DRC) January 2020

Insights Deck – Democratic Republic of the Congo (DRC) January 2020

www.fpcape.org Table of contents

T 01 Executive summary 03 DRC: findings a) Enabling environment b) Demand generation c) Service delivery d) Scale-up and impact e) Synthesis of facilitators and barriers

02 FP CAPE overview and DRC portfolio theory 04 Appendix of change (ToC)

2 01

Executive summary DRC findings and insights (2019)

3 Positive Overall portfolio progress in 2019 Mixed/stable Declining ToC Segment Geography Status Details

► The Reproductive health law with FP provision went into effect in March 2019

► National election has created a time of transition Enabling National ► Lack of funding releases for contraceptive procurement remains a significant Environment barrier ► National Family Planning (FP) Conference an opportunity to re-energize for future movement

► FP message exposure is flat for both women and youth Kinshasa ► Intention to use among all women is stable at approximately 70% Demand Generation Kongo ► Low and declining levels of exposure to FP messages Central ► Intention to use among all women has stabilized at about 50%

► Public facilities have declining offerings and increasing stockouts Kinshasa ► Modern method access increased in private facilities Service Delivery ► Increasing availability of at least five methods in public facilities Kongo ► Scale-up of DMPA-SC identifiable in percentage of facilities providing and Central reflected in increasing share of users

Kinshasa ► Continuing slight growth in modern contraceptive prevalence rate (mCPR) Impact Kongo ► Increase in mCPR after a slight downward trend Central Summary dashboard: Enabling environment The government’s release of funds for contraceptive procurement continues to be slow and difficult to track. A reproductive health law, repealing the 1920s law prohibiting use of FP, went into effect in March 2019.

14 provinces established Funding for the purchase of contraceptives CTMPs grew CTMPs over the past four years.

CTMP established $0 (BMGF deep investment Province) Nord-Ubangi CTMP established Bas-Uele Haut-Uele Sud-Ubangi National funds released for Two provinces, Sud Kivu CTMP newly established Mongala Ituri purchase of contraceptives and Kinshasa, allocated CTMP has not been established Equateur Tshopo Province reached by Advance Family Tshuapa Nord-Kivu in 2019 funds for FP commodities Planning (AFP) Mai-Ndombe in 2019 Sud-Kivu Sankuru Kinshasa Maniema Kwilu Kasai Kongo Central Kasai Lomami Central Reproductive health and FP law Kwango Tanganyika

Haut-Lomami Kasai Haut- Lualaba Oriental Katanga The law for reproductive health and New provincial FP went into effect in March 2019. CTMP established in This repealed the 1920s law which 1 2019: Tanganyika prohibited FP use.

5 Source: Grantee documentation Summary dashboard: Demand generation Overall, demand has been relatively stable at a moderate level for several years in both Kinshasa and Kongo Central.

Media exposure to FP messaging is stable in Kinshasa, and declining in Kongo Central.

All women exposure to FP messages, Kinshasa All women exposure to FP messages, Kongo Central

60% 60%

40% 40%

20% 20%

0% 0% R1/2013 R2/2014 R3/2015 R4/2015 R5/2016 R6/2017 R7/2018 R4/2015 R5/2016 R6/2017 R7/2018

TV Radio Health facility visit Newspaper or magazine CHW visit TV Radio Health facility visit Newspaper or magazine CHW visit

Intention to use among youth Intention to use among all women

70.2% 70.5% 61.5% 63.3% 65.9% 65.7% 57.3% 59.7% Overall demand for women and youth has not 56.1% 53.4% Kinshasa 49.1% Kinshasa 49.1% 49.7% 43.4% 43.4% 44.0% increased significantly, but Kongo Central Kongo Central from 2015 onwards there is a slight increase in

R4/2015 R5/2016 R6/2017 R7/2018 R4/2015 R5/2016 R6/2017 R7/2018 Kinshasa. 6 Source: PMA2020 data (R1-R7 Kinshasa; R4-R7 KC) Summary dashboard: Service delivery Contraceptive access has shown mixed results in Kinshasa, but has generally improved in KC public facilities. We see a rising share of DMPA-SC and EC use in the modern method mix.

Stockouts increase in Kinshasa The modern contraceptive method mix is shifting % of public facilities with stockouts by method Percent of modern method users who use in the last three months, 2015-18, Kinshasa 80% 75.0% condoms and EC, Kinshasa 70.0% 50.6% 48.9% 47.8% 41.2% 40.4% 50.0% 32.0% 43.8% 28.1% Condoms 40% 33.3% 29.4% 31.3% 26.1% 27.8% 12.9% EC 21.4% 8.0% 7.1% 15.8% 16.7% 4.3% 1.8% 3.2% 3.1%

0% R1/2013 R2/2014 R3/2015 R4/2015 R5/2016 R6/2017 R7/2018 Pills Implants IUD Injectables Condoms EC Public facility methods increase in KC DMPA-SC share increasing in KC

Public facilities offering at least five modern Percent of modern method users who use DMPA-SC, Kongo Central methods, 2015-18, Kongo Central 78.1% 58.2% 39.2% 43.6% 9.8% All women 6.6% Youth 2.5% 2.8% 8.1%

2.4% R4/2015 R5/2016 R6/2017 R7/2018 0.0% 2.3% R4/2015 R5/2016 R6/2017 R7/2018 7 Source: PMA2020 data (R1-R7 Kinshasa; R4-R7 KC) Summary dashboard: Impact Use in Kongo Central is increasing after a slight downward trend, while in Kinshasa use is steadily increasing.

mCPR longer-term trends

26.7% 27.4% 23.8% 23.4% 26.5% 22.0% 20.9% 20.4% 20.4% 21.0% 19.0% 20.9% 20.9% 18.5% 18.1% 16.9% 20.3% 20.0% 17.2% 16.8% 14.1% 16.7% 17.0% 16.0% 16.6%

10.3% 8.1% 6.7% 7.8% 5.8%

2007 2013 R1/2013 R2/2014 R3/2015 R4/2015 R5/2016 R6/2017 R7/2018

National All National Married Kinshasa All Kinshasa Married Kongo Central All Kongo Central Married 8 Source: PMA2020 data (R1-R7 Kinshasa; R4-R7 KC); DHS 2007 & 2013. Timeline of scale-up and BMGF expansion

