END-OF-PROJECT EVALUATION
Flexible Family Planning, Reproductive Health and Gender-based Violence Services 
for Transition Situations (“Flex FP”) Project
AA No. 623-A-00-08-00051-00
EVALUATION REPORT
FINAL
Submitted by: LTL Strategies
May 2013
 
LTL Strategies
4545 42nd Street NW - Suite 306 – Washington, DC 20016
Tel (202) 362-6800, Fax (202) 362-6881, www.ltlstrategies.com
 
 
ACKNOWLEDGEMENTS 
The Flex FP Project evaluation team wishes first to thank Pathfinder Team 
Leader Tanou Diallo for the time, effort and insights he provided us in the course 
of this evaluation. We also most warmly thank Chantal Inamahoro, Dr. Theoneste 
Nimpagaritse, Diane Nezerwe, Franck Akamba, and Jean Paul Niyibigira of 
Pathfinder, Tharcisse Niyonizigiye of IntraHealth, and the rest of the project team 
for their warm welcome and consistent support during our two weeks gathering 
data in Burundi and the DRC. Their pride in this project was in evidence 
throughout the time they spent with us in site visits and in answering our many 
questions. On a practical note, the availability of Pathfinder vehicles and drivers 
was both appreciated and essential to our reaching the project’s far-flung sites.
We appreciated the time given to discussions with the team by Dr. Irenée 
(Director, DSPS) and Dr. Ndereye (Director, PNSR) of the Burundian Ministry of 
Health, Dr. Nyamugaragaza (Director, PNSR) of the South Kivu MOH office in 
the DRC, and the provincial and district health officers in both countries who 
made themselves available to speak, and in some cases to travel, with us. A 
special word of thanks as well to Dr. Godefroid Mayala of USAID/Kinshasa for his 
efforts to join the evaluation team for site visits in South Kivu, only to be thwarted 
by circumstances beyond his control. 
We acknowledge USAID/Burundi and USAID/DRC for insights into the evaluation 
process, inputs during debriefs, and logistical support. Special thanks go to 
Wairimu Gakuo, Strategic Information Specialist, and Julia Henn, Director, of 
USAID/EA/RHH, for technical support and guidance. Finally, we thank the 
directors and staff of LTL Strategies, who developed the winning proposal for 
conducting this evaluation and supported the team throughout. For this we are 
grateful to Mélodie Cerin and Gnima Diop of the LTL office in Dakar, and to the 
company’s directors, René Lake and Hillary Thomas-Lake.
Eliot Putnam, Team Leader 
Katherine de la Rionda, USAID/East Africa 
Sarah Onyango, USAID/East Africa 
May, 2013 
3
 TABLE OF CONTENTS 
ABBREVIATIONS 4 
EXECUTIVE SUMMARY 6 
I. INTRODUCTION 10
II. BACKGROUND TO FLEX FP PROJECT 10
III. EVALUATION METHODOLOGY AND TIMETABLE 12
IV. FINDINGS 13
1. What have been the achievements of the project in reaching vulnerable 
populations with FP/RH/GBV services? 
2. How has the menu of options tested by Flex FP increased access to 
services for vulnerable populations, and are these services sustainable? 
3. What have been the successes and failures in achieving “buy-in” to the 
project on the part of communities, Ministries of Health, local authorities 
and NGOs? 
4. What have been the significant challenges faced by the project? How 
have they been, or could they be, addressed? 
5. What have been the costs of different models of FP/RH/GBV service 
delivery tested by the project? 
6. What aspects of Flex FP have the potential for replication or scale-up at 
regional or country levels? 
V. CONCLUSIONS AND RECOMMENDATIONS 24
VI. LESSONS LEARNED 25
ANNEX I Interview Guide 
ANNEX 2 Persons Contacted 
ANNEX 3 Bibliography 
ANNEX 4 Evaluation Timetable 
4
ABBREVIATIONS 
ABUBEF Association Burundaise pour le Bien-être Familial 
AHA African Humanitarian Action (Ethiopia-based NGO) 
ARVs Anti-retroviral drugs 
CA Cooperative Agreement 
CBD Community-based distribution (of contraceptives); also, CBD agent 
CHW Community health worker 
DMPA Depo medroxyprogesterone acetate (depo-provera) 
DRC Democratic Republic of Congo 
DSPS Direction des Services des Programmes de Santé 
FGD Focus group discussion 
FP Family planning 
GBV Gender-based violence 
HIM Healthy Images of Manhood 
HIV Human immunodeficiency virus 
IDPs Internally displaced persons 
IMT Integrated mobile team (for outreach services) 
MCH Maternal and child health 
MISP Minimum initial service package (for emergency situations) 
MOH Ministry of Health 
MOU Memorandum of Understanding 
NGO Non-governmental organization 
PBF Performance-based financing 
5
PEP Post-exposure prophylaxis (following rape or other sexual violence) 
PNSR Programme National de Santé de la Reproduction 
RH Reproductive health 
SGBV Sexual and gender-based violence 
SOW Scope of work 
USAID/EA USAID East Africa Regional Health and HIV Office 
WHO World Health Organization
6
EXECUTIVE SUMMARY 
A. BACKGROUND 
This report presents the end-of-project evaluation of the regional Flexible Family 
Planning (FP), Reproductive Health (RH) and Gender-based Violence (GBV) 
Services for Transition Situations, or “Flex FP”, project that was implemented in 
two provinces of Burundi and in South Kivu Province of the Democratic Republic 
of Congo (DRC) from October, 2008 to March, 2013. The project was funded at a 
level of $4 million by the USAID/East Africa Regional Health and HIV Office 
(USAID/EA), and implemented by Pathfinder International and its sub-contractor, 
IntraHealth International. 
The cooperative agreement (CA) under which the project was awarded was 
originally for four years. However, implementation was delayed by indecision as 
to the countries to be targeted and other factors, which meant expenditure of the 
funding pipeline was slowed as well. For this reason, in September 2012, a no￾cost extension was signed between Pathfinder and USAID/EA, extending the 
project for six months, and enabling it to fully complete its mission. Formal project 
activity came to a close on March 31, 2013. 
The concept of the Flex FP project evolved from a desire on the part of 
USAID/EA to test approaches, on a regional basis, to delivering urgently needed 
FP/RH and related services to populations – refugees, internally displaced 
persons (IDPs), returnees and populations in transit –who have been buffeted by 
political unrest and social disruption in recent decades in East and Central Africa. 
USAID felt that such approaches needed to be uniquely responsive and flexible, 
providing models for responding to different phases of crisis situations, such as 
emergency preparedness, immediate response, and long-term recovery 
strategies. USAID/EA also wanted such approaches to provide for meeting the 
special needs of people, largely women, who are invariably victimized by sexual 
and gender-based violence (SGBV) in the course of such crises and their 
aftermath. 
B. EVALUATION APPROACH 
In February 2013 USAID/EA contracted with LTL Strategies to conduct an end￾of-project evaluation to document the project’s performance and assess the 
impact and lessons learned from its activities. A three-person team, consisting of 
LTL Strategies’ Eliot Putnam (US-based) and two staff persons from the 
USAID/EA office in Nairobi, undertook the evaluation for LTL. Field visits and 
data gathering by the team in Burundi and the DRC took place in March 2013. 
This was preceded by a period of document review and development of an 
evaluation work plan and Interview Guide, and followed by team debriefings with 
USAID/Burundi and USAID/EA/Nairobi. 
7
In visiting project sites in the Muyinga and Kayanza Provinces of Burundi and 
Walungu and Miti Health Zones in Eastern DRC, the evaluation team had 
extensive exposure to several examples of each of the models of FP/RH/GBV 
services that the Flex FP project had tested, as well as to health facilities that 
had benefited from project support. A detailed timetable of site visits is included 
in the report that follows. The team met with national, provincial and district 
health officials wherever it went, and was often accompanied by them on its field 
visits, affording excellent opportunities for dialogue about the project and its 
impact. It also contacted key NGOs and other institutions with which the project 
has worked to obtain their perspectives. Information was gathered by the team, 
in the course of its many contacts, through a combination of directed interviews, 
informal discussions with service providers, and focus group discussions with 
CBD agents, other outreach workers, and beneficiaries. 
C. FINDINGS 
Findings of the Flex FP evaluation team are presented in this report within the 
framework of six Key Evaluation Questions listed by USAID in the evaluation 
scope of work (SOW): 
 What have been the achievements of the project in reaching vulnerable 
populations with FP/RH/GBV services? 
 How has the menu of options tested by Flex FP increased access to 
services for vulnerable populations, and are these services sustainable? 
 What have been the successes and failures in achieving “buy-in” to the 
project on the part of communities, Ministries of Health, local authorities 
and NGOs? 
 What have been the significant challenges faced by the project? How 
have they been, or could they be, addressed? 
 What have been the costs of different models of FP/RH/GBV service 
delivery tested by the project? 
 What aspects of Flex FP have the potential for replication or scale-up at 
regional or country levels? 
