MIDTERM EVALUATION OF THE FISTULA CARE PROJECT NOVEMBER 2011 This publication was produced for review by the United States Agency for International Development. It was prepared by Oladosu Ojengbede, Deborah Caro (Team Leader), Erin Mielke, and Patricia MacDonald through the Global Health Technical Assistance Project. MIDTERM EVALUATION OF THE FISTULA CARE PROJECT DISCLAIMER The views of the authors expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government. This document (Report No. 11-01-509-2) is available in printed or online versions. Online documents can be located in the GH Tech website library at http://resources.ghtechproject.net. Documents are also made available through the Development Experience Clearing House (http://dec.usaid.giv).Additional information can be obtained from: The Global Health Technical Assistance Project 1250 Eye St., NW, Suite 1100 Washington, DC 20005 Tel: (202) 521-1900 Fax: (202) 521-1901 [email protected] This document was submitted by The QED Group, LLC, with CAMRIS International and Social & Scientific Systems, Inc., to the United States Agency for International Development under USAID Contract No. GHS-I-00-05-00005-0. ACKNOWLEDGEMENTS The authors would like to extend our thanks to all those who made this report possible. We greatly benefited from the hands-on involvement of the USAID staff, Erin Mielke, Patricia MacDonald, and Mary Ellen Stanton. Project Director, Karen Beattie, Deputy Director, Evelyn Landry, and the staff at EngenderHealth in New York, who were extremely generous with their time, analytical insights, and showed great patience with our persistent questions and requests for data. The project teams in Ethiopia, Uganda, Nigeria, and Guinea ensured that our country visits were highly informative under severe time constraints. We would like to extend special thanks to Adamu Isah and Iyeme Efem, FC Project Manager and Deputy Manager in Nigeria, Edith Mukisa, FC Project Manager in Uganda, Moustapha Diallo, FC Project Manager in Guinea, and Aynalem Yigaw Aynalem Yigaw, IntraHealth FC Project Manager in Ethiopia, along with their staff, for arranging and guiding us expertly through our country visits. The authors are also grateful to the USAID Mission staff in the four countries who met with us, particularly to Joseph Monehin (USAID Nigeria) and Premla Bartlett (USAID/Ethiopia), who traveled with us on our field visits. Finally, we were inspired by the healthcare providers, government officials, and community members we met who are supporting fistula prevention and care efforts in Ethiopia, Guinea, Nigeria, and Uganda. Our greatest appreciation and gratitude goes to the women who shared their personal stories about life stories before and after fistula surgery. We hope the report contributes to a better understanding of the accomplishments and challenges of addressing the multiple dimensions of fistula. The opinions and conclusions found in this report are the authors alone. MIDTERM EVALUATION OF THE FISTULA CARE PROJECT i ii MIDTERM EVALUATION OF THE FISTULA CARE PROJECT CONTENTS ACRONYMS ............................................................................................................ v EXECUTIVE SUMMARY ..................................................................................... vii Successes .................................................................................................................................. vii Challenges ............................................................................................................................... viii Recommendations for Current Project ............................................................................. ix Recommendations for Future Programming ...................................................................... x I. INTRODUCTION ......................................................................................... 1 Purpose ....................................................................................................................................... 1 Background ................................................................................................................................ 1 Funding ........................................................................................................................................ 3 Project Activities ....................................................................................................................... 5 Methodology .............................................................................................................................. 6 II. FINDINGS ...................................................................................................... 7 Fistula Care and USAID Management .................................................................................. 7 Global Leadership for Research, Innovation and Technology Transfer ....................... 8 Responsiveness to USAID, its Missions, and Global Stakeholders ................................ 9 Strategic Objectives ...............................................................................................................10 Result I: Strengthen the Capacity of Centers to Provide Quality Services to Repair and Care for Women with Obstetric and Traumatic Gynecologic Fistula. ....13 Result 2: Enhance Community and Facility Understanding and Practices to Prevent Fistula and Utilize and Deliver Services .............................................................17 Result 3: Gather, Analyze, and Report Data to Improve the Quality of Performance of Fistula Services ...........................................................................................20 Result 4: Strengthen a Supportive Environment to Institutionalize Fistula Prevention, Repair and Reintegration of Services ...........................................................26 III. CONCLUSIONS AND LESSONS LEARNED .......................................... 29 IV. RECOMMENDATIONS FOR FISTULA CARE ........................................ 31 V. ISSUES AND QUESTIONS FOR FUTURE DIRECTIONS .................... 33 MIDTERM EVALUATION OF THE FISTULA CARE PROJECT iii APPENDIXES Appendix A. Assessment Scope of Work......................................................... 35 Appendix B. Persons Contacted/Places Visited ................................................ 51 Appendix C. List of Documents Collected and Reviewed ............................... 59 Appendix D. Fistula Care Tools ......................................................................... 61 Appendix E. Four Country Summary Reports ................................................. 63 TABLES Table 1. USAID-funded Fistula Programming Countries ................................. 5 Table 2. Strategic Objective Indicators ............................................................. 12 Table 3. Number Of Health Providers Attending Training, All Countries By Year ................................................................................................... 15 Table 4. Number Of People Counseled And Accepting Fp Methods By Year In Project-Supported Sites ......................................................... 18 FIGURES Figure 1. Fistula Care Results Framework .......................................................... 4 Figure 2. Total Number Repairs from January 2005–September 2011 by Source of Support .......................................................................... 11 Figure 3. Number of USAID Supported Sites and Countries, January 2005 to September 2011 .............................................................................. 12 iv MIDTERM EVALUATION OF THE FISTULA CARE PROJECT ACRONYMS AOTR Agreement officer‘s technical representative ANC Antenatal care DHS Demographic Health Survey DRC Democratic Republic of the Congo EH EngenderHealth EmONC Emergency obstetric and neonatal care ECSA Southern African Health Community ESD Extending Service Delivery FC Fistula Care FGC Female genital cutting FIGO Federation of International Gynecologists and Obstetricians FMOH Federal Ministry of Health FP Family planning GHI Global Health Initiative HIDN Health, infectious diseases, and nutrition IEC Information, education, communication IR Intermediate result ISOFS International Society of Obstetric Fistula Surgeons MCH Maternal and child health M&E Monitoring and evaluation MNH Maternal and neonatal health MOH Ministry of Health MOU Memorandum of understanding NGO Non-governmental organization OAA Office of Assistance and Acquisitions OB-GYN Obstetrics/gynecology OFWG Obstetric Fistula Working Group PAUSA Pan African Urological Surgeons Association PMP Program monitoring plan QOC Quality of care RCT Randomized controlled clinical trial RH/FP Reproductive health and family planning RVF Recto-vaginal fistula MIDTERM EVALUATION OF THE FISTULA CARE PROJECT v UNFPA United Nations Population Fund USAID United States Agency for International Development USG United States Government VVF Vesico-vaginal fistula WHO World Health Organization vi MIDTERM EVALUATION OF THE FISTULA CARE PROJECT EXECUTIVE SUMMARY Fistula is a severe birth-related morbidity resulting from prolonged and obstructed labor (obstetric fistula), severe sexual violence (traumatic fistula), or surgical error (iatrogenic fistula). Fistula causes deterioration in tissue between the vagina and bladder or rectum (and sometimes both); and it subjects