USAID/ECUADOR STRATEGIC OBJECTIVE No. 2 – FAMILY PLANNING AND HEALTH CLOSE-OUT REPORT (Family Planning) I.- BACKGROUND DATA Activity Title: Population/Family Planning Activity Number: 518-0128 Agreements Date: September 1997 PACD: Original September 30, 2000 Revised: September 30, 2001 Amount: $ 15,501.640,00 Implementing Agencies: - Asociación Pro Bienestar de la Familia Ecuatoriana-APROFE. CA 518-G-00-97-00267 $7.766.028 - Centro Médico de Orientación y Planificación Familiar-CEMOPLAF. CA 518-A-00-97-00268.00 $7,773.972 - Centro de Estudios de Población y Desarrollo Social-CEPAR CA 518-A-00-95-00133-00 $2,400.000 II.- DISCUSSION USAID continued to be the major donor in the sector during this period and therefore a critical player in achieving reduced fertility, increased contraceptive use and strengthening the role of NGO service providers and demographic analysis. USAID/Ecuador’s Family Planning/Health Strategic Objective No.2 supported the two US national interests of protecting human health and reducing the spread of infectious diseases and stabilizing world population. This SO was scheduled for phase-out at the end of FY2000. However, a one-year limited extension of SO2 “Increased use of Sustainable Family Planning/Maternal Child Health Services” to the end of FY2001 was approved by AA/LAC on October 15, 1999, in order to continue supporting the two largest family planning NGOs in Ecuador, Association for Ecuadorian Family Well Being (APROFE) and Medical Center for Orientation and Family Planning (CEMOPLAF). Family Planning activities were undertaken through a Grant with APROFE and a Cooperative Agreement with CEMOPLAF. USAID/Ecuador has been the primary donor of family planning assistance, for twenty-five years. 2 Health activities under SO2 ended September 30, 2000 as planned, including financing of the Center for the Studies of Population and Social Development (CEPAR), which included the conducting of the 1999 National Demographic and Reproductive Health Survey ENDEMAIN, which provided valuable programming and SO and IR indicator data. The goal of the program was to increase the sustainability of these FP NGO partners and to improve the quality and access to family planning services. Activities concentrated support to more than forty private clinics operated by APROFE and CEMOPLAF. This support to the APROFE and CEMOPLAF programs has been instrumental in their growth from small regional organizations, to national level impact with twenty-one clinics each. The provision of family planning and reproductive health services has been expanded and the demand for quality private sector FP services is high. Medical services provided by both NGOs include: gynecology, post natal care, laboratory services, Since 1999 both partner NGOs had to overcome the effects of the nation’s financial crisis and the Congressional hold on the Mission’s population activities throughout 2000. These circumstances threatened to erode the important sustainability/cost recovery accomplishments the Mission had worked hard to promote, particularly among NGO family planning clinics. But, they also served as an additional catalyst to force USAID’s partners to urgently address sustainability issues. III.- ACCOMPLISHMENTS: One of the primary focus of the Strategic Objective was to increase use of contraceptives and couple years of protection while achieving greater levels of sustainability of the partner NGOs and improving the quality of their services. Key overall results achieved over the life of the SO include: · Increased consolidation of local Family Planning NGOs hard hit by financial constraints in 1999-2000 (through approval of an additional $ 1.1 million for contraceptives and logistics technical support in FY2001). At the same time these local NGOs managed to make a significant recovery in late FY 2000 and early FY2001 from the harsh effects of devaluation, inflation of costs of imported goods, and GOE’s decision in 1999 to freeze bank accounts; and they still attracted a growing clientele to their private clinics. · Cost recovery targets were met despite these severe challenges, with an average of over 90% for APROFE and CEMOPLAF. · Special emphasis was given to institutional strengthening. After a thorough analysis of both NGOs to prepare them for the USAID phase out, some institutional structure and 3 management weaknesses were identified. After implementation of strategic plans to address these issues, both institutions now have solid administration and empowered management staff. · Contraceptive prevalence rate, CPR, the primary measure of SO results significantly increased. According to National Demographic Survey of 1994 and 1999 (ENDEMAIN) there was an increase in the CPR from 56.8 in 1994 to 66.3 in 1999. · Total Fertility Rate declined from 3.6 in 1994 to 3.3 in 1999, a modest but still significant decline given the difficulty of reducing this rate. · 61% of family planning users obtain contraceptive services from private sources. Private sector includes for-profit and non-profit organizations, as well as private doctors, and private clinics, etc. From this percentage, 36.6% was use of female sterilization. The Ministry of Health (MOH) provides the highest percentage of female sterilization reaching 62.7% of their users. · CEPAR with technical assistance from the Centers for Disease Control (CDC) carried out both 1994 and 1999 the nation’s most widely representative and respected demographic and reproductive health survey ENDEMAIN. It is the largest survey of its kind in Latin America including 25,000 households in the sample and provides extensive provincial level demographic and reproductive health data for all provinces including the Galapagos Islands. · Preparation and dissemination of the National Reproductive Health Services Guidelines. JHPIEGO had a lead role through national coordination among all participant institutions. This was a very participatory process with active participation of PAHO, UNICEF, UNFPA, CONAMU, universities, IESS, NGOs, Colegio de Médicos, Colegio de Obstetrices and Colegio de Enfermeras. Printing and dissemination of the norms were completed under this SO with funding contribution