EVALUATION OF THE WHITE RIBBON ALLIANCE FOR SAFE MOTHERHOOD 1999–2007 SEPTEMBER 2007 This publication was produced for review by the United States Agency for International Development. It was prepared by Claudia S. Morrissey, MD, MPH, and Linda Sanei, MA, through the Global Health Technical Assistance Project. Blank page inside cover. EVALUATION OF THE WHITE RIBBON ALLIANCE FOR SAFE MOTHERHOOD1999–2007 Claudia S. Morrissey, MD, MPH Linda Sanei, MA September 2007 DISCLAIMER The authors’ views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government. Evaluation of the White Ribbon Alliance 1999–2007 ii This document (Report No. 07-001-34) is available in printed or online versions. Online documents can be located in the GH Tech web site library at www.ghtechproject.com/library/. Documents are also made available through the Development Experience Clearing House (www.dec.org). Additional information can be obtained from The Global Health Technical Assistance Project 1250 Eye St., NW, Suite 1100 Washington, DC 20005 Tel: (202) 521-1900 Fax: (202) 521-1901 info@ghtechproject.com This document was submitted by The QED Group, LLC, with CAMRIS International and Social & Scientific Systems, Inc., to the United States Agency for International Development under USAID Contract No. GHS-I-00-05-00005-00. Evaluation of the White Ribbon Alliance 1999–2007 iii ACKNOWLEDGMENTS This evaluation could not have been conducted without the assistance and support of a large number of people from across the globe who shared their insights, experiences, and passion for safeguarding the health of women and newborns. The evaluation team wishes to express sincere appreciation to the staff and leadership of the White Ribbon Alliance for Safe Motherhood (WRA) Global Secretariat, the WRA India, and the WRA Tanzania. Senior WRA leaders engaged the team in fruitful discussions that greatly enhanced our understanding of the WRA and thus improved the framing and content of the report. In particular, the team wishes to thank Theresa Shaver, WRA Executive Director; Betsy McCallon, WRA Safe Motherhood Advisor; Bridget McHenry, WRA Program Manager; Aparajita Gogoi, WRA India National Coordinator; and Rose Mlay, WRA Tanzania National Coordinator. The team also acknowledges the generous support of the Bureau for Global Health, U.S. Agency for International Development (USAID), Washington D.C., especially the staff of the Health, Infectious Diseases and Nutrition Division, who crafted a clear and thorough scope of work and graciously oriented the team to undertake the evaluation. In particular, the team expresses special thanks to Mary Ellen Stanton, Senior Reproductive Health Advisor, and Nahed Matta, Senior Maternal and Newborn Health Advisor, for their encouragement, guidance, and support. The team also extends its thanks to USAID Mission staff in India who met with the team and provided keen insights and suggestions. In addition, the team wishes to express its appreciation to Camille Hart and Brienna Becker of the Global Health Technical Assistance Project for facilitating the work of the evaluation. Evaluation of the White Ribbon Alliance 1999–2007 iv Evaluation of the White Ribbon Alliance 1999–2007 v ACRONYMS AND ABREVIATIONS ACCESS Access to Clinical and Community Maternal, Neonatal and Women’s Health Services AMTSL Active management of the third stage of labor ANM Auxiliary nurse midwife CBO Community-based organization CEDPA Center for Development and Population Activities CTO Cognizant technical officer EmOC Emergency obstetric care GS Global Secretariat HIDN Health, Infectious Diseases, and Nutrition HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome HPI Health Policy Initiative IAG Inter-Agency Group for Safe Motherhood ICM International Confederation of Midwives IMR Infant mortality rate IR Intermediate result LSS Life-saving skills M&E Monitoring and evaluation MCH Maternal and child health MDGs Millennium Development Goals MMR Maternal mortality ratio MNH Maternal and Newborn Health MNPI Maternal and Neonatal Program Index MOH Ministry of Health NA National alliance NGO Nongovernmental organization PATH Program for Appropriate Technology in Health PHN Population, health, and nutrition PMM Prevention of maternal mortality PMNCH Partnership for Maternal, Newborn and Child Health PMTCT Prevention of mother-to-child transmission PPH Postpartum hemorrhage RH Reproductive health SBA Skilled birth attendant SO Strategic objective TA Technical assistance TOT Training of trainers TNA Trained Nurses Association of India UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund USAID U.S. Agency for International Development Evaluation of the White Ribbon Alliance 1999–2007 vi WABA World Advocates Breastfeeding Alliance WHO World Health Organization WRA White Ribbon Alliance for Safe Motherhood WRAI White Ribbon Alliance India WRAM White Ribbon Alliance Malawi WRATZ White Ribbon Alliance Tanzania ZWRASM Zambia White Ribbon Alliance for Safe Motherhood Evaluation of the White Ribbon Alliance 1999–2007 vii CONTENTS ACKNOWLEDGMENTS.................................................................................................. iii ACRONYMS AND ABREVIATIONS ................................................................................ v EXECUTIVE SUMMARY .................................................................................................. 1 INTRODUCTION...................................................................................................... 1 KEY FINDINGS........................................................................................................ 1 RECOMMENDATIONS............................................................................................ 3 CONCLUSION ......................................................................................................... 4 I. BACKGROUND............................................................................................................. 5 INTRODUCTION...................................................................................................... 5 EVALUATION SCOPE ............................................................................................ 5 METHODOLOGY..................................................................................................... 5 WRA HISTORY AND STRUCTURE........................................................................ 6 II. KEY FINDINGS .......................................................................................................... 11 WRA MAJOR STRENGTHS AND WEAKNESSES .............................................. 11 WRA OUTCOMES AND ACHIEVEMENTS .......................................................... 16 WRA OPERATIONS.............................................................................................. 23 ALLIANCE MODEL COMPARISONS................................................................... 29 III. LESSONS LEARNED ............................................................................................... 31 IV. RECOMMENDATIONS ............................................................................................. 33 USAID 33 WRA 33 V. CONCLUSION ........................................................................................................... 37 Evaluation of the White Ribbon Alliance 1999–2007 viii APPENDICES................................................................................................................. 38 APPENDIX A: SCOPE OF WORK ........................................................................ 39 APPENDIX B: PERSONS CONTACTED.............................................................. 49 APPENDIX C: DOCUMENTS REVIEWED............................................................ 53 APPENDIX D: NATIONAL COORDINATOR QUESTIONNAIRE ......................... 57 APPENDIX E: WHITE RIBBON ALLIANCE MISSION, VISION, AND PRINCIPLES.................................................................................. 59 APPENDIX F: WRA AFFILIATION AGREEMENT ............................................... 61 APPENDIX G: WRA GLOBAL SECRETARIAT WORK PLAN OUTPUTS, FY 2004 THROUGH FY 2007............................................................. 67 APPENDIX H: HIGHLIGHTS OF MAJOR COORDINATED WRA EVENTS AND PUBLICATIONS SINCE 2000....................................................... 69 APPENDIX I: WRA GLOBAL SECRETARIAT FUNDING SUMMARY ................ 73 APPENDIX J: REFERENCES ............................................................................... 75 FIGURES FIGURE 1. GLOBAL SECRETARIAT ORGANIZATIONAL CHART............................... 8 FIGURE 2. 2006 EXPENDITURES BY CATEGORY ..................................................... 25 FIGURE 3. WRA FUNDING 1999–2007 ........................................................................ 27 TABLES TABLE 1. WRA GROWTH OVER TIME .......................................................................... 8 TABLE 2. STATUS AND IMPORTANCE OF NATIONAL ALLIANCES........................ 17 TABLE 3. NON-US GOVERNMENT FUNDS................................................................. 26 TABLE 4. DIRECT FUNDING TO NATIONAL ALLIANCES ......................................... 26 EXECUTIVE SUMMARY INTRODUCTION The evaluation team was tasked by USAID with capturing the growth, influence, and results of the White Ribbon Alliance for Safe Motherhood (WRA) since its inception, and examining the coherence between WRA’s goals and mission with those of projects and institutional homes and with USAID’s frameworks for maternal and newborn health. The evaluators were also asked to undertake a brief analysis of WRA’s progress in relation to that of a comparator alliance with similar mandate and funding levels. KEY FINDINGS Founded in 1999, “The White Ribbon Alliance is a global grassroots movement for safe motherhood that builds alliances, strengthens capacity, influences policies, harnesses resources, and inspires action to save women’s lives everywhere.”1 WRA’s mission has never wavered. WRA has achieved impressive growth since its inception: • From a loose group of maternal health advocates with an idea, to a world-wide presence with formalized Mission, Vision, and Principles; • From a coordinator housed within a project to a fully independent not-for-profit organization; • From 35 to 2,025 individuals and organizations;2 • From 3 to 15 active national alliances (NAs); • From 0 to 26 state and provincial alliances; and • From 5 to 91 countries. WRA is organizing in countries where reducing maternal deaths would significantly accelerate the achievement of a Millennium Development Goal: Reduce the maternal mortality ratio by three-quarters by 2015. Active NA countries contribute 48 percent of worldwide maternal deaths. If the NAs in Nigeria and Ethiopia were reactivated, that percent would increase to nearly 60 percent. In India and Tanzania alone, WRA activities are estimated to have reached over three million people. Strengths and Weaknesses Each stakeholder interviewed was asked two key questions: What would you say are the major strengths and weaknesses of the WRA Global Secretariat? Of the National Alliances? 3 Three answers typify the responses: “WRA is by far the best group that exists” for advocacy on safe motherhood (major donor representative); “WRA National Alliances can put safe motherhood on the national agenda with more authority and urgency than any external agency can” (senior ministry official); “If WRA were not here, it is not clear there would be another champion focused on Safe Motherhood” (senior NGO official). Strengths of the Global Secretariat (GS) and NAs Universally, respondents commented on how committed the WRA leadership is to safe motherhood. Many noted that the most fundamental strength of WRA is the model itself, an organizational paradigm of inclusiveness, transparency, accountability, and shared decision making. There was resounding agreement 1 WRA Mission Statement. 