POPULATION AND FAMILY HEALTH OFFICE
REVIEW OF PFH PROGRAM AND PROJECT EVALUATIONS
(2005-2019)
UPDATED JULY, 2020
This publication was produced for review by the United States Agency for International Development by XL Associates
Inc. under the Middle East Regional Platform (MERP) contract.
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 1
DISCLAIMER
The author’s views expressed in this publication do not necessarily reflect the views of the United States
Agency for International Development or the United States Government.
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REVIEW OF PFH PROGRAM AND PROJECT
EVALUATIONS (2005-2019)
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Table of Contents
Executive Summary........................................................................................................................ 8
Overview of Programs ..............................................................................................................8 
Introduction ................................................................................................................................... 11
Background ............................................................................................................................. 11 
Process ................................................................................................................................... 11 
Limitations ............................................................................................................................... 12 
Thematic Analysis of Evaluations and Final Reports................................................................... 13
Family Planning ..................................................................................................................... 13 
Reproductive and Maternal Health ........................................................................................ 18 
Newborn and Child Health ..................................................................................................... 18 
Nutrition ................................................................................................................................... 19 
Health Systems Strengthening .............................................................................................. 19 
Issues and Recommendations Related to Monitoring and Evaluation .................................. 25 
Annex A - Summaries of Individual Evaluations and Reports ..................................................... 26
Health Service Delivery (Evaluation)..................................................................................... 27
Jordan Human Resources for Health 2030 (Midterm Evaluation)........................................ 30
Health Finance and Governance (Early Evaluation) ............................................................ 33
Jordan Family Planning Assessment (Evaluation Of Previous USAID FP Activities).......... 35
Strengthening Health Outcomes through the Private Sector (Final Evaluation).................. 40
Jordan Health and Communication Partnership (Final Evaluation) ..................................... 44
Health Systems Strengthening II (Midterm Evaluation)........................................................ 48
Health Systems Strengthening II Bridge Project (Final Report)........................................... 51
Private Sector Project for Women’s Health (Final Report)................................................... 54
Expanding HIV Prevention in Jordan (Final Report)............................................................. 56
Annex B - Examples of Pilot Projects Discontinued or Not Scaled Up........................................ 57
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ACKNOWLEDGMENTS
This review builds on many evaluations written for USAID/Jordan’s Population and Family Health Office
between 2005 and 2019. Many of the recommendations are included in this review and have been transcribed
verbatim or as near to the original as possible. This summary therefore builds on the work of many
individuals and organizations who have contributed to evaluating and sharpening Jordan’s programmatic
response over the past fifteen years.
The report was initiated and reviewed by Andrea Halverson, Deputy Director of the Population and Family
Health Office. Additional feedback was John Callanta, Monitoring and Evaluation Specialist with PFH.
The following authors are named in the evaluations or final reports referred to in this document; their
previous diligence is acknowledged.
Midterm Performance Evaluation of the USAID/Jordan Health Service Delivery Activity (2019): Dr. Adriane
Hilber Martin; Dr. Fouad Fouad; Dr. Hildy Fong Baker; Yusef Srouji; Cara Nolan; Marvy El Moujabber; Huda
Murad; Mary Sayej; Hannah Mufti and Sabreena Kazem (Link)
Human Resources for Health In 2030 (HRH2030) Midterm Activity Evaluation (2018): Alanna Shaikh, Raed
Azmi, Hamouda Hanafi, Khaled Hasan, and Wisam Qarqash (Link)
Health Finance and Governance Internal Assessment (2017): Caroline Ly; Arin Dutta and Kate Britton
Jordan Family Planning Assessment (2016): Dominick Shattuck, Esther Spindler, Julie Solo, Nisreen Bitar,
Jordan Tompkins, Lizzy Menstell and Victoria Jennings (Link)
Strengthening Health Outcomes through the Private Sector Evaluation (2015): Pamela Putney, Nedjma Koval￾Saifi, Huda Murad and Wisam Qarqash (Link)
Health Systems Strengthening II Midterm Evaluation (2012): Thomas Park, Kelly O’Hanley, Jennifer Peters, and
Muntaha Gharaibeh (Link)
Jordan Health Communication Program Evaluation (2011): Gary Lewis, Carolyn Barnes, and Inaam Khalaf (Link)
Enhancing Performance of Health Systems. End of Project Report. USAID-funded Health Systems Strengthening
II Bridge Project (2015): Submitted by Dr. Sabry Hamza (Link)
Private Sector Project for Women’s Health (2012): Submitted by Reed Ramlow (Link)
Expanding HIV Prevention in Jordan Final Report (2008): Submitted by Dr. Lina Al Hadid (Link)
Finally, my thanks to Holly Penfold for proof reading.
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ACRONYMS
AWSO Arab Women Speak Out
BCC Behavior Change Communication
CAT Critically Appraised Topic
CBO Community Based Organization
CPD Continuing Professional Development
CYP Couple Years of Protection
DHS Demographic Health Survey
EBM Evidence Based Medicine
EHP Enhancing HIV Prevention
EQuiPP Enhancing Quality in Private Providers
FGD Focus Group Discussion
FP Family Planning
GBV Gender Based Violence
GOJ Government of Jordan
HC Health Center
HCP Health Care Provider
HCSI Health Competent Schools Initiative
HFG Health Finance and Governance [program activity]
HRH2030 Human Resources for Health 2030 [program activity]
HSD Health Service Delivery [program activity]
HSS Health Systems Strengthening
IP Implementing Partner
IRH Institute for Reproductive Health
IUD Intra-uterine Device
JCAP Jordan Communication and Advocacy Project [program activity]
JHCP Jordan Health and Communication Partnership [program activity]
JOD Jordanian Dinar
KII Key Informant Interview
MENA Middle East and North Africa
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MNCH Maternal, Newborn and Child Health
MOH Ministry of Health
PFH Population and Family Health [Office]
PLHA Person Living with HIV/AIDS
PSP Private Sector Project for Women’s Health
RH Reproductive Health
(R)MNCH (Reproductive) Maternal Newborn and Child Health
RMS Royal Medical Services
SBC(C) Social and Behavioral Change (Communication)
SDIC Service Delivery Improvement Collaborative
SHOPS Strengthening Health Outcomes through the Private Sector [program activity]
VAW Violence Against Women
WHO World Health Organization
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EXECUTIVE SUMMARY
OVERVIEW OF PROGRAMS
This review captures key findings from seven program evaluations, supplemented by three final
reports (where no evaluation was available). The main part of the report groups the findings into
themes under the broad headings of (i) Family Planning, (ii) Maternal, Newborn and Child
Health, (iii) broader Health Systems Strengthening and finally (iv) issues and recommendations
related to monitoring and evaluation of USAID’s program activities. Evaluations demonstrated a
large number of issues and recommendations for (i) and (iii), with fewer recommendations
specific to maternal health. There was a notable scarcity of recommendations specifically
relating to newborn and child health, where most gains appear to be related to capital building
projects, although these are not quantified in any of the documents. 
FAMILY PLANNING
Contraceptive effectiveness rather than contraceptive use was identified as the key determinant
of stagnation of the fertility rate, according to the Institute for Reproductive Health’s (IRH) 2016
Assessment. Assuming this is still correct, then many other key recommendations still hold true.
Counseling bias was a consistent theme across most evaluations, pointing to a need for far
greater emphasis on working with professionals to reduce misconceptions. At the same time
positive interventions included “internal referral within a health center”; “increased education in
health centers”; “couples counseling with CHWs”; and campaigns such as Together for a Happy
Family (1996-2000) which demonstrated significant improvements in the numbers considering
IUDs and pills to be safe.
Social and cultural barriers feature in most evaluations. The IRH stressed the need to focus on
the “social” component of SBC. Some interventions targeting youth, such as the Health
Competent Schools Initiative which was handed over to RHAS and the Ministry of Education
were described as “cost effective and low maintenance”. In contrast approaches such as the
“University Ambassador [Peer] Initiative” was not recommended for continuation because it was
considered too labor intensive, with a relatively small reach that required audience-specific
messages and material. Other approaches, such Mabrouk which targeted newlyweds through
the Civil Service and Passports’ Department were praised by evaluations during the life of the
activity, but failed the sustainability test once a program ended. (Annex B provides a list
compiled by IRH of FP-related interventions in Jordan that were not scaled up or were
discontinued soon after a program activity ended.)
Access to FP, and in particular to both female doctors and IUD-trained staff has been a
recurrent issue in multiple evaluations and most recently it was described as inconsistent. This
also relates to post-graduate training opportunities for Ob/Gyn staff. Naturally, the importance of
midwives being able to take on the fitting of IUDs featured repeatedly, after practices became
more restrictive in 2010.
Service delivery quality improvement for FP, such as SDIC, in some cases doubled the uptake
of family planning in health centers, yet due to lower levels of autonomy, fell flat in hospitals.
Helping to expand post-partum FP into public hospitals with a dedicated clinician to provide
phone call follow-ups, was part of IRH’s recommendations (2016). Conversely, an initiative to
improve post-partum FP in private hospitals produced results with negligible gain, that itself was
attributed to women coming from a more educated background rather than as a direct impact
from the program.
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Vouchers and subsidizing the cost of FP commodities and services was identified as
unsustainable long term, yet necessary until a critical mass has been built for prolonged social
change in attitudes to FP.
MATERNAL, NEWBORN AND CHILD HEALTH
Recent findings from the Health Service Delivery (HSD) evaluation found that there is a lack of
clarity on how many antenatal visits are required. In addition, some women were found to not be
receiving the full range of tests, while iron and folic acid were not always available. They also
identified a lack of respect, dignity and humanity in childbirth. Previous evaluations noted
concerns about a lack of privacy in clinics.
The introduction of Evidence Based Medicine for different professions and at varying times
appears in several evaluations. While it was described as “valued by MOH” in one document, a
subsequent evaluation by IRH stated that the stand-alone EBM approach did not improve
knowledge or practice.
In one of the references to improvements in newborn care, the HSS II Bridge final report
documented the introduction of the Active Management of the Third Stage of Labor, which
introduced cord-clamping 1-3 minutes after birth. However, this could be worth revisiting
because WHO guidelines recommend delaying clamping until 2-3 minutes, which can lead to
significant increase in newborn hemoglobin and higher serum ferritin concentration at 6 months
of age and other research found is associated with a 39% reduction in need for blood
transfusion and a lower risk of complications after birth. Meanwhile staff shortages were
identified as a key reason why there was little support for breastfeeding post-partum.
HEALTH SYSTEM STRENGTHENING
Several evaluations identified issues with how programs work with MOH and other
stakeholders. For example, the HSD evaluation found that Health Directorates were “not
engaged” and HAD Directors felt “overstepped and ignored”. The HSS II Bridge final report
stressed the benefits of “uniting a health facility and their health directorate teams in a common
goal” which allowed them to achieve rapid progress, while engagement with central and mid￾level stakeholders improved ownership. Meanwhile HRH2030’s evaluation noted the need for
communication strategies with both high- and mid-level officials had been “woefully
underestimated”. The need for communications strategies among project stakeholders rather
than simply to their beneficiaries, appears to be a key lesson, particularly for harder-to-achieve
activities.
Accreditation as a mechanism for raising the quality of care in primary and secondary care in
both the public and private sector, was described as sustainable and “the shortest and best way
to improve [services]”. Leveraging gains through accreditation increased CYPs by 13% in
participating HCs compared to 5% increases in non-participating ones. It was also cited as a
crucial incentive in motivating private hospitals’ participation a violence against women (VAW)
initiative.
The role of CHWs features as part of a broader HSS approach, although evaluation findings
were variable. IRH described home visits as one of the most effective methodologies to raise
awareness and encourage women to seek services. In contrast the HSD evaluation noted that
anemia testing vouchers were issued to under 5% of households visited, and of these only one
third of vouchers were then used. Some CHWs had trouble mastering a host of health topics,
and consequently spent less time on challenging issues while gravitating to easier topics.
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Staffing is a recurrent issue in most of the reviewed documents, with turnover rates of up to 60%
in some hospitals, bringing into question the sustainability of training clinical staff. This was also
a particular problem for IT staff in MOH, who are frequently offered higher salaries in the private
sector once their skills are improved. Recommendations included focusing on systems and
processes that have longevity, and strengthening the role of mid-level staff who are MOH
leaders of the future. Several documents referred to gaps between pre-service training and
actual need and deficiencies in the Ob/Gyn residency programs.