2016 2017 2018 2019

Enabling environment Enabling environment Enabling environment Enabling environment ‣ AFP & AcQual II scale-up of ‣ AFP & AcQual II scale-up of ‣ AFP & AcQual III scale-up of ‣ AFP & AcQual III scale-up of CTMPs in 10 provinces CTMPs in 12 provinces CTMPs in 13 provinces CTMPs in 14 provinces ‣ Pilot DMPA-SC studies were Demand generation Demand generation accepted by the General Secretary; Service Delivery ‣ JHU under AcQual II expanding ‣ DKT expansion of youth campaign it’s now included in the CBD ‣ Jhpiego, EngenderHealth, activities to target police/military to Equateur, North Kivu, Kasai, and training curriculum. Pathfinder and the PNSR are populations and into Kongo Central Bandundu working to scale-up the PPFP Service Delivery approach to all public health Service delivery Service delivery ‣ Nursing student CBD are now structures in Kinshasa ‣ DKT scaled up DMPA-SC model in ‣ In the process of obtaining official trained to insert/remove Implanon ‣ PROMIS is scaling-up models, Kinshasa to Kongo Central authorization for scale-up of NXT. tools, and approaches that ‣ AcQual II expanding activities to community-based distribution of DRC CTMP scale-up, grantees developed with the MoH Kongo Central DMPA-SC & self-injection 2019 to other provinces ‣ Planned scale-up of Implanon NXT ‣ AcQual III, ExpandNet and D6

at the community level with Nord-Ubangi Bas-Uele Haut-Uele scaled-up CBD training in nursing Sud-Ubangi medically trained CBD Mongala schools to Lualaba and Tanganyika Ituri ‣ DKT expansion of FP sales via Equateur Tshopo ‣ Nursing school curriculum now boat up the Congo River Tshuapa Nord-Kivu includes training on DMPA-SC self- injection Mai-Ndombe Sud-Kivu Sankuru Kinshasa Maniema Kwilu Kasai Kongo Central Kasai Lomami Kwango Central Tanganyika Haut-Lomami CTMP established (BMGF deep investment Kasai Haut- CTMP newly established Province reached by AFP Lualaba Province) Oriental Katanga CTMP established CTMP has not been established 02

FP CAPE overview and DRC portfolio theory of change A portfolio evaluation

10 FP CAPE takes a systems perspective to evaluating the complex, constantly changing portfolio of grantees Active for four years (2016-2019), FP CAPE has analyzed multiple rounds of quantitative and qualitative data to understand how/why the BMGF DRC FP portfolio may be driving changes.

BMGF’s work is in support of the DRC Grantees form an interrelated and dynamic The Family Planning Country Action Process government’s National Strategic Plan for portfolio to evaluate, as they interact in an Evaluation is a systems-aware, realist, theory- Family Planning (2014-2020). ever-changing system. based evaluation that synthesizes many kinds of real-time evidence on how/why the portfolio Simple evaluation approaches are not may be driving change, from 2016 to the BMGF FP grantee sufficient to understand the portfolio of present. investment portfolio grantees at a country level.

Grantee Grantee

The DRC

11 FP CAPE synthesizes a variety of DRC data sources We utilize qualitative and quantitative information, including our own data-collection activities to add to the body of evidence on BMGF-funded FP activity in the DRC.

Sentinel indicators Synthesis of SSM using PMA2020, and bottom-up data, Round 7/2018 2016-2019

BMGF Program Officer Funding information at interviews, national and provincial levels, September 2019 Ongoing

Updated systematic GIS mapping of grantee document review, activity coverage, Ongoing November 2019

12 Theory of Change: BMGF DRC investment portfolio FP CAPE’s research questions are based on a Theory of Change which defines and monitors causal linkages, starting with portfolio investments and moving to increased national mCPR.

National/provincial-level capacity ‣ Advocacy Improved enabling ‣ National system strengthening for environment implementation & scale-up ‣ Data generation and use

Model testing, learning & replication ‣ Test service delivery and demand generation models ‣ Test service models for youth Scale-up of Increased Effective service successful national delivery and demand models mCPR generation models

Investment Portfolio Investment Engaging the private sector ‣ Marketing of FP methods through pharmacies and youth services

13 BMGF DRC FP Grantees, by Theory of Change area

Model testing, learning & Engaging the National/provincial level capacity replication private sector

Advocacy Service delivery and Marketing of demand generation models FP methods through pharmacies and youth Nat’l system strengthening for services implementation and scale-up Bien Grandir 2

Momentum AcQual III AcQual III Service models for youth Data generation and use

Bien Grandir 2 Momentum AcQual III 14 DRC investment portfolio: Critical assumptions FP CAPE’s research agenda is driven by explicit critical assumptions underlying the portfolio ToC.

Project area Critical assumptions

‣ Favorable FP policies are enacted National/provincial level ‣ PNSR and PNSA coordinate partners in support of national and provincial strategies capacity ‣ Effective national supply-chain ensures commodity availability and GIBS-MEG contributes to estimating needs

‣ Service delivery models increase quality and access to full range of services Model testing and learning ‣ Learning about sexual/RH behaviors improves youth-related outcomes ‣ Model program strategies will create demand for modern FP methods

‣ Private sector models increase access to FP Engaging the private sector

Investment Portfolio Investment ‣ Adults and youth will purchase socially marketed FP methods

‣ Improved coordination and planning will attract scale-up investments Scale-up of successful ‣ Strong measurement drives performance, scale-up and donor coordination demonstration models ‣ Demonstration models seen as relevant and feasible for other provinces and donors

Outcomes Increased national mCPR ‣ Model programs remain effective when scaled up by others in new contexts

15 03

DRC: Findings Targeted evaluation findings and new results

16 03a

Enabling environment DRC findings

17 Enabling Environment Enabling environment DRC

Expected Critical assumptions changes Sentinel indicators

Favorable FP policies are enacted Enabling environment ► FP2020 government commitments improved ► Instances of policy changes related to FP

PNSR & PNSA coordinate partners Donor coordination ► # of national CTMP meetings held in support of national & provincial increased strategies Provincial CTMP ► # of provincial CTMP created & where strengthened

