In-depth with the Evidence Project: Episode 1

Ben Bellows on strengthening provision of family planning through the public sector in Zambia

Ben Bellows

In the first installment of the Evidence Project’s new podcast, In-depth with the Evidence Project, Ben Bellows talks about public sector provision of family planning in Zambia. Bellows talks about the first Scaling Up Family Planning project (led by Abt Associates, with funding from DFID) and how results from that project are informing government and donor efforts to increase demand for and supply of family planning through the public sector.


This episode leave you wanting more? Check out episode 2!


Kate Gilles

Hello, and welcome to the first Evidence Project podcast. In this series, we'll be talking to Evidence Project researchers from around the globe for an inside look at their work to strengthen family planning programs and reproductive health programs through implementation research.

Today, I'm speaking with Ben Bellows, an associate with the Population Council’s Reproductive Health Program in Zambia, and a researcher on the Evidence Project. We're going to talk about public sector provision of family planning in Zambia and the Scaling Up Family Planning Project, or SUFP. SUFP ran from 2012 to 2016. It was funded by the United Kingdom Department for International Development, and it was led by Abt Associates. The Evidence Project was asked to conduct an assessment of SUFP, including the feasibility of continuing the approach at the close of the project, and a costing study which was done by MSH.

Ben, it's a pleasure to talk with you today. I'm going to start us off by asking you to give us a brief overview of the SUFP program and what it was designed to do.

Ben Bellows

Thank you very much for having me. I'm glad to get the chance to talk about some very interesting work here in Zambia. The SUFP program, as you mentioned, was funded by British DFID, and it was intended to boost public sector provision of family planning services. It started in 2012, although the contracting process and the thinking behind it was initiated in 2011. It was designed to not provide services directly, but to boost the public sector provision and supply of services and it brought a technical assistance approach, working hand-in-glove with the ministry, both at the national level and then locally, in 26 of Zambia's more than 100 districts - there are about 106 districts in Zambia now. The 26 districts were selected from regions that generally had weaker development indicators, they had high unmet need for family planning, lower contraceptive prevalence and the program was intended to both strengthen service delivery at the clinics, at these health centers, the outpatient sites, in what were largely rural areas, as well as strengthen the coordination between these sites and the communities and their catchments.

The project, SUFP, had identified what they called a district outreach coordinator, somebody who would bring a stronger emphasis and focus and priority setting for family planning to the district level management team, and then this DOC, this district outreach coordinator, would engage with the various healthcare facilities, these outpatient sites in their district and work with those providers to then link with community-based distributors, the local leadership in the neighboring communities and develop a schedule for outreach so that the providers could engage in service provision, support the community-based distributors in their service provision in a more active fashion.

This approach was to generally boost family planning services and take it to a higher level - boost the overall numbers, help women who had an interest in avoiding pregnancy find services they needed when they needed them and strengthen the supply chain so that commodities were reaching not just the facilities but - for short-term methods, for injections - were also getting out into the communities where consumers would want the services and would find the services more regularly.

There is this overall emphasis on boosting services in the facilities, but also the neighboring communities and strengthening that demand link back to the clinics. So that was the overall focus. The Evidence Project, as you mentioned, was asked to do an assessment of that, so we did look at both the implementation process and the costing, as you mentioned, and I think that was where we developed some interesting insights around the value of this particular approach, which I'd be glad to explain in more detail.

Kate Gilles

Yeah, so before we get to what you found in the report, I wanted to ask, so you mentioned that the main emphasis of SUFP was not direct service provision but was really strengthening existing public health systems and family planning services with an emphasis on reaching all the way down to the community level, and that included both this demand generation and also strengthening the supply chain all the way down to communities and really making sure that women and couples in need were being reached with family planning services through the existing public health system.

Can you tell me why public sector provision of family planning is so important in Zambia?

Ben Bellows

Great question. Public sector services are so important in Zambia. Just given their size, they’re the single largest network of family planning providers in the country, and outside of urban areas, the public sector really is the only provider. Well, one of the major ... the most significant provider, let's say, of family planning services in rural areas. There are not-for-profits providers who partner with government and engage in outreach activities where they'll send their teams out to government sites to boost the range of services available, for instance. But, public sector service providers are really the largest network in these rural areas, in particular, so it's a very important channel through which services can be provided and donors, when they're looking at this question of value for money, find it a good investment to strengthen provision of services and help the Zambian taxpayer achieve better value for money on the government revenues being invested in the public sector provision of family planning.

For donors looking at this equation, it makes a lot of sense to invest in public sector and to look at the mechanisms that can boost the effectiveness of public sector family planning.