2 The size of organizations range from less than 10 members to greater than 100,000 members each. 3 From the many questions on the guides and probes that were tailored for 6 specific cadres of the over 80 individuals interviewed. Evaluation of the White Ribbon Alliance 1999–2007 1 among respondents on the impressive amount of work that has been accomplished by the WRA with few staff and limited resources in a short time span. NAs are characterized as uniquely collaborative organizations, able to bring together policymakers, providers, educators, NGOs, activists, and community members on an equal footing. In the main, responders are impressed with the traction NA events and messaging has had with top policymakers. Several national leaders noted that WRA builds trust because it is not about selling itself as an organization but about an issue—a compelling issue—saving the lives of mothers and newborns. Weaknesses of GS and NAs Without exception, respondents felt that the GS is underfunded and understaffed. This is also the most referenced challenge for the NAs. Some felt the GS needs to be less facilitative and more directive with the NAs. “They need to step forward and push a little.” Many related that WRA monitoring and evaluation is weak, a weakness acknowledged by GS staff. NAs have also been perceived as weak at tracking progress and outcomes, especially at the local levels. Achievements Building Coalitions WRA has engaged multilateral and bilateral donors, government ministries, Private Voluntary Organizations, NGOs, USAID Cooperating Agencies, Global Partnerships, and Foundations, as well as film producers, journalists, and other individuals from over 90 countries. “WRA provides a forum for people to channel their passion and energy around Safe Motherhood.” Strengthening Capacity Beyond individual technical assistance to emerging and established NAs, the GS has assisted NAs with organizing and hosting four Capacity Building Workshops in Zambia, Indonesia, India, and Malawi, and has produced three Field Guides. Topics covered include: key components of social mobilization and effective advocacy; how to build, structure, and govern an NA; how to undertake a strategic planning process; and how to write a proposal, prepare a newsletter, and use the media. Several NAs characterized these workshops and resources as essential guides for moving their country-level efforts forward. Influencing Policies WRA efforts have influenced country-level maternal health policies and financial outlays, contributed to the policy dialogue, and recruited champions for safe motherhood. For example, the Government of Burkina Faso has increased its health budget by 6 percent, and the Government of Tanzania has agreed to hire all graduating providers to address the severe health manpower shortage. The Government of India created a new cadre of birth attendants and adopted protocols and practice guidelines, developed under WRA’s leadership, that expand the mandate of frontline providers to include life-saving skills. Harnessing Resources For a young organization, WRA has been able to attract and leverage an impressive amount of resources, such as volunteer labor, in-kind contributions, and financial support. Since FY05, non-USG funding has represented 26 percent of total funding to the Global Secretariat. Inspiring Action WRA has organized high-profile public events that have catalyzed action. The March to the Taj Mahal in 2002 resulted in the Government of India designating April 11 as “National Safe Motherhood Day,” and sparked a reexamination of maternal health policies, services, and provider practice guidelines. Evaluation of the White Ribbon Alliance 1999–2007 2 Contributions to USAID frameworks for maternal health All WRA activities have contributed to USAID’s strategic objective for maternal health. WRA has recently facilitated focused attention in Malawi, Tanzania, South Africa, and Zambia on USAID’s maternal pathways—focused antenatal care, skilled birth attendance, prevention of postpartum hemorrhage, newborn care, and fistula prevention. Sustainability Key factors that auger well for sustainability are the commitment of WRA leaders, the degree of volunteerism at the GS and NA levels, the positive relationships with governments and donors, and the broad-based, multisectoral membership at the country level. Monitoring and Evaluation (M&E) This is an area that has lagged compared to other WRA efforts—an assessment shared by WRA staff and others. Since incorporation, the GS has placed more emphasis on M&E and has developed several tracking tools. NAs have been trained in the use of the tools and have agreed to report to the GS twice yearly. Alliance Model Comparison The selected alliance comparator for WRA, the World Alliance for Breastfeeding Action (WABA), has a similar mission and resource base. However, WRA has exceeded WABA’s growth in half the time with a much smaller staff, 3 versus 10 FTEs. Operations WRA GS achieved independent 501(c) (3) status in May 2006. The WRA is governed by an 11-member Board of Directors. Each individual, organizational and national alliance member receives one vote. Currently the WRA GS has three FTEs with an additional 1+ FTE in volunteer labor. Financials WRA received a clean audit for its first reporting period, June through December 2006. In-kind contributions were not monetized until 2005. Including anticipated FY07 obligations, total USAID funding to the WRA over an 8-year period is $3,644,072. In addition, WRA has received $699,948 in non-U.S. government funding and $347,000 in direct funding to the NAs. RECOMMENDATIONS USAID • Increase and sustain USAID funding over the next three to five years, with an emphasis on supporting NAs and possibly Regional Coordinators. Establish a sunset provision on further support after that timeframe. • Initiate a process that engages global stakeholders in identifying, developing and subsequently endorsing key social mobilization indicators, in keeping with USAID’s global leadership role. WRA/GS • Given its new 501(c) (3) status, undertake a second strategic planning process for 2008–2013. • Institute and maintain tighter tracking and monitoring systems at all levels of the WRA. • Continue to prioritize launching and building NAs, as the primary function of the GS. • Strategically package growth and funding information for marketing and advocacy purposes. Evaluation of the White Ribbon Alliance 1999–2007 3 • Promote high-impact interventions and tools throughout the alliance in a more systematic manner. CONCLUSION Perhaps the most salient conclusion to be drawn from this evaluation is that mobilizing societies to create the conditions necessary to reduce maternal deaths is a promising yet long-term, large-scale, and labor￾intensive undertaking. WRA staff and volunteers have mobilized and capacitated an impressive number of change agents for safe motherhood across the globe with limited funds. WRA is currently receiving only one-half of one percent of overall USAID maternal health resources. The evaluators conclude that WRA is an important contributor to USAID’s maternal health objective and believe that a well-resourced WRA has the potential for even greater impact. In short, WRA represents real value for money. Evaluation of the White Ribbon Alliance 1999–2007 4 I. BACKGROUND INTRODUCTION The evaluation team was tasked by USAID with capturing the growth, influence, and results of the WRA since its inception, and examining the coherence between WRA’s goals and mission with those of the projects and institutional homes where it has resided and USAID’s frameworks for maternal health. We have attempted to analyze and report on fit, growth, outputs, outcomes, and sustainability. The evaluators were also asked to view WRA through a comparative lens, looking at its progress in relation to the progress of other alliances with similar mandates and funding. While we were unable to undertake an exhaustive review, we were able to perform a brief analysis with a comparator alliance. EVALUATION SCOPE USAID commissioned this external evaluation of the WRA to identify and assess WRA’s principle contributions to USAID’s strategic objective to improve maternal health, SO2: Increased use of key maternal health and nutrition interventions. (See Appendix A, Scope of Work.) Specifically, USAID Washington wanted answers to the following questions: 1. How effective and appropriate are WRA activities in furthering the achievement of USAID’s maternal health intermediate results, particularly IR1: Global leadership for maternal, neonatal, and women’s health and nutrition programs and policies strengthened? 2. Has the alliance model facilitated or hindered the achievement of WRA’s mission? How effective is the Global Secretariat (GS) in terms of project management, coordination, and communication? 3. What are the key strengths and weaknesses of the WRA GS and NAs? 4. What are the broad lessons learned and recommendations to USAID and WRA based on this evaluation? 5. Is there value-added by supporting WRA efforts? Is there continuing need for USAID support to the WRA GS? METHODOLOGY Team The evaluation team consisted of two public health practitioners experienced in the design, implementation, and evaluation of international reproductive health policies and programs, with additional expertise in maternal and newb health, community mobilization, and organizational development. The team conducted the evaluation over a seven-week period from June to August 2007. Methods The key questions of interest were selected from a matrix of questions extracted from the SOW and vetted with USAID staff at the onset of the evaluation. Data to answer these questions were gathered through a variety of techniques: document mining; semi-structured, in-depth in-person and phone interviews; fielding of a questionnaire with response analysis; group observation; stakeholder question and answer sessions; and a field visit to India—one of the WRA NAs. More than 80 documents were reviewed, including those covering the history, operations, performance, and results of WRA global and national activities (Appendix C), and over 80 persons contacted (Appendix B). Evaluation of the White Ribbon Alliance 1999–2007 5 Prior to initiating interviews, six stakeholder cohorts were identified: WRA National Coordinators; WRA Board Members; USAID Mission PHN Officers in countries with a National Alliance; USAID Health, Infectious Diseases, and Nutrition (HIDN) Washington staff; WRA host organizations; and Donors/NGOs/USAID Cooperating Agencies. An open-ended questionnaire was developed and fielded to 18 WRA NA Coordinators/Leaders (Appendix D) and tailored interview guides/probes were crafted for each additional cohort. These guides were sent to the identified key stakeholders prior to phone or in￾person in-depth interviews. After informing interviewees of confidentiality safeguards and obtaining verbal consent to participate, interviews were conducted using the guides/probes with both evaluators present and scribing key responses; exchanges ranged from 40 to 90 minutes and can be characterized as frank and open. Interview notes were typed and collated for each cadre, and then served as the basis for the contents of this report. In addition to document review and interviews, the team observed a WRA India monthly meeting of the members and participated in a community gathering organized by Prerana, a WRA India NGO member. Limitations Evaluating WRA’s performance and direct contributions to USAID’s maternal health intermediate results as outlined in the SOW posed some unique challenges. During its formative years, 1999 to 2006, WRA staff operated within a series of host Cooperating Agencies. USAID funds for WRA activities were channeled through project monies to the host and then to WRA (see History and Structure below). WRA did not become an independent 501(c) (3) organization, able to receive direct funding, until spring of 2006. As a consequence, during most of the period of interest, WRA reported its activities and results to the host organization rather than directly to USAID. The evaluation team approached this attribution challenge by reviewing the planning and performance documents of the various host projects (NGO Networks for Health, The Policy II Project, Health Policy Initiative) to ascertain if discrete WRA activities were reported against the SO2 IRs. Unfortunately, WRA activities were generally folded into aggregate project activities reported by IRs. In addition, activities carried out by the WRA NAs—the majority of which are volunteer organizations without USAID global or mission funding—have only recently been subject to a systematic monitoring scheme with the first reporting deadline later this year. Within the last year, four of the NAs have developed action and monitoring plans focused on one of the four USAID Pathways but have not reported on results to date. Given the above, this evaluation primarily examined the extent to which WRA activities are effective and appropriate for achieving the five commitments expressed in the WRA Mission Statement, all clearly supportive of USAID’s maternal health objective: “The White Ribbon Alliance is a global grassroots movement for safe motherhood that builds alliances, strengthens capacity, influences policies, harnesses resources, and inspires action to save women’s lives everywhere.” WRA HISTORY AND STRUCTURE History It takes passion, commitment, and vision to create an organization that can launch a global movement. In 1999, a small group of maternal health advocates—disappointed by the lack of progress in decreasing maternal deaths despite increased global attention at landmark conferences, inclusion of maternal health into the MDGs, and greater awareness on the part of funders, technocrats, and scholars—decided that