 1E PROGRAM PRESENTATIONS

Objective: • Information on Program Context and 2) Participants were asked to note To share program information in a History during each presentation key questions way that promoted synthesis and • RH Component Design: How are and lessons learned that they found sharing of lessons learned. each of the seven key elements relevant to their programs. Methods: implemented in the program? 1) Each country had 30 minutes to • Program Objectives present their program followed • Unique Aspects or Initiatives of the by questions for clarification as RH Component necessary. They presented ac- • Key Accomplishments and Evalua- cording to the following format: tion Results • Lessons Learned and Sharing

Burkina Faso described a key lesson as the importance of influ- encing of key leaders, such as religious leaders, elders, and traditional singers, because of the important roles they play in local decision-making. Special training improved their knowledge of RH and their attitudes toward the program so that they became supportive.

The Nepal and India programs discussed the importance of women’s savings and credit activities in their programs. They noted that the activities influenced health service use in two ways. First, because women had access to money, they could afford to use services when they needed them. Second, women with their own income have more influence in a household and more autonomy.

The Kenyan program talked about their capacity building efforts with the local health facility management committees. They high- lighted the necessity for communities to understand and have expectations regarding the quality of care provided at health facilities. They noted that in their experience “community participation will create a sense of ownership of health activities, services and facilities.”

WNIA SPRING/SUMMER 2003 SUBJECT: INTEGRATING REPRODUCTIVE HEALTH IN DEVELOPMENT PROGRAMS VOLUME 29, NO. 1E ROUNDTABLES

The presentations were followed by Method: roundtable sessions in which the par- 1) Presenters from each of the 3) After 30 minutes, each group ticipants had the opportunity to ask country presentations were rotated to a different table. In questions and deepen their under- stationed at different tables. this way, each group had a standing of the programs. 2) Participants were divided into chance to visit each table where small groups of 5-8. Each small presenters were stationed. Objective: group went to a different table To explore issues in more depth in and further discussed questions small group sessions. and issues raised from the presentations. A record keeper was assigned to each table.

How are the RH outreach services (gynecamps) organized? WN works with the local NGOs to organize volunteer physicians to go to communities to provide health services. They travel with all the necessary equipment and supplies. In this way, they can carry out minor surgery as necessary, including tubal ligations. They can also perform important diagnostic procedures such as EKG and ultrasound.

In Ecuador, why do you think that sustainable agriculture promotes health? There are three basic reasons. First, there are cultural reasons, because there is a logical link between the concepts of soil fertility and human fertility. Second, there is the involvement of men. The inclusion of agriculture permitted male participation. The men began to have better impressions of CEMOPLAF (World Neigh- bors’ partner in Ecuador), and began to permit women to work with the organization. Third, there is economics. Agriculture leads to income generation and food production—that motivated people to get involved.

How does migration affect reproductive health in Haiti? In areas where the harvest is poor, women are usually the ones who travel to do petty commerce. This means that women spend long periods away from their husbands and families. These women are very vulnerable, because they are often forced to sleep in the open markets to protect their goods. When women have the possibility to do income-generating activities at home, they will stay with their families. This is one reason that the program has dedicated some funds for women’s income-generating activities.

WNIA SPRING/SUMMER 2003 SUBJECT: INTEGRATING REPRODUCTIVE HEALTH IN DEVELOPMENT PROGRAMS VOLUME 29, NO. 1E FIELD VISITS

Objectives: 3) To gain a better understanding of 2) Participants visited local NGO 1) To gain a better understanding the integrated approach of World partners, community-based of the community management Neighbors in Kenya. organizations, health facilities of facilities and quality of care and communities. Method: monitoring. The next day, the participants 1) Participants were divided into two worked in small groups to highlight 2) To get to know the roles and groups of 12-14. Each group key lessons learned. responsibilities of community visited a different field site. They health promoters and how were each accompanied by a they coordinate with health WN- East Africa staff person and facilities. local staff.

The committment of the traditional The extensive record keeping birth attendants (TBA)is impres- that the TBA maintains in sive. Payment for services is not Kenya would not be possible compulsory. Sometimes they have in West Africa, where to pay from their own pocket to illiteracy is a problem. buy supplies for their kits.

The community trainers in Kenya They gave me a clear picture of are impressive. Despite an unclear the goal of the community phar- focus, the high price of medicine and macy, which is to provice services only minor incentives, the Trainer of nearer to the house. From their Trainers remain highly motivated. income they are able to do development work.