The report answers these questions by assessing the achievement of the Flex 
FP project’s multi-sectoral approach to achieving project objectives, which was 
centered on eight specifically defined Project Strategies: 
Mobile outreach activities, implemented through integrated mobile teams 
(IMTs), complemented services provided through fixed health facilities. They 
brought comprehensive primary care services to remote areas where health 
centers were not readily accessible to refugees, IDPs, and other population 
groups in transition situations. The evaluation team found the IMT model to be 
particularly dynamic and appropriate to the needs of populations in transition. 
Community-based distribution of FP methods and supplies has been a 
bulwark of the Flex FP project from the beginning. A significant CBD success 
8
story lay in the fact that, in the DRC, CBD agents who are also trained nurses 
have, since early in the project, been permitted to administer injectable 
contraceptives along with condoms and oral contraceptives in the community. 
Training of core cadres of service providers was a major contribution of the 
project to the expansion of FP/RH/GBV services at all levels. A key element was 
training of clinicians and master trainers in SGBV services at the Seruka Center 
in Bujumbura. However, the 24-hour drop-in centers to which these cadres 
were assigned did not attract a significant increase in patients who were victims 
of SGBV, for reasons including non-availability of proper PEP kits and concerns 
about security, especially at night. Also, and sadly, there is a stigma attached to 
women who come forward to report sexual violence, so the tendency is not to do 
so, especially if the quality of SGBV services in clinics is not of the highest. 
The project’s focus on addressing gender issues was highlighted by its 
implementation of the Healthy Images of Manhood (HIM) model. HIM clearly has 
made great strides in its limited target areas in raising awareness, especially on 
the part of men, of the importance of sexual and reproductive health, greater 
balance in family roles, and the destructive nature of SGBV. It is a model that is 
more than ready for implementation on a larger scale. 
Access to health services was enhanced by the commitment of the Flex FP 
project to invest in rehabilitation and equipping of selected health facilities. A key 
to the project’s strategy of community advocacy and health promotion, this 
investment in the condition and appearance of communities’ health facilities 
became a source of considerable pride in the affected populations. 
Less successful, in the view of the evaluation team, was the project’s strategy of 
early planning for emergency preparedness, which seemed to the team to 
have been overly elaborate, costly and time consuming, without significantly 
enhancing access to services. 
From its meetings with provincial, district and zonal health officials, as well as 
with NGOs, the team observed a high level of cooperation and commitment to 
mutually agreed goals. This clearly validated the project’s strategy of partnering 
and coordination with Government and international and local NGOs, 
notably apparent in the existence of MOUs between the project and various 
entities. More worrisome was the concern of health officials as to how activities 
launched under Flex FP could be maintained after its conclusion. In most cases 
there seemed little chance of that happening without alternative sources of 
external funding. 
Challenges to the project included delays, over which project management had 
no control, between the time the CA was awarded and when significant project 
interventions could be initiated. Approving a five-year, rather than a four-year, 
project could have avoided this. Also, as noted, the low level of patients, largely 
women, presenting for treatment and counseling as the result of sexual and/or 
9
domestic violence remains a challenge, for reasons of stigma, lack of confidence 
in the health system, and lack of faith in the legal system. And two challenges 
face the maximization of CBD services. One is to convince health authorities of 
the inherent value and safety of permitting CBD agents that are trained nurses to 
administer injectable contraceptives in the community. The second is to meet the 
training and support needs that are essential to maintaining a vibrant, responsive 
cadre of CBD agents in the field. 
D. CONCLUSIONS / RECOMMENDATIONS / LESSONS LEARNED 
The evaluation team believes that IMTs, HIM, and CBD are the service models 
tested by the Flex FP project with the greatest potential for expansion and 
replication. The project team is to be commended for the diligent and visionary 
work that went into their conception and implementation. They are relatively low 
cost (representative cost figures are included in the report), have achieved wide 
acceptance and/or appreciation, and are well appreciated in the public sector. It 
recommends that these approaches to delivery of services to populations in 
transition be replicated and scaled up in these and other countries and regions. It 
even suggests that continuation of the Flex FP project itself, which it feels has, 
on the whole, been very successful, could provide a continuing laboratory for 
further testing and analysis of these and other models. 
Finally, the report discusses what the team concluded were the important 
lessons that have been learned from the Flex FP project experience, as well as 
from the evaluation process. Among others, these have to do with the changing 
nature of the populations the project was designed to serve, the inherent value of 
key project innovations, and reflections on the work that remains in combating 
sexual and gender-based violence. 
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I. INTRODUCTION
This is the report of the end-of-project evaluation of the Flexible Family Planning 
(FP), Reproductive Health (RH) and Gender-based Violence (GBV) Services for 
Transition Situations, or “Flex FP”, project. The project was funded by the 
USAID/East Africa Regional Health and HIV Office under an Associate 
Cooperative Agreement (CA) Award, #623-A-00-08-0051-00, to Pathfinder 
International, with IntraHealth serving as sub-contractor. The four-year 
agreement in the amount of $3,999,257 was signed in September 2008. In 
September 2012, a no-cost extension signed between Pathfinder and USAID/EA 
extended the project for six months, until the end of March, 2013, at which time 
formal project activity ended. 
In February 2013 USAID/EA contracted with LTL Strategies, an international 
business and development consulting firm, to conduct a final evaluation to 
document the project’s performance and assess the impact and lessons learned 
from its activities. A three-person team, consisting of an independent consultant 
from the U.S. and two staff persons from the USAID/EA office in Nairobi, 
undertook the evaluation for LTL. Field visits and data gathering by the team in 
Burundi and the Democratic Republic of Congo (DRC), the two countries in 
which the Flex FP project was implemented, took place in March 2013. 
This report describes the approach used by the evaluation team in gathering and 
analyzing information, and the scope of its contacts in the countries in question. It 
details the team’s findings, outlines the team’s recommendations for the future, 
and describes the significant lessons it feels have been learned from the 
implementation of this small but vital project over the past 4 ½ years. 
II. BACKGROUND TO FLEX FP PROJECT 
Design of this project grew out of a desire on the part of USAID/EA to test 
approaches, on a regional basis, to delivering reproductive health and other 
services to populations emerging from periods of social unrest or conflict, of 
which there have been many in East and Central Africa. It felt that such 
approaches needed to be uniquely responsive and flexible, providing models for 
national response to different phases of crisis situations, such as emergency 
preparedness, immediate response, and long-term recovery strategies. 
USAID/EA also wanted such approaches to provide for meeting the special 
needs of people, largely women, who are invariably victimized by sexual and 
gender-based violence (SGBV) in the course of such crises and their aftermath. 
As noted, in September 2008 Pathfinder International was awarded a four-year 
CA to design and test models for providing FP/RH/GBV services in crisis and 
post-crisis situations in the region. Delays in project implementation immediately 
11
ensued, due to uncertainty as to which countries would be involved. Rwanda and 
Uganda had originally been considered, but did not agree to take part in the 
project, citing the fact that they were not in a “conflict situation.” Burundi agred to 
take part, as a country emerging from years of political crises, and one with 
significant populations of both refugees and internally displaced persons (IDPs), 
as well as victims of SGBV. But it took almost a year until the South Kivu region 
of the DRC, where such crises are still very real, was confirmed as the second 
participant in this regional experiment. 
Further delays were caused by disagreement over the wording used to describe 
the project. Both governments objected to its referring to populations “in crisis”, 
and settled instead on designating them as populations in “transition situations”. 
The volatile security situation in South Kivu, which often led to attacks on health 
centers, also contributed to delays in the launch of full project activity in the DRC, 
as did the slowness of procuring equipment and materials for clinic rehabilitation 
in both countries. 
Pathfinder was not idle during this period. Its many preparatory activities 
included: 
 Conduct of situational analyses of FP/RH/GBV services in Muyinga and 
Kayanza Provinces of Burundi, and selection of sites in these provinces 
for testing approaches to delivery of FP/RH/GBV services. (The two 
provinces were selected due to their already being served by a separate 
Pathfinder-funded MCH program.) 
 Conduct of a feasibility study on community-based delivery (CBD) of 
injectable contraceptives in Burundi, hoping it would mirror a decision 
taken by the DRC to permit such services to be provided by CBD agents 
who are also trained nurses. 
 Development of memorandums of understanding (MOUs) and action 
plans with target provinces in Burundi and Walungu Health Zone in the 
DRC where the Flex FP project would be active. MOUs were also signed 
with partner NGOs such as ABUBEF (for jointly fielding IMTs) and AHA 
(for promoting the Healthy Images of Manhood, or HIM, model in Gasorwe 
commune and refugee camp) in Burundi. 