Health financing and fiscal reform featured little in earlier evaluations, although its importance
has risen due to unsustainable pressures created by rapid population growth. This will require
closer work with EDE and DRG to harmonize approaches at central and decentralized levels
and avoid duplication of efforts.
While development of Information Systems such as HMIS, was described as helpful, the HSS II
evaluation observed that USAID had left a “legacy of multiple, parallel information systems”.
This continues with HSD’s recent evaluation identifying data collection running in parallel to
government systems such as HAKEEM. In contrast, IRH identified a study in 2014 that used
existing data from birth registries to estimate the TFR rather than waiting for DHS.
Other evaluations pointed to a lack of engagement with stakeholders such as UN agencies
which limited both learning from other countries and acceptance of systems as anything other
than a USAID initiative. HFG’s review proposed a shift in priority towards generating data￾demand and enhancing information use.
MONITORING AND EVALUATION
Despite high levels of reported compliance for clinical pathways for FP, ANC, delivery and PPC,
the HSD evaluation did not find the same high-standards of care reflected in client experiences.
This points to a need for better routine triangulation of outputs and outcomes.
Finally, it is worth remembering that End of Project evaluations typically report during the life of
an activity, (although ADS 201 permits evaluations to be done at any time). In doing so, they are
unable to assess the degree of sustainability of individual components. Annex B (originally
compiled by IRH) lists seven significant pilot projects that were either not scaled up, or were
discontinued after the project activity ended. As PFH works with the GoJ on the journey to self￾reliance, learning how to ensure country ownership for interventions that offer the greatest
impact will surely be the most important lesson for programming in this new decade.
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INTRODUCTION
BACKGROUND
USAID’s work in Jordan has spanned over five decades, resulting in many significant
improvements in health. Much of the programming has been focused on improving maternal
health and reducing fertility rates. In recent decades the Total Fertility Rates has remained
almost unchanged until the most recent Jordan Population and Family Health Survey (2017/18).
In the meantime, the population has grown 112% between 2000-2018 (GOJ figures). Much of
this increase has been attributed to the influx of refugees from neighboring conflicts, although
live births accounted for 60% of the population increase between 2000-2018. Nonetheless, this
represents a heavy and unsustainable burden on a country with very limited financial and
natural resources. Therefore, learning lessons from previous programs, to maximize USAID’s
input is essential.
This document is one of a number of background documents intended to inform and shape
USAID/Jordan’s forthcoming Project Appraisal Document (PAD) which provides the strategic
framework for the Mission’s investment in health programming over the next five years.
PROCESS
USAID’s internal systems in country were checked for both final and mid-term evaluations.
Where these could not be identified, PFH team members were asked to check their own files.
Where this still did not identify evaluations, the Jordan Knowledge Management Portal was
searched. In October 2019 a request was submitted to USAID’s Knowledge Service Center to
track down any missing evaluations through the Development Experience Clearing House.
Either mid-term or final project evaluations were identified for the following:1
• Health Service Delivery (2019)
• Human Resources for Health 2030 (2018)
• Health Finance and Governance (2017)
• Strengthening Health Outcomes through the Private Sector (2015)
• Health Systems Strengthening II (2013)
• Jordan Health Communication Program (2011)
Between 2015-2016, USAID tasked the Institute for Reproductive Health (Georgetown
University) with undertaking a Family Planning assessment to review previous USAID activity
and make recommendations for future projects. This is included and categorized as an
evaluation.
Where neither mid-term nor final evaluations were identified, information has been sought from
the program activities’ Final Report for the following projects:2
• Health Systems Strengthening Bridge (2015)
• Private Sector Project for Women’s Health (2012)
• Enhancing HIV Prevention (2008)
1 In the Thematic Review section evaluations are noted as [project/Eval], reports are shown as [project/Rep] and
assessments are [project/Assessment]
2 These were written by the Implementing Partner and therefore offer limited objectivity
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LIMITATIONS
Lessons and recommendations are based on those identified by previous evaluations; they may
not necessarily reflect changes implemented since then. Furthermore, the absence of some
mid-term or final evaluations inevitably means that lessons are incomplete. Evaluations and
Reports are taken at face value, although historically USAID might not have accepted all the
findings, recommendations or conclusions at the time. Only one evaluation systematically
identified previous interventions that were not sustainable, therefore some promising activities
that were praised in evaluations written before the close-out of a project, might have
subsequently failed to survive the transition to local ownership. Nevertheless, where themes
emerge, they are captured in this Review.
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THEMATIC ANALYSIS OF EVALUATIONS AND FINAL REPORTS
FAMILY PLANNING (FP)
OVERALL LESSONS
• Contraceptive effectiveness, rather than contraceptive use, is the key determinant of
fertility stagnation in Jordan [IRH/Eval]
• Community Outreach needs to go beyond information sharing to active engagement of
community members [HSD/Eval]
• The USAID strategy should focus at HC level, where the bulk of FP interactions take
place. Interventions could include HC renovations, supervision, referrals and accreditation
[HSS II/Eval]
• Engagement with stakeholders at central and health directorate level, and facility level
improved ownership [HSS II Bridge/Rep]
BEHAVIOR CHANGE COMMUNICATION
Changing Social Preferences and Gender Norms:
• Include the “social” aspect of social and behavior change communication (SBCC) to
deconstruct gender and social norms, rather than targeting or correcting specific
behaviors [IRH/Eval]
• The need to address the cultural preference for male children, which often results in
families continuing to have children until a sufficient number of male children are
produced, was not part USAID’s programming or design. Changing deeply-seated social
preferences for male children is likely to require considerable social research to identify
messaging that is culturally acceptable and not perceived to be based on a foreign
agenda [SHOPS/Eval]
• In a 2009 study, only two-thirds (65%) of women thought that modern methods were more
effective than traditional methods [IRH/Eval]
• Opposition from husbands only account for about 2% of method choices, and a similar
percent for discontinuation [IRH/Eval]
• A lack of attention to gender differentials in messaging and engagement “may have
diluted achieving objectives” [SHOPS/Eval]
• BCC should be preceded by research to carefully identify messaging and segment
audiences, recognizing the sensitivities relative to the perception of imposing Western
agendas [SHOPS/Eval]
• The Together for a Happy Family campaign targeted over 2 million people (just under half
the population at the time) and was the first-ever national campaign to specifically target
men. From 1996 to 2000 – when the campaign was conducted – the number of men who
considered the IUD safe for their wives rose from 34% to 50%, respectively; while the
number of men considering the pill safe increased from 25% to 36% [IRH/Eval]
• Use of Social Workers (1996-2015): Interviews conducted in Jordan showed that the
social worker outreach program may be an effective and targeted way to promote
behavior change and communication, in particular among husbands and mothers-in-law
[IRH/Eval]
BCC targeting Youth:
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• MOH school health and sports programs are excellent channels for youth engagement
and could be used to encourage youth to delay having children after marriage and plan for
their lives [IRH/Eval]
• The Health Competent Schools Initiative (HCSI) was described as “cost effective and low
maintenance”, and subsequently institutionalized in the Ministry of Education through the
Royal Health Awareness Society. Once materials were distributed to schools and the
teachers trained, there was limited continuing involvement needed with individual schools
[JHCP/Eval]
• Behavior change and expanded awareness of health competency issues among students
was “substantial” suggesting a long-term impact on student health [JHCP/Eval]
• The University Ambassador Initiative was “not recommended for continuation” for multiple
reasons. These included: the training for ambassadors was insufficient to address student
shyness about FP; it failed to give them tools for addressing FP issues (e.g., gender￾specific groups, instructional DVDs or protected Web sites, external expert speakers);
there was irregular follow-up from JHCP; and the lack of a longer-term plan reduced
impact and institutionalization. Student peer approaches, while effective, were considered
labor intensive, with a relatively small reach that required audience-specific messages and
material.
BCC for Newly Married and Parents of Newborns:
• Mabrouk was identified as a cost-effective, innovative way to reach a primary audience for
FP messages through the Civil Status and Passports Department, achieving national
scale. Mabrouk I was aimed at newly-married couples and Mabrouk II targeted those who
came to register a birth [JHCP/Eval]. However, a subsequent evaluation called into
question the actual content and messaging. The intervention ceased when the JHCP
activity ended [IRH/Eval]
BCC through Workplaces:
• Despite low levels of exposure to interventions (8% to18%), behavior change related to
stigma showed a substantial improvement among those exposed to the program
compared to those not part of the intervention showed [EHP/Rep]
Religious Leaders:
• The involvement of religious leaders in addressing FP issues was a powerful intervention
that increased the impact of all other activities and FP projects, by opening up public
dialogue on an otherwise taboo topic. Not all trained leaders integrated FP messages into
their sermons [JHCP/Eval]
• Participating religious leaders had a high opinion of USAID, despite earlier misgivings
[JHCP/Eval]
Mass Media:
• Despite a well-planned media campaign, evaluation results suggest that coverage was not
as far-reaching as expected, probably due to the fragmented nature of Jordanian media
[JHCP/Eval]
FP ACCESS
Vouchers:
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• CHWs provided vouchers for free FP to women, but their value was diminished by the lack
of free transport and the locations where it could be exchanged [SHOPS/Eval]
• Increased access to FP, commodities and services requires subsidized vouchers for FP
consultation products until a critical mass has been built for sustained social change in
attitudes and decision-making for long-term, continuous use of FP [SHOPS/Eval]
FAMILY PLANNING COUNSELING
• Provider bias in counseling is a repeated theme in most evaluations [HSD/Eval]. Health
programming should focus heavily on addressing misconceptions about the side effects of
contraceptives, targeting medical practitioners, clinic staff, pharmacists, CHWs, and the
general public [SHOPS/Eval] The IRH (2016) report recommended a specific focus on the
“social” aspect of SBC to tackle cultural issues
• Counseling was normally only on request [HSD/Eval]
• Some clinics lack appropriate privacy [HSD/Eval]
• “Internal referrals within a health center” that identified unmet need, alongside “increased
health education sessions in health centers” generated far higher rates of switching to
modern methods (98% and 89% respectively) than couples counseling or referrals to a
health center. Both of the successful approaches reached far larger numbers of women in
the study of 858 women [HSS II bridge/Rep]
Community Health Workers (see also HSS – CHWs)
• In-home couples counseling through CHWs increased uptake of modern methods by
around 59%, compared to a 48% increase for women counseled alone, compared with
those who received no counseling [SHOPS/Eval]
• USAID should strengthen CHW-clinic collaboration and create direct and active CHW
linkages to UNRWA and other NGO clinics in the target catchment areas in order to
increase FP demand [SHOPS/Eval]
• Community outreach efforts have been shown to be effective in increasing uptake of
modern methods and should be expanded as they serve a dual role of behavior change
and service provision [IRH/Eval]
METHOD MIX AVAILAIBILITY
• The increases in use of traditional methods and decreases in the use of more effective
methods suggest that much more needs to be done to change strong social norms and
behaviors of all women, men, family members, health service providers, in addition to the
political will of policy-makers [IRH/Eval]
• Expanding the method mix and encouraging shifts from traditional methods to more
effective modern methods is an important priority. This will require improving service
providers’ counseling biases, in addition to increasing community outreach activities
involving women, men, mothers-in-law, and other influential opinion leaders [IRH/Eval]
• Campaigns for oral contraceptives and Intrauterine Device (IUDs) boosted the uptake of
IUD insertion services, the effect on demand was transient [SHOPS/Eval]
Method-Specific Issues
• IUDs are the most popular FP method in Jordan; they have the lowest discontinuation
rates and the greatest impact on CYPs [HSD/Eval] [HSS II/Eval]
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• Access to IUD-trained staff was reported as patchy in multiple evaluations, and dropped
12% between 2010 and 2012 due to legal ambiguity prompting many midwives to stop
fitting IUDs. Prior to this 47% of IUDs were fitted by midwives (2009); in 2011 this dropped
to 26% [HSS II/Eval]
• The Women and Child Health Directorate at MOH were “resistant” to the introduction of a
modern natural method of FP [HSS II Bridge/Rep]
FP COMMUNITY-BASED SERVICE DELIVERY
Quality Improvements within Clinics
• Use of the Service Delivery Improvement Collaborative (SDIC) in the busiest Health
Centers, resulted in uptake of FP more than doubling. This was attributed to “increased
efficiency, awareness and quality of services” [HSS II Bridge/Rep]
• A similar approach in hospitals had minimal impact, which the evaluation ascribed to lower
levels of autonomy [HSS II Bridge/Rep]