Effective national supply chain Increased funding for ► Funding for contraceptive procurement: allocations and ensures commodity availability and contraceptive disbursements GIBS-MEG contributes to procurement estimating needs

18 ToC critical DRC government FP funding status assumption Effective national supply While money is consistently committed or allocated to FP, disbursement issues for chain ensures commodity availability and GIBS-MEG contraceptive procurement results in years-long wait for funds or no funds released at contributes to estimating needs all. 2013 2014 2015 2016 2017 2018 2019

$2.5M allocated: No funds for purchase & allocated or distribution of $0.3M committed: $0.3M released: disbursed contraceptives No national to purchase to health zones [FY 2018] contraceptives (HZs) and [FY 2017] funds allocated [FY 2014] partners or disbursed Nord-Kivu and [FY 2019] Sud-Kivu allocated money for the No data purchase of $1M released: contraceptives for the first time $2.5M committed: to UNFPA for funds not to purchase contraceptives Sud-Kivu and released when $0.1M allocated in contraceptives Kinshasa created budgeted Lualaba: for the [FY 2015] $1.5M budget lines for the not released purchase of No data purchase of contraceptives for contraceptives the first time Committed Allocated Tshopo and Meeting of CTMP funds not Lomami created a No funds Released $3.5M allocated and MoB, funds released when budget line for the allocated or [FY 2016] will not be Funds not released budgeted purchase of disbursed released contraceptives for [FY 2019]19 the first time Source: Grantee documentation ToC critical Legislation that impacts FP officially ratified assumption

A previously documented law and code were officially passed in the DRC. Favorable FP policies are enacted

‣ Public health law with FP provision went into effect in March 2019 ‣ Repeals and replaces the 1920s colonial law prohibiting use of FP ‣ Protects access to FP services for all women (including adolescents and youth) ‣ Protects a woman’s choice to use FP, even without spousal support ‣ Mining Code increases companies’ responsibilities ‣ Requires the support of socially-responsible programs by mining companies ‣ Advocates are pushing for investment in FP ‣ Nursing school curriculum updated to include trainings on self injection of DMPA-SC

‣ Guidelines and curricula for PPFP are updated 20 Source: AFP website (2019) ToC critical DRC CTMPs continued to expand in 2019 assumption PNSR & PNSA coordinate Tanganyika province added a CTMP in 2019, resulting in a total of 14 provinces with partners in support of national & provincial CTMP. The national CTMP organized two national events in 2019. strategies

CTMP established (BMGF deep investment province) Nord-Ubangi Bas-Uele One new province, Haut-Uele CTMP established Sud-Ubangi Tanganyika, added +1 CTMP newly established Mongala a CTMP in 2019 Added province Ituri CTMP has not been established Tshopo Equateur Province reached by Advance Family Planning Nord-Kivu Tshuapa

Mai-Ndombe Provinces with Sud-Kivu CTMP 14 Sankuru Kinshasa Maniema Total provinces Kwilu Kasai Kongo Central Kasai Lomami Central Tanganyika Kwango CTMP organized two national events in 2019: the “Consensus Meeting” of all Haut-Lomami th national CTMPs in April and the 4 Kasai Haut- Lualaba Katanga National Conference to Reposition FP Oriental in December. CTMP held several national meetings in preparation for these events. 21 Source: Grantee documentation, verbal report ToC critical 4th National Conference to Reposition FP, assumption PNSR & PNSA coordinate partners in support of December 3-5, 2019 national & provincial strategies A diverse range of high level FP stakeholders met to discuss best practices, celebrate successes and create an action plan for 2020 and beyond.

Topics of ► Demographic dividend discussion ► Domestic resource mobilization strategies of the central and provincial governments ► Mobilization of more resources from the private sector, including mining companies ► Increasing FP service use, particularly among youth and adolescents ► Innovations in providing FP services ► Current legal environment of FP in the DRC, including the evolution of legal framework such as the Public Health Law and the Maputo Protocol ► Involvement of media in advocacy to mobilize additional resources for FP

Key moments ► Government/donor round table – focused on the mobilization of additional resources for FP ► Mining company meeting – involving the private sector as part of their social responsibility work ► Field visit – medical school students who provide community FP services ► Youth pre-conference – culminating in reading the youth statement on the last day of the conference

22 Photo source: Didier Malongo Recommendations from the National Conference Participants identified areas of improvement for four main sectors/groups in the FP community.

CTMP Private Sector

► Organize the final evaluation of the ► Invest more in FP as part of social National Strategic Plan of FP (2014- and societal responsibility 2020) ► Write the new Strategic FP Plan for the period 2021-2025 with a focus on more services for adolescents and young people

Government FP2020 and constituents

► Honor the commitments for FP, ► Increase investments in FP for the including the disbursement and use of DRC and mobilize new investments in funds favor of the DRC ► Initiate reforms that focus on women's ► Set up the Central Africa Partnership health and education with its headquarters in Kinshasa, ► Initiate reforms to ensure that mining similar to the Ouagadougou companies include FP interventions in Partnership their specifications

23 Photo source: Didier Malongo Summary dashboard: Enabling environment The government’s release of funds for contraceptive procurement continues to be slow and difficult to track. A reproductive health law, repealing the 1920s law prohibiting use of FP, went into effect in March 2019.

14 provinces established Funding for the purchase of contraceptives CTMPs grew CTMPs over the past four years.