WNIA SPRING/SUMMER 2003 SUBJECT: INTEGRATING REPRODUCTIVE HEALTH IN DEVELOPMENT PROGRAMS VOLUME 29, NO. 1E SYNTHESIZING LESSONS LEARNED

Objectives: 1) To identify lessons learned 1. Three Case Studies Brainstorm Key Lessons 2) To synthesize key lessons and cluster by category 3) To better define categories of 2. Three Case Studies Brainstorm Key Lessons lessons learned Method: 1) After the presentations and Cluster roundtables, participants cap- tured key lessons learned by writing them on cards. 2) In a large group, the participants 3. Field Trips Feedback & Lessons clustered the cards by category. 3) The clusters were reviewed by the facilitators. The facilitators Synthesis chose five clusters to be ex- plored in more depth and synthesized by small groups. Taskforce 4) The participants broke into five small groups, each with a large cluster, or two related clusters. 4. Review Framework Reviewed the clusters and the lessons learned, and synthesized each group into major learnings. 5. Revisions

Initial Synthesized Participants brainstormed lessons Clusters Clusters learned after the presentation and Capacity Building roundtables by writing their key lessons Capacity Leadership on cards. In total, more than 100 cards Leadership were generated. These lessons were Quality then organized into clusters. See Quality RH Services graphic on right for clusterings. RH Services Integration Similar categories were combined. then Integration Income five key categories were selected by Income Generation the facilitators and discussed in small Generation groups. The small groups synthesized Gender Gender the cluster of lessons learned and made recommendations regarding the key Leveraging categories and lessons Community Norms Advocacy

Advocacy

IEC

WNIA SPRING/SUMMER 2003 SUBJECT: INTEGRATING REPRODUCTIVE HEALTH IN DEVELOPMENT PROGRAMS VOLUME 29, NO. 1E REVISING THE FRAMEWORK

Objective: Revising the Framework: For gender, rather the broad category, To review and make modifications A group of six participants volunteered it was suggested that it was more useful to RH Key Elements Framework to review the framework and make rec- to specify sub-elements that appeared based on lessons learned from the ommendations based on the lessons to be key to better componenets. workshop. learned. These were couple and family commu- Methods: For several of the categories, such as nication, men’s involvement in RH, and 1) A small group of six participants action learning and capacity building, it women’s organization and leadership. volunteered to review the was felt that no changes were neces- With regard to special populations, the framework. sary as these were fundamental elements group recommended that adolescents 2) The group first reviewed each of all WN programs. However, it was be specified, noting the challenges of en- element using the synthesized felt that three categories could be more suring access to information and ser- lessons learned to validate or precisely defined. These were integra- vices. question each element. tion, gender and special populations. Finally, one new element was added. 3) The group then added addi- For integration, it was felt that it was This was advocacy at three levels, com- tional elements as they felt were useful to specify the importance of sav- munity, regional and national. indicated. ings and credit activities, sustainable 4) The small group reported on the See box on right. agriculture and natural resource man- modifications in plenary. The agement as they all contributed in dif- revised framework was dis- ferent ways to the success of the RH cussed by the whole group. activities. PARTICIPANT ACTION PLANS

Objective: Method: Applying Learning to Programs To reflect on lessons learned and 1) Participants met in country or Participants identified what they felt were describe how they might be applied program teams. the lessons learned most applicable to in participant’s own programs. 2) They identified major lessons their own programs, and also took the learned for application in their time to consider resource requirements. programs. An example of the action plan from 3) They used the following format Southeast Asia follows. for gallery walk feedback: Action / Source of Lesson.

Actions With more With same Learned from resources resources which country Philippines 1) Encourage partners to involve more family X India members - men and women Nepal 2) Help BANGON leverage funds to integrate RH X SEA and NRM Indonesia 1) Involve the influencial people (village leaders, religious leaders) X Burkina Faso

2) Issue-based groups and adolescents X India 3) Collective leadership X Haiti WNIA SPRING/SUMMER 2003 SUBJECT: INTEGRATING REPRODUCTIVE HEALTH IN DEVELOPMENT PROGRAMS VOLUME 29, NO. 1E REVISED RH KEY ELEMENTS

RH Program Comments Suggestions for Dimensions Revising Framework

Capacity Building Essential to all WN work Maintain

Action Learning Essential to all WN work Maintain

Information and Counseling * May need to be more specific with regard Maintain to special groups, i.e. adolescents. * IEC activities linked to social change at community level.