• For religious or cultural reasons most Syrian and Jordanian husbands were against
allowing their wives to seek services from male doctors, except (i) in emergencies or (ii)
for lack of an alternative female doctor [IRH/Eval]
JAFPP and other NGOs:
• Between 2002 and 2012, the percentage of women accessing modern contraceptive
methods from JAFPP virtually halved, while the percentage relying on a private doctor
dropped by almost two-thirds (although uptake through private hospitals/clinics doubled)
[IRH/Eval]
• SHOPS was tasked with assisting Jordan Association of Family Planning and Protection
(JAFPP) to become more sustainable. Despite the recommendation to raise prices three
times, JAFPP did so only once, generating a 40% rise in revenue. However increased
salaries and overheads meant that cost recovery remained stubbornly at 58%. The
evaluation concluded that “JAFPP’s leadership is not inclined toward sustainability”
[SHOPS/Eval]
• This was supported by an OIG finding (2014): “JAFPP did not make progress toward its
financial sustainability target”, noting it lost money on every client [OIG report cited in
SHOPS/Eval]
• Provide TA and financial support to a wider range of NGOs, such as the Institute for
Family Health [IRH/Eval]
Private Sector:
• Interventions such as Public Private Partnerships (PPP) did not have a tangible
partnership mechanism for sustainability built into the design [SHOPS/Eval]
• Training should be expanded to pharmacists to improve FP counseling on contraceptive
effectiveness and correct use [IRH/Eval]
• A Public Private Partnership grant fund should be established for implementation of joint
FP-related activities [SHOPS/Eval]
• A private sector partnership with Bayer Schering Pharma (BSP), enabled the introduction
of EBM approach. More than 1,790 private sector physicians participated in one or more
PSP-Jordan training programs [PSP/Rep]
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• To better engage the private sector, the curriculum was expanded to include topics of
interest to providers, including cancer and diabetes, and sessions were scheduled in short
segments in order to meet providers’ competing demands [PSP/Rep]
• A range of incentives motivated private providers to deliver FP, including opportunities to
update clinical skills and knowledge and to earn CME credits [PSP/Rep]
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HOSPITAL-BASED POST-PARTUM FP
• A pilot initiative offering post-partum FP counseling through private hospitals
demonstrated significant potential for increasing FP access to women [SHOPS/Eval]. This
was contradicted by a subsequent evaluation which found modern contraceptive use was
at 46% three months postpartum compared to a national average of 42%. The difference
could also be attributed to more educated women using the private sector [IRH/Eval]
• In the public sector, sustainability was affected by a lack of staff; the requirement for
existing staff to take on additional work, and the need for hospitals to supply IEC material
[SHOPS/Eval]
• Expand post-partum/post-miscarriage FP to all public hospitals, and follow up PPFP with a
phone call [IRH/Eval]
REPRODUCTIVE & MATERNAL HEALTH (RMH)
OVERALL LESSONS
• Pursuing an integrated MCH/FP program is important going forward. This might include
allowing projects to tackle previously un-identified issues in order to aide ownership by the
health facility and their staff [HSS II/Eval]
• Improvements in MNCH can be challenging because they do not fall within the mandate of
any one Directorate within MOH [HSS II Bridge/Rep]
SAFE MOTHERHOOD
• Although Jordan has some of the highest levels of ANC uptake, there remains a lack of
clarity about how many visits are required [HSD/Eval]
• Some women do not receive the full range of tests; while iron and folic acid not always
available [HSD/Eval]
• The introduction of Evidence Based Medicine (EBM), updating of clinical guidelines and
creation of Centers of Excellence were highly valued by the MOH [HSS II/Eval]. Despite it
being “valued” the stand-alone evidence-based medicine (EBM) HSS approach was found
not improve knowledge or practice scores [IRH/Eval]
CHILDBIRTH
• A lack of respect, dignity, and humanity during their delivery is a significant issue
[HSD/Eval]
• Active Management of the Third Stage of Labor introduced cord clamping 1-3 minutes
after birth.3 Implementation across six hospitals was patchy because of a need for
additional clinical and management capacity [HSS Bridge II/Rep]
3 WHO guidelines recommend “Waiting to clamp the umbilical cord for 2–3 min, or until cord pulsations cease”
(WHO 2014)
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 19
NEWBORN AND CHILD HEALTH (NCH)
• One HSS activity supported the introduction of a nasal-bubble continuous positive airway
pressure (NB-CPAP) protocol at 30 MOH and RMS hospitals. Later six hospitals were
provided more intensive support. Results proved variable, in part due to data collection
issues. Ongoing availability of CPAP consumables was described as a limiting factor for
sustainability [HSS II Bridge/Rep]
• A pre-conception component for unmarried youth in universities and out-of-school youth.
(This appeared to not learn the lessons from the evaluation of JHCP’s project activities in
Universities) [HSS II Bridge/Rep]
• The JMMSR conceptual framework built upon existing structures and procedures. Almost
all births are in health facilities, which lends itself to a facility-based follow-up. Requiring all
births to be recorded correctly and reported to DOS would aid the tracking of all births
[HSS II Bridge/Rep]
• Substantial investments were made to improve infrastructure for maternal and newborn
care and emergency services in public hospitals around the country [HSS II/Rep]
NUTRITION
INFANT AND YOUNG CHILD FEEDING
• More than half of respondents did not receive support with breastfeeding because of staff
shortages and a focus on the newborn rather than the mother [HSD/Eval]
Recommendation: Identify staff who can assist with the early initiation of BF
HEALTH SYSTEMS STRENGTHENING (HSS)
OVERALL APPROACH
• Health Directorates were not engaged and HAD directors felt “overstepped and ignored”
[HSD/Eval]
• Uniting a health facility and their Health Directorate teams in a common goal allowed them
to achieve rapid progress [HSS II Bridge/Rep]
• There is insufficient priority to components to improve access (e.g. Client Service Station,
mitigating gender barriers) [HSD/Eval]
• The need for communication strategies to ensure buy-in among both high- and mid-level
officials for the activities was woefully underestimated and is a fundamental lesson for the
future [HRH2030/Eval]
• The health systems approach may not be enough as a standalone approach to address
contraceptive effectiveness, in addition to clients’ and providers’ strong social norms
around fertility and family size. For instance, while the health systems approach has been
successful in increasing family planning use, it has had a weaker effect on reducing
method discontinuation and provider bias, both of which are strongly affected by social
norms and can ultimately affect the national mCPR [IRH/Eval]
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 20
SERVICE DELIVERY
Accreditation
• Accreditation was perceived as sustainable, and described as “the shortest and best way
to improve [ourselves]” [IRH/Eval]
• Supporting accreditation of Primary Healthcare facilities was found to have raised service
quality, while accreditation activities related to FP standards led to a 13% increase in
CYPs in participating HCs, compared with 5% in non-participating HCs [IRH/Eval]
• The Private Hospital Association’s hospital accreditation requirement for family protection
was a critical incentive in motivating private hospitals’ participation in the VAW initiative
[PSP/Rep]
Community Health Workers/Social Workers: (see all FP – Community Health Workers)
• Home visits are one of the most effective methodologies to raise awareness and
encourage a woman to identify her needs for family planning and seek services [IRH/Eval]
• Women find CHW visits beneficial, but >259,000 visits yielded just 12,000 anemia
vouchers issued and only one-third were used for tests [HSD/Eval]
• Women visited by CHWs adopt modern methods following visits three, four, seven, and
eight, with the largest number of women adopting following the fourth and eighth visits.
Once a new user adopts an FP method, she requires continued counseling and support in
the first three to six months of use to help reduce the likelihood of discontinuation
[PSP/Rep]
• Some CHWs had trouble mastering a host of health topics while others spent less time on
challenging topics such as family planning and instead gravitated to other health
messages [PSP/Rep]
• Community Outreach needs to go beyond repeating health messages and embrace active
engagement of community members [HSD/Eval]
• Link and strengthen service delivery components with community-based approaches (for
example social worker outreach and HSS II Bridge models) [IRH/Eval]
• The outreach program should be continued and expanded to reach areas with
underserved and very rural and Bedouin areas [IRH/Eval]
Community Health Committees:
• Potentially effective at raising key issues, while some “perpetuate misinformation about
FP”, although Health Directorates had minimal knowledge of their activities [HSD/Eval]
• CHCs were previously measured on activities, rather than how effective they were [HSS
II/Eval]
• Mitigating gender barriers: one CHC works with the community to provide information for
husbands at Mosques and through events to refer them to the hospital for STD screening,
and to help them recognize the importance of ANC and FP for their wives. They also
discuss GBV in the community. Such efforts are led by active CHC leaders/providers
[HSD/Eval]
• Increase civil society engagement and feedback for improved health sector accountability,
especially related to improved access and quality, and enhancing gender-responsive
service delivery [HFG/Review]
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 21
• In 2014, two CHCs were supported legally transition into community-based organizations
(CBOs) capable of fundraising and providing information and services to their target
communities
Community Scorecards:
• The use of Community Scorecards should be reformed or USAID should cease using
them because community members are not aware of or empowered then [HSD/Eval]
HUMAN RESOURCES
Supportive Supervision and Mentoring:
• USAID-funded supportive supervision and mentoring needs to be aligned with MOH’s
system (not in parallel) [HSD/Eval]
• The current system was found to be a monitoring tool/check box unless managers were
truly engaged, and not considered to be well-aligned with MOH’s MCH supportive
supervision [HSD/Eval]
Staffing Levels and Turnover:
• Turnover rates of between 50-60% brought into question the sustainability of training
clinical staff in some of the main teaching hospitals [HSS II/Eval]
• High staff turnover is a particular problem in IT for MOH, because of recruitment of staff
into the private sector. This creates challenges for IT and HMIS system maintenance
[HSS II Bridge/Rep]
• There must be a focus on systems and on processes strengthened that will have longevity
past individuals; and on strengthening the role of mid-level staff who will be MOH leaders
of the future [HFG/Review]
• There is an absence of clear criteria for the allocation of staff to health facilities, resulting
in some Health Centers being over-stretched while others had staff that lacked core
competencies [HSS II Bridge/Rep]
Staff Training and CPD:
• There is a “large gap” between pre-service education for physicians and midwives and the
actual skills the MOH needs from these cadres [HSS II Bridge/Rep]
• Improve Ob/Gyn residency programs [IRH/Eval]
• Focus training on reducing provider bias and misconceptions about modern methods
[IRH/Eval]
HR Management Practices:
• Training, facilitating policy development, and drafting various tools used in HR
management, would not lead to change on their own; they were necessary but not
sufficient for change [HRH2030/Eval]
• Where supervisors also attended the training, there were more positive outcomes in areas
such as sharing information, day-to-day management, showing flexibility, conducting more
meetings with agendas and minutes, and commitment to regular attendance
[HRH2030/Eval]
• The need for an enabling environment was under-estimated. Old hiring practices and
improper selection of training participants continued after USAID’s HR management
training [HRH2030/Eval]
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 22
• The MOH and Civil Service Bureau compensation systems did not recognize or reward
innovation or increased performance [HRH2030/Eval]
• Recommendation: USAID should also consider combining service delivery and
infrastructure projects with interventions that are more challenging to stakeholders,
including HRH interventions. This would allow the more challenging interventions to
leverage the relationships and goodwill created by infrastructure activities. Last, USAID
should consider a multisectoral approach to HRH that includes the Ministries of Finance,
Higher Education, and Public Sector Development [HRH2030/Eval]
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 23
FINANCE
Programming Considerations:
• PFH needs to work closely with EDE and DRG to avoid duplication on fiscal reform
[HFG/Review]
Specific Activity Issues:
• Capacity building at subnational governorate level in both financial management and
planning is critical given ongoing decentralization of capital funds [HFG/Review]
• The private sector will be critical in Jordan’s mixed health system and USAID needs to
engage through key initiatives, e.g., the Mandatory Insurance bylaw facility construction
• Recommendation: Integrate a result-driven purchasing mechanism to drive efficiencies
and quality improvements into Jordan’s health financing system [World Bank (2017) in
HFG/Review]
• Strategic planning of new health facility construction is important because of
decentralization of budgets to those who lack experience in handling such substantial
budgets [HFG/Review]
INFORMATION SYSTEMS
System-Specific Recommendations:
• While development of HMIS was helpful, USAID has left a legacy of multiple, parallel
information systems [HSS II/Eval]
• Systems such as ISDIC needs to re-orientate beyond clinical pathways to systemic
changes in accountability, supervision, leadership and ownership [HSD/Eval]
• Data is not always used effectively for decision making and sometimes data collection ran
in parallel to government systems (e.g. HAKEEM), resulting in increased workload
[HSD/Eval]
• Multiple evaluations found USAID-funded systems were perceived as “owned” by the IP
rather than MOH (e.g. ISDIC) [HSD/Eval]
• Accountability for the JMMSR was poorly defined, and without consultation/cooperation
with UN agencies, which limited learning from other countries [HSD/Eval]
• Feedback loops need to be tightened to help make data more valuable to providers (e.g.