CTMP established $0 (BMGF deep investment Province) Nord-Ubangi CTMP established Bas-Uele Haut-Uele Sud-Ubangi National funds released for Two provinces, Sud Kivu CTMP newly established Mongala Ituri purchase of contraceptives and Kinshasa, allocated CTMP has not been established Equateur Tshopo in 2019 funds for FP commodities Province reached by AFP Tshuapa Nord-Kivu Mai-Ndombe in 2019 Sud-Kivu Sankuru Kinshasa Maniema Kwilu Kasai Kongo Central Kasai Lomami Central Reproductive health and FP law Kwango Tanganyika

24 Source: Grantee documentation 03b

Demand generation DRC findings

25 Demonstration models: Demand generation Program demonstration models Updated sentinel indicators and additional deeper analyses featured in this section. DRC

Critical assumptions Expected changes Sentinel indicators Progress KIN/KC

Model program strategies Increased exposure to FP ► % of women exposed to FP messages through radio will create demand for messages in focus provinces and TV (by age)  / ▼ modern FP Increased intention to use FP ► % of all women who are not using a FP method who among all women intend to use a method in the future  /  Learning about Increased intention to use FP ► % of youth (15-24) who are not using a FP method  /  sexual/RH behaviors among youth who intend to use a method in the future improves youth-related outcomes

 No change ▲ Increasing ▼ Decreasing 26 ToC critical Exposure to FP messages in Kinshasa assumption

Model program strategies Media exposure has levelled off across age groups, with television remaining will create demand for the most common source of FP messages in Kinshasa. modern FP

All women exposure to FP messages, Youth (15-24) exposure to FP messages, Kinshasa Kinshasa 100% 100%

90% 90%

80% 80%

70% 70%

60% 60% 57.6% 55.6% 50% 50%

42.2% 40% 40% 35.0% 34.2% 30% 30% 30.2% 25.2% 20% 20% 16.9% 18.4% 14.3% 11.1% 10% 10.4% 10% 9.9% 10.4% 4.8% 4.6% 3.5% 3.5% 0% 1.7% 0% 0.7% R1/2013 R2/2014 R3/2015 R4/2015 R5/2016 R6/2017 R7/2018 R1/2013 R2/2014 R3/2015 R4/2015 R5/2016 R6/2017 R7/2018

TV Radio Health facility visit Newspaper or magazine CHW visit TV Radio Health facility visit Newspaper or magazine CHW visit

27 Source: PMA2020 data (R1-R7 Kinshasa) ToC critical Exposure to FP messages in Kongo Central assumption

Model program strategies Exposure to FP messages through mass media is declining. Exposure through will create demand for facilities and CHWs may be increasing again after a slight decline. modern FP

All women exposure to FP messages, Youth (15-24) exposure to FP messages, 50% Kongo Central 50% Kongo Central

40% 40%

30% 30% 27.1% 24.5%

20.3% 20% 20% 19.3% 17.7% 18.5%

10.1% 9.7% 10% 10% 8.9% 10.0% 10.7% 8.8% 8.2% 7.1% 8.2% 6.6% 6.3% 5.5% 3.8% 3.4% 0% 0% R4/2015 R5/2016 R6/2017 R7/2018 R4/2015 R5/2016 R6/2017 R7/2018

TV Radio Health facility visit Newspaper or magazine CHW visit TV Radio Health facility visit Newspaper or magazine CHW visit

28 Source: PMA2020 data (R4-R7 KC) ToC critical Intention to use FP, Kinshasa & Kongo Central assumption Model program strategies will create demand for Intention to use FP in the future among non-users fluctuates from year to year but is modern FP

fairly stable among women and youth in KC, and increased since 2016 in Kinshasa. Learning about sexual/RH behaviors improves youth- related outcomes

Intention to use by age, Kinshasa Intention to use by age, Kongo Central 100% 100%

90% 90%

80% 73.6% 80% 72.2% 70.2% 70.5% 70% 65.9% 65.7% 70% 59.0% 60% 60% 56.1% 64.6% 63.3% 53.4% 60.7% 61.5% 59.7% 49.1% 49.7% 50% 57.3% 50% 53.1% 49.1% 40% 40% 43.4% 43.4% 44.0% 30% 30%

20% 20%

10% 10%

0% 0% R1/2013 R2/2014 R3/2015 R4/2015 R5/2016 R6/2017 R7/2018 R4/2015 R5/2016 R6/2017 R7/2018

All women Youth All women Youth

29 Source: PMA2020 data (R1-R7 Kinshasa; R4-R7 KC) ToC critical Traditional method use in Kinshasa & KC assumption

Model program strategies After a few years of increase in Kinshasa and Kongo Central, women’s use of will create demand for traditional methods appears to have stabilized. modern FP

Percent of all women (15-49) using a traditional Percent of all women (15-49) using a traditional method, Kinshasa method, Kongo Central

50% 50%

40% 40%

30% 30%

21.5% 21.4% 20.1% 20% 18.5% 20% 16.9% 17.1% 14.4% 13.7% 13.0% 11.3% 9.9% 10% 10%

0% 0% R1/2013 R2/2014 R3/2015 R4/2015 R5/2016 R6/2017 R7/2018 R4/2015 R5/2016 R6/2017 R7/2018

30 Source: PMA2020 data (R1-R7 Kinshasa; R4-R7 KC) Summary dashboard: Demand generation Overall, demand has been relatively stable at a moderate level for several years in both Kinshasa and Kongo Central.

Media exposure to FP messaging is stable in Kinshasa, and declining in Kongo Central.

All women exposure to FP messages, Kinshasa All women exposure to FP messages, Kongo Central

60% 60%

40% 40%

20% 20%

0% 0% R1/2013 R2/2014 R3/2015 R4/2015 R5/2016 R6/2017 R7/2018 R4/2015 R5/2016 R6/2017 R7/2018

TV Radio Health facility visit Newspaper or magazine CHW visit TV Radio Health facility visit Newspaper or magazine CHW visit

Intention to use among youth Intention to use among all women

R4/2015 R5/2016 R6/2017 R7/2018 R4/2015 R5/2016 R6/2017 R7/2018 Kinshasa. 31 Source: PMA2020 data (R1-R7 Kinshasa; R4-R7 KC) 03c

Service delivery DRC findings

32 Demonstration models: Service delivery Program demonstration models Updated sentinel indicators and additional deeper analyses featured in this section. DRC Critical Expected changes Sentinel indicators Progress Assumptions KIN/KC Service delivery Access to services is ‣ % of public facilities offering at least five modern contraceptive method ▼ / ▲ models increase increased in focus provinces ‣ % of pharmacies/drug shops offering modern FP methods  /  quality and access ‣ % of public facilities with a CHW that provides FP ▼ / ▲ to full range of ‣ % of women hearing FP message from CHW  /  services ‣ % of public facility with stockouts in the last 3 months (IUD, implant, ▲ / ▼ injectable, pill) Quality of services increased ‣ % of women counseled on side effects ▼ /  in focus provinces Increased demand for ‣ % of facilities offering DMPA-SC (public, private) ▲ / ▲ DMPA-SC and Nexplanon, ‣ % of modern method users using DMPA-SC  / ▲ especially among youth ‣ % of modern method users using implants ▲ / ▲