Nonetheless, despite Pathfinder’s best efforts the delays described led to 
significant under-expenditure of funds in the project pipeline during its early 
stages. The first trainings of nurses in delivery of FP/RH/GBV services, as well 
as of HIM trainers, did not take place until the spring of 2010. Launching of 
integrated mobile health teams (IMTs); purchase and distribution of clinic 
equipment; and rehabilitation of selected clinic facilities, including installation of 
solar panels for electricity, all occurred more slowly than anticipated. Indeed, due 
to the uncertain security situation in the DRC, rehabilitation of two health centers 
there was only completed in August of 2012. All of this led to the decision by 
USAID/EA in September of 2012 to grant the project an unfunded six-month 
extension. This was a sound and reasonable decision, in the eyes of the 
12
evaluation team, one that assured the project of the time required to utilize all 
authorized funds in completing its mission. 
NOTE: It is important to make clear that, while several of the models tested 
under this project were designed to deliver FP, RH and GBV services, Flex FP 
was not intended to be a “service delivery” project per se. Rather it was intended 
as a laboratory to, in the words of the original project document, “identify and 
develop flexible approaches that can be packaged and mixed and matched into 
models to deliver services to communities in different phases of crises.” 
Individual models tested were of a size and scope too small to achieve significant 
statistical results in terms of services delivered. While the evaluation team did 
gather quantitative data of interest, it was cognizant of the fact that service 
statistics alone would not be the true measure of the project’s value. 
III. EVALUATION METHODOLOGY AND TIMETABLE 
Once the contract for this evaluation had been awarded by USAID/EA to LTL, the 
evaluation team undertook a desk review of project-related documents. These 
included quarterly project reports, an internal mid-term review of the project by 
Pathfinder, needs assessments, and the aforementioned feasibility study on 
community-based provision of DMPA. They also included a recent report by 
IntraHealth on the HIM experience, and two reports, on sexual violence in 
Burundi and services available for its victims, that were commissioned by the 
USAID Mission in Burundi. A list of documents reviewed by the evaluation team 
appears in the Annex to this report. 
The team developed a Work Plan for the field portion of the evaluation and an 
Interview Guide for use in structuring its interactions with project personnel, other 
stakeholders, service providers, project beneficiaries and others. Questions 
contained in the Interview Guide (included as Annex 1) were keyed to the Key 
Evaluation Questions specified by USAID in the Flex FP evaluation scope of 
work (SOW), for which see Section IV below. 
Data collection was accomplished through site visits and interviews at many 
levels, and took place during the weeks of March 18 and 25, 2013. The detailed 
evaluation timetable can be found in Annex 4. 
Following completion of the data-gathering portion of the evaluation, the team 
disbanded and reconvened on April 2 at USAID/Nairobi to brief the Mission on its 
findings and conclusions. The LTL Strategies consultant then returned to the 
U.S. to draft the evaluation report. 
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IV. FINDINGS 
Structure of this section:
Findings of the Flex FP evaluation team are presented within the framework of 
the Key Evaluation Questions listed by USAID in the evaluation SOW, as follows: 
 What have been the achievements of the project in reaching vulnerable 
populations with FP/RH/GBV services? 
 How has the menu of options tested by Flex FP increased access to 
services for vulnerable populations, and are these services sustainable? 
 What have been the successes and failures in achieving “buy-in” to the 
project on the part of communities, Ministries of Health, local authorities 
and NGOs? 
 What have been the significant challenges faced by the project? How 
have they been, or could they be, addressed? 
 What have been the costs of different models of FP/RH/GBV service 
delivery tested by the project? 
 What aspects of Flex FP have the potential for replication or scale-up at 
regional or country levels? 
The report addresses each question in the context of eight project strategies 
that made up the multi-sectoral approach the Flex FP project and its 
implementers, Pathfinder and IntraHealth, used in testing models for the delivery 
of FP, RH and GBV services to populations in different phases of transition. 
These strategies, a mix of specific project interventions and broader coordinative 
approaches, were implemented at different stages of the project depending on 
circumstances and overall readiness. They are contained in the following box: 
1. Early planning for emergency preparedness, notably contingency planning 
to ensure access to Minimum Initial Service Package (MISP) of treatments 
(post-exposure prophylaxis [PEP] kits, emergency contraception, etc.) for 
victims of sexual violence 
2. Partnering/coordination with Government and international and local NGOs 
3. Training of core cadres of service providers at several levels 
4. Community-based distribution of FP methods, including DMPA 
5. 24-hour drop-in centers and post-rape care 
6. Addressing gender issues, especially through the HIM initiative 
7. Mobile outreach activities 
8. Community advocacy and health promotion 
14
Each of these strategies is addressed and assessed (and referenced in italics) in 
the findings presented in the following pages, most from more than one 
perspective. Again, findings are structured around USAID/EA’s Key Evaluation 
Questions listed above. Concluding sections containing Recommendations and 
addressing Lessons Learned are drawn from these findings. 
1. Achievements in reaching vulnerable populations with FP/RH/GBV 
services 
Integrated mobile health teams (IMTs). Mobile outreach activities were initiated 
through establishment of IMTs in Muyinga and Kayanza Provinces in Burundi in 
early 2011, a bit later in Walungu Health Zone in the DRC. Five such teams were 
active over the life of the project. The IMTs quickly established themselves as 
essential complements to services provided through fixed health facilities, 
bringing services on a semi-regular basis to remote areas where health centers 
were not readily accessible to refugees, IDPs, and other population groups in 
transition situations. 50 IMT outreach sessions were held over the life of the 
project, against a target indicator of 40. 
IMTs were joint ventures of the Flex FP project and local partners. For example, 
in Burundi’s Muyinga Province, the IMT was fielded under an MOU between 
Pathfinder and ABUBEF, the leading family planning NGO in Burundi. On the day 
of the evaluation team’s visit to the IMT site in Nyungu District, ABUBEF provided 
the vehicle to transport workers and materials to the site, as well as FP service 
personnel. At other times, a local government vehicle might be used. Also 
participating were clinical staff from the Nyungu health center, health workers 
seconded from the Pathfinder-supported MCH program, and volunteers and CBD 
agents from the community. A full team assembled for an IMT session numbered 
15-16 workers. 
Frequently IMT visits coincide with a local market day, to ensure maximum 
access for members of the community. Services are offered from early morning 
through the afternoon, to allow for people to plan their visits to the clinic site 
around their work tending crops in the fields. Integrated services offered by IMTs 
include: 
 Confidential FP counseling and a full range of methods (condoms, pills, 
injectables and implants) as well as referrals for permanent methods 
 HIV counseling and testing 
 Education on nutrition and meal preparation for infants and children; 
growth monitoring promotion; screening for acute malnutrition 
 Ante-natal counseling and child health care 
 Home-based management of malaria 
 Immunizations for mothers and children 
 Confidential GBV services and counseling. 
 In some cases a physician is also on scene for patient consultations. 
15
The evaluation team witnessed several IMTs in action. It was impressed by the 
range of services offered and the obvious enthusiasm for them on the part of 
community members, many of whom would be far less likely to travel to a distant 
health center. The concept and rationale for mobile health teams is not a new 
one, but the popularity and comprehensiveness of this model, and its relatively 
low cost (the Flex FP project office estimated that fuel, travel time and supplies 
for a typical, day-long IMT session averaged $480) made it especially appealing. 
Equally impressive was the fact that IMTs are joint efforts, engaging local health 
authorities and service providers, NGOs, volunteers and CBDs, a factor in favor 
of the model being sustained. 
A notable IMT success story can be found in Kayanza Province. The evaluation 
team visited a busy Saturday/market day session of an IMT in the colline of 
Rugogwe. At first supported by Flex FP, this IMT is now fully financed by the 
District Health Office under the performance-based financing (PBF) program 
underwritten by the World Bank. But it also pointed out the fact that maintaining 
regular services of other IMTs is by no means assured, now that Flex FP is over. 
CBD outreach. The community-based distribution of contraceptive information 
and supplies has been a bulwark of the Flex FP project from the beginning. As in 
many countries, CBD agents constitute the most basic point of contact between 
the community and the health system, a fact especially true for populations in 
transition, in places such as IDP camps, for whom dependable health care can 
be elusive. Over 800 CBD agents were trained and/or retrained by the project, 
and equipped with appropriate information and contraceptive supplies – pills, 
condoms, cycle beads, and (in the DRC), injectables. CBD agents are so 
essential to Burundi’s health system that the Government has determined their 
16
numbers will be increased from two for each colline to one for each sous-colline.1
 
The most significant CBD success story, thanks in part to vigorous advocacy on 
the part of the Flex FP project, lay in the decision, first by South Kivu RH 
authorities and then by the central DRC government, to permit DRC nurses 
designated as CBD agents to provide injectable contraceptives in the community, 
without requiring a clinic visit. Since the summer of 2010, over 100 such CBD 
agents were trained to provide DMPA in the community, and over 4,100 
injections have been administered, against a target of 2,800. On the other hand, 
despite preparation of a detailed feasibility study on the advantages of 
community-based provision of injectables, Flex FP was unable to prompt a 
similar decision from the Burundian MOH, which rejected what it called the “de￾medicalization” of injectables. The most popular contraceptive method must still 
be administered in a health facility. 
Training. The training of core cadres of service providers was a major 
contribution of the project to the expansion of FP/RH/GBV services at all levels. 