JMMSR) [HSD/Eval]
• HSS II worked on developing an off-line version of the Perinatal Information System to
improve system flexibility and increase efficiency of facility staff in collecting data [HSS
II/Rep]
Data Use:
• Priority should be given to activities that create Data Demand and enable Information Use
[HFG/Review]
• Set long-term FP use as a clear project target and track discontinuation [SHOPS/Eval]
• Log-frames should reflect outcome data to improve project focus [HSS II/Eval]
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 24
LEADERSHIP AND GOVERNANCE
• The IRH evaluation of FP in Jordan identified three specific failures of commitment:
expressed, institutional and financial. Earlier desk reviews identified the “lack of
government funding as the key limiting factor in family planning program sustainability”
(HPI 2009) [IRH/Eval]
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ISSUES AND RECOMMENDATIONS RELATED TO MONITORING AND EVALUATION
MONITORING
• Despite high levels of reported compliance for clinical pathways for FP, ANC, delivery and
PPC, the same high-quality of care was not mirrored in client perceptions. This points to a
need for better routine triangulation of outputs and outcomes [HSD/Eval]
• The M&E plan did not have a documented theory of change to tell the story of how
activities will lead to outcomes (at multiple levels), nor did it list assumptions upon which
the design was based [SHOPS/Eval]
• Indicators should measure outcomes (or at least outputs) and targets should be ambitious
rather than based on a slight increase in the baseline position [HSS II/Eval]
• One study from 2014 used existing data from birth registries to estimate TFR rather than
waiting for a DHS [IRH/Eval]
EVALUATION
• End of program evaluations typically report during the life of an activity. In doing so, they
are unable to assess the degree of sustainability of individual components. Annex B
originally compiled by IRH reviews lists seven significant pilot projects that were either not
scaled up, or were discontinued after the project activity ended. 
• Field visits identified the importance of a functioning referral system among MOH staff,
however the same staff indicated that the referral system was not well established and
achievements were slow. This reinforces the need for field-level evaluation to assess
actual achievements, rather than reported progress [HSS II/Eval]
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 26
ANNEX A - SUMMARIES OF INDIVIDUAL EVALUATIONS AND
REPORTS
(in reverse chronological order for Evaluations, followed by IP Reports)
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 27
HEALTH SERVICE DELIVERY (HSD) (Evaluation)
Start March 2016
End March 2021
Value $50,254,872
Focus Health Systems Strengthening; RMNCH; Family Planning
Implementing Partner Abt. Associates
The 2019 mid-term evaluation used four categories (Quality of Care; Barriers to Access; HSD
Components; and Engaging the Community).
ISSUES AND THEMES IDENTIFIED IN THE EVALUATION:
Quality of Care
Clinical Pathways: although HSD monitoring information and a Provider survey for the mid-term
evaluation found high levels of compliance for FP, ANC, delivery care and PPC, this was not
mirrored in client perceptions.
• FP counseling not consistently delivered; evidence of provider bias or misinformation in
FP advice; counseling often not delivered in a private place (described as “rated: red”)
• Fewer ANC visits than the expected 8 visits (between 3 – 6). There was a lack of clarity
about how many visits were required. Some women did not receive full range of tests; iron
and folic acid not always available (rated: amber)
• Most women reported not being treated with respect, dignity, and humanity during their
delivery (rated: red)
• More than half respondents did not receive support with breastfeeding (challenge with
staff shortages). The focus was on the newborn, not the mother. (rated: amber)
Barriers to Access
Lack of engagement at Health Directorates meant that HAD directors felt “overstepped and
ignored” by HSD. The report also identified that the program had not given sufficient priority to
components to improve access (e.g. Client Service Station, mitigating gender barriers).
Access to IUDs and FP counseling was reported as “inconsistent”. Counseling was normally
only on request, and access to IUD-trained staff was unreliable.
HSD Components
• Supported Supervision: appears to be a monitoring tool/check box unless managers are
truly engaged, and not considered to be well-aligned with MOH’s MCH supportive
supervision
• Client Service Stations: the idea is welcome but few clients were aware of CSS, and
waiting times (30 mins to 3 hrs).
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 28
• JMMSR: Accountability has been poorly defined, and without consultation/cooperation
with UN agencies, which limited learning from other countries
Engaging the Community
• Community Health Committees: Potentially effective at raising key issues, while some
“perpetuate misinformation about FP”. Minimal knowledge of their activities at Directorate
level
• Community Scorecards: community members are not aware or empowered by Community
Scorecards; providers are “equally not engaged”
• Community Outreach: most women found the visits beneficial, but >259,000 visits yielded
just 12,000 anemia vouchers issued and only one-third were used for tests
Program-Management Issues
• M&E data was reported as being “important” but not “always used effectively for decision
making”. In some instances, HSD data collection ran in parallel to HAKEEM, resulting in
increased workload.
• Ownership was also an issue for ISDIC, which was still perceived to be “owned” by HSD
rather than MOH
• There were limited uses of outcome measures. These need to be measured more
systematically
• ISDIC needs to re-orientate beyond clinical pathways to systemic changes in
accountability, supervision, leadership and ownership
RELEVANT LESSONS
RMNCH - general
• KII and FGDs are required to verify clinical pathways
• Involve beneficiaries [more effectively] in the design of interventions
• Tighten accountability and feedback loops for JMMSR
• Supportive supervision & mentoring needs to be aligned with MOH system (not in parallel)
• Community Outreach needs to go beyond information sharing to active engagement of
community members
Family Planning
• Misinformation and misconceptions continue about FP causing infertility; validation of
quality of care indicators is required to identify where a provider is spreading
misinformation
• Clinics lack privacy [for FP]
Antenatal Care
• Communication about the number of visits needs improving
• Access to tests, iron & folic acid needs improving
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 29
Childbirth:
• Look at ways to improve the consistency and quality of care (“humanized”)
Postnatal Care:
• Identify staff who can assist with the early initiation of BF
Child Health:
• Ensure CHWs are engaging with mothers, not simply repeating health messages
Community Engagement
• More engagement with CHCs can maximize the benefits of RMNCH+
• Review facility & population needs to identify the basis of the change package required
• Syrians in particular do no understand service eligibility, free coverage or availability
• Either substantially reform community scorecards, or cease using them
Engagement with GOJ
• Work directly with Health Directorates: at a minimum MOH should be partners, but under
J2SR they should be taking more of a lead
NOTED EXAMPLES OF BEST PRACTICE
Accountability for quality of care
RMS hospital manager and health facility manager that using the indicators each week or each
month (periodically) to review staff and facility progress and offer support for improvements or
help in addressing challenges. This resulted in better performance by staff with measurable
effect on health outcomes. They demonstrate accountability through the data on a day-to-day
basis.
Reaching the most vulnerable
In one facility, the doctor and midwife make visits to the community to bring health care to
remote areas for women who cannot access the facility.
Mitigating gender barriers
A CHC works with the community to provide information for husbands at Mosques and through
events to refer them to the hospital for STD screening, and to help them recognize the
importance of ANC and FP for their wives. They also discuss GBV in the community. Such
efforts are led by active CHC leaders/providers.
Functioning CSS is appreciated by clients and staff
Good example in a facility working in one of the poorest regions. In this facility, direction cards
are being used for example to the appreciation of staff and clients
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 30
JORDAN HUMAN RESOURCES FOR HEALTH 2030 (HRH 2030)
(Midterm Evaluation)
Start 2015
End February 2019 (ended prematurely)
Value 10,848,000
Focus HSS - Human Resources
Implementing Partner Chemonics
This was the first HSS activity in Jordan to be solely focused upon human resources in the
health sector. The goal of HRH 2030 Jordan was to work with the MOH to increase the
accessibility to a higher-quality health workforce to boost service quality and coverage, helping
Jordan to achieve its goal of universal health coverage. The activity aimed to support 30,000
MOH staff – including 16,000 service providers – to better meet the needs of the population.
The activity initially had four key objectives:
1. Optimize performance, productivity, and efficiency of the health workforce
2. Increase competency, distribution, and number health workers
3. Improve public sector stewardship and leadership
4. Increase sustainability of health workforce investments
A mid-term evaluation identified significant challenges, resulting in a recommendation to narrow
the focus of the work to two priorities. Around the same time as the review findings were
announced, a very substantial overspend was identified, resulting in the activity being
terminated a few months later by the Implementing Partner, a year earlier than anticipated.
ISSUES AND THEMES IDENTIFIED IN THE EVALUATION:
The evaluation asked seven specific questions.
Evaluation Question 1: To what extent are HR practices at the MOH improving and why?
Fundamentally, the review found that HRH2030’s inputs, such as training, facilitating policy
development, and drafting various tools used in HR management, would not lead to change on
their own; they were necessary but not sufficient for change. Only those managers colleagues
or staff regarded as intrinsically motivated attempted new management approaches or used
new tools. The MOH and CSB compensation systems do not recognize or reward innovation or
increased performance.
Evaluation Question 2: To what extent are staff receiving training and using their newly acquired
skills? Why or why not?
HRH2030 trained between 300 and 400 people. Participants trained in HR management, HR
development, and health management and leadership only applied their training to a limited
degree due to a lack of time and management support. Where supervisors also attended the
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 31
training, there were more positive outcomes in areas such as sharing information, day-to-day
management, showing flexibility, conducting more meetings with agendas and minutes, and
commitment to regular attendance.
Evaluation Question 3: To what extent are capacity, knowledge management, transparency, and
accountability in planning, managing, and retaining Jordan’s health workforce increasing? Why or why
not?
The review found some signs of improvement in policies and procedures, although FGDs and
KII frequently noted the continuation of old hiring practices, improper selection of training
participants, lack of transparency in employee appraisals, and lack of fairness in assessing
employee performance and determining promotions and incentives. FGDs and key informant
interviews also indicated an absence of transparency and accountability.
Evaluation Question 4: To what extent is the Jordan HRH2030 Activity influencing women’s
management and leadership in the health workforce?
At the time of this evaluation, therefore, HRH2030 had not had any influence on women’s
management and leadership in the health workforce, though this appears to be due to the
Activity’s timeline rather than the quality or appropriateness of its interventions.
Evaluation Question 5: What are the next steps for institutionalizing the new law that requires CPD for
Jordan’s health workforce?
The reviewers identified the need for: dissemination; development of CPD capacity for remote
areas; monitoring and registration, and coordination
Evaluation Question 6: How can USAID best sustain the achievements and reforms accomplished
under HRH2030 in Jordan?
Three aspects were identified: (1) Supporting the relicensure bylaw; (2) Engaging with the Civil
Service Bureau, to assist in revising bylaws and notably articles relating to promotion and
training and (3) Supporting the Women in Leadership Network to support women leaders
Evaluation Question 7: What does the evaluation team recommend regarding any potential follow-on
HRH activity? If a follow-on is necessary, should it be similar to HRH2030, or be combined with
another existing USAID/Jordan activity, or take the form of direct support to the government of
Jordan through the utilization of partner government systems?
USAID should consider reducing the number of awards but implementing larger activities in the
period following HRH2030. It should also consider combining service delivery and infrastructure
projects with interventions that are more challenging to stakeholders, including HRH
interventions. This would allow the more challenging interventions to leverage the relationships
and goodwill created by infrastructure activities. Last, USAID should consider a multisectoral
approach to HRH that includes the Ministries of Finance, Higher Education, and Public Sector
Development.
The conclusion noted the following themes:
• Activity documents do not mention scaling up; furthermore, scale-up is not possible using
approaches that rely solely on the Activity’s own resources and staff without engaging the
capacity and resources of the host country
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 32
• Knowledge about HRH2030 and its interventions was poorly disseminated. There was an
absence of a clear strategy for communication within the MOH at central and directorate
levels. This lack of communication proved detrimental to participation and to the visibility
of MOH achievements, and to garnering support for change and new policies. It
perpetuates the current perception that little or nothing has changed for the better at the
MOH.
RELEVANT LESSONS
• HRH2030 needed to develop a sustainability plan across the activity as a whole, rather
than at the intervention level
• The need for communication strategies to ensure buy-in for the activities were “woefully
underestimated”. This applied at high-level and with mid-level officials and is a
fundamental lesson for the future
• Prioritize local expertise and institutions where possible. This resulted in local consultants
being contracted rather than local institutions.