Private sector Increased access to FP ‣ % of private facilities offering at least five modern methods ▲ /  models increase services in the private sector ‣ % of pharmacies/drug shops offering modern FP methods  /  access to FP for KIN, KC Adults and youth Increased private sector ‣ % of women who obtained their most recent method from a pharmacy  / ▼ will purchase market share or drug shop/kiosk socially marketed FP methods

 No change ▲ Increasing ▼ Decreasing 33 ToC critical Facilities offering at least five modern methods assumption

Service delivery models is generally increasing in public facilities in KC increase quality and access to full range of services The percentage is also increasing in private facilities in Kinshasa. Public facilities are still the most likely to offer 5+ methods, though this is decreasing in Kinshasa.

Percent of facilities offering at least five modern Percent of facilities offering at least five modern 100% contraceptive methods, Kinshasa 100% contraceptive methods, Kongo Central 90% 87.1% 90% 79.2% 80% 80% 78.1% 70.8% 70% 70% 63.6% 60% 56.7% 60% 58.2% 52.6% 50% 50% 44.3% 43.6% 41.4% 40.2% 39.2% 40% 36.3% 40% 31.3% 30.1% 29.0% 30% 24.7% 30% 22.1% 20.4% 20% 20%

10% 10%

0% 0% Public Private Public Private

R2/2014 R3/2015 R4/2015 R5/2016 R6/2017 R7/2018 R4/2015 R5/2016 R6/2017 R7/2018 34 Source: PMA2020 data (R2-R7 Kinshasa; R4-R7 KC) ToC critical Access to products through pharmacies and assumption Service delivery models increase quality and access drug shops is relatively flat to full range of services Private sector models Both Kinshasa and Kongo Central have seen some annual fluctuations in pharmacy increase access to FP access. Percent of pharmacies/drug shops offering modern Percent of pharmacies/drug shops offering modern 100% contraceptive methods, Kinshasa 100% contraceptive methods, Kongo Central 91.7% 90% 90% 84.1% 82.8% 81.6% 80.0% 80% 80% 77.4%

68.8% 67.9% 70% 66.1% 70%

60% 60% 55.0%

50% 50%

40% 40%

30% 30%

20% 20%

10% 10%

0% 0% R2/2014 R3/2015 R4/2015 R5/2016 R6/2017 R7/2018 R4/2015 R5/2016 R6/2017 R7/2018 35 Source: PMA2020 data (R2-R7 Kinshasa; R4-R7 KC) ToC critical Public facilities with community health workers assumption

Service delivery models increased in Kongo Central increase quality and access to full range of services The percentage of facilities with CHW providing FP (condoms and pills) decreased in Kinshasa.

100% Percent of public facilities with CHW that 100% Percent of public facilities with CHW that provide FP, provide FP, Kinshasa Kongo Central 90% 90%

80% 80%

70% 70%

60% 60% 50.0% 50% 50% 43.6% 45.3%

40% 40% 32.3% 30.9% 30.0% 29.2% 30% 30% 27.5% 22.7%

20% 15.8% 20%

10% 10%

0% 0% R2/2014 R3/2015 R4/2015 R5/2016 R6/2017 R7/2018 R4/2015 R5/2016 R6/2017 R7/2018

36 Source: PMA2020 data (R2-R7 Kinshasa; R4-R7 KC) ToC critical Both Kinshasa and Kongo Central had low assumption

Service delivery models exposure of women to FP messages from CHWs increase quality and access to full range of services Less than 7% of women report receiving FP messages from CHWs and this has not changed much since 2015 despite increases in facilities with CHWs providing FP in KC.

50% Percent of women exposed to FP messaging 50% Percent of women exposed to FP messaging through CHWs, Kinshasa through CHWs, Kongo Central 45% 45%

40% 40%

35% 35%

30% 30%

25% 25%

20% 20%

15% 15% 10.7% 10% 10% 6.6% 6.9% 6.3% 6.4% 6.6% 5.4% 6.0% 4.6% 4.0% 5% 5% 1.7%

0% 0% R1/2013 R2/2014 R3/2015 R4/2015 R5/2016 R6/2017 R7/2018 R4/2015 R5/2016 R6/2017 R7/2018

37 Source: PMA2020 data (R1-R7 Kinshasa; R4-R7 KC) ToC critical Stockouts are increasing recently in Kinshasa assumption

Service delivery models In Kongo Central, IUD and EC stockouts are generally high and increasing, but increase quality and access implant, pill and injectable stockouts are decreasing. to full range of services

Percent of public facilities with stockouts by method in the last Percent of public facilities with stockouts by method in the last three months, Kinshasa three months, Kongo Central 100% 100%

90% 90%

80% 75.0% 80% 70.0% 70% 70% 66.7% 62.5% 60% 60% 50.0% 50% 50% 48.2% 46.7% 43.8% 40% 40% 33.3% 29.4% 31.3% 30% 26.1% 27.8% 30% 25.0% 23.3% 21.4% 18.2% 19.2% 20% 15.8% 16.7% 20% 15.0% 11.1% 9.1% 10.2% 10% 10%

0% 0% Pills Implants IUD Injectables Condoms EC Pills Implants IUD Injectables Condoms EC

R3/2015 R4/2015 R5/2016 R6/2017 R7/2018 R4/2015 R5/2016 R6/2017 R7/2018

38 Source: PMA2020 data (R3-R7 Kinshasa; R4-R7 KC) ToC critical Counseling on side effects for current method assumption

Service delivery models continues to fluctuate in Kinshasa increase quality and access to full range of services In Kongo Central, counseling has increased for implants and injectables, and decreased for pills and condoms.