Kate Gilles

You mentioned that you all have some interesting ... you've got some interesting insights that came out of the assessment that was done. I want to hear a little bit about those and, in particular, thinking about the value for money of public sector approach, what the feasibility of the SUFP approach to strengthening the public sector was, and any learning that came out of the assessment for that.

Ben Bellows

It's a great question, it's a great issue to bring up. There are a number of different topics and we explored them at some length in two reports that are available on the Evidence Project website. The reports capture both this implementation perspective, the process that went into running the project, and important elements - and fairly standard in some ways - that go into service provision, so everything ranging from leadership and governance to the question of financing at the national level, issues of workforce and health information systems, the role of supply chain management, of course service delivery. Actors at the community level, not just the health facility but also in the community. Also this role of demand, thinking about consumers or clients and that they're engaging in the system.

We have recommendations around each of these major areas. I'll just highlight a few of them here, but thinking about financing, for instance, this notion of priority-setting or agenda-setting in the national budget and then earmarking funds for different services. We recommended, and the government has been looking into this issue, earmarking funds for family planning activities, distinct from other activities that fell under mother and child health. It’s bringing greater salience to the family planning services associated with that particular budget plan and emphasizing the importance of family planning, and that translates into staffing, that translates into budgets for human resources, thinking about the SUFP project’s emphasis, for instance, on getting a district outreach coordinator, that was a project position under SUFP 1. That was an important innovation getting, at the district level, family planning, making it more visible to public health planning professionals at a district level.

The DFID approach - I'll mention this, perhaps I'm jumping ahead a bit, but the project in this next phase is thinking about the value of bringing this scaling up of family planning at the provincial level. Our recommendation, essentially, that HR is driven by a budget and that the budget-setting priorities need to emphasize the importance of family planning, I think, were carried forward both by DIFID and by the Ministry of Health.

The other element to HR, without getting too far out of myself here, is at the community level, ensuring that community-based distributors, or CBDs, were properly remunerated for their time. They have been largely viewed as volunteers, and one of the recommendations that came out of our assessment was that the CBDs ... that there ought to be a career pathway for them, that there ought to be a system in place that recognizes their effort, rewards that effort in some way and gives them a sense of progression as they become more adept at providing family planning services. Now, it's a much larger policy question that the government's been wrestling with when facing how to strengthen service provision at the community level, in rural areas where it's hard to get staff an education, where it's hard to get medical professionals, and where it's hard to provide services generally. How can you boost the presence, productivity of, essentially, lay actors? And so that's an ongoing discussion but we contributed to that and provided, I think, another perspective and some evidence that made the case that there needs to be a stronger mechanism to ensure that the community-based distributors stay with the program. It was a high turnover, the CBDs in that first initiative, so it's going to be an ongoing point to determine ... to what extent the program in the government, more generally, can on-board CBDs and their community-based service delivery.

Kate Gilles

That starts to get at my next question, which is: the first phase of the project ended in 2016, we're not too far from that, but looking back at that and then looking at where you are now with family planning in Zambia, particularly through the public sector, where do things stand now, for SUFP and for the efforts that were started under the project? You mentioned that there's some discussion around budget priorities, for example earmarking FP funds, but there is a larger conversation that is happening around compensation for community-based distributors.

From your perspective, have any of the changes been sustained, what impact has SUFP had on the discussion moving forward?

Ben Bellows

The SUFP project was unique in that it was an initiative that…it was a good example of a donor initiating a project that was supporting public sector service provision. What it produced, then, was a lot of interest in that particular model. Prior to SUFP, many of the donor activities, at least in Zambia, have been implemented to some degree in a silo. It's a bit of a stereotype here that we have, that may oversimplify the story some, but projects tend to be implemented with their own timelines and somewhat independently, perhaps, lacking coordination in some ways or with weaker coordination than ideally, with government. I think SUFP was one of these examples where there was significant coordination. Where it was well implemented with government. The result at the end of 2016 was a lot of interest in continuing this model, so the Ministry of Health had recognized the value and from my perspective, it really bought into this model of how to move forward together, government to government. There was a lot of interest in seeing this model go forward.

The result was that DIFID made a second award, SUFP 2, that just went live a few months ago. The focus now, as I alluded to earlier, was implementing a program at the provincial level, so now Western Province and Central Province both have got a provincial level outreach coordinator, family planning coordinator, that bring to the province and indirectly to the districts within those provinces a greater emphasis on family planning.