Sustainable RH Services * Challenge of providing services to adoles- Maintain FP/MH/STI cents. * Importance of income activities to access services.

Special Populations * Adolescents emerged as the most impor- Replace by Information tant group here. and Services for Adoles- * We discussed that other groups may repre- cents sent marginalized populations with whom WN works by virtue of purpose statement.

Advocacy: This is a new category. The small group Add Advocacy: Community, Community recommended micro, meso and macro levels Regional and National Regional of advocacy. However, the task force felt National that those concepts were not easily under- stood and preferred to maintain three levels.

Gender-Related Issues The task force felt this was an important area Maintain Gender but also of learning and that the element needed to be specify three elements: more specific. From the presentations three 1) Female organization & clear areas emerged: Leadership * Female organization and leadership 2) Couple and family * Couple and family communication communication * Men’s participation in RH decisions and 3) Men’s participation in activities RH

Integration * Importance of income generation for access Maintain, but highlight to services and female autonomy Income Generation and * Importance of linking RH with other sec- acknowledge linkages with tors like sustainable agriculture, CBNRM other elements for reasons of male participation and couple and family communication

WNIA SPRING/SUMMER 2003 SUBJECT: INTEGRATING REPRODUCTIVE HEALTH IN DEVELOPMENT PROGRAMS VOLUME 29, NO. 1E More Resources On Integration Programs

Evaluating an Integrated Reproductive Health Program: “Union Makes Strength”::: India Case Study Building a Peasant Organization in Rural Haiti This report details the methods and This report details the growth of the grassroots findings of a participatory evaluation of peasant association OPD-8, supported by integrated reproductive health programs in World Neighbors - Haiti. The program and re- two villages in India, with comparisons to a sulting organization were intentionally de- third village that had no reproductive signed to encourage broad-based participation health programming. The results suggest and democratic decion-making, and to test the that the integrated approach used by theory that strong local organizations are es- World Neighbors - India and its partners is sential to the effectiveness and sustainability effective in achieving high rates of of any development Program. This case study reproductive health knowledge and shares methods used to improve members’ overall well-being by positive practice, improvements in women’s status, and signifi- providing tangible benefits in the areas of sustainable agriculture cant benefits from participation in savings and credit programs. and food production, income and asset building, and community 60 pp; English; $10.00 plus shipping; 2002 and reproductive health. 52 pp; English; $10.00 plus shipping; 2002

Gender and Decision Making: Kenya Case Study World Neighbors is a people-to-people, non-profit organiza- This report presents the methods and results tion working at the forefront of worldwide efforts to eliminate of a series of workshops focused on gender hunger, disease, and poverty in Asia, Africa, and decision making at the household level. and Latin America. Conducted by World Neighbors staff with World Neighbors’ purpose is to strengthen the capacity of participants from Makueni District, Kenya, marginalized communities to meet their basic needs. We the workshops helped community members affirm the determination, ingenuity, and inherent dignity of all discuss and analyze how decisions about people. Working in partnership with people at the community family resources and childbearing were be- level since 1951, World Neighbors is recognized as a leader ing made, and what impact these patterns in participatory community development. had on men’s and women’s well-being. The publication outlines three participatory exercises as well as the results and key lessons Program priorities are sustainable agriculture, community- learned from the process. based health, gender and reproductive health, and capacity building. 24 pp; English; $5.00 plus shipping; 2000 World Neighbors is a non-sectarian, self-help movement supported by private donations. World Neighbors does not solicit nor accept U.S. government funding.

World Neighbors In Action is a how-to-do-it newsletter This issue of World Neighbors In Action was written by Dr. Catharine designed for development program workers. It is published McKaig, Reproductive Health and Africa Regional Coordinator twice a year in English, French and Spanish. for World Neighbors, with editing and design by Natalie Elwell, International Publications Associate. Two-year subscriptions (four issues) to World Neighbors In Action are available to readers in industrialized nations for US$10. Subscriptions in developing countries are free. When ordering, please specify your language preference World Neighbors (English, French or Spanish). 4127 NW 122nd Street To subscribe to World Neighbors In Action, to download a Oklahoma City, OK 73120-8869 USA free PDF version, or to find out more about World Neigh- tel: 405/752-9700 bors’ publications, please contact us directly or go to our on- line bookstore at www.wn.org. fax: 405/752-9393 email: [email protected] www.wn.org