Women counseled on side effects for current modern method Women counseled on side effects for current modern method by 100% 100% by method, Kinshasa method, Kongo Central 90% 90% 83.3% 82.4% 79.0% 78.2% 76.4% 78.1% 76.9% 80% 74.3% 80% 67.9% 67.6% 70% 70% 71.7% 68.6% 68.1% 60% 60% 62.4% 54.3% 59.5% 58.8% 57.9% 50% 50% 53.5% 53.8% 42.8% 49.2% 40% 33.4% 33.8% 40% 42.0% 31.3% 30% 30% 22.4% 32.6% 24.3% 20.0% 16.3% 17.4% 16.9% 20% 13.6% 20% 19.4% 17.4% 19.2% 18.0% 10% 14.8% 13.9% 14.2% 10% 14.3% 9.3% 7.8% 0% 0% R1/2013 R2/2014 R3/2015 R4/2015 R5/2016 R6/2017 R7/2018 R4/2015 R5/2016 R6/2017 R7/2018

Implants Injectables Pills Condoms Implants Injectables Pills Condoms

39 Source: PMA2020 data (R1-R7 Kinshasa; R4-R7 KC) ToC critical Facilities providing DMPA-SC have increased assumption Both Kinshasa and Kongo Central have more facilities providing DPMA-SC in both Service delivery models increase quality and access the public and private sectors. to full range of services

Percent of facilities* providing DMPA-SC, by facility type, Percent of facilities* providing DMPA-SC, by facility type, Kinshasa Kongo Central 100% 100%

90% 90%

80% 80%

70% 70%

60% 60% 54.6% 50.0% 50.0% 50% 50% 41.7% 40.6% 40% 40% 30.9% 29.0% 30% 28.0% 30% 18.8% 20% 20% 12.1% 10.9% 9.3% 10% 6.5% 6.9% 10% 4.1% 0.0% 0% 0% Public Kinshasa Private Kinshasa Public Kongo Central Private Kongo Central

R4/2015 R5/2016 R6/2017 R7/2018 R4/2015 R5/2016 R6/2017 R7/2018

40 Source: PMA2020 data (R4-R7 Kinshasa and KC); *Excluding pharmacies ToC critical DMPA-SC use grew in Kongo Central assumption DMPA-SC use increased among all women and youth in Kongo Central, while use in Service delivery models increase quality and access Kinshasa remains low but stable. to full range of services

Percent of modern method users who use DMPA-SC, all Percent of modern method users who use DMPA-SC, all 25% 25% women and youth (15-24), Kinshasa women and youth (15-24), Kongo Central

20% 20%

15% 15%

9.8% 10% 10%

6.6% 8.1% 5.0% 5% 5% 2.6% 3.8% 2.5% 2.8% 2.6% 3.7% 3.4% 2.4% 2.2% 2.2% 2.3% 0% 0% 0.0% R4/2015 R5/2016 R6/2017 R7/2018 R4/2015 R5/2016 R6/2017 R7/2018

All women Youth All women Youth

41 Source: PMA2020 data (R4-R7 Kinshasa & KC) ToC critical Private facilities are popular for obtaining FP assumption

Adults and youth will In Kongo Central an increasing number of women are turning to private facilities for purchase socially marketed contraceptive methods. Pharmacies and drug shops remain the most popular FP methods method source in Kinshasa.

Percent of women obtaining current method* by source in Percent of women obtaining current method* by source Kinshasa, 2013-2018 in Kongo Central, 2015-2018 100% 100%

90% 90%

36.8% 80% 41.8% 80% 42.4% 47.0% 47.5% 48.1% 48.7% 48.0% 54.8% 52.0% 51.7% 70% 70%

60% 60%

50% 50%

33.4% 41.7% 40% 28.3% 24.1% 24.7% 40% 16.0% 21.1% 24.9% 42.2% 36.0% 30% 30% 43.7% 10.3% 20% 15.0% 20% 18.1% 16.1% 14.0% 17.8% 15.2% 7.1% 17.4% 10% 18.9% 10% 10.5% 13.4% 10.6% 8.8% 11.2% 6.0% 7.1% 8.2% 8.2% 4.9% 0% 0% 2.3% 4.1% R1/2013 R2/2014 R3/2015 R4/2015 R5/2016 R6/2017 R7/2018 R4/2015 R5/2016 R6/2017 R7/2018

Other Private Public Pharm/Drg shp Other Private Public Pharm/Drg shp 42 Source: PMA2020 data (R1-R7 Kinshasa; R4-R7 KC) *Excluding LAM ToC critical Modern method mix is more diverse assumption

Service delivery models In both provinces there has been a decrease in the share of condoms in the method increase quality and access mix. In Kongo Central, we see an increase in the share of most other methods, while to full range of services in Kinshasa the share of implants and EC is generally increasing.

Percentage distribution of modern method users Percentage distribution of modern method users by method type, Kinshasa by method type, Kongo Central 100% 3.1% 100% 7.1% 12.9% 4.3% 8.0% 4.6% 3.2% 1.4% 0.9% 90% 1.8% 90% 0.0%

80% 80%

30.2% 70% 32.0% 70% 47.8% 28.1% 41.8% 39.8% 41.2% 40.4% 48.9% 48.0% 60% 50.6% 60%

50% 13.4% 50% 16.0% 22.7% 10.4% 17.7% 40% 14.4% 10.5% 40% 17.8% 14.1% 12.3% 12.3% 14.1% 30% 30% 17.6% 14.8% 14.8% 13.8% 19.7% 20% 12.3% 20% 21.9% 22.4% 28.2% 19.9% 13.0% 26.9% 10% 18.6% 19.8% 20.3% 10% 14.3% 14.8% 10.5% 5.6% 5.1% 7.1% 0% 0% R1/2013 R2/2014 R3/2015 R4/2015 R5/2016 R6/2017 R7/2018 R4/2015 R5/2016 R6/2017 R7/2018

Implants Pills Injectables Condoms EC Implants Pills Injectables Condoms EC

43 Source: PMA2020 data (R1-R7 Kinshasa; R4-R7 KC) ToC critical Youth (15-24) use an increasingly diverse range assumption

Service delivery models of modern methods increase quality and access to full range of services Among youth, there has been a shift from dominance of condom use to a more diverse range of methods. In recent years the EC share in Kinshasa has increased.