• HRH2030 succeeded in training only around 300-400 individuals, and crucially had under￾estimated the need to establish an enabling environment that would facilitate changes in
practice. “Old ways” of doing things continued. Training a supervisor and a manager
provided a more supportive environment for changes to be implemented
Additional notes:
• HRH2030 was unclear whether their client(s) were MOH or the staff in MOH. This
fundamental issue affected how they developed their program activity. The focus on the
latter for training led to a minimal legacy. Had they sought to develop courses in
conjunction with the CSB or Institute for Public Administration, they may have created
something more culturally appropriate that outlasted the activity
 
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 33
HEALTH FINANCE AND GOVERNANCE (HFG) (Internal Assessment)
Start November 2016
End TBC
Value TBC
Focus HSS - Finance (UHC; health insurance); Governance
Implementing Partner Palladium
USAID Washington and staff from Palladium’s Headquarters undertook a review to refine the
scope of work for the HFG project at the end of the first year.
ISSUES AND THEMES IDENTIFIED IN THE REVIEW:
The review identified a two-track focus to HFG’s work. The first addressed high-level legal and
regulatory reforms that would have “major structural impact on the health system”. The second
track focused at sub-national level to deliver tangible, short- and medium-term gains in health sector
efficiency and governance.
The review provided specific feedback on the following:
• Improved enabling environment for UHC: engagement is critical to continuing high visibility
partnership with MOH to strengthen enabling environment
• Efficiency in public health sector resource use, including cost containment and increased
resources for preventive/primary health care: We advise enhancing PHC focus as a priority
• More equitable and sustainable health coverage is expanded: Developing true insurance
functions may not be feasible in current environment. There seems to be very limited
political will for an EPHS. Proposals for coverage expansion to the uninsured need to
rely on better data and strategies based on the CIP, and align with ensuring
sustainability
• Capacity to use financial and performance data in budgeting, monitoring and policymaking is
strengthened: The USAID Fiscal Reform Project is undertaking work to support Results
Orientated Budgeting (ROB). Given the described pace of pilot ministry implementation
and limited ability to drive efficiencies through ROB, we do not see this as a critical area
for engagement
• Innovative public private partnership financing mechanisms for achieving UHC are implemented:
We did not find any defined plans or models [for private sector finance in UHC] and
hence it is unclear what JHFG support should focus on. The private sector will be critical
in Jordan’s mixed health system and JHFG should engage through key initiatives, e.g.
the Mandatory Insurance bylaw
• Improved HHC and MOH health sector leadership, coordination and multi-sectoral engagement:
JHFG should build capacity at the MOH but HHC-related project investments will have to
be highly focused to ensure relevance. Governance and decentralization will be
addressed at a lower level. It was not apparent how the project plans to strategically
engage media to advocate for UHC at the current stage of the project
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 34
• Strengthened capacity and authority to act at mid- and subnational levels: Capacity building at
subnational governorate level in financial management and planning is critical given
ongoing decentralization of capital funds.
• Strengthened individual and institutional capacity in professional administration, strategic and
operational planning, financial management and M&E: Decentralization of financial
management should be integrated into improved strategic planning and decision-making
processes
• Increased demand for and use of high quality, transparently available data to inform decision
making and monitoring in the health sector: Re-focus activities to create Data Demand and
Information Use
• Increased civil society engagement and feedback for improved health sector accountability:
Focus upon enhancing patient/health consumer rights, especially related to improved
access and quality, and enhancing gender-responsive service delivery
Some of the original activities overlapped with other non-health USAID activities, such as the
USAID Fiscal Reform Project. In other elements, (e.g. Gender Responsive Budgeting) the
approach taken was too narrow.
RELEVANT LESSONS
• “Given high levels of turnover in senior staff at the MOH, there must be a focus on
systems and on processes strengthened that will have longevity past individuals; and on
strengthening the role of mid-level staff who will be MOH leaders of the future”.
• PFH needs to work closely with EDE and DRG to avoid duplication on fiscal reform
• Gender-related programming needed to focus on civil society engagement to enhance
consumer rights, especially rights of women and vulnerable communities
• The scale of project financial and intellectual resources devoted to [some of] the work was
out of proportion to the likelihood of success in some of these areas within the life of the
project
• Recommendations in the past, including in the World Bank publication “The Last Mile to
Quality Service Delivery in Jordan” (2017), have emphasized the need to integrate a
result-driven purchasing mechanism to drive efficiencies and quality improvements into
Jordan’s health financing system
• Strategic planning of new health facility construction is important because of
decentralization of budgets to those who lack experience in handling such substantial
budgets (JD 26 million in 2017)
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 35
JORDAN FAMILY PLANNING ASSESSMENT (Evaluation of previous
USAID FP activities)
Start 2015
End 2016
Value -
Focus FP – stagnation of the TFR over the past decade
Implementing Partner Institute for Reproductive Health, Georgetown University
Between October 2015 and March 2016, the Institute for Reproductive Health (IRH) at
Georgetown University conducted an assessment of USAID/Jordan’s family planning
contributions. The assessment explored reasons for fertility stagnation in Jordan over the last
decade. To tell the backstory of USAID programming in family planning, the IRH team
conducted an extensive desk review of over 83 documents and 69 key informant interviews with
168 participants both in Jordan and Washington, D.C
ISSUES AND THEMES IDENTIFIED IN THE ASSESSMENT:
Summary
• The IRH team reviewed a number of different theories and evidence exploring TFR
stagnation in Jordan. The results from this assessment show that contraceptive
effectiveness, rather than contraceptive use, is the key determinant of fertility stagnation in
Jordan. Jordan provides a context where family planning access and use are relatively
high, but the diversity of methods used by women is low and has shifted towards less
effective methods such as withdrawal.
• The increases in use of traditional methods such as withdrawal and decreases in use of
more effective methods such as IUDs, suggest that much more needs to be done to
change strong social norms and behaviors of all women, men, family members, health
service providers, in addition to the political will of policy-makers.
• USAID’s investment in health systems strengthening over the last decade has increased
access to and use of family planning services. However, this investment has not
necessarily translated into improved contraceptive effectiveness, identified above as a key
determinant of fertility. As a result, the health systems approach may not be enough as a
standalone approach to address contraceptive effectiveness, in addition to clients’ and
providers’ strong social norms around fertility and family size. For instance, while the
health systems approach has been successful in increasing family planning use, it has
had a weaker effect on reducing method discontinuation and provider bias, both of which
are strongly affected by social norms and can ultimately affect the national mCPR.
Additional Details
• Given the strong norms around family size and preference for sons, as well as
misperceptions and biases against modern methods (see behavior change below),
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 36
increased efforts should be invested toward behavior change and communication and
community-based activities addressing social norms
• An important focus of the work should be expanding the method mix in the country and
encouraging shifts from traditional methods to more effective modern methods. This will
require improving service providers’ counseling biases, in addition to increasing
community outreach activities involving women, men, mothers-in-law, and other influential
opinion leaders.
• Community outreach efforts have been shown to be effective, and should be expanded as
they serve a dual role of behavior change and service provision
• Shortages of female clinicians, and among those, not all are willing to fit IUDs
• Most Syrian and Jordanian husbands were against allowing their wives to seek services
from male doctors for religious or cultural reasons, except in emergencies or for lack of an
alternative female doctor (JCAP 2016).
• Only two-thirds (65%) of women thought that modern methods are more effective than
traditional methods, which likely contributes to the relatively high prevalence of traditional
method use in Jordan (JCAP 2015c)
• Opposition from husbands only account for about 2% of method choices, and a similar
percent for discontinuation
• The role of the mother-in-law appears to be important and “increasing the baseline
knowledge acceptance, and access to a range of hormonal methods may produce a
generational impact.
• Data should measure the percent of demand met by modern methods. (E.g. 1997-2012:
mCPR increased, and unmet need declined, but traditional method use increased
proportionally faster than mCPR)
• In interviews with Key Informants, BCC-related issues were low down the list of perceived
successes.
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 37
• Accreditation was perceived as sustainable, and described as “the shortest and best way
to improve [ourselves]”
• Accreditation activities related to FP standards led to 13% increase in CYPs in
participating HCs, compared with 5% in non-participating HCs
• The stand-alone evidence-based medicine (EBM) HSS approach was found not improve
knowledge or practice scores
• Introduction of postpartum FP in private hospitals (partly because more educated groups
use private sector services, and their rates of modern contraceptive use were at 46%
three months postpartum compared to a national average of 42%.)
• The health systems approach may not be enough as a standalone approach to address
both clients’ and providers’ strong social norms around fertility and family size. For
instance, while the health systems approach was successful in increasing family planning
utilization, it had a weaker effect on reducing method discontinuation and provider bias,
both of which were strongly affected by social norms
• Initial investment in JAFPP has helped strengthen their services, but they have yet to
reach financial sustainability. In addition, despite USAID training investments with private
network doctors, their share of family planning services has drastically decreased (from
19.5% in 2002 to 7.4% in 2012)
• A key challenge moving forward entails identifying an appropriate balance in USAID
investment and collaboration across public and private sector
• Between 2002 and 2012, the percentage of women accessing modern contraceptive
methods from JAFPP virtually halved, while the percentage relying on a private doctor
dropped by almost two-thirds (although uptake through private hospitals/clinics doubled)
Behavior Change
• The Together for a Happy Family campaign targeted over 2 million persons and was the
first-ever national campaign to specifically target men. From 1996 to 2000 – when the
campaign was conducted – the number of men who considered the IUD safe for their
wives rose from 34% to 50%, respectively; while the number of men considering the pill
safe increased from 25% to 36% (Cobb et al. 2003)
• Other behavior change approaches – such as the Mabrouk initiative – used premarital
counseling as an entry to discuss life planning and family spacing among newly married
couples. However the initiative had mixed results: although reports touted the Mabrouk
initiative as effective, some interviewed stakeholders thought that the materials were not
well-contextually adapted and that counselors needed more training. In addition, the
initiative was not sustained after project end
• Use of Social Workers: A 2015 randomized study about the outreach program showed
48% and 59% gains in modern method uptake among the women-only counseling and
couples counseling intervention groups, respectively, in comparison to the no-counseling
control group. The study also showed lower use of traditional methods and fewer
concerns about side effects in the intervention groups (SHOPS 2015c). Between October
2014 and September 2015, outreach workers conducted a total of 466,961 family planning
counseling visits and generated 29,139 new users of modern “USAID covers around 70%
of family planning projects on the ground (JCAP planning 2015a; projects p. 7).
• Provider bias: Research suggests that providers may at times refuse to prescribe
hormonal methods until the woman has given birth to at least two children (Maffi 2013). In
other instances, providers may be fearful of becoming liable for potential miscarriages. For
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 38
instance, some health service providers will not administer tetanus shots to pregnant
women for fear of being held liable by the woman’s family in the case of a miscarriage
(Maffi 2013)
• More recent mass media campaigns (2010-2015) showed more mixed results.
“What should USAID’s strategy be going forward?”
Community-centered SBCC and Engaging Men:
• Include the “social” in social and behavior change communication (SBCC) to deconstruct
gender and social norms rather than targeting or correcting specific behaviors
• Link and strengthen service delivery components with community-based approaches (for
example social worker outreach and HSS II Bridge models)
• At the community level, target men’s engagement in family planning
Youth:
• MOH school health and sports programs are excellent channels for youth engagement.
Encourage youth to plan for their lives and delay having children after marriage
Community health workers outreach program
• Home visits are one of the most effective methodologies to raise awareness and
encourage a woman to identify her needs for family planning and seek appropriate
services.
• The outreach program should be continued and expanded to reach areas with
underserved and very rural and Bedouin areas
Health Systems Priorities
• Conduct an assessment of the health systems needs in response to the refugee crisis,
and as per assessment, prepare strategies to educate and raise awareness among Syrian
refugees on reproductive health, family planning, service providers, and services
• Improve Ob/Gyn residency programs
• Focus training on reducing provider bias and misconceptions about modern methods
• Expand post-partum/post-miscarriage FP to all public hospitals, and follow up PPFP with a
phone call
• Provide TA and financial support to a wider range of NGOs, such as the Institute for
Family Health
• Expand training of pharmacists to improve FP counseling on contraceptive effectiveness
and correct use
RELEVANT LESSONS
• One study from 2014 used existing data from birth registries to estimate TFR rather than
waiting for the next Demographic Health Survey
• Use of Social Workers (1996-2015): Interviews conducted in Jordan showed that the
social worker outreach program may be an effective and targeted way to promote
behavior change and communication, in particular among husbands and mothers-in-law
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 39
• J2SR: The report described USAID’s substantial investment in FP in Jordan, while
identifying three specific failures of commitment: expressed, institutional and financial.