from other donors. · Quality index of seven factors were applied and accomplished by 42 APROFE and CEMOPLAF clinics. These factors are: stockouts of any method/brand; at least three modern methods available; private exam space in facility; staff trained in methods available in counseling and on side effects; state-of-the-art national guidelines available on site; facility staffed and open at least five hours per day; and staff trained on handling/disposal of medical wastes. · Cost recovery levels of both assisted NGOs continued to increase even during the economic crisis of the late 1990s and 2000. The amounts deposited in the sustainability fund show the great efforts made by local partners to costs recovery, while maintaining their social mission of serving poor and lower middle class. Amounts reached by both NGOs sustainability fund as September 30, 2001 show: One of the reasons why CEMOPLAF achieved so much lower amount was that they maintained the fund in local currency, sucre, and deposited in local banks. High 4 devaluation of the sucre and bank accounts freezing impacted negatively in their sustainability fund. Also CEMOPLAF reached lower levels of efficiency compared to APROFE and that also impacted negatively in their sustainability fund. Specific Achievements by each NGO: APROFE: Two issues were identified at the beginning of the grant: the institution was reluctant to receive technical assistance as well as to implement a comprehensive social marketing program. Through intense and continuous involvement of Mission staff with the Executive Director and the Management Committee that includes Financial, Operations, IEC and Evaluation Directors, APROFE realized the need and importance of implementing new marketing strategies, receiving technical assistance and implementing a social marketing program. A survey was conducted in the 15 cities were APROFE clinics operate to identify the market needs and the perception of the institution’s image. A FODA study was carried out in the twenty clinics of APROFE. Based on the results of these studies, a strategy was developed to recover lost ground in its achievement of service targets. In addition an emergency plan was implemented to strengthen the community based distribution network and the collaborating private doctors and obstetrics network and to increase the Couple Year of Protection level (CYP). As a result of these actions, APROFE doubled the number of CYPs in six months exceeding the target for FY99. The technical assistance focused on marketing promotion expansion of the social marketing program, and improvement of the quality of service. APROFE demonstrated a solid and serious financial management through the entire implementation of the program. The exceptional result of this is the amount deposited in the sustainability fund which exceeded the original amount planned in 1997 ($5,150,000). Despite the weakened economy, banking crisis, dollarization process and political instability during the implementation period of the program, this NGO developed an austere economic plan to keep expenses to a minimum, increasing prices of services for cost recovery and maintaining the quality of services. CEMOPLAF: As stated in the agreement, the following conditions were accomplished as of December 31, 1998: - that no members of the General Assembly may be CEMOPLAF’s employees - that the President of CEMOPLAF will no receive a salary - to change their personnel structure creating a new position of Deputy Executive Director. The implementation of reforms in their personnel structure meant a long process to persuade them to manage the institution toward sustainability. One key element to deal 5 with was the recruitment of the new members of the Board of Directors representing a wider and more experienced group of professionals. This effort overcame the issue created by an inoperative Deputy Director/Finance Director position that was abolished. During FY2000 and FY2001 much work was done simultaneously with staff to empower each area director and with the members of the board to manage the institution to increase the sustainability level and improve the quality of services. To address these problems, intensive technical assistance, from our field support projects Johns Hopkins University and JHPIEGO, was provided. A strategic plan was prepared that included organizational development and financial control. Some strategies were developed to conduct CEMOPLAF toward sustainability. Team work and delegation of authority concepts were implemented in this institution born as a family group of medical women. Two main senior management positions were created: Financial Director and Service Marketing Director. As a result of these actions, CEMOPLAF now has successfully implemented internal controls, empowered their senior staff who participates actively in the preparation of the annual work plans, sharing budget information and participating in institution’s decisions. The present members of the Board of Directors were appointed in April 2001 and represent all sectors of the civil society: health, finance, press, production, marketing, environment, culture, social work and international relations. · A Trust Fund will be established in the amount of $ 3,365,720 to assure the institution’s long term sustainability. SO Level Indicator: The SO indicator “Contraceptive Prevalence Rates” (CPR) illustrates the success in the implementation of the family planning activities. The National Demographic Survey ENDEMAIN/99 showed a substantial increase in contraceptive prevalence from 56.8% in 1994 to 66.3% in 1999 (modern methods 51.3% and traditional methods 15%). IR 1.- “Cost Recovery of FP NGOs”.- - APROFE: From 69% cost recovery in 1996, they achieved 97% self￾sustainability in FY2000. - CEMOPLAF: From 66% in 1996, they achieved 86% cost recovery in FY2000. Both institutions are well on their way to long term sustainability. - Both institutions built up sustainability funds: APROFE $ 5,150.000 and CEMOPLAF $ 3,365.720 to support their efforts after USAID’s assistance ends. IR2.- “Improved Quality and Access of Family Planning Services”.