Percentage distribution of youth (15-24) modern method users Percentage distribution of youth (15-24) modern method users by method type, Kinshasa by method type, Kongo Central

100% 4.0% 12.9% 19.4% 100% 2.1% 2.5% 4.5% 4.5% 3.0% 8.4% 0.7% 90% 90% 0.0%

80% 80% 40.5% 70% 70% 40.0% 30.7% 56.6% 60% 62.1% 60% 62.2% 68.3% 69.5% 54.2% 72.0% 70.1% 50% 50% 14.1% 17.1% 40% 11.3% 40%

6.9% 30% 30% 9.0% 15.5% 6.0% 19.2% 9.0% 4.3% 6.0% 22.8% 20% 20% 18.1% 13.5% 8.6% 12.5% 3.7% 8.4% 11.4% 18.3% 10% 20.7% 10% 16.6% 9.5% 12.1% 8.6% 8.8% 12.0% 8.6% 10.5% 10.1% 2.9% 3.0% 0% 0.0% 0% R1/2013 R2/2014 R3/2015 R4/2015 R5/2016 R6/2017 R7/2018 R4/2015 R5/2016 R6/2017 R7/2018 Implants Pills Injectables Condoms EC Implants Pills Injectables Condoms EC 44 Source: PMA2020 data (R1-R7 Kinshasa; R4-R7 KC) ToC critical Youth access at pharmacies and drug shops assumption

Adults and youth will fluctuates in Kinshasa purchase socially marketed FP methods Kongo Central youth use of pharmacies/drug shops trended downward in last survey.

Percent of youth (15-24) who obtained most recent method Percent of youth (15-24) who obtained most recent method 100% from pharmacy/drug shop, Kinshasa 100% from pharmacy or drug shop, Kongo Central

90% 90%

80% 80%

68.7% 70% 67.8% 70% 64.4% 61.7% 60.1% 60% 56.4% 60% 57.3% 52.3% 52.3% 52.0% 50% 50%

40% 40% 35.1%

30% 30%

20% 20%

10% 10%

0% 0% R1/2013 R2/2014 R3/2015 R4/2015 R5/2016 R6/2017 R7/2018 R4/2015 R5/2016 R6/2017 R7/2018

45 Source: PMA2020 data (R1-R7 Kinshasa; R4-R7 KC) ToC critical Kinshasa GIS study: Who’s doing what, where? assumption As the number of BMGF FP partners working in the DRC increases, it is important to Service delivery models increase quality and access determine where each partner works and the type of activity that each carries out. to full range of services

Goals and ‣ Visually map the BMGF FP portfolio’s activities by Health Zone (HZ) and Grantee Grantee objectives Health Area (HA) in Kinshasa ‣ Identify Kinshasa interventions by ToC area: service delivery and demand generation Grantee Grantee ‣ Improve the coordination of FP interventions in order to optimize the use of resources within the BMGF portfolio Grantee Grantee

Methodology ‣ In collaboration with Tulane, FP CAPE developed and implemented a survey to collect data on the different FP activities implemented by grantees and the areas covered ‣ The survey looked at 13 service delivery activities and 4 demand generation activities ‣ ArcGIS was used to map activity coverage at the health zone and health area levels

Respondents ‣ Four grantees managing seven projects responded 46 ToC critical Most Kinshasa HAs have at least one grantee assumption

Service delivery models supporting FP services increase quality and access to full range of services BMGF grantees are supporting service delivery activities throughout Kinshasa.

Grantees providing support for FP services

number of grantees 0 1 2 3 Source: FP CAPE KFKO survey (2019) ToC critical Few HAs receive support for adolescent- assumption

Service delivery models focused FP services increase quality and access to full range of services Only one grantee is supporting adolescent-focused FP services in most HAs that receive this support. Grantees providing FP services for adolescents, including health facilities, mobile services, and/or at special events

number of grantees 0 1 2 3 48 Source: FP CAPE KFKO survey (2019) Summary dashboard: Service delivery Contraceptive access has shown mixed results in Kinshasa but has generally improved in KC public facilities. We see a rising share of DMPA-SC and EC use in the modern method mix.

0% R1/2013 R2/2014 R3/2015 R4/2015 R5/2016 R6/2017 R7/2018 Pills Implants IUD Injectables Condoms EC Public facility methods increase in KC DMPA-SC share increasing in KC

2.4% R4/2015 R5/2016 R6/2017 R7/2018 0.0% 2.3% R4/2015 R5/2016 R6/2017 R7/2018 49 Source: PMA2020 data (R1-R7 Kinshasa; R4-R7 KC) 03d

Scale-up and impact DRC findings

50 Demonstration models: Scale-up and overall impact Updated sentinel indicators and additional deeper analyses featured in this section.

Critical Assumptions Expected changes Sentinel indicators Progress KIN/KC Improved coordination Successful models are ‣ # of instances of scale-up of intervention models and planning will attract adopted & replicated or scale-up investments scaled-up

Strong measurement will drive performance, scale- up and donor coordination Model programs remain Effective models are chosen ‣ mCPR in Kinshasa and Kongo Central ▲ / ▲ effective when scaled up and tailored to the context of by others in new contexts the scale-up/replication site

‣ National mCPR No data Demonstration models seen as relevant and feasible models by other provinces

 No change ▲ Increasing ▼ Decreasing 51 Summary dashboard: Impact Use in Kongo Central is increasing after a slight downward trend, while in Kinshasa use is steadily increasing.

mCPR longer-term trends

26.7% 27.4% 23.8% 23.4% 26.5% 22.0% 20.9% 20.4% 20.4% 21.0% 19.0% 20.9% 20.9% 18.5% 18.1% 16.9% 20.3% 20.0% 17.2% 16.8% 14.1% 16.7% 17.0% 16.0% 16.6%

10.3% 8.1% 6.7% 7.8% 5.8%

2007 2013 R1/2013 R2/2014 R3/2015 R4/2015 R5/2016 R6/2017 R7/2018

National All National Married Kinshasa All Kinshasa Married Kongo Central All Kongo Central Married 52 Source: PMA2020 data (R1-R7 Kinshasa; R4-R7 KC); DHS 2007 & 2013. Timeline of scale-up and BMGF expansion

2016 2017 2018 2019

Synthesis of facilitators and barriers DRC findings from System Support Mapping (SSM) and Bottom Up Results, 2016-2019