it would take a global people’s movement to save women and newborns. The white ribbon was chosen as the name and unifying symbol for this diverse alliance of donors, UN Agencies, NGOs, PVOs, USAID Cooperating Agencies, and individuals because it symbolizes both mourning and hope in various cultures. Evaluation of the White Ribbon Alliance 1999–2007 6 USAID maternal health staff were among the first to recognize the potential of the WRA. The Agency assessed WRA’s objectives as supportive of its own maternal health objective and became the initial and principal ongoing funder of the WRA central organizational hub, the GS. Because WRA was an unincorporated entity and could not accept direct funding, USAID support was channeled through various projects with funds managed by a host organization that also provided an administrative home. Within six months of its founding, the GS was established at the NGO Networks for Health Project (Networks). The project’s mandate to create viable health and development networks was a perfect fit for WRA and served as its home from 1999 to 2004. Impressively, during this same time, national alliances were established in Indonesia, India, and Zambia. In 2000, USAID provided $59,262 over three years through the MEDS Project to assist WRA in developing a five-year strategic plan. According to those respondents who were aware of or involved in the process, this early planning was inclusive, transparent, and thorough. As part of this process, the informal, open-membership steering committee was replaced with a membership-nominated and -elected Decision-Making Committee (DMC). The DMC was tasked with selecting the organizational form for WRA. Through a slow and sometimes arduous process, consensus developed to incorporate as a 501(c) (3) not-for-profit organization. Once agreement was reached, the process of incorporating moved swiftly. In anticipation of the closure of Networks in 2004, WRA engaged in a methodical process to select its second institutional home. The Center for Development and Population Activities (CEDPA), through the Policy II Project, was chosen and served as WRA’s home until May 2006 when WRA became independent. Since that time, WRA contributes to the Health Policy Initiatives project at Constella/Futures International and rents space from the host organization. Structure The current organizational structure of the WRA is depicted in Figure 1, below. WRA is governed by an 11-member Board of Directors, elected by the membership for four-year terms. Two seats are reserved for NA representatives. Membership to the GS is free and open to all who espouse the WRA Mission, Vision, and Principles (Appendix E). NAs can charge membership dues as needed to cover administrative costs, but most have elected not to. Each individual, organizational, and NA member gets one vote. WRA currently can claim over 2,000 organizational and individual members, 15 NAs, 6 Indian State Alliances, and 21 Indonesian Provincial Alliances. WRA has also provided limited technical assistance to a local Alliance in Bhazong Province, China. Presently, three full-time staff, several masters-level interns, and many member volunteers carry out the work of the GS. Evaluation of the White Ribbon Alliance 1999–2007 7 Table 1. WRA Growth over Time Evaluation of the White Ribbon Alliance 1999–2007 8 Figure 1. Table 1 below outlines WRA growth over time. See also Table 2, Status and Importance of NAs, which provides more detailed information regarding NAs, including launch dates, current status, and maternal mortality ratio data. Table 1. WRA Growth over Time 1999 2000 2001 2002 2003 2004 2005 2006 2007 Sum Host 1999 NGO Networks (SAVE US) Æ Æ Æ Æ 2004 CEDPA Policy II Project Æ 2006 501(c)(3) Constella/ Futures HPI Project Æ Governance Structure 1999 Steer Com. (20-25 org. reps) Æ Æ Æ 2003 Decision￾Making Com. 2003 8-10) Æ Æ 2006 Board of Directors (11) Æ Mgmt (# of Staff) 1999 Coord. T Shaver (1) 2000 (1) 2001 (1) 2002 (2) 2003 (2) 2004 Director Shaver (2.5) 2005 (2.5) 2006 Exec Dir. Shaver (2.5) 2007 (3) 3 FTEs Table 1. WRA Growth over Time 1999 2000 2001 2002 2003 2004 2005 2006 2007 Sum Members # Orgs & 35 0 0 200 218 260 686 1670 2,025 2,025 Individuals # NAs 3 5 6 6 8 10 12 13 15 15 # State & Sum 26 Provincial # Emerging Sum 4 # Failed 4 # Local Sum 1 # Countries 5 14 14 25 32 36 70 84 91 91 with WRA Presence Evaluation of the White Ribbon Alliance 1999–2007 9 Evaluation of the White Ribbon Alliance 1999–2007 10 II. KEY FINDINGS WRA MAJOR STRENGTHS AND WEAKNESSES All of the stakeholders interviewed, regardless of their relationship to WRA, were asked two key questions: What would you say are the major strengths and weaknesses of the WRA Global Secretariat? Of the National Alliances? What follows is a compilation of responses received. We assessed the frequency with which main themes emerged and those expressed most often are recorded here. Of particular interest is the frequency with which respondents characterized certain strengths as potential weaknesses and visa versa, e.g., "Staff commitment is awe inspiring but may lead to burnout," "The alliance framework makes for less structured accountability but serves to empower national groups." GS Strengths Commitment Universally, respondents commented on how passionate and committed the GS leadership is to safe motherhood. This commitment has attracted members, volunteers, and in-kind contributions. The continuity of leadership throughout WRA’s history is cited as one indicator of that commitment. Leadership Style The leadership style of the GS staff, described as “leading from behind,” is credited with drawing in a wide circle of supporters from many different sectors. “There is a generosity that attracts the best of the best of the best.” “There is a special spirit associated with the WRA: something about their respect for women, their kindness, their lack of egotism.” GS staff is seen as putting aside its own agenda to work for safe motherhood. Many commented on the flexibility and even-handedness of the GS, not getting drawn into ideological struggles but playing the role of honest broker when conflicts arise. Respondents related that the GS respects differing opinions and works to reach consensus. “There is an absolute commitment to collaboration, transparency, and democracy as advocates for safe motherhood.” The NAs look at the GS as a model for how to build cohesive organizations in their own countries. Productivity There is resounding agreement on the impressive amount of work that has been accomplished by the GS with few staff and resources. In seven years, WRA has grown from a small group of committed individuals to a worldwide presence, transitioning from an idea to an independent not-for-profit. The GS has provided support to a growing number of emerging and established NAs and individual and organizational members in over 90 countries. WRA is seen as value for money. GS maximizes the use of existing funds while efficiently managing the time and talent of board members, interns, and volunteers. GS has been able to effectively utilize a significant amount of in-kind contributions, e.g., pro-bono legal work for incorporating. Alliance Model Many noted that the most fundamental strength of WRA is the model itself, as codified in WRA’s Mission, Vision, and Principles, because it is co-driven by the international community and country constituents and has a field focus. Open membership brings together diverse groups to interact and act— broadening discourse, promoting creativity, building energy, and reaping synergies. One respondent remarked that WRA “even allows mothers to be members!” Another, that small indigenous organizations are welcomed and have a voice. “The SM (safe motherhood) effort has been focused on technical details. WRA is one of the first and only organizations to say we need a broad-based people’s movement to save Evaluation of the White Ribbon Alliance 1999–2007 11 women’s lives.” “In the end, you need to mobilize the grassroots as well as the technocrats and politicians.” WRA is seen as able to reach out to constituents whom donors have rarely accessed, such as rural women’s groups and faith-based organizations, tapping into a lot of heretofore unused energy and talent. In addition, informing, engaging and empowering civil society increases the likelihood that change is sustainable, unlike projects that have foreign staff and defined life-spans. Horizontal Structure A commonly cited strength (and occasionally cited weakness) is WRA’s lack of hierarchy. The GS and NAs are held together by their mutual commitment to abide by the WRA Mission, Vision, and Principles that provide guidance on focus, structure, and operations, and by an Affiliation Agreement (Appendix F). The GS is characterized as respecting the independence of the NAs by playing a facilitative rather than directive role. The horizontal alliance model is strengthened when the GS promotes and facilitates NA capacity building by taking a back seat during regional conferences. “Regional meetings are actually run by people from the region, rather than by the Washington experts.” National Capacity Building and Facilitation The GS has been successful at nurturing and enabling NAs by providing technical assistance on organizational development, social mobilization and advocacy, goal setting, monitoring and evaluation, fundraising, proposal writing, and use of media. It also provides logistical support (white ribbons, publications, reports, “WRA Members Matter” newsletter, folders, etc.). NAs are kept informed about recent activities in the field of maternal and newborn health through technical updates. “They are great at capacity building because they see those at the grassroots as experts who can benefit from some additional skills.” The GS also fosters collaboration between countries by facilitating South-to-South TA and assisting NAs with organizing and holding regional workshops. This focused national capacity￾building is seen by many as a unique contribution. “Capacity-building is such an important need at this time in the safe motherhood movement. Unfortunately, no one wants to pay for building this kind of social capital.” Through its national work, WRA has identified and promoted a number of “rising stars” who are active at the global level, including members of the WRA Board of Directors and on the Partnership for Maternal, Newborn and Child Health Advocacy Working Group. GS Weaknesses Under-Resourced Without exception, respondents felt that the GS is underfunded and understaffed. Staff themselves related that they cannot always respond as needed—quickly and forcefully—to requests for TA from members or to weigh-in on global policy issues; windows of opportunity have been missed. Stakeholder suggestions to remedy this reality included: hire staff with fundraising, marketing, M&E, and organizational development expertise; contract out for management services and reshuffle responsibilities of existing staff; expand staff with two regional coordinators to cover countries that do not have established or emerging NAs in regions with the highest MMR (SSAfrica and South Asia); build a Board with a broader skill-set. Obviously, most suggestions require additional funds at a time when predictable operational funds are at question. There was also wide agreement that lack of GS funds earmarked for NAs inhibits the growth of country-level alliances and advocacy. Personality-Driven Another frequently shared concern was that the WRA survives and flourishes, to some extent, because of its leadership. Some wonder what will happen when the present Executive Director steps down, and recommend that succession planning be part of the next strategic plan. Evaluation of the White Ribbon Alliance 1999–2007 12 Alliance Model Along with the strengths noted above, stakeholders identified challenges associated with the alliance structure. WRA must help members transcend local needs for the greater good of the alliance, create a sense of engagement and shared purpose, position the alliance to take advantage of social trends, and maintain its horizontal structure while moving the organization forward. Specific to the last challenge, WRA’s loose structure allows for a more egalitarian relationship between the GS and the NAs, but in cases where the NA Coordinator is ineffectual, the GS has no leverage to replace weak leadership. In addition, the GS will always need support for operations and “funding is difficult to attract for WRA’s ‘process-focused’ organizational style.” Management Style The lack of standard, enforced operating procedures vis-à-vis the NAs was seen by some as detrimental to the WRA now that it is an independent organization and will have to count and count-on national-level efforts to show impact. “The fact that they (GS) are willing to and comfortable with standing in the background and allowing things to take