(Earlier desk reviews identified the “lack of government funding as the key limiting factor in
family planning program sustainability” (HPI 2009))
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STRENGTHENING HEALTH OUTCOMES THROUGH THE PRIVATE
SECTOR (SHOPS) (Final Evaluation)
Start July 2010
End September 2015
Value $38,062,336 (amended from $24,362,336 in 2010 to $33,362,336 in 2011
and an additional $4,700,000 in field support in 2012)
Focus Family Planning and use of the Private Sector
Implementing Partner Abt. Associates
SHOPS (also known through its Arabic name as “Ta’ziz”) began in 2010 with the primary goal of
expanding the access, quality and utilization of Family Planning (FP) services by partnering with
the private and non-governmental sectors. SHOPS interventions were designed to overcome
the challenge of Jordan’s plateauing contraceptive prevalence and total fertility rates.
According to SHOPS ’Cooperative Agreement, family planning challenges were to be
addressed by SHOPS as follows:
• Increasing the use of existing methods, particularly underutilized methods such as
injectable contraceptives and implants;
• Increasing the range of product options in the injectable/implant category;
• Developing marketing and behavior change strategies to improve the acceptance of
hormonal methods;
• Maintaining and expanding current collaborative relationship with pharmaceutical
companies while exploring new partnership opportunities, and;
• Removing medical barriers (provider bias)
SHOPS worked closely with six grantee partners, building capacity in 78 service delivery points
(clinics) across Jordan, four private hospitals (for post-partum FP), 300 network doctors, and
300 pharmacists, supported by a team of 200 community health workers (CHWs) referring
women to SHOPS ’family planning outlets. (CHWs made 1.4 million household outreach visits,
reaching 678,595 women of whom 89,600 were new acceptors of FP)
ISSUES AND THEMES IDENTIFIED IN THE EVALUATION:
Effectiveness
• SHOPS increased demand for, access to, and quality of FP services with targeted clients,
however, cultural norms and practices that were not addressed through SHOPS are likely
to have diluted the results to effect of reducing fertility to slow population growth
• Vouchers provided by CHWs referred women to private doctors and health clinics for cost￾covered consultations for family planning decision-making, resulting in a 22 percent
uptake in modern methods
• While SHOPS campaigns for oral contraceptives and Intrauterine Device (IUDs) boosted
the uptake of IUD insertion services, the effect on demand was transient
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 41
• SHOPS’ pilot initiative offering post-partum FP counseling through private hospitals
demonstrates significant potential for increasing FP access to women at a critical juncture
in their reproductive lives
• The lack of data tracked by SHOPS on discontinuation makes it challenging to address
the issues of long-term modern FP and impact on Couple Years of Protection (CYP) and
total fertility
• SHOPS’ inability to contract with UNRWA (due to incompatible contracting protocols)
resulted in a missed opportunity for engagement with ten percent of the target population
for FP services, dampening project potential reach in UNRWA catchment areas
Gender
• The cultural preference for male children, which often results in families continuing to have
children until a sufficient number of male children are produced, was not part of SHOPS’
programming or design. Changing deeply-seated social preferences for male children may
require considerable social research to identify messaging that is culturally acceptable and
not perceived to be based on a foreign agenda
• Although men were recognized as significant influencers in family planning decisions,
SHOPS lack of attention to gender differentials in messaging and engagement “may have
diluted achieving objectives”
Sustainability
• Interventions such as Public Private Partnerships (PPP) did not have a tangible
partnership mechanism for sustainability built into the design
• Based on current financial models and practices, JAFPP is not sustainable without donor
funding, nor is the CHW program
• The level of clinic visits and clientele growth rate are unlikely to continue at the same rate
as with SHOPS support, due to unsustainability of the uptake in FP services associated
with voucher redemption
JAFPP
• SHOPS was tasked with assisting Jordan Association of Family Planning and Protection
(JAFPP) to become more sustainable. Despite the recommendation to raise prices three
times, JAFPP did so only once, generating a 40% rise in revenue. However increased
salaries and overheads meant that cost recovery remained stubbornly at 58%. The
evaluation concluded that “JAFPP’s leadership is not inclined toward sustainability”.
Theory of Change
• SHOPS’ M&E plan did not have a documented theory of change to tell the story of how
activities will lead to outcomes (at multiple levels), nor did it list assumptions upon which
the design was based
• Future programming needs to consider the cultural context – norms and practices that are
contrary to or could dilute intended results programming
• Systematic collaboration between the private sector and MOH could improve sustainability
of FP gains in the private sector
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RELEVANT RECOMMENDATIONS AND LESSONS
Effectiveness
• If USAID wishes to ensure increased access to FP, commodities and services should
continue to be subsidized through vouchers for FP consultation products until a critical
mass has been built for sustained social change in attitudes and decision-making for long￾term, continuous use of FP
• Coupons for FP products should be continued but the process should be streamlined to
eliminate the need for women to make multiple trips. A directory of participating
pharmacists should be readily available in print or through mobile technology to eliminate
uncertainty of travel and locations. Relationships should be facilitated between clinics and
pharmacies; coupon expiration dates should be eliminated
• USAID should continue to fund CHWs and leverage them as a key resource to expand
community outreach. USAID should strengthen CHW-clinic collaboration and create direct
and active CHW linkages to UNRWA and other NGO clinics in the target catchment areas
in order to increase FP demand
• Expand services of CHWs to include pre-marital girls, preconception, extended family
members living in the same house and male relatives (husbands, fathers, brothers), and
Syrian communities
• Health programming should focus heavily on addressing misconceptions about the side
effects of contraceptives, targeting medical practitioners, clinic staff, pharmacists, CHWs,
and the general public in order to increase the use of long-term methods such as IUDs,
and to reduce discontinuation. Given cultural practices and norms in which information is
delivered in-person, a cost/benefit analysis should be conducted of mass media versus
social means such as CHWs and if possible, the impact of each on CYP
• Post-partum counseling through private hospitals should be expanded, following the
model SHOPS supported at Specialty Hospital
• Strengthen PPPs by establishing a PPP grant fund for implementation of joint activities by
private/public FP actors
• Performance based grants should have a one-year grace period to allow grantees to build
adequate capacity and systems to measure performance and meet targets
• Performance based grants should continue to be used as a contracting mechanism,
directly tying key benchmarks to activity/project objectives of increased FP demand,
access and cost recovery
• Set long-term FP use as a clear project target and track discontinuation
Gender
• Programming objectives, activities, and indicators need to acknowledge cultural norms
and practices relative to family size and preference for male children. Such
acknowledgement should include behavior change communication to change these norms
and practices; identify other stakeholders who are conducting behavior change
communication to change these norms and practices; or lower expectations to account for
cultural norms and practices
• If behavior change communications is conducted it should be preceded by research to
carefully identify messaging and target markets, and recognize sensitivities relative to the
perception of imposing Western agendas
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• Programming objectives and activities, and indicators need to acknowledge husbands’
role in family planning decisions; gender sensitive interventions and messaging should be
designed accordingly
JAFPP
• If JAFPP sustainability is a priority for USAID, a Project Implementation Letter (PIL) or
Memorandum of Understanding (MOU) stating this agreement should be signed with
JAFPP. Terms of the PIL/MOU should include intent for financial sustainability, agreement
to reducing Head Quarter (HQ)/clinic expense ratios, and agreement to set prices and
services based on market research for each location.
• Assistance to JAFPP should focus on clinic decentralization and facilitating clinics to
operate as individual business units (profit centers).
• Financial assistance to JAFPP should be predicated on meeting performance targets, and
funding should be provided in tranches conditional upon meeting benchmarks such as
cost recovery targets. Support for HQ costs should be minimal with a phase-out plan.
• USAID should support market research to determine whether JAFPP could increase cost
recovery and its client base by offering a wider range of medical services for families as a
one-stop shop for all maternal and child health needs
OIG-related finding: In 2013, an audit of SHOPS by the Office of the Inspector General (OIG)
found that: “JAFPP did not make progress toward its financial sustainability target.” While
JAFPP offered services at a steep discount, it lost money on each client. Increasing the number
of clients thus accelerated JAFPP’s revenue losses, putting the sustainability of project
achievements at risk.” OIG recommended that USAID/Jordan require JAFPP to formally commit
to specific sustainability measures (e.g., price increases) as a condition of receiving additional
assistance under the agreement. In response, SHOPS provided JAFPP with a performance￾based grant that included performance bonuses based upon JAFPP meeting sustainability
benchmarks. In Q1 2015, JAFPP reported that 13 of 23 clinics had received performance
bonuses for meeting targets that created competition among clinics to improve. However, the
JAFPP performance incentive system criteria did not include cost recovery as an incentive
target.
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 44
JORDAN HEALTH AND COMMUNICATION PARTNERSHIP (JHCP)
(Final Evaluation)
Start 2004
End 2011
Value $26 million
Focus Family Planning/BCC
Implementing Partner Johns Hopkins University
The evaluation was commissioned approximately 15 months before the project’s conclusion.
The program had three main aims:
(1) Implementing a national health communication strategy using the life-stages
approach
(2) Assisting local communities in adopting healthy behaviors
(3) Supporting child spacing and the small family norm
From May 2008, the project focused more on FP rather than broader healthy lifestyle issues.
The evaluation team was directed to focus primarily on JHCP’s performance against the
program’s revised objectives to promote FP behavior change through promotion of a three-year
birth spacing interval and promotion of a cultural shift in favor of a smaller desired family size.
ISSUES AND THEMES IDENTIFIED IN THE EVALUATION:
The evaluation found that JHCP’s activities had been effective in training selected audiences
and communicating behavior change communication (BCC) messages through media and
Internet campaigns.
Involvement of Religious Leaders
• Involvement was shown to increase discussion of FP messages, but not all trained
leaders integrate FP messages into their sermons.
• JHCP facilitated the issuance of a fatwa (an interpretation of Islamic law) that found FP,
contraception, and birth spacing to be acceptable practices. The fatwa addressed the
widespread misconception that large families are an Islamic value, when they are in fact a
traditional or cultural value
• The involvement of religious leaders in addressing FP issues was a powerful intervention
that increased the impact of all other JHCP activities and other USAID FP projects, by
opening up public dialogue on an otherwise taboo topic
• Monitoring data suggest that the training and follow-up needed to improve to increase
religious leader activity and address their remaining biases and discomfort discussing FP. 
The unique participation of Jordanian women religious leaders in the training facilitated
more direct, less structured communication with women in the community
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• The strong partnership between the two religious agencies and JHCP is reflected in the
stakeholder’s stated desire to institutionalize training and expand activities to the national
level.
• Participating religious leaders had a high opinion of USAID, despite earlier misgivings
Media Campaigns
The media campaign was well-designed, but the fragmented nature of media in Jordan prevented it from
reaching the broadest possible audience.
Hayati Ahla [My life is more beautiful] National FP Multi-Media Campaign
• The media campaigns were described as “well designed”, according to many Jordanian
officials and media figures. There was 23% un-prompted recall and 30% prompted recall.
Follow up actions were taken by 40% of those who recalled the messages
• The evaluation results suggest that media coverage was not as far-reaching as expected,
probably due to the fragmented nature of Jordanian media and the dominance of
international and regional media
Mabrouk Packets for First Birth Couples and Newly Married Couples
• Mabrouk was identified as a cost-effective, innovative way to reach a primary audience for
FP messages through the Civil Status and Passports Department, achieving national
scale. Mabrouk I was aimed at newly-married couples and Mabrouk II targeted those who
came to register a birth. Training was provided for 200 CSPD staff to aide discussions,
and production costs were $0.87 for each packet. There are no dissemination costs
beyond materials production. CPSD offices also had video screens which played Mabrouk
messages
• JHCP’s work with Civil Status and Passports Department (CSPD) was also considered an
innovative partnership
• The CSPD took ownership of Mabrouk to the degree that it has allocated an operating
budget for the activity, but the budget was inadequate for reproduction of Mabrouk
packets
Innovate Internet Activities
JHCP has used innovative Internet activities to provide international-standard health information to a
wide audience.