- 6 - Couple Years of Protection (CYP) is the indicator that best illustrates the improved access in family planning. CYP services provided by APROFE and CEMOPLAF increased from 279.117 in 1994 to 706,,017 in FY2000 and it is expected to reach 750,000 in FY2001. Implementation of all 7 Quality Index measures in all clinics is the indication of quality improvement. IV.- INPUTS AND RESOURCES EXPENDED · Extensive amounts of state of the art equipment were bought for the network of 42 clinics of APROFE and CEMOPLAF and their central offices: office equipment, medical equipment, computers, laboratory equipment. Medical equipment included: colposcopies, gynecological beds, clinical lamps and eco. This equipment have an estimated value of $ 4 million leaving the clinics equipped with advanced technology for the next five or six years. · Large volumes of contraceptives were donated to APROFE, CEMOPLAF and a small amount to COF. ENDEMAIN/99 confirmed that private sector is the dominant supplier of family planning commodities. The intrauterine device, pills and injectable are the methods most commonly used. During the implementation of the program an estimated total value of $ 3,7 million was expended in contraceptives and technical assistance for our partner NGOs APROFE and CEMOPLAF. · The following technical assistance was provided to partner NGOs APROFE and CEMOPLAF through our field support projects: - Johns Hopkins University-Population Communication Services (PSC) assisted both institucions in: assessing communication needs, designing communication strategies, building capacity in IEC, designing promotion campaigns using mass media, implementing monitoring and evaluation system in each clinic and developing demand-side strategies for quality of care. - JHPIEGO provided assistance to APROFE and CEMOPLAF to strengthen reproductive health policy and services, train both institutions’ medical staff in infection prevention, strengthen medical, training and service protocols. Valuable assistance was provided in the development of the National Reproductive Health Service Guidelines with active participation of both partner NGOs. - John Snow Inc. provided technical assistance on focused on the delivery of commodities, capacity building in forecasting, procurement, distribution, management and information systems. - Centers for Disease Control (CDC) assisted CEPAR in the preparation of the ENDEMAIN/99. This technical assistance included: questionnaire design, data 7 collection activities, interviewer training, creation of analysis files, reports preparation and dissemination activities. V.- LESSONS LEARNED · Ecuador as a developing country experiences rapid change in political, economic and social context; therefore success of a project should be measured beyond target figures and include indicators such as transparency in management and solid leadership. · Long term actions are required to prepare the local partners for self-sustainability giving more attention to the long-term institutional strengths and weaknesses of the NGO partners. Capacity building should be strengthened to improve the organizations’ overall performance. · Technical assistance should be focused in institutional strengthening as most of the local NGOs are born as family organizations, where nepotism is a daily practice and business like management practices uncommon. · Project indicators should include measures for institutional strengthening such as: administrative procedures and management systems in place; financial management; human resource management; leadership capacity and organizational values. · An objective of the SO was to increase access to family planning services. Although the coverage has increased for both NGO partners, the poorest populations are generally still far away from the services. It is convenient to increase the number of participating partners in order to expand the access of services. · Local NGO partners were urged to achieve selfsustainability which forced them to increase the prices of health and family planning services partically abandoning many of the original target population, the poor and marginalized people specially women. · The accomplishment of project indicators do not reflect the entire institution’s performance. It could be a performance of a group of employees but not a result of a well managed organization. Other level indicators not included in the Mission Performance Monitoring Plan should be tracked in order to evaluate other efforts of the institution. · Despite the reports received by the Mission, it is particularly important to work closely with the NGOs to identify their strengths and weaknesses; and to address our assistance in due time and direction. VI.- POST COMPLETION ACTIONS 8 · It is expected that CEMOPLAF Trust Fund will be created by September 28, 2001 (last working day of FY01), but if this is not completed, a close monitoring is required to assure this is done during the following week. · Contraceptive orders for APROFE and CEMOPLAF and COF (through CEMOPLAF) were placed in July 2001. Local NGO partners are instructed to address their correspondence and issues directly to Contraceptive Logistics Management (CLM) G/Bureau, Newvern and Panalpina (shipping company). Despite these instructions the Mission will regularly receive the shipment report requiring confirmation of shipments and review of balance in the contraceptive account. · Note some $120,000 in Deliver Project available (in excess of funds needed for Contraceptives already ordered). This money to be used by Contractor, JSI for monitoring and technical assistance to the NGOs during FY02. · APROFE and CEMOPLAF must submit to the Mission, during October the last voucher to liquidate their last fund advances: APROFE $ 83,673,32 and CEMOPLAF $ 299,158.30. · APROFE and CEMOPLAF should deliver to the Mission the Annual Report of Indicators for FY01 (Oct.00/Sept.01) · The draft of APROFE and CEMOPLAF audits reports for year 2000 are expected to receive at the end of October. Audits for year 2001 should be contracted under the same conditions as previous ones. · Mission should follow-up findings and/or recommendations of final evaluation of the program.