a long time to germinate is a strength, but also a weakness. They need to step forward and push a little.” Monitoring and Evaluation Many responders related that WRA monitoring and evaluation is weak, a weakness acknowledged by GS staff. The early developmental phase, 1999–2006, required attention to mobilization and there was neither the funding nor staff to carryout rigorous monitoring and evaluation with baselines and follow-on data gathering. Now WRA is in a new phase and will need to build more robust information and tracking systems to convince donors of their value added. Baselines need to be taken. That said, “Measuring the impact of advocacy on safe motherhood is problematic for every organization that does this work.” Western-Driven Although not shared by the majority of stakeholders, the perception that the WRA is a USAID-funded project with Western-driven priorities was occasionally raised. Others felt that European donors assume USAID is “taking care of its own” and are less inclined to fund. Many responders believed this would change as the GS increases its efforts to diversify funding. The GS’s location in Washington D.C. was seen as both a strength and weakness. Some of the NAs would like to see it located in a developing country. NA Strengths Identifying the strengths and weaknesses of the WRA NAs is central to understanding the promise of the WRA. One of the difficulties with making a judgment on the effectiveness and vitality of the 15 NAs is their extreme variability. The GS has developed and disseminated guidelines and provided technical assistance to emerging NAs, but there is a lack of research on why some NAs flourish while others fail. Social Mobilization As is evident from the WRA Mission, Vision, and Principles, robust NAs are seen as key to building the global “tidal wave” necessary to save the lives of women and newborns. This assignment of importance to national-level activity was echoed by many stakeholders interviewed. Time and again the team heard interviewees express frustration at the inability of well-resourced maternal health projects, highly skilled technocrats and scholars, and venerable organizations—such as the Inter-Agency Group (IAG) for Safe Motherhood, now folded into the Partnership for Maternal, Newborn and Child Health—to create the policy and implementation environment necessary to protect those most vulnerable. Strong NAs are characterized as ones that successfully build support for zero tolerance for unnecessary maternal death and disability through advocacy at the top and grassroots action at the base. Getting the message out and Evaluation of the White Ribbon Alliance 1999–2007 13 mobilizing champions for safe motherhood from marginalized communities and rural areas is seen as a major strength. “If WRA weren’t around, no one else would reach these groups.” Massive marches and events have been organized by volunteers with few resources. Events are often chaired or led by top government officials or pop culture icons—singers, actors, sports stars. Alliance Model Successful NAs are seen as uniquely inclusive organizations, able to bring together policymakers, providers, educators, NGOs, activists, and community members on an equal footing. “Transparent” and “democratic” were terms frequently used to describe the processes and operational style of the alliances. This focus on providing a forum for all seems to flow from the commitment made to the WRA Mission, Vision, and Principles and the example provided by the GS. NAs have the possibility of combining scarce resources and reducing duplication of effort. And because members come from many different sectors, initiatives often reflect this diversity. One example is a project in Tanzania, where five midwives and one doctor were trained in filmmaking and produced a 14-minute video, “Play Your Part.” The film has been viewed across the globe, influencing policymakers and powerbrokers. Local ideas can be tried and then replicated throughout the WRA system, if successful. This is in contrast to the more proprietary approach often found among competing CAs. Effective Advocacy Many responders are amazed at the traction NA events and messaging has had with top policymakers. “NAs can put safe motherhood on the national agenda with more authority and urgency than an external agency can.” NAs are seen as “translators” of technical information, making it accessible to local policymakers and activists. “WRA doesn’t just disseminate information; it diffuses it throughout the various constituencies.” “The National Alliance here has been able to translate global technical knowledge into grassroots action.” In Tanzania, Burkina Faso, and India this has led to progressive policy changes and increases in funding for maternal health. The ability of NAs to use mass media was commonly referenced as another reason for their effective advocacy. NA events have received radio, TV, and newspaper coverage. Some NAs host radio shows and write weekly newspaper columns. Trustworthy When national political leaders were questioned, there was agreement that WRA builds trust because it is not about selling itself as an organization but about an issue, a single issue: Safe motherhood. South-to-South Technical Assistance NAs are seen as powerful vehicles for South to South cooperation, collaboration, and sharing of lessons learned. There is a sense of pride and ownership among the country-based stakeholders interviewed. NAs see themselves as self-directed, agentic organizations responding to local needs and opportunities. At the same time, they acknowledge and value support from the Global Secretariat, and see affiliation with a global movement as a real advantage. Affiliation brings increased credence for in-country efforts and access to resources, and, as was often shared, provides inspiration. Productivity and Commitment Interviewees were impressed with the amount of outreach, education, and advocacy that has been accomplished with so little money. The regional conferences, organized by the NAs with the assistance of the GS, were uniformly characterized as well-organized, impressive events featuring local and regional talent. NA Coordinators are described as extremely dedicated. Most are volunteers. Evaluation of the White Ribbon Alliance 1999–2007 14 NA Weaknesses Most stakeholders preferred to use the term “challenges” when asked about perceived weaknesses of the NA model or individual NAs. Under-Resourced By far, the most referenced challenge was the lack of resources available: the absence of a predictable operational budget; a lack of funding to implement action plans; and a lack of staff to manage, track and monitor activities. NA’s are generally “house guests” in one of the alliance members’ offices, with these organizations often providing all or a percentage of the Coordinator’s time. Some Coordinators have been able to attract small amounts of donor funding to cover salary, while others do their NA work as volunteers in addition to full-time jobs. Coordinators related that it often takes a couple of years to find a suitable host that will support the NA. All 15 NAs are at the beginning stages of their organizational lives and will need financial assistance until they mature into locally sustainable alliances. Lack of Planning A corollary challenge for the NAs is trying to undertake long-term planning without secure funding. “It is hard to plan ahead when there is no money. Activities are randomly timed as opposed to regularly scheduled.” This lack of systematic planning and follow through was seen by some as NAs focusing on “one-off” events with no results. “You can’t just have a march with nothing to show at the end of the day.” Responses from WRA leaders made it clear that they do not confuse events with impact and that they understand that mobilizing civil society is a difficult and long-term process. Fundraising Many country-level stakeholders see fundraising for the NAs as an important function of the GS. Because NGO and PVO members of the NAs are also looking for institutional funds for their own organizations, it can become a contentious issue within an alliance. “It would be best if NA Coordinators could be full-time with their salaries paid for by the GS.” A minority of respondents believed that when outside money was introduced in the hopes of strengthening an NA, country commitment was stifled. “You can’t gin-up country commitment from Washington.” Most felt that once countries had shown commitment and initiative, providing funding for the salaries of NA Coordinators would accelerate country-level action substantially. Personality-Driven Several NAs that started out with a great deal of support and fanfare have faltered. One reason put forth on why some NAs fail and others flourish rests on the strengths and weaknesses of the leadership—that the NAs are personality-driven. Some former Coordinators were seen as unable to delegate authority, be inclusive, or nurture the leadership potential of other members, so that when they left the post, the organization fell dormant. In a country with weak leadership, the NA may continue to exist but do little more than host occasional meetings. M&E NAs have been weak at tracking progress and outcomes, especially at the local levels. Most cite lack of staff time available for monitoring and evaluation (M&E) as the reason. Now that the GS has made reporting part of the Affiliation Agreement, more information should flow to the GS. Respondents felt this was vital in order for WRA to attract future funding and be responsive to funders. The question that was asked serial times: What’s the best way to measure the outcomes of social mobilization? There doesn’t seem to be a consensus. Evaluation of the White Ribbon Alliance 1999–2007 15 WRA OUTCOMES and ACHIEVEMENTS Since its founding in 1999, WRA has grown exponentially yet never wavered from its original intent to be “an international coalition of individuals and organizations formed to promote increased public awareness of the need to make pregnancy and childbirth safe for all women…” Over the last eight years, WRA has heightened attention to safe motherhood by building alliances, strengthening capacity, influencing policies, harnessing resources, and inspiring action. These activities also support USAID’s maternal health objective. What follows is a brief overview of select initiatives and an assessment of their results. Building Alliances Global and Regional At the global level, WRA has been very effective at building alliances with diverse organizations. “Coordination has been their strength.” WRA has engaged multilateral and bilateral donors, government ministries, PVOs, NGOs, USAID Cooperating Agencies (CAs), Global Partnerships, and Foundations as well as film producers, journalists, and other individuals from over 90 countries to join forces in calling for an end to needless maternal and neonatal death and disability. “WRA provides a forum for people to channel their passion and energy around Safe Motherhood.” WRA participated on the Steering Committee of the Partnership for Safe Motherhood and Newborn Health, which merged in the Partnership for Maternal, Newborn, and Child Health (PMNCH) in 2005. WRA currently serves on both the Advocacy and the Country Support Working Groups of PMNCH. It is a member of the CORE group, and WRA staff provide expert guidance on advocacy and social mobilization at international meetings. WRA has recently executed a Memorandum of Cooperation with the International Confederation of Midwives to partner on capacity building at the country level. At the Women Deliver conference in London in October 2007, WRA members will participate on several panels and WRA will sponsor the “Life Stories” exhibition. Quilt panels, memorializing women who have died in childbirth, will be suspended in a labyrinth, with accompanying testimonials of maternal deaths in writing, video, and audio. The GS has hosted several global conferences and assisted NAs with convening four Regional Workshops that have brought together safe motherhood advocates from across those regions. National and Regional Alliances The GS has been assisting in the formation of NAs since its inception. Capacity-building workshops, field guides, and individual TA have provided national stakeholders with guidance on, inter alia: how to build, structure, and govern an NA; whether or not to incorporate; how to undertake a strategic planning process that includes resources needed and how to capture and assess results; what is social mobilization; what is advocacy; how to write a proposal; how to prepare a newsletter; and how to use the media. “The Global Secretariat has been extremely instrumental in indicating potential funding opportunities, avenues to build and foster partnerships and networks, and sharing of information and ideas through regular Communication.” Regional meetings have helped to