JHCP Internet Activities—Sehetna
• Sehetna was considered innovative and creative as a tool to reach young people, and
provided international-standard health information, to help counteract misconceptions held
by youth, health services recipients, and health providers. It also effectively disseminates
JHCP and Ministry of Health (MOH) materials. This was transferred to GOJ at the end of
the activity, and then promptly shut down
Arab Women Speak Out Community Mobilization Activity
• Arab Women Speak Out (AWSO) was identified as a powerful tool for empowering women
with positive models and information, by presenting sensitive FP messages in the context
of larger health and social issues which helped women accept them
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 46
• AWSO reached a secondary audience, with many women reporting that they talked to
friends and neighbors about FP and other topics. In addition, AWSO materials and
techniques have been adopted by health projects that work at the community level
Health Competent Schools Initiative
• JHCP was successful in institutionalizing Health Competent Schools Initiative (HCSI) in
the Ministry of Education. The activity was adopted by the Royal Health Awareness
Society and initially received USAID Education funding
• HCSI was described as “cost effective and low maintenance”. Once materials were
distributed to schools and the teachers trained, there was limited continuing involvement
needed with individual schools
• While community outreach was not a major component in the design, during
implementation schools used it extensively with parents, then with the larger community,
introducing health competency to many more beneficiaries than a school-based program
could reach
• Behavior change and expanded awareness of health competency issues among students
was “substantial” suggesting a long-term impact on student health
Ambassadors/University Training for Selected Students as Ambassadors
• The training for ambassadors was insufficient to address student shyness about FP. It
also failed to give them tools for addressing FP issues (e.g., gender-specific groups,
instructional DVDs or protected websites, external expert speakers)
• Irregular follow-up from JHCP and a lack of a longer-term plan of activities reduced
longer-term impact and institutionalization
• Student peer approaches to communicating were effective, but considered labor intensive,
with a relatively small reach that required audience-specific messages and material.
Maintaining motivation was also identified as an issue. The evaluation explicitly concluded
“for these reasons the University Ambassador Initiative is not recommended for
continuation”
Consult and Choose Counseling Materials
• Consult and Choose (CC) training and materials were intended to raise the quality of
FP/RH counseling in GOJ facilities. JHCP developed the material, and HSSP II supported
the roll-out. Twelve health centers were equipped with TVs and DVD players to help with
the roll-out of messages about birth spacing and modern contraceptive methods
• Most materials focused on the use of FP but not sufficiently on the critical behavior
change messages related to smaller families and use of modern FP methods
• In the clinics observed, the clients getting counseling were those already seeking FP
services, so there are still missed opportunities for counseling
• Clinic staff rated the training as “good but limited.” Suggestions for improvements include
more practical/applied training; follow-up training; and a better training module on dealing
with problem clients. Staff also recommended improvements to the training
implementation, including added incentives and moving off-site
• The presence of a designated midwife counselor increased the quantity and quality of
information provided to clients, there are still missed opportunities for disseminating
information
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 47
• The counseling training did not fully address provider biases, particularly for short-term
methods, where discontinuation rates were high.
• Staffing should be an issue of concern for MOH and the Health Systems Strengthening
Program. Several people with counseling assignments shifted responsibilities depending
on workloads.
• Discussions with women at health centers point to gaps in private sector support for
contraceptive methods, with counseling rarely available at pharmacies. The centers
should offer counseling to all clients, especially for user-dependent methods like the pill
and condoms
• CC exemplifies a collaborative working relationship with other USAID projects focused on
FP
GOOD PRACTICE
• The network of local partners that JHCP has built was strong and partners regarded their
relationship with JHCP as positive. The partnerships were credited for the
institutionalization and going-to-scale of some activities (although “the large number of
JHCP partners and activities probably limited the potential contributions of some activities
due to human and financial resource constraints.”)
• JHCP has established a good model for public-private partnerships, notably with Fine
Paper Products through the HCSI. With the precedent now established, the positive
experience with Fine Paper Products has opened the door for MOH to undertake future
partnerships
RELEVANT LESSONS
• The evaluation noted that “FP service provision was not a constraint to the adoption and
use of contraception. Access to public and private health services, contraceptive
knowledge, and contraceptive use levels were already high, now was cost considered a
barrier. Improved quality of care could affect fertility timing, but would not change fertility
levels without a change in desired fertility”
• “Based on the evaluation’s findings, BCC priorities should be the following: the
involvement of religious leaders, as key influencers of social norms, to champion FP at a
national level; and a mass media strategy using a range of available channels to support
religious leaders’ messages, educate couples and providers, and create demand for
modern FP methods”
• Building consensus among partners can be difficult and time consuming; moreover, the
products of consensus building often tend to be weak, as they often reflect the position of
the weakest partner (e.g., spacing as a lead message rather than family size norms).
 
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 48
HEALTH SYSTEMS STRENGTHENING II (Midterm Evaluation)
Start 2009
End 2014
Value 73,000,000
Focus HSS - support of reduced fertility rates and improved women’s health
Implementing Partner Abt.. Associates
No end of program evaluation could be identified on any local systems (USAID or on the Jordan
Knowledge Management portal) or by the Development Experience Clearing House. The
report’s authors noted the project was “on track to meet all of its objectives”4 and that some of
the achievements “go beyond what its indicators capture”. They also noted the project had
“excellent relations with both the Ministry of Health (MOH) and U.S. Agency for International
Development (USAID).”
ISSUES AND THEMES IDENTIFIED IN THE FINAL REPORT:
The report addressed the six different result areas that HSS project was tasked with delivering.
Knowledge Management
• Capacity-building and institutionalization of data systems has resulted in MOH ownership
of the health management information system (HMIS), and MOH was beginning to use the
system for decision making. However better outcome indicators were required
• USAID had supported the development of multiple, parallel information systems, which the
evaluation team “struggled to understand”
Primary Health Care
• Supporting accreditation for PHC centers created a “culture of quality”
• The inclusion of accreditation criteria for FP services would likely result in more FP users
• At the time of the evaluation, the project had not managed to meet its annual targets for
creation of a satisfactory referral system
• While the use of health outcomes (e.g., management of hypertension and diabetes) as a
proxy for supervision was described as “plausible”, the evaluators were not confident that
clinical outcomes would improve in the short term. In addition, targets set for these
4 Figures in the main body of the report suggest otherwise: HSS only met 13/23 of its Year 3 Targets.
Some figures in the report were themselves contradictory. For example, under the MNCH task, the
following was reported in the evaluation: “An indicator of quality is the percent of women monitored during
labor using the partograph. The baseline was 80%; the year 3 target was 90%, and the year 5 target is
95%. The year 3 achievement was 86%. Another indicator of quality is the percent of women with
pregnancy-induced hypertension managed according to the clinical guidelines. The baseline was 80%;
the year 3 target, 90%; the year 5 target, 95%. The year 3 achievement was 88%. These targets were
achieved.” (p.12)
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 49
indicators were essentially unchanged from baseline levels. The evaluation team believed
project activities were very likely to have a substantial impact on effective supervision, but
poor selection of indicators meant that important gains were not captured and lessons
were missed.
Maternal and Neonatal Health: Safe Motherhood
• The introduction of evidence-based medicine, update of clinical guidelines, and creation of
centers of excellence were highly valued by the MOH
• The use of other maternal indicators, such as incidence/1000 births of eclampsia seizure
and blood transfusions, would track outcomes better
• In the span of one year, turnover of MOH trainers can be between 50 and 60%
• HSS II identified and tackled unrecognized problems—such as neonatal transfer and IV
fluid preparation
Improve Quality of and Access to FP/RH Services
• The percentage of 444 MOH HCs offering four or more methods of contraception declined
below the baseline in Year 3. The number of CYPs also dropped by almost 12% between
2010 and 2012. This was because midwives largely stopped fitting IUDs because of legal
ambiguity. (In 2009 47% of IUDs were fitted by midwives; this dropped to 26% in 2011)
• The MOH conducted a situational analysis on the safety of midwives inserting IUDs. No
safety issues emerged from the analysis. A compromise policy emerged (captured in the
midwives’ newly drafted job description) whereby the MOH decided that a midwife could
insert an IUD if a “trained” physician, who would assume medical/legal responsibility, was
present at the same facility. In order to meet this requirement, physicians with no prior
expertise in IUD insertion received a two-day course in supervision of IUD services
• IUDs are the most popular FP method in Jordan; they have the lowest discontinuation
rates and the greatest impact on CYPs5
• The legal/administrative barriers placed on midwives performing IUD insertions are the
major reasons for the failure to reach targets
• Post-partum FP (after deliveries and miscarriage) rose from a baseline of 0% to 20.4% in
three years. (The evaluation outlines the programmatic approach used). Intervention
sustainability was affected by a lack of staff; the requirement for existing staff to take on
additional work, and for hospitals to supply IEC material
Engage and Empower Communities to Adopt Healthier Lifestyles
• Community Health Committees had been established, although their sustainability was
questioned
• Indicators measured activity. Evaluators noted that without outcome measures it was not
possible to determine the effectiveness these community interventions
5 HSD’s Discontinuation Study (2018) found this still to be the case, with IUD discontinuation at 14.8% after 12
months, compared with 23.6% for implants; 30.2% for condoms; 37.9% for COCs and 42.8% for injectables
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 50
Renovations
• MOH embraced the American Institute of Architects design standards, although it was
difficult to assess whether this directly impacted health outcomes
RELEVANT LESSONS
• Pursuing the change in the midwifery law to allow IUD insertions is still relevant
• Log-frames should reflect outcome data to improve project focus
• Indicators should measure outcomes (or at least outputs) and targets should be ambitious
rather than based on a slight increase in the baseline position
• Turnover rates of between 50-60% brought into question the sustainability of training
clinical staff in some of the main teaching hospitals
• The USAID strategy should focus at HC level, where the bulk of FP interactions take
place. Interventions could include HC renovations, supervision, referrals and accreditation
• Pursuing an integrated MCH/FP program is important going forward. This might include
allowing projects to tackle previously un-identified issues in order to aide ownership by the
health facility and their staff
• Intervention sustainability (e.g. post-partum FP) was affected by a lack of staff; the
requirement for existing staff to take on additional work, and for hospitals to supply IEC
material
• Supporting accreditation of PHC facilities raises service quality
• USAID should support broad BCC campaigns that focus on the health advantages of birth
spacing and enable families to plan their desired family size. This needs to target men as
well as women
• While development of HMIS was helpful, USAID has left a legacy of multiple, parallel
information systems
• Field visits identified the importance of a functioning referral system among MOH staff,
however the same staff indicated that the referral system was not well established and
achievements were slow. This reinforces the need for field-level evaluation to assess
actual achievements, rather than reported progress.
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 51
HEALTH SYSTEMS STRENGTHENING II BRIDGE PROJECT (Final
Report)
Start 2014
End 2015
Value 10,848,000
Focus HSS - Finance (UHC; health insurance); Governance
Implementing Partner Abt.. Associates
The HSS II Bridge project lasted for just one year. There was no formal evaluation. Instead key
points have been derived from the Project’s final report.
ISSUES AND THEMES IDENTIFIED IN THE REPORT:
FP
• Service Delivery Improvement approaches can dramatically increase uptake of FP
• Uniting a health facility and their Health Directorate teams in a common goal allowed them
to achieve rapid progress
• Engagement with stakeholders at central and health directorate level, and facility level
improved ownership
• Data ownership improves with prompt feedback of results
Maternal and Newborn Care
• HSS II Bridge focused on reducing post-partum hemorrhage, and introduced the Active
Management of the Third Stage of Labor. (Part of the advice includes “cut and clamp the
cord 1-3 minutes after birth”. This is contrary to evidence from the Lancet that identified
delaying cord clamping to 3 minutes could increase serum ferritin concentration at 6
months of age (used for storing and releasing iron) and reduce the need for blood
transfusions and complications after birth by up to 39 percent in healthy term infants.
(Studies typically compared clamping at 1 minute and 3 minutes) 6
Community Health Councils
• In 2014, the project partnered with two of these CHCs as they underwent legal recognition
to become community based organizations (CBOs) capable of fundraising and providing
information and services to their target communities. These two CBOs, Entrepreneurial
Association for Health Promotion (Al Nohoud Al Sihhi Pioneer Society, also known as Al
Hashmi) in Amman and the Howara Health Society in Irbid both chose FP promotion
among their main objectives. “As a direct result of project support, two CHCs completed
6 Bhutta ZA, Das JK, Rizvi A, et al. (2013) Evidence based interventions for improvement of maternal and child
health nutrition what can be done and at what cost. The Lancet 382: 452–77. DOI: dx.doi.org/10.1016/ S0140-
6736(13)60996-4.
