9 Lessons for Sustaining Family Planning Interventions with Governments
Earlier this year, EngenderHealth and its partners transitioned leadership of its maternal and reproductive health program to the Government of Tanzania. The successful transition to government ownership of the Maternal and Reproductive Health Project (MRH) was the result of consistently building the government’s capacity to sustain program interventions.
The MRH Project used a variety of strategies to increase the potential for government ownership of and investments in successful project interventions beyond the life of the project. These strategies strengthened local government capacity to deliver services and educate women, girls, and community members about family planning and postabortion care services.
The project improved maternal and neonatal health and increased contraceptive prevalence by improving access to maternal and reproductive health services, particularly emergency obstetric and neonatal care (EmONC), and contraception. Interventions included:
- upgrading facilities
- supplying essential drugs and equipment for family planning and EmONC
- providing training and supportive supervision in EmONC and contraceptive technology
- ensuring adequate contraceptive supplies.
Under the project, Thamini Uai led the EmONC interventions, while EngenderHealth expanded access to family planning and postabortion care services. EngenderHealth built the local government’s capacity to sustain these services using the Supply Enabling Environment Demand (SEED) model. The SEED model is based on the principle that sexual and reproductive health programs will be more successful and sustainable if they comprehensively address the multifaceted determinants of health, and if they include synergistic interventions.
EngenderHealth offers the following recommendations for sustaining the interventions going forward, both in Tanzania and beyond.
1. Leverage existing government structures to sustain interventions.
Sustaining interventions beyond project-specific donor funding requires sound technical, management, and budget support from the government. EngenderHealth’s experience implementing the MRH Project in Kigoma shows that leveraging existing government structures and systems—such as the national task-shifting policy that allows non-physicians conduct EmONC and decentralization of comprehensive EmONC services to low-level health facilities—helps to increase the potential for the government’s ownership of interventions. It is essential to work closely with the government going forward to identify existing structures, such as public health delivery systems and data management and information systems, that can be strengthened to sustain project initiatives over time. Any new systems and structures should be integrated easily in existing structures and systems using limited resources.
2. Strengthen local government capacity to support family planning and postabortion care services.
In Kigoma, the Regional Medical Officer established a technical team to train providers and provide mentorship to health facilities (both facilities supported by the MRH Project and those that did not receive project support) on family planning and postabortion care. Each district in the Kigoma region had two mentors/”trainer of trainers” who helped to ensure all family planning and postabortion care providers provided services that adhered to national and global service delivery standards. The mentors reduced need for the MRH project to provide oversight and improved providers’ capacities to offer high-quality services.
3. Invest in facility management and leadership capacity.
Facility management and leadership capacity are as vital as clinical skills. The MRH Project not only focused on the strengthening providers’ clinical skills but also supported the local government to strengthen health facility leadership and management capacity. Fostering good leadership and management helped to increase staff morale and ensure clients’ access to quality family planning and postabortion care services. Facility in-charges integrated their new skills soon after training, and as a result, providers expressed improved morale and clients expressed satisfaction with services.
4. Upgrade health facility infrastructure and equipment to improve services and staff productivity.
EngenderHealth renovated and equipped 31 health facilities in Kigoma (5 comprehensive EmONC health centers and 26 dispensaries). The 31 facilities served 145,922 clients, and providers remained motivated throughout the implementation period. To ensure the facility remains at the same standard beyond the life of the MRH Project, EngenderHealth trained health facility in-charges to budget for equipment and health facility maintenance. Going forward, the government must continue to provide technical assistance and supportive supervision, continuing to improve the management capacity of the health facility in-charges.
5. Ensure mentorship is used to improve health providers’ skills.
It is easy to assume once the providers have undergone family planning and postabortion care training that they will return to their health facilities and offer high-quality health services. This is not often the case. In some cases, providers fail to practice their skills; in others, providers stop providing services altogether. Mentorship should be used to continually build staff confidence and skills to offer family planning and postabortion care services. Providers mentored through the MRH Project scored high in delivery of services, meeting the minimum standards set by the Ministry of Health during training certification reviews. Many have continued to offer family planning and postabortion care services.
6. Develop a robust community engagement plan.
The MRH Project continuously engaged the community to ensure they held their local leaders and health facility management committee accountable. Community participation in improving the quality of health facilities through EngenderHealth’s COPE® complimented government support, in the form of financial and in-kind contributions, to improve health facility infrastructure. At the same time, community participation allowed individuals to learn more about available health services.
7. Do not ignore the routine services.
Outreach services expand access but do not ensure continuity of services. For women and girls to have continuous access to family planning and postabortion care services, routine services need to be strengthened. Outreach services should serve as an additional mechanism to expand access to family planning services and strengthen health facility capacity to deliver family planning services through routine care. Outreach services should be integrated and linked back to the health facilities in the catchment area to ensure continuity of services over time.
8. Ensure providers and the community value data.
In the past, both partners and Health Management Teams emphasized the collection of quality data, rather than increasing the value of data to users. When providers do not understand the value of data, they may fail to ensure the collection and use of high-quality data. The MRH Project linked data collection and use with direct health financing and results-based financing initiatives. The inclusion of family planning and maternal health indicators in results-based financing encouraged providers to value data and the community to monitor facility performance closely through the health committees. Additionally, decentralization of budget planning and management hastened providers’ use of data.
9. If you want to sustain the interventions, have a long-term investment plan.
Through the MRH Project, we have learned short-term projects do not last. It requires time and considerable effort to design, learn, and deliver an intervention that is context sensitive. During the implementation of this project, we adopted different initiatives and accepted failure quickly. System strengthening requires partners to engage and allow the system to correct itself. To achieve this, projects designer needs to have a long-term investment plan, which will develop or change depending on the reality on the ground.