Training and refresher training of CBD agents, FP training for clinical service 
providers, and “sensitization” and training of HIM champions (Burundi) and peer 
educators (DRC), were an integral part of project inputs beginning in 2010. 
A significant component of the project’s overall training strategy was its contract 
with the Seruka National Referral and Training Center in Bujumbura to train 
clinicians in SGBV service provision. During the 2011-2012 period, 24 nurses, 
selected by the Burundian MOH, participated in intensive one-week training 
courses at the Seruka Center in the treatment and counseling of SGBV victims, 
followed by a 10-day supervised practicum. In late 2012, 5 of the most skilled of 
these service providers received an additional 5 days of training as SGBV master 
trainers. At about the same time, similar training, of both care givers and master 
trainers from Walungu and Miti Health Zones, took place in the DRC under the 
aegis of the South Kivu Department of Reproductive Health. 
One of the objectives of the specialized SGBV training was to enable health 
facilities staffed by newly trained providers to serve as 24-hour drop-in centers
for victims of sexual violence. 17 such centers were established, and these 
facilities may yet develop into fully functioning drop-in centers2
, but certain factors 
have muted that result to date. (1) Many facilities are not fully equipped with the 
latest post-exposure prophylaxis (PEP) kits, i.e., those that contain three 
antiretroviral drugs (ARVs), which is now the WHO standard, rather than the 
previous two. (Some may lack PEP kits altogether.) (2) All nurses have not yet 
 
1 Colline, for “hill”, and sous-colline, for “small hill”, are the most basic administrative 
units in mountainous Burundi. Each colline is made up of several sous-collines.
2 All health facilities in the Burundian health system are normally open 24 hours per day, 
or staff can be quickly summoned from their nearby homes. The “drop-in” facilities in 
question, supported by the project, were staffed by nurses trained at Seruka specifically to 
treat and counsel sexual assault victims. 
17
been fully trained to initiate ARVs with patients suspected of being infected with 
HIV. Those without such training must refer patients to a doctor at the hospital for 
initiation, which can present daunting logistical problems for the patient. (3) There 
is an issue of security, especially at night, when patients may be unwilling to go 
to the clinic no matter how dire their circumstance. 
Healthy Images of Manhood (HIM). The importance of addressing gender 
issues has been highlighted with considerable success with the introduction in 
pilot areas of the HIM model for raising awareness, especially on the part of men, 
of the importance of sexual and reproductive health, and of the destructive nature 
of SGBV. The rationale for the HIM approach, based on a model first used in 
Tanzania, is put forth in an excellent recent paper, “Healthy Images of Manhood”, 
by IntraHealth, the partner responsible for this aspect of the Flex FP project. The 
HIM model was piloted in the Gasorwe Commune and Refugee Camp in 
Muyinga Province of Burundi, and in the Walungu and Miti Health Zones of the 
DRC. A HIM training manual was developed, and used to train HIM 
champions/peer educators in the two countries. 
In visits to these sites, the evaluation team was struck by the vehemence with 
which many men, having had HIM “sensitization” and/or training as champions or 
peer educators, expressed their determination to change their behaviors by 
showing greater respect for their wives and shouldering more of the household 
burdens. In a training exercise that had particular impact, men and women were 
asked to separately list the different duties for which they are responsible on a 
normal day. The women’s list (preparing meals, child care, housework, washing 
clothes, tending the fields, going to market, carrying water, tending to animals) 
invariably proved to be far longer than the men’s. One particularly energized man 
who had participated in the exercise confessed, “we are not doing anything!” He 
and many like him are vowing to do more, to share burdens, and to break out of 
traditional habits and ways of thinking. 
A second observation of the team was the extent to which testimonies of men 
who had embraced the HIM concept invariably circled back to the importance 
and desirability of contraception for birth spacing. This is especially impressive in 
light of the Situation Analysis conducted in Burundi by the Flex FP project in 
January 2010 (see Bibliography, Annex 3.) In referring to the Gasorwe 
Commune and Refugee Camp, the analysis observed that, at the time, Un 
comportement pro-nataliste est perceptible 
chez les populations du site de Gasorwe. 
(“A distinctly pro-natalist attitude is 
observed among residents of Gasorwe.”) 
The HIM model has clearly made inroads 
into that attitude. 
The HIM model as implemented by Flex 
FP was small in scope. But the positive 
responses it engendered in sites where it 
18
was tested speak well for testing it on a much broader scale. They also highlight 
its potential not only to begin to lessen the proclivity toward sexual and gender￾based violence but to promote family planning in the process. 
A dynamic success story. In the 2010 Situation Analysis referenced above, 
mention was made of the Nyarurama District in Kayanza Province of Burundi, 
where, selon nos interlocuteurs, la pratique contraceptive leur est pratiquement 
inconnue. (“According to our contacts, contraception is practically unknown.”) At 
the time of the evaluation team’s visit to Nyarurama, where the project had made 
significant investment in outreach, training and clinic rehabilitation, it found a very 
different state of affairs. Health center statistics indicated a high level of 
acceptance of contraceptive methods, with DMPA the preferred option, followed 
by implants. More striking still were the team’s FGDs with CBD agents and 
beneficiaries. All were anxious to talk about their desire to space births and their 
contraceptive methods of choice. The Pathfinder Team Leader spoke proudly of 
Nyarurama’s progress as one of the project’s most impressive achievements. 
2. Has the Flex FP menu of options increased access to services to 
vulnerable populations, and are these services sustainable? 
Integrated mobile health teams. There is no question that the Flex FP project’s 
support for mobile outreach activities through IMTs has significantly increased 
access to integrated FP/RH/GBV services for populations in transition. Even as 
IDPs, refugees and others become gradually more settled in their present 
locations, where they have been, in some cases, for several years, their camps 
and settlements may be far from fixed health facilities, with limited access to 
transport, and IMTs fill a pressing need for primary health services. 
Whether they are sustainable is 
another matter. The average 
cost to the Flex FP project of a 
full day IMT session was $480, 
not a high price considering the 
range of services offered but 
one that nonetheless may be 
hard to meet. For example, the 
Chief Medical Officer of the Miti 
Health Zone in the DRC told the 
evaluation team that the ending 
of the Flex FP project and its 
support for outreach services 
would mean a sharp reduction, 
or even cancellation, of such services because of the high cost of fuel. He will try 
to find alternate sources of external funding, but this is by no means assured. 
In some cases in Burundi, Kayanza Province being an example, costs of 
maintaining IMTs and other service activities have been absorbed by provincial 
19
health structures through the World Bank-financed PBF program. Provincial and 
District health systems are reimbursed by the MOH for every contraceptive 
acceptor or consumer of other services, according to a strict, and carefully 
monitored, formula. Records are regularly reviewed by a team of MOH and 
Pathfinder inspectors to verify service statistics before reimbursements are 
approved. The system is rewarding for high performing facilities and programs, 
such as in Kayanza. On the other hand, those that perform less well either do not 
qualify or fail to generate significant reimbursements. 
CBD outreach. The emphasis on community-based distribution of 
contraceptive information and products, through training of core cadres of CBD 
agents and their logistical support, has added substantial value in providing 
access to services for populations in transition. This is especially true in the DRC, 
where trained nurses serving as CBD agents have been administering injectable 
contraceptives in the community for almost three years. DMPA is the preferred 
contraceptive for a majority of women in the region. Increased access to 
injections without requiring a clinic visit has significantly increased numbers of 
acceptors. It is hoped that efforts to convince the Burundian MOH of the value of 
this intervention will eventually bear fruit. 
Rehabilitation of health facilities. Access to services was also enhanced by 
investment of the Flex FP project in rehabilitation of selected health facilities in 
project areas. Six such facilities, small hospitals and referral health centers, were 
renovated, repaired, painted, and/or otherwise brought up to standard by 
Pathfinder, at an average cost of $39,000 per facility. It can certainly be said that 
the project strategy of community advocacy and health promotion was enhanced 
by this investment in the condition and appearance of communities’ health 
facilities, in which community members took unabashed pride. 
Rehabilitation included the installation of solar panels to provide health facilities 
with dependable electricity. Under a separate budget category, the project also 
equipped most of the health facilities covered by the project with basic equipment 
such as new beds, delivery and examination tables, sterilizers, and plastic rain￾collection barrels. 
The risks and insecurity of implementing services in the region covered by the 
Flex FP project were brought home when, mid-way through the project, a referral 
health center in Walungu Health Zone in the DRC that had been rehabbed by the 
project was destroyed in the course of rebel military action. The facility was 
subsequently rebuilt with project assistance. 
Services for victims of SGBV. One of the service models tested by the Flex FP 
project was the introduction of the concept of 24-hour drop-in centers for 
treatment and counseling of victims of sexual violence, with clinics staffed by 
nurses trained for the purpose. This has probably marginally increased access to 
such services, but records are incomplete, and, as described above, certain 
factors have so far prevented optimal utilization. One is that PEP kits at health 
20
facilities may be lacking or not up to current standards. A second is that, while 
the MOH now allows nurses to prescribe ARVs, appropriate training has not yet 
been rolled out in all areas, meaning that women potentially infected with HIV 
may still be referred to a doctor at the hospital to initiate ARVs, with health 
centers only stocking ARVs to resupply HIV+ patients. Late night security is also 
an issue. 