So rather than putting staff at district level, the project now has fewer staff, two coordinators, essentially, and then encouraging the existing health management infrastructure and staff, both the district and at the provincial level, to create technical working groups that emphasize and problem-solve issues around family planning. Again, it's this idea of priority-setting, of bringing greater salience to a pressing development challenge that the country faces and recognizing the value that an effective family planning program can bring to related questions that the government has to deal with on an ongoing basis.

The project has basically sat back, thought about what the value for money proposition is and scaled back its presence a bit but leveraged the staff and the presence it does have for greater impact by going to the provincial level and going forward with this notion of emphasizing family planning services which continue the idea of service delivery happening at high level referral hospitals and health centers, and most importantly, out in the communities where the bulk of the population lives, where the clients can be reached most effectively and the lowest cost to themselves in this effort.

That's what SUFP is doing now. In addition to that, there's a lot of other activity in the family planning space in Zambia. At the London summit in 2012, the Family Planning Summit in London, the country made commitments there to increase modern ... I'm sorry, all method contraceptive prevalence to 58 percent, women of reproductive age by 2020 and to reduce unmet need to 14 percent by 2020. These commitments and others related to that increasing financial commitment, for instance, in the national budget and other priorities were all driving this interest in making family planning more visible, making it an important priority in the development agenda for the country and I look forward to SUFP and the Evidence Project generating more interest in this topic, identifying what the priority questions are as well as contributing to and helping to, perhaps, settle some questions about the value of particular strategies over others. We look forward to further engagement with government, with development partners and generating, disseminating and ensuring that the evidence takes root with policymakers across the spectrum.

Kate Gilles

You mentioned opportunities to continue these discussions. You and I have talked about a couple of important meetings that will be coming up in Zambia that are either specifically about or relate to family planning. That's starting with a national family planning review meeting coming up but then also a couple of other events later this year. Do you want to talk a little bit about those and the opportunities they offer for raising the visibility of family planning and also thinking through what the remaining challenges and priorities are?

Ben Bellows

Great points, and yes, there's a lot of activity, a lot of interest in seeing family planning achieve national commitments and help their country achieve its national commitments as well as go forward more successfully to contraceptive uptake and at the end of the day families doing better because of family planning. There are a number of events planned in line with FP 2020 and the commitments that Zambia made in the London Summit 2012. There have been a series of annual family planning review meetings that take place with selected districts and provincial-level public health officers where, essentially, the country takes stock of family planning program recommendations over the previous year. Questions of supply chain management, demand generation, reaching youth and adolescence, thinking about strategies to boost overall demand. These topics are discussed, each province gets a chance to share where they are. They present trends on contraceptive distribution and they get to hear from the Ministry of Health, at the national level, from key development partners and others working in the space about the state of family planning, essentially, in Zambia. At the end, it's a three-day workshop and it starts next week so I'm very excited to be participating in this. This will be my third year.

It's a wonderful event to connect with people from across the country on topics that all of us hold dear and I'm glad to see that there's ever more interest in discussing strategies around what works and what doesn't, the learning from the successes and the failures in a way that builds consensus and agreement on how to tackle some of the challenges in family planning going forward.

Later this year, we anticipate two other consultations, two other large events. One is slated for the first week of July, it'll be a high-level stakeholders consultation around family planning, specifically looking at some of the research while taking stock of where we are with family planning, again, as well as the research priorities and research needs and the resources and means to address these research priorities going forward. That's going to be a very interesting and highly relevant meeting the first week of July.

The end of the year, in December, there'll be a larger research symposium, a multi-day event convened to take stock of where we are as a country around reproductive health, maternal health, neonatal/child/adolescent health and what the state of the research is currently in Zambia as well as what the research gaps would be going forward.

This will be an interesting opportunity, I think a unique opportunity, for universities, for research institutes like Population Council and implementation partners, Ministry of Health and others active in family planning in the maternal health space, in the reproductive health space, to submit cutting-edge research to discuss and debate topics around these research priorities and learn from each other in a very proactive and a very engaging way. A unique opportunity, I think, for the research community to come together at the end of this year.

I'm looking forward to all of these events.

Kate Gilles

I have to say, I'm very excited about the investments it sounds like Zambia and donors and implementing partners but also the government is really putting in ... thinking through this issue, thinking through their commitment to family planning and trying to ensure that they're addressing the challenges that are out there and really taking advantage of all the thinking that's going on around that.

I know that you have to prepare for that meeting next week and your presentation, so I want to thank you for taking the time to talk to us about family planning and the public sector provision of family planning in Zambia today, and we look forward to hearing more about SUFP as this next phase of it continues, too.

Ben Bellows

Great, well, thank you very much and I appreciate the opportunity to speak on this topic.