create informal regional alliances with South-to￾South TA from India to Nepal, Bangladesh, Indonesia and Philippines; Burkina Faso to West Africa; Malawi to Zambia and Tanzania; and Indonesia to South Asia. The GS has provided small amounts of money to some of the NAs and facilitated identifying and securing outside funding for others to attend international conferences and undertake dissemination activities. Most NAs responded that additional funding would allow them to build stronger alliances. “Certainly, additional discretionary funding or funding specifically targeted to support country Alliances would give them (GS) a lot more ability to fill gaps and support nascent organizations.” Evaluation of the White Ribbon Alliance 1999–2007 16 NAs have used the media to build their memberships: the Weekend Nation, a widely circulated newspaper in Malawi, has a column on safe motherhood, and in South Africa, the WRA is working with the TV show Soul City to promote safe motherhood messages. In another NA, members conducted a safe motherhood journalists’ update and competition that generated over 40 articles and radio and TV spots on maternal health. Table 2, below, outlines the current status of the WRA NAs. WRA is clearly reaching those countries where reducing maternal deaths would significantly alter the global statistics and thus accelerate reaching the MDG goal for reducing maternal deaths: Reduce the maternal mortality ratio by three-quarters between 1990 and 2015. Active NA countries contribute 48 percent of worldwide maternal deaths. If the NAs in Nigeria and Ethiopia were reactivated, that figure would increase to nearly 60 percent Table 2. Status and Importance of National Alliances Official Count Country # Members/ Orgs. # Maternal Deaths MMR4 WRA Status 1 Bangladesh 150 16,000 380 Active since 2005 2 Bolivia 30 1,100 420 Emerging; ready to sign affiliation agreement (2007) 3 Burkina Faso 540 5,400 1000 Active since 2002 Bhazong 4 (11,000) (56) Provincial Alliance only; limited TA Province provided by WRA; does not meet (China) national affiliation agreement requirements 4 Dominican 40 300 150 Active since 2004 Republic Ethiopia 147 24,000 850 Launched 2003; does not currently meet affiliation agreement requirements; no longer WRA, effective 2007 Ghana 15 3,500 540 Launched 2000; does not currently meet affiliation agreement requirements; no longer WRA, effective 2007 5 India National 101 136,000 540 Active at national level since 1999 & 6 State and in 6 states: AP (2001); Rajasthan (2001); Maharastra (2007); MP (2001); Orissa (2003); UP (2007); W. Bengal not officially launched, active since 2005 6 Indonesia 60 10,000 230 Active since 1999 National & 20 Provincial 7 Liberia 7 1,200 760 Emerging; ready to sign affiliation agreement (2007) 8 Malawi 400 9,300 1800 Active since 2002 4 UNICEF, UNFPA, WHO. (2004). Maternal mortality in 2000: estimates developed by WHO, UNICEF and UNFPA. Geneva: WHO. http://www.who.int/reproductive-health/publications/maternal_mortality_2000/ executive_summary.html Evaluation of the White Ribbon Alliance 1999–2007 17 Official Count Country # Members/ Orgs. # Maternal Deaths MMR4 WRA Status 9 Nepal 449 6,000 740 Active since 1999 Nigeria 25 37,000 800 Launched 2003; does not currently meet affiliation agreement requirements; no longer WRA, effective 2007 10 Pakistan 311 26,000 500 Active since 2007 11 South Africa 259 2,600 230 Active since 2004 12 Tanzania 600 21,000 1500 Active since 2004 13 Uganda 15 10,000 880 Emerging; ready to sign affiliation agreement (2007) 14 Yemen 50 5,300 570 Emerging; ready to sign affiliation agreement (2007) 15 Zambia 35 3,300 750 Active since 2001 Total Number of Maternal 253,500 48% of all Maternal Deaths Worldwide Deaths in Active NAs Table 2. Status and Importance of National Alliances ### MMRs ≥ 500 in Active NA Countries Active NA Countries with Highest Number of Maternal Deaths Strengthening capacity An important focus for WRA is building capacity of the NAs and its developing country members. Beyond individual technical assistance to emerging and established NAs, the GS has assisted NAs with organizing and hosting four Capacity Building Workshops in Zambia (2003), Indonesia (2005), India (2005) and Malawi (2006), and has produced three Field Guides: • Awareness, Mobilization, and Action for Safe Motherhood, 2000 • Saving Mothers’ Lives: What Works, 2002 • Building, Maintaining, and Sustaining National White Ribbon Alliances, 2006 To promote information equity about safe motherhood and keep members informed, WRA has utilized varied media: • A listserv with 2,100 subscribers • A website that receives 12,000 hits per month • A quarterly newsletter, “WRA Members Matter” Several NAs are educating community members on their health entitlements. In India, the Orissa State Alliance builds on this training by facilitating interchanges between empowered community members and local healthcare provides and politicians. Influencing policies WRA efforts have influenced country-level maternal health policies and financial outlays, contributed to the policy dialogue, and recruited champions for safe motherhood. Select key results: • The Government of India designated April 11 as “National Safe Motherhood Day.” Evaluation of the White Ribbon Alliance 1999–2007 18 • The Government of India now allows Auxiliary Nurse Midwives to perform life saving skills. • Life Saving Skills protocols and guidelines were produced under the guidance of the WRA India. • The Government of Tanzania is committed to hiring and posting all graduates of medical and nursing schools in order to address the healthcare provider shortage. • The MOH in Tanzania has adopted and is promulgating the Home Based Life Saving Skills program. • The use of Maternal and Neonatal verbal Death Audits to detect system failure to protect women’s lives in India has led to greater awareness by community members and government officials of needed policy changes to ensure skilled attendance at birth. • The Government of Burkina Faso has increased its health budget by 6 percent. • WRAs in Tanzania, Zambia, and Malawi assisted with the development of the African Road Map to accelerate meeting the Millennium Development Goals (MDGs). • WRAs in India, Indonesia, Malawi, Tanzania, and Zambia have undertaken nation-wide campaigns to inform the public of health service entitlements and to strengthen government provision of skilled attendance at birth through “Social Watch” activities. • In Malawi, there is collaboration with the Ministry of Health and Population and Ministry of Women and Community Development to increase resource allocation for MNH services and advocacy for community midwives to replace TBAs. • WRA Tanzania is a core member on PMNCH/Tanzania Steering Committee to reduce MMR and IMR. • Statements of commitment to safe motherhood have been made by high-level political leaders: Presidents, First Ladies, Speakers of the Parliament, Ministers of Health, Directors of MCH Divisions, MPs; religious leaders, Village Elders, etc. • The First Ladies of Tanzania and Indonesia have become WRA Patrons. Harnessing Resources WRA has been able to attract and leverage an impressive amount of resources. These successes are detailed in the Operations Section under Resource Mobilization. Inspiring Action WRA has organized high-profile public events that have catalyzed action: • International Safe Motherhood Contests, with recipients receiving awards at the Global Health Council Annual Meeting, Washington D.C. 1999–2003, 2005 • March on the Taj Mahal, Agra, India, 2002 • Safe Motherhood Media Campaign, Zambia, 2003 • Advocacy for Safe Motherhood policy implementation, India, 2005 • Male Involvement Traveling Theater production, Burkina Faso, 2005 • White Ribbon Day Marches, Tanzania, 2006 and 2007 • Debut Showing of “Play Your Part,” Tanzania, 2006 • Mother’s Day Awareness Campaigns, USA, 2006 and 2007 • March on Pita Putih Day, Indonesia, 2007 Evaluation of the White Ribbon Alliance 1999–2007 19 • Various Quilt Projects, including unveiling at upcoming Women Deliver Conference, UK, 2007 • Launch of UK NA, October 2007 WRA estimates that over 1,850,000 people have been reached by activities in India and 1,250,000 more in Tanzania. Contributions to USAID SO2 Intermediate Results5 and Pathways6 As previously noted, it was difficult for the evaluators to tease outputs from the annual reports and work plans of WRA’s host organizations and peg these to specific SO2 and GH/HIDN Pathways. As became evident, SO2 represented only a minor focus of these projects. In most cases, the entire work plan and annual reporting for SO2 funding comprised 1–2 pages in 100+ page documents. WRA’s activities were covered in a couple of paragraphs within those pages. Recently, in support of the objectives of the ACCESS project, the White Ribbon Alliance in India (WRAI) has undertaken an initiative in Jharkhand State, India to test whether introducing a set of safe motherhood interventions at one time improves their use in communities, particularly the increased use of Skilled Birth Attendants at birth. Some targeted work on the maternal health pathways was done in FY06 and FY07. In October 2006, the GS sponsored a five-day WRA Regional Workshop in Lilongwe, Malawi, for members of the Malawi, South Africa, Tanzania, and Zambia National Alliances. The objectives of the workshop were to: • Provide technical updates on key maternal and newborn health (MNH) interventions • Share relevant resources and tools • Select a focus intervention from one of the USAID Pathways for each participating NA • Develop Action Plans to execute the intervention with monitoring and evaluation components • Devise approaches to share Action Plans and outcomes with the WRA broader membership. The focus areas selected were: Malawi—Focused Antenatal Care; South Africa—Post-Partum Hemorrhage Prevention; Tanzania—Availability of Skilled Birth Attendants; and, Zambia—Fistula Prevention and Reintegration. Each NA developed an Action Plan with goals, objectives, activities, and a monitoring and evaluation plan. Reporting will begin in the fall of 2007. Please see Appendix G for GS Work Plan Outputs for FY04 through FY07 and Appendix H for Highlights of Major Coordinated Events and Publications. 5 SO2 Intermediate Results: IR1. Global leadership for maternal and neonatal health and nutrition programs and policies strengthened IR2. Preparation for childbirth improved IR3. Safe delivery and postpartum and newborn care improved IR4. Management of obstetric complications improved 6 Pathways: 1. Focused Antenatal Care 2. Skilled Birth Attendants 3. Newborn Care 4. Post-Partum Hemorrhage Prevention 5. Fistula Evaluation of the White Ribbon Alliance 1999–2007 20 Output Quality Materials produced and disseminated by WRA, based on review by the evaluators and opinions of stakeholders, have been well done and appropriately tailored for the target audience. Most characterize the website as user friendly. However, strategic packaging of information for purposes of fundraising and advocacy has been uneven and could be improved. A sterling example of effective packaging is the “I Want to Live” advocacy kits for media representatives and legislators produced by WRAI with UNICEF funding. Sustainability Key factors that auger well for sustainability are the commitment of WRA leaders, the degree of volunteerism at the GS and NA levels, the positive relationships with governments and donors, and the broad-based, multisectoral membership at the country level (Levine 2007). Gifts of time, energy, and expertise have been given with little or no compensation. Another important factor is that several of the NAs were in existence before affiliating with the WRA in the form of indigenous organizations that came together around the issues of maternal and newborn health, e.g., Pakistan and Bolivia. They are homegrown and independent. Leaders of these groups know the local political and bureaucratic environment and, in many cases, are acquainted with key government decision-makers. They also understand how civil society engagement can be fostered to affect local governments and donors. Early on, GS assisted with the launch of a few NAs by providing modest start-up funding. What became evident was that without ongoing funding for a Coordinator, it is very difficult for an Alliance to gain a foothold and grow. Absent this predictable funding, it seems vital that motivated in-country individuals and organizations commit to providing a stable home and salary support for NA staff. Momentous change must build nearly irreversible momentum long before becoming the dominant social phenomenon. Will WRA create a movement that reaches the “tipping point” for sustainability? We argue that it is too early to tell as WRA has only been an independent organization for 14 months. As one interviewee said, “WRA has sparked a movement that has not