Contingency planning. The strategy of early planning for emergency 
preparedness seemed to the evaluation team to have been overly elaborate and 
time consuming, without significantly ensuring access to services. Substantial 
time and expense was devoted to developing and publishing detailed “Plans de 
Contingences”, both national and specific to Muyinga and Kayanza Provinces. 
These contained elaborate scenarios and lists of responsible agencies for 
dealing with any sort of emergency, from fires to road accidents to natural 
disasters, as well as outbreaks of violence and civil unrest. 
Largely lost in the detail were the key items dealing with health issues resulting 
from conflict and its inevitable sexual violence. These involve making certain that 
the “minimum initial service package”, or MISP, for victims of SGBV, containing 
PEP kits and emergency contraceptive methods, is readily available and in 
competent hands. In future, the team feels that such contingency planning should 
be limited to ensuring that the MISP is in plentiful stock or immediately accessible 
for any eventuality, and that health service providers are appropriately trained in 
its utilization. This would put the focus directly on patients, and their specific 
emergency needs, that the Flex FP project was designed to support. 
Contraceptive supply. Access to services was also enhanced, at least in 
Burundi, by a strong contraceptive logistics system, an important contributor to 
this project’s success. Indeed, Burundi has not recorded stock-outs of 
contraceptive commodities in many years. 
3. What have been the successes and failures in achieving “buy-in” to the 
project on the part of communities, Ministries of Health, local authorities 
and NGOs? 
Overall. From its visits and observations, the evaluation team felt that the 
strategy of partnering and coordination with Government and international and 
local NGOs has been achieved. Mention has been made of the MOUs or 
contracts signed between the project and various entities: 
 ABUBEF, in support of IMT activities 
 AHA, in support of HIM promotion in Gasorwe Commune and Refugee 
Camp 
 The Seruka Center for training in SGBV services and counseling 
 Local health authorities in Health Zones (DRC) and Provinces (Burundi), 
for implementation of agreed work plans. 
21
From its meetings with provincial, district and zonal health officials the team 
observed a high level of cooperation and commitment to mutually agreed goals. 
The success of Kayanza Province in Burundi in having innovations launched by 
the Flex FP project, such as IMTs, absorbed under the PBF program was 
testimony to strong collaboration and mutual growth. Equally eloquent, but in a 
more worrisome way, was the concern expressed by health officials wondering 
how activities launched under Flex FP could be maintained after its conclusion. 
In most cases it appeared as if there would be little chance of that happening 
without alternative sources of external funding. 
CBD. The one striking contrast in terms of government “buy-in” to the project’s 
approaches was the fact that the Government of the DRC early on approved the 
community-based administration of injectable contraceptives in the community by 
CBD agents who are trained nurses, while the Burundian Government has not. 
The result has been substantial levels of request for DMPA in the DRC, well 
above targets. 
SGBV services. In its concentration on addressing gender issues, the Flex FP 
project invested substantial time and resources in creating awareness and 
strengthening services related to SGBV. The HIM model, training in SGBV 
treatment and counseling, the establishment of 24-hour drop-in centers, all were 
evidence of this focus. 
The level of “buy-in” at different levels seems to vary. Certainly an institution such 
as the Seruka Center understands that sexual and gender-based violence, 
including domestic violence, are enormously serious issues requiring continued, 
intense attention. At senior government levels, as well, there seems a willingness 
to discuss and a serious commitment to dealing with these issues, resources 
permitting. 
At provincial and district levels, the level of commitment is harder to quantify. The 
evaluation team felt that, in its interviews and FGDs, people tended to downplay 
the issues. Sadly, there is a stigma attached to women who come forward to 
report domestic violence, so the tendency is not to do so. When women are 
brave enough to come forward, they may be sent to have ARVs initiated by 
doctors in the hospital because nurses in the health center have not been 
properly trained. Changes in practices and policies, and especially in attitudes, 
come slowly. Efforts to bring them about must be unrelenting. 
4. What have been the significant challenges faced by the project? How 
have they been, or could they be, addressed? 
Delays in implementation. Mention was made earlier of significant delays that 
occurred, over which Flex FP project management had no control, between the 
time the CA was awarded and significant project interventions could be initiated. 
These included indecision on countries to be targeted, and the insecurity 
situation in the DRC. Testing of models of service delivery for populations in 
22
transition did not in fact begin until well into Flex FP’s second year, and most 
service activities took place during the second half of the four year project. 
Delays in implementing projects are not unusual, especially when dealing with an 
experimental project design with a regional focus, i.e., one requiring approvals 
and development of work plans in more than one country. In this case, although 
project activities were indeed held up, the full project budget was ultimately 
utilized as intended, thanks to the decision to grant the project a six-month 
unfunded extension. But in retrospect, given its complexities, USAID/EA might 
have been well advised at the outset to approve a five-year project, rather than 
one with a duration of only four years. 
Treatment of SGBV victims. The low level of patients, largely women, 
presenting for treatment and counseling as the result of sexual and/or domestic 
violence will remain a challenge well into the future. Training a limited number of 
service providers and master trainers at the Seruka Center, and establishing 24-
hour drop-in centers for victims, were important first steps in meeting this 
challenge, and in helping to raise the profile of the issues, but much more is 
needed. 
The goal now must be to strengthen available services through (1) expanded 
training of service providers; (2) ensuring routine availability of standardized PEP 
kits at health centers; and (3) reinforcement of policies that permit trained nurses 
at the health center to initiate ARV treatment for HIV+ patients. Too often patients 
are referred to doctors at the hospital for such initiation, with obvious negative 
implications in terms of transportation costs and time lost. 
Equally important will be more accessible, informed counseling of victims as to 
their options in seeking legal redress for their suffering. Realization of these 
goals could hopefully establish a climate that is more “user friendly”, one that 
would convince more women to come forward. 
But this will be a slow process, and this report has touched on some of the 
reasons as they have surfaced in the course of this project. For an excellent, 
expanded description of the cultural, technical and policy-related obstacles to 
greater and more accessible utilization of SGBV treatment and counseling, 
readers are referred to the October 2012 report by the Respond Project on 
“Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, 
Burundi.” 
CBD. Two challenges face the maximization of community-based distribution of 
contraceptive services. Utilization of nurses in the DRC to provide injectable 
contraceptives in the community grew from the availability of unemployed trained 
nurses who could fill this role. Many were subsequently employed by the MOH 
and now provide both CBD and clinic-based services. This gives rise to the 
suggestion that Burundi and other countries could seek out trained but 
23
unemployed nurses, clinical officers and others who are available in the 
community and could be trained as CBDs to provide injectables. 
These countries would also need to pursue a parallel track to overcome policy 
obstacles to such utilization of these cadres. Despite rigorous effort, Flex FP was 
unsuccessful in obtaining policy changes in this regard from the Burundian MOH. 
But success in the DRC for almost three years demonstrates that this can be a 
sure-fire way to increase rates of acceptance of the most popular of 
contraceptive methods. 
The second challenge is to meet the training and support needs that are 
essential to maintaining a vibrant, responsive cadre of CBD agents in the field. 
The Government of Burundi has authorized an increase in the size of that cadre, 
but it is not clear that it has also assured the means of their support. What that 
support should entail deserves continual review. Many CBD agents with whom 
the evaluation team spoke were outspoken in expressing their need for some 
sort of motivation, i.e., modest financial compensation, for all that they do in their 
communities. This is of course a familiar issue wherever community health 
workers (CHW) are an integral part of national health systems, and the core 
question is one of affordability. Nonetheless, there is a need for new ideas as to 
how to reinforce motivation and effectiveness of this key cadre of health worker. 
5. What have been the costs of different models of FP/RH/GBV service 
delivery tested by the project? 
Representative costs for key Flex FP project innovations are listed, based on 
figures provided in project documents and the project office in Bujumbura. 
 Integrated mobile teams. Overall cost to the project of implementing the 
IMT model was slightly more than $24,000. For the approximately 50 IMT 
outreach sessions conducted in Burundi and the DRC the average per￾session cost came to $480. This covered fuel and other transportation 
costs, food for demonstration nutrition activity, and other small equipment 
or supply expenses. Time of health center staff and other public sector 
participants was contributed by governments. 
 The HIM model. Training of approximately 700 HIM champions in 
Burundi and another 100 HIM peer educators in the DRC came to 
$61,000. This works out to about $76 per trainee, quite reasonable when 
one considers that most individuals trained as HIM promoters remained in 
their communities to continue their promotional work. 
 CBDs. The cost of training roughly 1,100 CBD agents in Burundi and the 
DRC, including nurse CBDs in the DRC, came to $210,000, or about 
$200/trainee, which covered travel costs and per diem during training and 
starter kits of contraceptive supplies, bags, shirts, and bicycles. 