54 In synthesizing SSM and bottom up results from 2016-19, system-wide themes emerged Both government capacity and model testing and learning have seen positive change that facilitates FP progress, but persistent barriers remain. Systems approach to the FP landscape   ‣ The DRC FP environment is a complex system where various parts (government, grantees, advocates, business, social Positive gains Persistent concerns enterprises, etc.) interact in differing ways. ‣ Growing government support ‣ Instability in the sociopolitical environment ‣ We have seen positive changes in some ‣ Increasing sophistication in grantee human ‣ Inconsistent contraceptive availability parts of the FP system, but persistent capital barriers to sustainable system change remain. ‣ The tensions in the evolving system and emerging issues create non-linear outcomes.   ‣ The categories to the right summarize Give & take Emerging issues some of these different system features. The two slides after this give more detail ‣ Collaboration/competition between ‣ Strong competition at the health zone level to the governmental capacity and model grantees testing and learning systems. ‣ Increasing grantee expectations ‣ Availability of resources ‣ Other healthcare crises (Ebola, measles) 55 Government capacity is increasing, along with needs While national level capacity has seen growth, this must be met with increased support at the HZ level. Also, improved human capital creates demand for further training and resources. Collaboration and tension ► Strengthened collaboration between Government capacity BMGF grantees, MoH, NGOs, and other generally is increasing, with FP stakeholders strong advocates in ► Grantees have stepped up to provide and Sociopolitical instability government and positive develop needed items (supervision tools, ► Difficulties accessing certain support, implementation, capacity strides in internal health zones due to instability development. building) ► Lack of activity/approach coordination ► Change in government However, there is both among partners at HZ level reduced efficiency during collaboration and tension at election time the grantee/NGO level. For Internal development National/ ► Closing of provincial example, increasing ► Gradual improvement in assemblies provincial collaboration is capacity (M&E, data provincial not always reflected at the visualization, ► Other pressing health issues health zone (HZ) level. in-house trainings) capacity (Ebola, measles) taking ► Technical and financial precedence Finally, overall sociopolitical resources at HQ level to support instability creates a difficult advocacy, data use, and capacity building environment with which to Expectations increasing push forward FP changes, ► Low levels of data for decision ► More financial resources needed making by gov’t and partners given other ongoing crises. to support greater abilities Advocates in government ► Increased capacity and ► Increased political will to support FP, availability of local actors for Facilitators (darker = stronger impact) strengthened collaboration with MoH training, data entry

Barriers (darker = stronger impact) ► New FP/RH laws ► Increased grantee data awareness leading to need for Both facilitators and barriers ► CTMPs increasingly involved and supporting improved data systems and use advocacy activities Sources: SSM (2016-2018), FP CAPE Bottom-up synthesis (2016-2019) Model learning is tempered by collaboration issues Grantee work is progressing, however several factors including collaboration problems create barriers to achieving FP results.

Collaboration Limited resources (human, ► Good collaboration between BMGF financial, etc.) creates partners, grantees, and government competition between partners, and constrains the ► Weak activity coordination and competing approaches among partners overall effectiveness of grantee work. ► Delays in data collection due to sociopolitical instability, lack of Availability of contraceptives Community level-support for coordination, limited capacity of local FP has seen growth in some actors ► Many contraceptive supply key groups, but sociocultural chains have been ► Data collection tools not standardized Model strengthened over the 2016- barriers to access remain. across implementing partners testing & 19 period ► However, increased stockouts learning are also reported due to rising demand for certain methods and instability

Availability of non-monetary resources Community-level work ► Availability of trained internal staff ► Community-level support for FP (acceptance of CBD, increased FP ► Availability and use of FP tools (data demand, support by key groups like collection, training manuals, media miners) support) Facilitators (darker = stronger impact) ► Sociocultural barriers like rumors ► Shortages of trained providers, provider spread about FP and media sensitivity Barriers (darker = stronger impact) instability, and lack of training materials to FP messaging

Both facilitators and barriers ► Difficulty accessing HZs due to instability Sources: SSM (2016-2018), FP CAPE Bottom-up synthesis (2016-2019) 04

Appendix

58 The purpose of FP CAPE FP CAPE takes a complex systems look at BMGF FP investment portfolios in the Democratic Republic of the Congo and Nigeria towards achieving national mCPR goals.

Mechanisms of action Context & interaction Design features A clear Theory of Change A portfolio-level evaluation A prospective design documents identifies critical assumptions independently assesses FP change, issues, and learning on drivers of FP use. investments in DRC and concurrently with implementation. This Nigeria. allows FP CAPE to test critical By testing theorized assumptions in real time. processes, FP CAPE By observing how multiple generates evidence on how activities work together, rather Realist, theory-based models define and why each mechanism than focusing on individual and test theoretical assumptions, use can achieve sustained grants, FP CAPE detects realist evaluation techniques, to adapt change. interactions and synergies portfolio theories of change in between programs. response to FP CAPE findings.

59 List of abbreviations

AcQual “Accès” et “Qualité” HZ Health zone AFP Advance Family Planning JHU Johns Hopkins University BMGF Bill & Melinda Gates Foundation IUD Intrauterine device CBD Community-based distribution KC Kongo Central CHW Community health worker LAM Lactational Amenorrhea Method CTMP Comité Technique Multisectoriel Permanent M&E Monitoring and Evaluation D6 6th Direction at the Secretary General of health mCPR Modern contraceptive prevalence rate DHS Demographic and Health Survey MoB Ministry of Budget DKT DKT International MoH Ministry of Health DMPA-SC Depot-medroxyprogesterone acetate (Sayana® Press) NGO Non-governmental organization DRC The Democratic Republic of the Congo PMA2020 Performance Monitoring and Accountability 2020 EC Emergency Contraception PNSA Programme National de la Santé de l’Adolescent FP Family planning PNSR Programme National da Santé de la Reproduction FP 2020 Family Planning 2020 PO Program Officer FP CAPE Family Planning Country Action Process Evaluation PPFP Post-pregnancy family planning FY Fiscal year R Round GIBS-MEG Groupe Inter-Bailleur pour la Santé-Médicaments Essentiels Génériques RH Reproductive health SSM System support mapping GIS Geographic information system ToC Theory of change HA Health area UNFPA United Nations Population Fund