peaked.” Certainly, the ingredients are in place for growth in size and impact, but WRA will continue to need core funding to sustain its operations for the foreseeable future. Optimistically, USAID had the vision to provide this funding over the past eight years and now other donors are finding value in the work that WRA is doing. Evaluation of the White Ribbon Alliance 1999–2007 21 INDIA CASE STUDY Each year over 130,000 Indian women die needlessly during pregnancy and childbirth, accounting for 26 percent of all maternal deaths worldwide. Well-funded Government of India (GOI) programs established to decrease maternal mortality have made little, if any, progress (Shiffman 2007). The stakes are high, the solutions elusive. The White Ribbon Alliance India (WRAI) was formed in 1999 to save mothers’ and newborn’s lives by promoting policy change at the top and mobilizing communities at the grassroots. In just 6 years, WRAI has become a dynamic enabler, harnessing the energy and resources of over 80 organizational members at the national level and thousands of individuals in the 6 State Alliances. WRAI has made impressive contributions to safe motherhood in India and globally through example by: increasing the visibility and importance of maternal health throughout the country; forming close working relationships with government officials, donors, and the media; educating civil society on its healthcare entitlements and empowering it to hold government accountable; advocating for and realizing significant policy changes in support of safe motherhood; and marshaling the technical expertise of the safe motherhood community to produce life-saving protocols and guidelines. How was WRAI able to accomplish so much as a low-budget, largely volunteer organization when other well-funded, well-positioned groups had failed? Three key elements of WRAI seem to have made the difference: structure, strategies, and leadership. WRAI is structured as a loose unregistered alliance with open membership. It has attracted a diverse set of stakeholders, including representatives from UN Agencies, bilateral donor organizations, foundations, the NGO community, USAID Cooperating Agencies, and individual members. The only requirement for admission is a belief in the mission and vision. WRAI’s reach stretches from the halls of Parliament to the grassroots. Alliance processes are democratic and transparent. The WRAI Secretariat is housed in a member organization selected by the membership, currently CEDPA, which also covers the Coordinator’s salary and provides administrative support. This structure has fostered collaboration and resource sharing while reducing duplication of effort and competition. One government official remarked, “WRAI is trusted because it is not about itself but about the issue of saving women’s lives.” WRAI’s main strategy is to utilize social mobilization techniques to build a peoples’ movement. Large public events are used to mobilize stakeholders, create a sense of shared identity, and catalyze advocacy and action. Building the capacity of this constituency is accomplished through information sharing and advocacy training. WRAI estimates that it has reached over 1.8 million Indians with events, education, and empowerment efforts. In 2002, WRAI received world-wide media attention for its march to the Taj Mahal—a memorial built for a beloved wife lost in childbirth. Several thousand people participated, including a leading Parliamentarian. This dramatic event was followed by an intensive lobbying effort by WRAI members that resulted in the GOI creating an official government holiday, National Safe Motherhood Day, on April 11. WRAI also successfully pushed for policy changes at the national level to allow Auxiliary Nurse Midwives and Nurses to practice life-saving skills and administer critical drugs. WRAI has been asked to assist with the training of these providers using the protocols and training manuals that the alliance developed. In four districts in Orissa state, WRAI is using checklists created for use by elected representatives and civil society organizations to track the implementation of health programs as “social watch” advocacy tools. The third vital element of WRAI’s success is its strong and participatory leadership. The WRAI Coordinator has been described as a visionary yet unassuming leader who is able to building commitment and capacity to protect mothers and newborns. Under her leadership, WRAI has grown in number and influence, and she is now recognized as a global leader for maternal health. In the Millennium Development Goals, the global community committed to significantly decreasing maternal and newborn deaths by 2015. Saving women and newborns in India is fundamental to achieving this goal. WRAI is well positioned to make a significant contribution to realizing that global commitment. Evaluation of the White Ribbon Alliance 1999–2007 22 WRA OPERATIONS GS and NA Management and Relationship Model In keeping with its grassroots advocacy vision and shared ownership of responsibility, the WRA is not a top heavy or top down organization. Instead, imagine a wheel with spokes. The GS serves as the hub with the NAs the spokes. Both are central to the functioning of the wheel, without either the wheel cannot turn. GS Functions The GS maintains the big global picture and helps to sustain the mission, vision and principles that bind the membership. The GS supports, maintains, and expands individual, organizational, and NA membership; participates as a vital member of global partnerships; adapts and disseminates technical, financial, management, and organizational information; provides fundraising and proposal development support to NAs; secures diversified funding sources to sustain GS operations; and serves as a central repository for monitoring data and for reporting to various constituents and funders. GS Structure and Staffing Current staffing is equivalent to three FTEs. Volunteer labor represents another 1+ FTE. WRA has an Executive Director accountable to the BOD and membership; a Safe Motherhood Advisor and a Program Manager, both supervised by the Executive Director but also accountable to the membership; and interns and volunteers who are supervised by the Safe Motherhood Advisor. In brief, the Executive Director liaises with the Board and is chiefly responsible for global external relations and fundraising; the Program Manager takes primary responsibility for maintaining finances and providing administrative support; and the Safe Motherhood Advisor provides technical support to the NAs. However, staff wear multiple hats. Plans are currently underway to recruit a Financial Manager. Given the current workload, staff size is small. What was clear in our discussions with interviewees, including host organizations, is that the WRA GS has achieved more than anyone could have imagined given its small staff and limited funding. Not one individual interviewed felt that the staffing for the GS or NAs is adequate for the enormous task at hand, particularly to satisfy the demand for national, state and local alliance formation. Recommendations for additional staffing varied but included the following skill sets: 1) fundraising; 2) strategic planning; 3) monitoring and evaluation; 4) program and membership support; 5) deputy support to Executive Director; and 4) financial management. GS Articulation with Host Organizations Past and current hosting organizations uniformly felt that WRA’s mandate dovetailed nicely or added value to the work of the organization and project within which it was housed. All expressed an excellent working relationship with what is now the Executive Director of WRA. It was felt that WRA contributed in a regular and timely manner to work planning and results reporting. NA Structure and Staffing Since its inception, WRA GS has accepted individual and organizational members based on interest. Affiliation arrangements have ranged from formal to loose in the early years. Because developing and sustaining alliances takes much more than interest, National Alliance Affiliation Agreements were recently formalized, laying out specific rights, requirements, and responsibilities for potential alliance affiliates. At a minimum, an applicant for alliance status must include a multisectoral group of at least five members comprising individuals, organizations, government entities and the donor community; must confirm acceptance of the WRA’s mission, vision and principles; and must agree to contribute to documentation (monitoring and evaluation) of successes and lessons learned. NAs self-determine their Evaluation of the White Ribbon Alliance 1999–2007 23 structure, decision-making mechanisms, communication channels and whether they will become legally registered as an independent organization or whether they will adopt a different governance model (e.g., simple affiliation, lead partner, general contractor, joint venture, secretariat, and cluster). This information and steps necessary to becoming an alliance are found in the field guide prepared by the GS, “Building, Maintaining and Sustaining National White Ribbon Alliances.” The GS supports NAs with other helpful tools, including: a fund raising guide; useful strategic planning and advocacy documents; information on how to link with other NAs; technical materials; the WRA newsletter, WRA Members Matter; and a copy of WRA’s Monitoring System, “Tracking and Sharing Results.” NA leaders interviewed or responding via questionnaire related that funding for NA staff was meager or nonexistent and felt a predictable source of funding would allow NAs to increase advocacy efforts substantially. Financial Management Both obtaining and portraying accurate historical financial data for this evaluation has been challenging. This is due in part to: 1) WRA not taking control of its financial reporting until May 2006 on becoming a 501(c)(3); 2) WRA reporting to its Board on a calendar year basis; and 3) USAID FY obligations information controlled by the hosting organizations and not always available to WRA. Therefore, yearly obligations may be a mix of actual obligation and expenditure information. GS Obligations Including anticipated FY07 obligations, USAID has provided $3,644,072 in funding over an eight-year period; $2,424,322 is attributable to G/HIDN SO2 funds for WRA operations, the remainder coming from other USAID sources: WRA’s subcontract with the ACCESS Project, HPI non-SO2 funds, MEDS funds for strategic planning, field support from the mission in Ethiopia for work in prevention of mother to child transmission of HIV (PMTCT), and an anticipated FY07 obligation from the ANE Bureau (see Appendix I, Funding Summary). GS Expenditures WRA maintains several budgets: project budgets to track individually funded activities against the funding periods set by respective donors and a calendar year organizational budget presented to and approved by the Board. WRA presented its first calendar year budget to the Board in 2007. Figure 3 breaks down WRA’s audited expenditures for May 2006 through December 2006, the first audited period, into major categories. Seventy-two percent of expenditures went to providing technical assistance to the membership and NAs, 27 percent to 501(c) (3) start up and management, and 1 percent to fundraising. Evaluation of the White Ribbon Alliance 1999–2007 24 2006 Expenses by Category Figure 2. Evaluation of the White Ribbon Alliance 1999–2007 25 Maternal Health Programs ($223,249) Organizational Start-Up and Management ($84,101) Fundraising ($3,216) We were not able to track historical financial expenditure data when WRA was situated within NGO Networks and POLICY II. What we can say is that the GS expended the total monies reserved for WRA activities on an annual basis, reporting to the host. The WRA reports its expenditure information to its project funding sources, the largest of which is currently HPI.7 Of the SO2 FY06 obligation of $500,000,8 WRA has expended approximately $414,467 through June 30, 2007, leaving an unexpended balance of $85,533. The average monthly burn-rate is $31,882. A 2007 organizational budget approved by the Board in May of this year projects revenues from all sources of $1,177,835 for the calendar year, which will cover projected expenditures of $1,139,487 and $38,350 to be contributed to unrestricted net assets for the year. Its current provisional indirect cost rate (G&A) is 35 percent.9 A five percent fee is charged on the bottom line. NA Funding We were unable to obtain complete financial data for all of the NAs, as they operate independently. However, we did hear directly from the NAs that most operate on a shoestring, with much of the work being carried out by volunteers. More complete financial data for NAs will be tracked by the GS from 2007 forward and will provide useful additional information to complement that of the GS. 7 Expenditure information is reported in four key areas: WRA advocacy (raising awareness), WRA technical assistance to NAs, maternal health pathways, and monitoring and evaluation. 