 Other training. The costs of training 24 nurses, and subsequently 5 
master trainers, in SGBV treatment and counseling at the Seruka Center 
in Bujumbura came to just over $15,000, or roughly $525 per trainee. 
24
 Renovations. The project spent $234,000 on renovations to 6 selected 
health facilities in Burundi and the DRC, for an average of $39,000 per 
facility. This included installation of solar panels to provide electricity for 
health center lighting. Contributions of equipment for most health facilities 
involved in the project, such as examination and delivery tables, sterilizers 
and other clinical equipment, and plastic rain collection barrels, were 
covered under a separate budget line item. 
The evaluation team was not able to make comparisons of these costs with 
similar costs for other projects. This was in part a function of time pressures, and 
in part because of the unique nature of Flex FP. However, based on team 
members’ experience over time with projects offering similar services, it feels that 
these costs are low to moderate, and in any case quite reasonable, especially as 
regards IMTs, HIM, and CBD training. It felt that costs of training offered by the 
Seruka Center were extremely reasonable. 
6. What aspects of Flex FP have the potential for replication or scale-up at 
regional or country levels? 
The evaluation team feels that, among the models for providing FP/RH/GBV 
services to underserved populations in transition situations that have been tested 
by the Flex FP project, three have the most potential for replication and scale-up. 
Integrated mobile teams. The team found that the particular format and 
approach to mobile community outreach represented by the Flex FP project’s 
IMTs has great potential for expansion and replication wherever underserved 
populations, whether in transition or simply neglected, are found. The 
integrated nature of the model, that provides a full range of primary health 
services at a pace and in settings that recognize the realities of peoples’ lives 
and situations, and makes the most of local resources, service providers and 
volunteers, is well suited to such situations. 
Healthy Images of Manhood. 
The HIM model was tested in 
quite limited settings in Burundi 
and the DRC, but the enthusiasm 
and acceptance that it clearly 
generated convinced the team 
that it is a model for addressing 
gender issues that should be 
taken to scale. Especially if 
accompanied with carefully 
developed publicity, it shows 
great promise as a strategy for 
developing a movement to 
increase awareness of the pain and terror of SGBV, engaging men to become 
more co-equal partners with their wives in shouldering family burdens, and 
25
making them active promoters of contraception for the purpose of spacing 
births. (Convincing men and women to embrace the concept of small families 
is a long shot, but if people determine that having 5-6 children makes more 
sense than having 8-9, progress will have been made!) 
CBD. Community-based distribution of contraceptive services is not a new 
model, but the Flex FP project has once again proved its importance and its 
viability. The project’s approach to CBD training and follow-up has produced 
impressive results in terms of methods distributed in target provinces and 
health zones. Given its importance to rural health outreach in many countries 
(CBDs are trained not only to inform on and distribute contraceptives, but also 
refer people to the nearest health facility for other health issues), the model 
needs constant analysis to determine ways that it can be strengthened. 
V. CONCLUSIONS AND RECOMMENDATIONS
 The evaluation team clearly felt that three models tested by the Flex FP 
project, Integrated Mobile Teams, Healthy Images of Manhood, and 
Community-based distribution of contraceptive information and 
methods, have been widely appreciated and accepted and should be 
replicated and scaled up in these and/or other countries or regions. 
Pathfinder and its partner, IntraHealth, deserve great credit for 
implementing these models so carefully and successfully. 
 With specific regard to CBD, strengthening the model should continue to 
be a priority, as should every effort for the (very reasonable) costs of 
fielding CBD agents to be covered under Ministry of Health budgets. This 
is especially true when, as in Burundi, government policy is specifically 
increasing authorized numbers of these community health workers. Where 
that is not yet possible, financing schemes along the lines of the 
performance-based financing approach are the next best thing. 
 Contingency planning has its place, especially in areas and circumstances 
of potential conflict or unrest. But such planning should be simplified and 
limited to a specific area of interest. In this case that would be assuring 
that the MISP for victims of SGBV is immediately accessible, in sufficient 
quantities, for any emergency, and that health service providers are 
appropriately trained in its utilization. 
 SGBV remains a sensitive issue. Focused attention must be paid to 
increasing awareness of its often tragic results, and to continually 
improving access to and quality of services for those affected. One 
specific measure in this regard would be to ensure the capacity of trained 
nurses at the health center level to initiate ARVs for HIV+ women, and to 
eliminate any policy obstacles to such services, real or imagined. A 
second would be to give service providers and counselors more training in 
helping victims of violence to seek legal redress for damage done them. 
26
 Even when health providers are fully trained to offer GBV services, and 
selected facilities offer 24 hour services, PEP kits may not be available. 
Where they are, they often contain two, instead of the recommended 
three, ARVs. This is a situation that must be rectified and standardized. 
 Flex FP was intended by USAID/EA as a pilot project, to test particular 
innovations on a small scale over a finite period of time, and to determine 
which models would be appropriate for replication and scale-up in these or 
other regions or countries. Since it did not seem to be expected, the 
evaluation team has stopped short of recommending a second Flex FP 
phase along the same lines and in the same locations. If, however, the 
project were approved for a second phase, even while the models it tested 
are also being implemented elsewhere, it could continue to be a laboratory 
for approaches to serving populations in transition. It could take the HIM 
model to more varied population groups. It could work towards greater 
sharing of roles and costs of IMTs with local entities, and to transitioning 
key activities to the government or other partners. In Burundi, it could 
potentially achieve approval for trained nurse CBD agents to deliver 
injectable contraceptives in the community. It could make 24-hour drop-in 
centers a fully viable concept. In short, a second phase of Flex FP could 
expand substantially on progress achieved in the first. 
VI. LESSONS LEARNED 
 It was apparent to the evaluation team that the nature of IDPs, refugees 
and other population groups in transition served by the Flex FP project is 
changing, and has done so over the life of the project. Situations are fluid, 
and there will always be some movement of residents of these 
communities, whether back to their original homes or somewhere else. 
But in the absence of disruptive events they are tending more and more to 
stay where they are, where they have rebuilt their lives. This calls for 
ensuring access to services more like those provided to more settled, non￾transient communities, rather than populations at risk and on the move. 
 In settings where access to basic health services is limited, there is no 
substitute for bringing mobile, integrated services to the people where they 
live and work. It is also important to do it on a regular, dependable basis, 
and in a way that allows members of a community to obtain all primary 
care services required, and have all questions answered, on a confidential 
basis when necessary. The Flex FP project IMT model did this with its 
day-long sessions in remote locations, and did so at reasonable cost. 
Where IMT visits cannot be maintained following conclusion of the project, 
they will be greatly missed, and community health may suffer. 
27
 Operationally speaking, trying to rush a project into operation without 
being fully prepared can lead to frustration, delays, and under-expenditure 
of its pipeline, at least in its early stages. This is especially true of a project 
such as Flex FP, which, while relatively small (total budget of $4 million), 
was breaking new ground in terms of services and target populations, and 
doing it in more than one country and in a variety of settings. 
 It is also important to note that insecurity, especially in the DRC, was a 
major contributor to delays in project implementation. In some instances, 
notably where health facilities were badly damaged, services were 
significantly disrupted. 
 A strong, dependable contraceptive logistics system in Burundi 
contributed to the success of the Flex FP project. Burundi has not 
recorded stock-outs of contraceptive commodities in many years. 
 HIM works, at least on a “micro” level. It is simple. It is low cost. And the 
champions and peer educators trained as its ambassadors are of the 
community, so their knowledge and motivation will remain a constant. 
 Combating sexual and gender-based violence is a long, slow process. 
HIM and models like it, if vigorously pursued, will help raise awareness. 
Training and retraining of nursing staffs, and ensuring availability of 
supplies and comprehensive services at health centers, should gradually 
increase utilization. But the efforts of policy makers, NGOs, service 
providers and the community must be unrelenting in creating a climate 
where SGBV is no longer tolerated in any form, and the stigma of making 
it public is erased. 
28
ANNEX I 
FLEX FP END-OF-PROJECT EVALUATION 
Interview Guide 
Methodology Note 
Interview questions, and the way they are posed, will be adapted to suit 
interlocutors or groups of interlocutors with varying levels of literacy, using the 
participatory data collection methodology. For example, if dealing with a rural 
association, versus an urban NGO, instead of using the interview technique with 
the questionnaire in hand, the evaluator will use a more conversation-based 
technique (either through focus groups or informal group chats). 
In such cases, the overall assessment of project achievements, shortcomings, 
and impact will be addressed by focusing on the who, what, when, where, how, 
and why questioning technique. 
LTL Strategies is sensitive to the need to remain flexible in the use of data 
collection methods, given that Flex FP has been implemented and managed in 
both urban and rural settings, and in a conflict-prone region. 
The following interview guide, therefore, is a sample, and will be dynamized and 
adjusted to suit the various situations we may encounter on the ground. 