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 52
organizational, structural, and legal transformations into official CBOs, laying the
foundation for increased impact and community engagement.”
• In June 2015, HSS II Bridge and MOH’s HCAD jointly assessed the effectiveness of
CHCs. This found that CHCs were a key part of the collaborative process and that for 21
out of 23 of them, they achieved a 30% increase in new FP visits over the course of the
SDIC. The report concluded that “CHCs should be considered an intrinsic part of any
future scale up of the FP SDIC”.
RELEVANT LESSONS
Family Planning
• Use of the Service Delivery Improvement Collaborative (SDIC) worked in 24 of the busiest
Health Centers, resulting in uptake of FP more than doubling. This was attributed to
“increased efficiency, awareness and quality of services”. This required intensive data
gathering, data review and regular performance reviews to enable health center staff to
solve longstanding service delivery problems
• A similar SDIC approach that worked (i) with hospitals in partnership with local health
centers and (ii) only with hospitals (for example to improve post-partum uptake of FP), had
minimal impact because levels of autonomy were far lower and changes were therefore
far harder to implement. In addition inconsistent supervisory systems led to reduced
opportunities for monitoring data
• Without hospital leadership having a clear mandate and autonomy, it will be difficult to
deliver significant changes in FP uptake
• The Women and Child Health Directorate at MOH were “resistant” to the introduction of a
modern natural method of FP
• The project pilot multiple approaches to encourage users of traditional methods of FP to
switch to modern methods. Four approaches were tested: couples counseling by
appointment; internal referral within a health center to identify and respond to unmet need;
increased health education sessions in health centers, and strengthen information about
modern methods by providers in the community. “Internal referral” achieved a 98%
success rate in switching, followed by 89% success for improved health education within
health centers. Neither of the other two approaches achieved similar gains. Of the four,
the two most successful also demonstrated substantial reach, although the percentage of
women who were users of traditional methods was relatively low (i.e. although “health
education” reached 545 women, only 64 were identified as users of traditional methods;
“couples counseling” only reached 49 couples but 38 of these were users of traditional
methods).
Maternal and Newborn Care
• Uptake of the ATSL was variable across the six hospitals. The project identified a need for
additional “clinical and management capacity” and through work with MOH’s Quality
Directorate, identified a need for improved consistency for documentation, as well as
clinical governance.
• The project helped implement a nasal-bubble continuous positive airway pressure (NB￾CPAP) protocol at 30 MOH and RMS hospitals. Several hospitals were outliers for survival
rates, notably those receiving Syrian refugee neonates described as “complex cases”.
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 53
(E.g. Mafraq Hospital’s survival rate dropped as low as 59%, while most hospitals were in
the 90+% range). 
• The Project worked with JCAP to design a pre-conception component for unmarried youth
into their plans for later implementation. The target were youth in universities and out-of￾school youth. (This appeared to not learn the lessons from JHCP’s work in Universities).
• The JMMSR conceptual framework built upon existing structures and procedures. Almost
all births are in health facilities, which lends itself to a facility-based follow-up. Requiring all
births to be recorded correctly and reported to DOS would aid the tracking of all births.
CHALLENGES IDENTIFIED
Human Resources for Health Issues
• HSS II Bridge identified multiple HRH-related issues, such as the absence of clear criteria
for the allocation of staff to health facilities. Some HCs were over-stretched while others
had staff that lacked core competencies
• There is a “large gap” between pre-service education for physicians and midwives and the
actual skills the MOH needs from these cadres
Budget Issues
• The project identified a large discrepancy between operational planning and actual
budgets at hospital level
Equitable Access to FP Services
• While FP SDIC worked in 24 HCs it did not work in hospitals. For example, financial and
organizational constraints restrict facilities’ ability to adapt and engage with regular
performance reviews
Strengthen MOH & RMS – Best Practice for M&NH
• Improvements can be challenging because they do not fall within the mandate of any one
Directorate
Capacity Building in MOH
• High staff turnover is a particular problem in IT for MOH, because of recruitment of staff
into the private sector. This creates challenges for IT and HMIS system maintenance
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 54
PRIVATE SECTOR PROJECT FOR WOMEN’S HEALTH (Final
Report)
Start 2005
End 2012
Value $18.97m
Focus FP, Improving Women’s Health, Breast Cancer Awareness and
Detection, and Medical Treatment in the Private Sector for GBV
Implementing Partner Abt.. Associates
No end of program evaluation could be identified on local systems or by the Development
Experience Clearing House.
ISSUES AND THEMES IDENTIFIED IN THE FINAL REPORT:
Community Outreach Program
• CHWs promoted awareness of birth spacing and use of modern contraceptives, self￾breast examination and pap smears, antenatal care for pregnant women, postnatal care,
and contraceptive options following delivery
• The home visit was the foundation of the community outreach program. Trained CHWs
visited women in their homes for a specified number of visits at four- to six-week intervals
• Women who were already satisfied users of a modern family planning method received
only two visits (65%). An additional 1-2 visits were justified for non-users of any method,
users of traditional methods or the lactational amenorrhea method, women with high
maternal risk, and pregnant women
• The program reached around 87% of MWRA, resulting in 12.5% of those reached
adopting a modern contraceptive method
• CHWs were trained in EBM through the use of Critically Appraised Topics (CATs), short
summaries of evidence to help provide a response to clinical questions
• A mid-term evaluation (2008) found that
o “Outreach is effective but requires persistence”. Women visited by CHWs adopt
modern methods following visits three, four, seven, and eight, with the largest
number of women adopting following the fourth and eighth visits. once a new user
adopts an FP method, she requires continued counseling and support in the first
three to six months of use to help reduce the likelihood of discontinuation
o “The referral system is an important component of the outreach service continuum
and is important to the CHWs’ credibility among the women in the communities.”
o Messages on different health areas helped introduce FP. However, managing
several health topics posed challenges for CHWs. Some CHWs had trouble
mastering a host of health topics while others spent less time on challenging topics
such as family planning and instead gravitated to other health messages
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 55
Enhancing Quality in Private Providers (EQuiPP)
• To improve private sector health services, PSP-Jordan partnered with Jordan’s leading
medical institutions to deliver clinical and evidence-based medicine (EBM) training
programs, quality assurance services, and Continuing Medical Education (CME) credits
• Two new methods—Implanon® and NuvaRing®—entered the market, introduced through
outreach and the PSP-Jordan-initiated network of private physicians
• Many private physicians and pharmacists failed to provide medically correct and client￾sensitive family planning or breast or cervical cancer screening services. Sometimes
providers lacked the appropriate knowledge or skills; others were reluctant to prescribe
modern family planning methods to younger married women or to explain the possible
side effects of such methods
• Potential clients expressed the desire for female providers, convenient resupply of
methods, empathetic counselors, and affordable services
Evidence Based Medicine and Training Approaches
• PSP used three approached: (1) classroom and clinical training, (2) the use of evidence￾based medicine and detailing, and (3) a quality assurance certification process
• PSP-Jordan collaborated with Bayer Schering Pharma (BSP), a major supplier and
marketer of oral contraceptives, to introduce the EBM approach
• More than 1,790 private sector physicians participated in one or more PSP-Jordan training
programs on their day off or even closed their clinics in order to participate
• The curriculum was expanded to include topics of interest to private providers, including
cancer and diabetes, and sessions were scheduled in short segments in order to meet
providers’ competing demands
• A range of incentives motivates private providers to deliver FP under certain conditions.
This included opportunities to update clinical skills and knowledge for both personal and
professional reasons and to earn CME credits
Pharmacies
• A mystery client study in 2006 showed several barriers to good counseling and correct
use, e.g., not providing appropriate advice if a client misses a pill. PSP-Jordan instituted a
CME program in family planning for pharmacy staff through the Jordan Pharmacists
Association (JPA) and two private pharmacy franchises. The project trained over 1,150
pharmacists
• PSP-Jordan developed a family planning curriculum for preservice training and signed
agreements with two of the largest private universities (Al Zaytoonah University and Al
Zarqa Private University) in Jordan to include family planning in their curriculum for
pharmacy students
Early Breast Cancer Detection
• During the first home visit, a CHW talked about the importance of early detection for the
successful treatment of breast cancer
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 56
Violence Against Women Domestic Violence
• In conjunction with the Institute for Family Health, the project trained 17 private hospitals
in procedures for detection of domestic violence and onward referral
• The Private Hospital Association’s hospital accreditation requirement for family protection
was a critical incentive in motivating private hospitals’ participation in the VAW initiative
EXPANDING HIV PREVENTION IN JORDAN (Final Report)
Start October 2006
End September 2008
Value 1,150,000
Focus HIV Prevention
Implementing Partner Family Health International (now FHI 360)
No end of program evaluation could be identified on local systems or by the Development
Experience Clearing House.
ISSUES AND THEMES IDENTIFIED IN THE FINAL REPORT:
The activity was focused on supporting GOJ with an HIV Prevention Strategy. This included
direct program activity with high-risk populations; collecting and analyzing strategic information;
providing a forum to help people living with HIV and AIDS, and to create an enabling
environment for an effective national response.
Cultural norms and sensitivities were repeatedly cited as challenges. Meanwhile access to
condoms was described as widespread, although their use for disease prevention appeared
secondary to their use as a contraceptive. Condom usage overall was described as “low”.
RELEVANT LESSONS
• SBC approaches made a significant and demonstrable impact on stigma-related issues
(such as “willingness to share a meal with a coworker PLHA” for those exposed to the
program’s interventions)
• The program’s own research found that there was “a surprisingly low level of exposure” to
SBC program interventions
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 57
ANNEX B - Examples of Pilot Projects Discontinued or Not Scaled Up
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 58
Examples of Pilot Projects Discontinued or Not Scaled Up (chronological order):
(Source: IRH/Eval)
Initiative Description
Comprehensive 
Postpartum Project 
(CPP) (1995-2000) 
[not scaled-up and 
discontinued after 
project end]
• Mentioned during interviews as one of the most successful projects.
• Twenty-one centers were established at public and NGO hospitals to
provide comprehensive mother and child health services including family
planning. After project end, MOH was unable to maintain the centers and
with time, trained staff shifted, well baby clinics closed, electronic
information system stopped, and client numbers dropped.
Training centers for 
laparoscopic tubal 
ligation (2000-2004) 
[not scaled-up and 
discontinued after 
project end]
• EngenderHealth established two training centers for laparoscopic tubal
ligation, one at Al-Bashir hospital for MOH and a second at the Al-Hussein
Hospital for RMS. These centers were equipped with needed equipment
and furniture, developed a training curricula and standards of care, and a
memorandum of understanding was signed with MOH.
• After the project end, none of these training centers conducted more
trainings
Sehetna web site 
(2006-2011) 
[discontinued after 
project end]
• The web site was established by the JHCP project to be run by MOH after
the project. However, it was closed after the project ended.
Mabrouk Initiative 
(2006- 2011) 
[discontinued after 
project end]
• Established by JHCP to target newlywed couples, the Mabrouk kit included
information on healthy lifestyles and family planning was distributed
through the Department of Civil Status for newly married couples at the
time of receiving their family card.
• The kit was not re-printed and the initiative stopped
Safe Motherhood 
Committees (2007-
2014) [discontinued 
after project end]
• The committees were established at all public hospitals to oversee safe
motherhood services including family planning. Activities include hospital
yearly workplan reviews and indicators review and action planning.
• Interviews conducted for this assessment suggest that some of the
committees stopped meeting and fulfilling duties after the HSS II project
ended
The perinatal 
information system 
(2007-2014) 
[discontinued after 
project end]
• Initiated by HSS, the web-based electronic system registers antenatal care, 
delivery, and postnatal care provided at MOH hospitals. The project provided the 
system and computers, and built staff capacity on its use.
• The system was not sustained because it depends on the Internet, which is not 
functional at many hospitals as suggested by interviews conducted for this 
assessment. In addition, service providers appeared to be reluctant to enter data 
as they are busy and data entry take time, and as a result the system was not used 
completely in many hospitals. In other hospitals it was replaced by the Hakim 
program for automating public hospitals
Initiative Description
Follow-up for 
postpartum women 
• HSS II project conducted a study to measure the effectiveness of postpartum 
family planning counseling and services at Al -Bashir hospital. 
Review of PFH Program and Project Evaluations (2005 - 2019) – July 2020 59
receiving family 
planning counseling
at Al- Bashir 
hospital (2013) 
[discontinued after 
project end] 
• The follow-up stopped after the study period ended due to funding constraints.