8 Year 1 of Task Order 1 covers the period June 2006 through September 30, 2007. 9 The 2007 budget uses an estimated rate of 30 percent. Audited records for 2006 confirm a contribution to unrestricted net assets of $68,368 and an actual indirect rate of 38 percent. Resource Mobilization From the beginning, WRA has received in-kind contributions from volunteers, interns, technical experts, and partner organizations, but these were not monetized and tracked until 2005. In anticipation of independent entity status, WRA turned greater attention in 2005 to fundraising, developing a fundraising matrix and plan as a management tool to track funding opportunities.10 The ability of WRA as a small organization to attract funding outside of USAID G/HIDN has been impressive. Figure 4 and the following tables delineate sources of non-U.S. government funding, sources of direct funding to NAs, and the proportion that non-USG funding represents since 2005. Table 3. Non-US Government Funds Year Source of Funding Amount 2005 Volunteer and pro bono labor $ 117,797 UNFPA $ 50,000 2006 DFID $ 103,290 Volunteer and pro bono labor $ 86,147 Individual/private donors $ 32,076 2007 UNFPA $ 197,000 World Bank $ 100,000 Individual/private donors $ 13,638 TOTAL $ 699,948 Table 4. Direct Funding to National Alliances Year Source of Funding Amount Global Fund for Women for Bali $ 20,000 Conference Bali Conference (multiple) $ 50,000 See Table 4 2005 UNFPA - Ethiopia $ 7,000 Multiple - Tanzania $ 110,000 2006 PMNCH - Bangladesh $ 10,000 USAID field support - Tanzania $ 150,000 TOTAL $ 347,000 10 Some of the sources from whom the WRA has sought funding include: USAID projects, DFID, UNFPA, WB, Big Lottery Fund, Gates, Johnson & Johnson, Northwestern Med Center, and Generous Adventures. The WRA also seeks support from individual donors, via events such as a fundraising dinner that raised $2,200. Evaluation of the White Ribbon Alliance 1999–2007 26 Figure 3. WRA Funding 1999–2007 $- $200,000 $400,000 $600,000 $800,000 $1,000,000 $1,200,000 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year Obligated Amount Funding Directly to National Alliances Non-USG Funds to Global Secretariat USAID Funding to Global Secretariat Since FY 05, non-USG funding represents 26 percent of total funding to the GS funding. WRA established a goal of increasing this to 30 percent during calendar year 2007. If current negotiations with UNFPA are concluded and monies received during the calendar year, the share of non-USG funds will jump to 49 percent. Monitoring and Evaluation Evaluating the success of policy and advocacy initiatives is challenging. According to Heather Weiss, Director of The Evaluation Exchange, a series produced by the Harvard Family Research Project,11 “advocacy has long been one of these ‘hard to measure’ activities. Until very recently, few resources existed to guide evaluation in this area. In just the last year, however, advocacy evaluation has become a burgeoning field.” To this end, Harvard produced, in the spring of 2007, an issue of The Evaluation Exchange that focuses on advocacy and policy change evaluations. The evaluators spent some time reviewing this issue and the materials referenced. It was pointed out that “in addition to informing policy, much advocacy work has a larger set of outcomes in mind (maternal mortality reduction in this case) as advocates try to sustain influence in the larger policy process. For example, in addition to interacting directly with policymakers, advocates might build coalitions with other organizations or develop relationships with journalists and editorial boards (as has been the case with WRA). Or they might aim to develop a network of community-based advocates who become active spokespersons (precisely what 11 Website is http://www.gse.harvard.edu/hfrp/eval.html Evaluation of the White Ribbon Alliance 1999–2007 27 WRA has done).” Another thing pointed out by the issue is that “most advocacy organizations are small both in size and their capacity to manage evaluation (also the case for WRA).”12 Given this backdrop, WRA has obviously not been the only organization that has faced challenges in reporting the results of its advocacy work. Other interviewees from donor organizations to other CAs expressed similar challenges, and referred us to resources, which, when examined, did not yield any new information regarding indicators. The evaluators believe that this area has lagged behind other areas in WRA's development. While the WRA GS has understood the importance of collecting data to demonstrate its results and has completely satisfied USAID’s and other donors’ needs for evaluative information, things did not really move forward quickly in this area until the organization was launched as an independent entity and the Affiliation Agreements were developed. It was only then that WRA's monitoring and evaluation toolkit, under development since 2003, was distributed to all established and emerging NAs. Alliances were asked to report to the GS for the first time by August 15, 2007. It will be important for USAID to monitor this aspect of WRA's work as collection of information is regularized. Key areas determined by WRA as important to track at the global level include the following: • Number of alliances (growth and diversity of alliance membership); • Partnerships, activeness, participation, and representation [interactions between group, government, and other organizations; level of member involvement in strategic planning, advocacy, fundraising, decision making, and evaluation; and representation of diverse (multisectoral) groups]; • Primary focus of Alliance activities (for example, maternal health pathways); • Innovation (activity level); • Advocacy (raised awareness, influenced policymakers); • Media and public attention; • Policy supports; • Policy changes (all levels); and • Financial resources leveraged (types of goods and services donated, member contributions, government, major donors, and other external resources). Of course, NAs and state alliances will continue to collect information relevant to their program activities and what donors are requesting. 12 This is directly quoted from an article entitled Theory & Practice: What’s Different About Evaluating Advocacy and Policy Change? Parentheses added are the evaluators’ comments. Evaluation of the White Ribbon Alliance 1999–2007 28 ALLIANCE MODEL COMPARISONS The World Alliance for Breastfeeding Action (WABA) WABA was founded in 1991 after the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding was signed by multilaterals, bilaterals, governments, and NGOs. The Innocenti Declaration was to the “breastfeeding movement” what the 1987 Nairobi, Kenya meeting was to the Safe Motherhood movement, giving global recognition to pressing problems and committing governments and organizations to action. Registered as an independent entity in Malaysia (Trust), WABA has operated on an annual budget of approximately $300,000 to $350,000 U.S. dollars. WABA has had two primary donors since its inception: the Dutch and Swedish foreign ministries. WABA serves primarily as an advocacy and social mobilization organization. One of WABA’s strongest links to the community is World Breastfeeding Week, celebrated annually the first week in August. WABA’s vision has remained constant over the years, although very recently there has been discussion to expand this vision in order to build synergies with other programs. Five-year plans, strategic frameworks, and evaluation indicators have been central to the organization’s work and its ability to measure impact. Over the past 16 years, WABA has grown slowly but steadily from 0 organizational and individual endorsers in 1991 to 156 organizations and 396 individuals from 108 countries in 2007. Organizationally, WABA is led by a 6-member Steering Committee (SC) serving 3-year terms and by 50 General Assembly members who vote on the endorser/membership￾nominated SC candidates. WABA has five core partner organizations—three of which are major international breastfeeding organizations—and regional focal points or existing breastfeeding organizations located in the five WHO regions. One such regional resource is the International Baby Food Action Network (IBFAN). IBFAM serves, in particular, to monitor violations of the Code of Marketing of Breastmilk Substitutes, but also to promote WABA’s work, vision, advocacy and outreach. At the present time, WABA supports 10 full-time staff members at HQ. Consultants, interns and volunteers also help to round out the GS operations. WABA does not charge endorser/membership fees. With the assistance of the MEDS Project, WRA engaged in a strategic planning process from 2000–2004 to define its future direction, goals, and strategies. As foundation for this process, a study was conducted to assess the type of organizational structure that would best fit WRA's mission, vision, and principles (Nagorski 2002). Eighteen potential comparator organizations were identified. Information was collected on these organizations' mission, vision, goals, guiding principles, organizational design, and the overall benefits and weaknesses of the alliance model. Eleven organizations were either unavailable for interview or did not meet the criteria established for interviewing. In-depth interviews were held with seven. During this data gathering exercise, the WABA was determined to be an organization particularly well-suited for comparison with WRA but was not available for interview. For this evaluation, WABA was actively pursued as a comparator to look at mandate, governance structure, funding levels and diversity, policy and advocacy indicators, and growth over time. A brief description of WABA is featured in the text box. In brief, WABA and WRA have been resourced similarly, but WBA has been able to hire more staff (10 vs. WRA's 3 FTEs) given its HQ location in Malaysia. However, even with a smaller staff, WRA has exceeded WABA's growth in half the time. Evaluation of the White Ribbon Alliance 1999–2007 29 Evaluation of the White Ribbon Alliance 1999–2007 30 III. LESSONS LEARNED 1. Passion, commitment, common purpose, and safe motherhood “champions” within an organizational paradigm of total inclusiveness, transparency, accountability, and shared decision making is a dynamic model for change, expansion, and impact, which has limitless potential. 2. Key ingredients to successful alliances are: • “Organic” growth, the impetus coming from individuals and organizations committed to the issue of safe motherhood, not imposed but supported by the North; • Strong, committed, effective, trusted, and visionary leadership; • Policy champions at all levels; • Supportive, strong, and capable institutional and host home or secretariat; • Democratic, transparent processes and shared decision making; • Mutual respect and active participation of a broad-based, multisectoral membership; • Technical and advocacy expertise among membership; • Evolution at a pace that builds trust and cohesion; • Sharing of information, resources, challenges, and celebrating successes, both big and small; and • Sustained resources; 3. WRA’s successes have lent support for the use of social mobilization techniques as effective development tools. Few would have predicted the rapid growth or impact made on policy and finance in several of the NA countries. Strengthening the capacity of civil society to first expect and then demand health sector accountability is one of the most impressive outcomes of the WRA. 4. Viewing NA members and organizations as experts who will be strengthened through targeted capacity-building creates the conditions for very productive partnerships. WRA’s Mission, Vision and Principles enshrine this orientation and agreeing to abide by them is the only prerequisite for membership. As funders require WRA to show “results” within a short timeframe, it may be tempting to alter its commitment to civil society strengthening. But this operational approach is cost effective and more sustainable over the long term (Howard-Grabman 2007, Russell 2003). 5. Attending to monitoring and evaluation is vital for the future growth and financial health of the WRA. A great deal of concern has been focused on the weak monitoring and evaluation efforts of the WRA to date, including by WRA staff itself. The GS has recently instituted a tracking system that should capture activities and outcomes at the national and local levels. 6. Undertaking routine strategic planning is clarifying and reaps benefits. WRA carried out a well￾planned and executed strategic planning process when deciding on which organizational structure to embrace. This exercise led to the decision to incorporate the alliance as a 501(c) (3), a decision endorsed by greater than 90 percent of the founding members. The process undertaken was uniformly identified as democratic, transparent, participatory, and comprehensive. 