Participatory Data Collection 
Participatory data collection is generally associated with qualitative methods of 
information gathering. Qualitative methods, in comparison to quantitative 
methods, tend to be more concerned with words than numbers. Qualitative 
methods are therefore based on data collection and analysis of that data. The 
focus is on interpreting the meaning of social phenomena based on the views of 
the participants of a particular social reality. (e.g., health training and product 
recipients in a rural, conflict-prone, or post conflict reconstruction setting). 
Participatory approaches contain a variety of data collection methods: (a) 
participatory listening and observation; (b) visual tools such as maps, daily 
activity diagrams, institutional diagrams and Venn diagrams, flow diagrams and 
livelihood analysis; (c) semi-structured interviews; and (d) focus group 
discussions. Among the participatory methods of evaluation, semi-structured 
interviews and focus groups are the most often used instruments for gathering 
the views of participants on certain topics and issues, particularly with 
interlocutors who are either illiterate or have relatively low levels of literacy. 
Participatory listening and observation, using various visual tools, would normally 
be undertaken at the initial stages of the evaluation process as they often provide 
the basis for the design of in-depth questionnaires for semi-structured interviews 
29
and the conduct of focus groups. 
Mixed Methods for Rapid Data Collection; Focus on Qualitative 
LTL Strategies is aware of the relatively short amount of time available to 
conduct the fieldwork for this evaluation, and of the need to “hit the ground 
running.” We will consult closely with our colleagues from USAID/EA, as well as 
with the representatives of implementing partners Pathfinder and IntraHealth to 
quickly get an initial sense of the literacy levels of our intended interlocutors, as 
well as of the methods they have already used to collect information. We will 
also inquire of, and carefully consider, the types of groups to be interviewed (e.g. 
youth groups, women’s groups, gender-based violence victims, first response 
care providers, community leaders, etc.). Based on this information, we will 
adjust this questionnaire and approach on the ground, on an interlocutor-type-by￾interlocutor-type basis. 
LTL will employ a mixed methods (quantitative and qualitative) strategy. LTL’s 
proposed methodology is based on a philosophy of the importance of 
appreciative inquiry. In designing the mid-term performance evaluation, LTL will 
use an appreciative inquiry approach – “What worked, and how can we get more 
of it?” LTL’s commitment to appreciative inquiry is predicated on an assets-based 
approach (towards both the suppliers and consumers of a program or service) 
that assumes that a) there is always something useful that comes out of program 
design and implementation, despite any challenges that may have occurred; and 
b) that there are tangible, and sometimes unidentified organic resources of 
excellence among beneficiary groups. 
In addition to a review of project documents to include the monitoring plan 
(especially benchmarks) established in the initial program document, LTL will 
conduct a mix of key stakeholder interviews and focus groups, and assess 
quantitative data (to the extent that it is available) to perform this evaluation. 
While quantitative questionnaires are structured in the variety of answers that a 
respondent chooses from, qualitative surveys and focus groups allow for more 
nuanced, semi-structured and open-ended responses. The objective of 
qualitative designs is to capture values, attitudes, and preferences of participants 
to permeate the ‘how’ and the ‘why’ underlying a phenomenon. Since data 
resulting from qualitative research approaches does not lend itself to numerical 
coding, evaluation of qualitative findings is more complex compared to 
quantitative research results. Tables, rows of data, or correlations are therefore 
not generated by qualitative research. Information collected will be grouped 
under topical headings and generalized in its diversity. 
Guiding Principles: Developmental Evaluation in Conflict Situations 
30
As we noted in our proposal, our approach will be based on careful consultation 
and collaboration with the Missions in Burundi, the DRC, and USAID/East Africa. 
Our overall approach is designed to support USAID/East Africa’s objective of 
assessing Flex FP’s success, and in extracting [potentially replicable] lessons 
learned about providing useful reproductive health services in crisis –particularly 
conflict—situations. 
Conflict, conflict transition, post-conflict reconstruction, and conflict-prone 
situations are complex by nature, and challenging to evaluate. Part of the 
challenge in evaluating conflict situations is that “causes” (conflict drivers and 
conflict triggers) are difficult to isolate, often rendering -–at best— a somewhat 
weak type of correlation that many evaluators may hasten to qualify as “inputs” 
that lead to the “effect”: conflict (or “outcome”). LTL understands that correlation 
is by no means definitively causality, and that when it comes to evaluating 
program efforts in conflict situations, complexity concepts must be considered 
and integrated. Complexity concepts can be used to identify and frame a set of 
evaluation approaches and [ultimately] program interventions appropriate to the 
often ambiguous and unpredictable nature of conflict contexts. Complexity 
concepts can be applied to enhance innovation and use in an evaluation mode 
known as Developmental Evaluation.3
 Developmental evaluation is a dynamic 
evaluation approach that goes beyond the classically summative (and often 
static) assessment in order to extract lessons learned or best practices to 
develop something: 
 A new program or policy based on medium- or long-term impact 
attributable to the distinct complexities and cross-cutting elements of 
conflict contexts; 
 A rapid response based on a sudden major change in a conflict-prone or 
conflict environment (emergency humanitarian assistance that also needs 
to support medium-term development goals in a country); or 
 An adaptive program effort designed to take an innovation to scale to 
increase impact and contribute to major systems change.4
Differentiating between Outcome and Impact 
Outcomes 
 Has the Flex FP program successfully identified approaches for 
developing models of a minimum package of family planning and GBV 
services to offer during emergency or unstable situations? What criteria do 
 
3
Patton, Michael Quinn, 2011. Developmental Evaluation: Applying Complexity 
Concepts to Enhance Innovation and Use (New York and London: Guilford Press). 
4
Ibidem. See Chapter 7: The Adaptive Cycle 
31
the program implementers use to analyze this? How do the intended 
beneficiaries analyze this? 
 Has Flex FP been able to realize an “early planning” strategy (e.g., in an 
unstable or potentially explosive socio-political situation, has the program 
been able to predict and prevent, or reduce the occurrence of rape?) If so, 
is this strategy applicable beyond Burundi and the DRC? 
 Has a core cadre of trainers been developed? If so, how effective has it 
been in training others (numbers and impact of those trained on other 
communities)? If not, what were the impediments to establishing this core 
cadre of trainers, and how might this obstacle/these obstacles be 
overcome in the future? 
 Has Flex FP been able to establish mobile outreach teams? If not, why 
not? 
 Has Flex FP been able to establish and successfully run 24-hour drop-in 
centers? I fnot, why not? 
 Has Flex FP provided post-rape and GBV services? If not, why not? 
 Has Flex FP been able to develop and test community-based distribution 
of Depo Provera? 
Impact 
 Has the impact of the services provided (drop-in centers, training of core 
cadre of trainers, post-rape counseling, contraceptives distribution, etc.) 
been the same in Burundi’s Muyinga and Kayanza provinces as in the 
DRC’s Bukavu? Why or why not? 
 Has the Flex FP project had an impact on perceptions of women’s human, 
social, and reproductive health rights in the communities in which it has 
been implemented? Why or why not? 
 What has been community reaction to the distribution of Depo Provera? 
To what extent has religion or culture played in role in that reaction? Why 
or why not? 
 Has the Flex FP project successfully collaborated with agencies working in 
the humanitarian aid field, and with those offering reproductive services 
and family planning and gender-based violence? If so, has this resulted in 
any kind of integrated emergency services among various 
agencies/organizations providing health services in crisis areas? If not, 
why not? 
 How, if at all, has the Flex FP project affected border community relations 
between Burundi and the DRC? 
Interview Guide 
32
1.) Overall project performance (Questions to be asked not only of 
implementing partners - Pathfinder and IntraHealth – but also, selectively, 
of principal stakeholders, notably Ministries of Health and NGOs in 
Burundi and the DRC with which the project has interacted.)
 What have been the principal achievements and challenges of the Flex FP 
project in reaching vulnerable populations with family planning and 
reproductive health services?
 How successful has the project been in reaching out in new and coherent 
ways to victims of sexual violence to provide them with dependable 
counseling and services?
 The project was designed to develop and test “flexible approaches” or 
models of service delivery to communities in different crisis situations. Has 
it done so, and which models have been most successful?
 To what extent have the project and its inputs contributed to strengthened 
quality and integration of services at national, provincial and community 
levels?
 To what extent has the project contributed to the strengthening of national 
health care policies, including contraception-related policies, as regards 
delivery of services to vulnerable populations?
 What is the project leaving behind? In other words, how much of what it 
has initiated will be sustainable over the long term?
2.) Access to services (Questions to be asked of health authorities and 
service providers at provincial and health facility levels.)
 How has the menu of service delivery options tested by the Flex FP 
project been applied to increasing access to FP, RH and GBV services for 
vulnerable populations? How have they complemented existing public 
health services? What is the likelihood that these new services will 
continue to be provided with the ending of project financial support?
 Please describe the steps involved, and any obstacles encountered, in 
implementation of the Minimum Initial Service Package (MISP) for 
reproductive health.
 Please comment on the strengths and weaknesses of such innovations as 
24-hour service delivery; mobile outreach teams; Healthy Images of 
Manhood (HIM) activities.
 Is access to contraceptive services, including community-based 
distribution of injectables and other contraceptives, as well as emergency 
contraception, assured in your area or facility? What are the obstacles, if 
any, to complete access?
 What are the principal challenges to FP/RH/GBV service access, and how 
has the Flex FP project strengthened such access?
33
3.) Quality of services (Questions to be asked of health authorities, service 
providers, and, where appropriate, clients at provincial, health facility and 
community levels.)
 How have Flex FP project interventions and innovations enhanced the 
quality of services provided to vulnerable populations in your area?
 What training or retraining has been provided under the Flex FP project? 
Please comment on its quality and comprehensiveness. In what areas do 
you feel that more training was/is needed? Has follow-up of trainees been 
effective? Will training continue to be available after cessation of project 
activities?
 How does quality and comprehensiveness of services offered at static 
health facilities compare with those provided by integrated mobile 
outreach teams (IMT)? 
 How have IMT services evolved over the life of the Flex FP project? Which 
services provided by IMTs are most appreciated? What is the follow-up 
system for patients served by IMTs? 
 Have supplies of contraceptives and other drugs and clinical materials 
provided by IMTs and static clinics been dependable? 
 What role to community health workers (CHW) play in providing 
information and services in the community? To what extent has 
community outreach by the FlexFP project resulted in increased 
knowledge and more positive behaviors at community level?
4.) Collaboration and coordination (Questions to be asked of MOH and 
NGO representatives at national and provincial levels.)
 How effective has coordination been between those implementing the Flex 
FP project, the MOH and local health authorities? Have there been 
significant obstacles, such as communication breakdowns or policy 
differences, that have hindered complete “buy-in” to the project on the part 
of these authorities? 
 How effective has coordination been between those implementing the 
project and local NGOs (such as ABUBEF in Burundi) as well as with 
international organizations? 
 Have the different approaches and models developed through the project 
(IMTs, 24-hour services, etc.) been well coordinated and complimentary? 
5.) Sustainability and scaling up (To be explored at all levels. This 
question will be asked in different ways on several occasions, because it 
is a key question for the future.)
 Which approaches/models developed under the project will be/are being 
maintained following termination of the project?
34
 Which aspects of the FlexFP project have greatest potential for replication 
or scaling up, at regional or country level, should additional funding be 
available?
35
ANNEX 2 
PERSONS CONTACTED 
BURUNDI
Dr. Juma Ndereye Directeur, PNSR 
Dr. Irenée Directeur des Services de Programme de Santé 
Josiane Karirengera Coordinatrice, Centre Seruka 
Mme. Léoncie Chargé Programmes des Jeunes, ABUBEF 
Dr. Eric Manirakita Médecin Directeur, Province de Muyinga 
Dr. Alexis Superviseur, District Sanitaire de Muyinga 
Dr. Jean Baptiste Médecin Chef, District Sanitaire de Gasholo 
Dr. Nestor Superviseur, District Sanitaire de Giterangi 
Jean Buchman Mpabansi Principal Advisor, Governor of Muyinga 
Jean-Baptiste Rumditse Nurse-in-charge, Kinazi Health Center 
Community leaders Nyarunazi Peace Village (IDP camp) 
HIM Champions Commune de Gasorwe 
M. Athanase Gouverneur, Province de Kayanza 
Dr. Jean Nepo Chef de District Sanitaire de Kayanza 
Nurse-in-charge Centre de Santé, Rubura 
DRC
Dr. R. Nyamugaragaza Directeur, PNSR, Province Sud-Kivu 
Estelle Bahati Superviseur, PNSR, Sud-Kivu 
Dr. Renée Médecin Chef de Zone de Santé, Walungu 
Nurse-in-charge Centre de Santé de Référence, Bideka 
Crispin Ishingwa Centre d’Information pour le Pays (civil society org.) 
Nurse-in-charge Centre de Santé, Kibododo 
Integrated mobile team Mugogo 
Dr. Julien Mbalama Médecin Chef de Zone de Santé, Miti 
Rafiki Mulihand Administrateur et Gestionnaire, Miti 
Godefroid Mayala, MD FP & RH Mgt. Specialist, USAID/Kinshasa 
PROJECT TEAM (partial listing; all Pathfinder unless otherwise noted)
Tanou Diallo Chief of Party 
Chantal Inamahoro Deputy COP 
Theoneste Nimpagaritse FP/MCH 
Diane Nezerwe Project Officer 
Jean Paul Niyibigira M&E 
Franck Akamba Field Coordinator, DRC 
Tharcisse Niyonizigiye IEC/HIM InItiative (IntraHealth) 
Jaques and Napoleon Drivers 
USAID/EA
Julia Henn USAID/EA/RHH Director for Technical Support 
Wairimu Gakuo USAID/EA/RHH Strategic Information Specialist 
36
ANNEX 3 
BIBLIOGRAPHY 
(A listing of some of the documents consulted for this evaluation.) 
Plan Stratégique de Santé de la Reproduction, 2010-2014, MOH/PNSR, Janvier 
2010 
Normes des Services de Santé de la Reproduction, Juillet 2012 
Plan de Contingence National de Gestion des Urgences, Mai 2012 
Plan de Contingence, Province de Muyinga, Octobre 2012 
Plan de Contingence, Province de Kayanza, Décembre, 2012 
Étude de Faisabilité et de Mise en Oeuvre de Distribution des Contraceptifs 
Injectables à Base Communautaire en Faveur des Populations Vivant en 
Situations de Transition au Burundi, Pathfinder, Mai 2010, Nzirubusa Pascal, 
Consultant 
Analyse Situationelle en Matière de Planification Familiale/Santé de la 
Reproduction et Violence Basée sur le Genre dans les Sites d’Intervention du 
Projet PF/VBG au Burundi, Janvier 2010, Habimana Faustin, Consultant 
Flex FP Quarterly Reports, April 2009 – December 2010 
Flex FP Quarterly Reports, January – December, 2011 
Flex FP Quarterly Reports, January – December, 2012 
Evaluation de la Violence Sexuelle au Burundi, Août-Septembre, 2011, The 
Respond Project, for USAID/Burundi 
Services for Sexual Violence Survivors in Kayanza and Muyinga Provinces, 
Burundi, October 2012, The Respond Project, for USAID/Burundi 
Healthy Images of Manhood, IntraHealth International, January 2013 
Burundi, Internal Mid-term Review, Flexible Family Planning, Reproductive 
Health and Gender-based Violence Services for Transition Situations, October 
2010, Cathy Solter and others 
Burundi Flex FP Project Proposal, 2008 
37
ANNEX 4 
EVALUATION TIMETABLE 
BURUNDI 
March 18, Bujumbura - briefings with Pathfinder and IntraHealth Flex FP project 
staff; meetings with Dr. Irenée and Dr. Juma of the Burundian MOH; visit to the 
Seruka Referral Center for victims of sexual violence, as well as the site used for 
training in treatment of SGBV over the life of the project.
March 19-20, Muyinga Province – meet with provincial and district health 
officials; visit to Nyungu District Health Center and IMT site; visit to Kinazi Health 
Center, refurbished with project assistance, and Mugano Peace Camp (no longer 
populated); visit to Nyarunazi Peace Camp for IDPs; visit to Gasorwe Commune 
and Refugee Camp to meet with HIM “champions”; FGDs with CBD agents and 
beneficiaries at health center and community levels. 
March 21-22, Kayanza Province – meetings with provincial and district health 
officials; visit to Rubura Health Center, refurbished with project assistance; visit 
to Nyarurama IDP Camp and Health Center, also refurbished with project 
assistance; visit to Rugogwe colline to see District IMT in action; FGDs with 
CBDs and beneficiaries. 
March 29, Bujumbura - visit to ABUBEF and follow-up visit to Seruka Center; 
debrief on evaluation to date with USAID/Burundi. 
DRC
March 25 – travel from Bujumbura to Bukavu; meet with Pathfinder DRC team; 
discussion with Dr. Nyamugaragaza, Director, PNSR, South Kivu Province. 
March 26 – accompanied by Walungu Health Zone officials, visit to Walungu 
Hospital and referral clinic, renovated and equipped by the Flex FP project; 
FGDs with service providers, CBDs, beneficiaries and HIM peer educators (the 
equivalent of HIM champions in Burundi); visit to Bideka Health Center; FGDs 
with CBDs and beneficiaries. 
March 27 – return to Walungu Health Zone to meet civil society organizations to 
discuss HIM model; visit to Kidodobo Health Center, refurbished by project, for 
FGDs with CBDs and beneficiaries; visit to Kavumu Health Center, refurbished 
with project assistance; lengthy visit with IMT in action in remote rural area. 
March 28 – travel to Miti Health Zone to meet with local officials and discuss the 
future “after Flex FP”; visit to Kavumu Health Center; FGDs with HIM peer 
educators, CBD agents, beneficiaries. Brief meeting with USAID/Kinshasa staff 
person in Bukavu to update him on evaluation team activity. 
38