7. Tracking and presenting financial information in strategic ways for different constituencies— including capturing cash, in-kind and volunteer contributions (whether of the GS, NAs, or local alliances)—is necessary to confirm and communicate the robustness of the WRA to donors and supporters. Evaluation of the White Ribbon Alliance 1999–2007 31 8. USAID's vision to create “a tidal wave” in safe motherhood was spot on. USAID's support has enabled the development of an organizational model that has the necessary ingredients to achieve even greater results. Sustaining some level of support for the core operational costs of the WRA is vital. Evaluation of the White Ribbon Alliance 1999–2007 32 IV. RECOMMENDATIONS The team respectfully submits the following recommendations: USAID 1. There remains a continuing need for USAID support to the WRA over the next three to five years. Rarely does a donor agency have the opportunity, with such modest amounts of funding—one-half of one percent of Agency funding for safe motherhood—to spin-off a robust organization that fills a critical public health niche. 2. We recommend USAID consider increased levels of funding to support the following: • GS operations tied to a WRA five-year strategic sustainability plan that includes measurable benchmarks and a sunset provision for USAID support. To ensure that strategic planning can be undertaken, USAID should provide support for this strategic planning process. • NA operations to support, in part: - Full-time NA Coordinators - Country-level initiatives • Two Regional Coordinators (likely for sub-Saharan Africa and South Asia where MMRs are highest), to be situated within strong country offices or at the GS to expand outreach and assistance to members in non-NA countries and help with emerging NAs. 3. USAID should not underestimate the potential of the WRA model, which is fueled by individual and organizational commitment and creativity, but should facilitate its growth. The tendency of donors to extinguish passion by force-fitting to specific program requirements, activities and objectives, is like “putting fire in a box” (Borren 2006). USAID needs to balance its need for specific alignment with goals and objectives with flexibility based on an understanding of the key elements that make this model unique and powerful. 4. USAID should consider tasking and supporting WRA by developing a set of key indicators to measure the outcome of advocacy, social mobilization/community mobilization efforts through a global consensus process, including input from the NAs. The lack of clarity and/or consensus around appropriate indicators became increasingly apparent as the evaluation proceeded. WRA (and other USAID projects) could then collect data on these indicators at the global and national levels as part of its overall monitoring and evaluation efforts. WRA 1. WRA should undertake a strategic planning process to direct WRA’s focus and activities over the next three to five years. WRA has undergone a tremendous amount of growth since its first strategic planning exercise and with its new not-for-profit status is ready to enter its next organizational phase. The process would include plans for: • Staffing. WRA should develop functional scopes of work based on organizational need and then determine how many and what types of additional staff are needed and at what cost. • Financial management. This strategic analysis should determine whether a person dedicated 100 percent of the time to financial management, as currently planned, is necessary at this juncture. Clearly, WRA needs staff who can present financial information strategically in addition to producing accurate and consistent financial data. Evaluation of the White Ribbon Alliance 1999–2007 33 • Fundraising and strategic marketing. Increasing fundraising and strategic marketing expertise on the Board of Directors or on core staff should be considered. There are websites that can assist with this process and also in identifying volunteers with needed skills: BoardMatch.org and UniversalGiving.org. • Monitoring and evaluation. Development of a framework for more systematic tracking and collection of information is underway and should be continued. Also, examining and understanding the factors that have contributed to the success or failure of NAs and incorporating this information into planning is important as an M&E exercise. • Board composition. Composition of the Board should be revisited to include greater NA representation. If Regional Coordinators are established, they could have designated seats on the Board. 2. Monitoring and evaluating WRA’s activities and impact is of paramount importance. Capturing data at the GS and NA levels should be a top priority and the recently issued Tracking and Monitoring tool is a useful first step. However, the GS will have to be judicious as it establishes tighter tracking and reporting requirements for the NAs in the absence of direct GS funding where contractual obligations would adhere. 3. The primary focus of the GS should continue to be that of enabling, building, and supporting NAs through overall coordination, information sharing, and assistance with fundraising. A basic strength of the WRA model is its field orientation. NAs expressed some unease with WRA’s new independent organizational status, fearing that the GS would change its emphasis from country support to becoming a separate implementer of programs and initiatives. 4. Recent research suggests that for safe motherhood to be placed high on the political agenda, there must be the confluence of three distinct streams: problem, policy, and political (Shiffman 2007). Anticipating or influencing when the conditions are ripe for change requires an understanding of the country-level political process. Who are the political actors? Who are the influencers? Who can help to create this change? As an advocacy organization, WRA should encourage and assist NAs with undertaking that kind of analysis. 5. WRA should select and promote high-impact interventions and tools throughout the alliance in a more focused and systematic manner. One powerful diagnostic and advocacy tool for broader use is the maternal and perinatal death audit. In India, the use of verbal autopsies that reach into the community has helped to build constituents for safe motherhood and pressure for change. Continuing to address the health provider shortage in countries is also critical. Services cannot be made accessible without a critical mass of trained providers. And efforts to educate civil society on health care entitlements and then organize “social watches” to hold governments accountable are empowering and effective. 6. Strategic packaging of information is a critical need. Information needs to be professionally and accurately portrayed, particularly with regard to growth and funding. Presenting information strategically would pack a powerful punch with potential donors and funders. WRA needs to be strategic in extolling the robustness of its membership and activities and the fact that NA membership is located in those countries that currently account for 48 percent of the maternal deaths worldwide. 7. WRA should explore other creative ideas such as: • Increasing use of tools developed under the POLICY Project, such as the Maternal and Neonatal Program Index (MNPI); the Safe Motherhood Model Training, which allows for multisectoral policy dialogue on interventions to reduce MMR; and the MH user fee study. Evaluation of the White Ribbon Alliance 1999–2007 34 • Establishing WRA NAs in developed countries to function as development offices, that is, developing north to south sister relationships to personalize, energize, and fund the WRA.13 • Revisiting the possibility of instituting membership fees on a sliding scale as revenue building. • Undertaking different fundraising activities rather than the annual dinner that yielded little more than $2,000 in donations for the WRA for an outlay of $8,000. • Stipulating in the National Alliance Affiliation Agreement that all NAs develop yearly Action Plans to be shared with the GS and that the GS be involved in an annual review of NA Coordinator. • Organizing an auxiliary workshop at the upcoming Women Deliver conference to brainstorm the development of key social mobilization indicators. • Rotate the GS location every set number of years to reinforce the global focus. 13 A sister relationship was formed between a midwifery school in the UK and the WRA Tanzania. The Goals for Goals program links U.S. athletic teams with countries. Since 1992, the American International Health Alliance (AIHA) has formed relationships between teaching hospitals in the U.S. and those in Russia and the Central Asian Republics. Evaluation of the White Ribbon Alliance 1999–2007 35 Evaluation of the White Ribbon Alliance 1999–2007 36 V. CONCLUSION What began in 1999 as an informal coalition of NGOs and donors has grown into a fully independent 501(c)(3) not-for-profit organization. Those interviewed who are aware of the history and growth of WRA have universally commented on what an impressive feat this represents. We heard that WRA has achieved more than anyone predicted, given its small staff and limited funding. Key factors that have distinguished WRA from other organizations are the level of commitment and passion of those involved, the extent of volunteerism, the highly qualified and diverse set of individuals and organizations at country level who share a belief in the social mission of WRA, and its field focus. The fact that NAs have been, for the most part, organically grown, is important to WRA’s potential for long-term sustainability. Early in its formation when housed within the NGO Networks for Health project, a conceptual model of network development was articulated: • Phase I—Mobilization. Focus is on raising awareness and exploring the level of interest and commitment of partners and stakeholders. • Phase II—Foundation-building. Focus is on creating a shared vision and goals, agreeing on programmatic focus, developing a governance structure, developing strategic plans and technical approaches, and beginning capacity building. • Phase III—Continuous Improvement. Focus is on networks increasing their effectiveness, with an emphasis on expanding and improving the quality of their programs and services and documenting their work and impact. • Phase IV—Sustainability. Networks are engaged in decision making and planning to achieve long-term financial and programmatic goals. WRA has moved through these phases almost seamlessly and finds itself concurrently within Phases III and IV of the model. Throughout this development, growth, maturity, and expansion, WRA’s mission has never wavered. Its vision and principles have remained steadfast. While building the foundation for a strong organization, WRA has had to undertake and report its activities within various host project objectives and goals, respond daily to its membership, build and strengthen diverse and dynamic alliances, sit and contribute at global partner tables, advocate and mobilize for policy and social change with national partners, assist in the building of organizational capacity of alliances, and both identify and enable safe motherhood champions. For a small staff these challenges are formidable. The evaluators echo the responses of those interviewed: WRA has succeeded on all fronts. Perhaps the most salient conclusion that can be drawn from this evaluation is that mobilizing civil society in order to achieve sustainable, measurable impact—in this case, a lowering of MMR—will require a very long-term, large-scale, labor-intensive effort. WRA—in only eight years with USAID funding that represents a mere one half of one percent of the Agency’s over-all budget for maternal health—has achieved truly impressive outcomes in terms of mobilizing millions of stakeholders across the globe and realizing significant policy changes at national levels, certainly an auspicious beginning. Whether WRA will continue have any greater success over the long range at decreasing maternal and neonatal mortality and morbidity than other better-resourced attempts remains to be seen. The evaluators are betting that it will. As one interviewee put it, “WRA is by far the best group that exists” for advocacy on safe motherhood. The evaluators agree and believe USAID is getting value for money. Evaluation of the White Ribbon Alliance 1999–2007 37 Evaluation of the White Ribbon Alliance 1999–2007 38 For more information, please visit http://www.ghtechproject.com/resources/ Global Health Technical Assistance Project 1250 Eye St., NW, Suite 1100 Washington, DC 20005 Tel: (202) 521-1900 Fax: (202) 521-1901 www.ghtechproject.com