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October 2012

REPOSITIONING FAMILY PLANNING IN BENIN


A Baseline

This publication was prepared by Sabine Attama Dissirama (consultant) of Futures Group.

Photo credit: Brian Kelley Suggested citation: Maiga, Modibo, and Aissatou Lo. 2012. Repositioning Family Planning in Senegal: A Baseline. Washington, DC: Futures Group and the William and Flora Hewlett Foundation. Futures Group gratefully acknowledges the support of the William and Flora Hewlett Foundation for this research.

Repositioning Family Planning in Benin: A Baseline

OCTOBER 2012
This publication was prepared by Sabine Attama Dissirama (consultant).

CONTENTS
Acknowledgments .................................................................................................................. iv Abbreviations ............................................................................................................................v Introduction ...............................................................................................................................1 Background: Benin ...................................................................................................................3 Benins Health System .............................................................................................................................. 4 Framework for Assessing the Repositioning FP Initiative........................................................5 Methodology ............................................................................................................................................. 6 Study Limitations ...................................................................................................................................... 7 Assessment Findings .................................................................................................................8 SO: Increased Stewardship of and Strengthened Enabling Environment for Effective, Equitable, and Sustainable FP Programming .............................................................................................................. 8 Intermediate Result 1: Resources for Family Planning Increased, Allocated, and Spent More Effectively and Equitably .................................................................................................................. 10 Intermediate Result 2: Increased Multisectoral Coordination in the Design, Implementation, and Financing of FP Policies and Programs ............................................................................................ 12 Intermediate Result 3: Policies that Improve Equitable and Affordable Access to High-Quality FP Services and Information Adopted and Put into Place ...................................................................... 14 Intermediate Result 4: Evidence-based Data or Information Used to Inform Policy Dialogue, Policy Development, Planning, Resource Allocation, Budgeting, Advocacy, Program Design, Guidelines, Regulations, and Program Improvement and Management ........................................... 15 Intermediate Result 5: Individual or Institutional Capacity Strengthened in the Public Sector, Civil Society, and Private Sector to Assume Leadership and/or Support the FP Agenda ......................... 16 Recommendations for Repositioning Family Planning in Benin ..........................................18 Annex 1: Persons interviewed ................................................................................................20 Annex 2: Repositioning Family Planning Results and Indicators for Benin .........................21 References and Additional Resources..................................................................................28

iii

ACKNOWLEDGMENTS
The author thanks Margot Fahnestock of the William and Flora Hewlett Foundation for her interest in and financing for this activity, as well as her support and guidance during its planning and implementation. Many colleagues at Futures Group also deserve thanks: Maj-Britt Dohlie, Elizabeth McDavid, and Modibo Maiga for their instrumental management support, practical suggestions, and technical expertise; Karen Hardee for her support of all aspects of the studyfrom the questionnaire design to report writing; and Cynthia Green for her invaluable contributions to the report. The authors particularly thank Nicole Judice, who supported the development and pilot testing (in Tanzania) of the Framework for Monitoring and Evaluating Efforts to Reposition Family Planning and provided our study team with technical assistance related to the framework. We also thank Laura McPherson and Sandra Duvall for their insights, and Molly Cameron and Lori Merritt for editing the report. Gratitude also goes to the head of the Directorate of Maternal and Child Health (DSME) in Benin, Dr. Olga Agbohoui-Houinato. She provided indispensable assistance and facilitated our work through securing meetings with many family planning stakeholders, including her staff and important leaders at all levels. Finally, we thank Dr. Gaston D. Ahounou and the DSME staff, who accompanied the team on the district visits and facilitated access to key informants.

iv

ABBREVIATIONS
ABMS ABPF AFD AIDS AIMS/CTB AWARE II CAME CARMMA CBD CEFORP CSO DEPOLIPO DHS DSME FHI FP FSS GOB HIV INMES INSAE IPPF IR IRSP IUD JICA M&E MS NGO PASMI PNDS ProFam Association Bninoise pour le Marketing Social et la Communication pour la Sant Beninese Association for Social Marketing and Health Communications Association Bninoise pour le Bien Etre Familial Beninese Association for Family Welfare Agence Franaise de Dveloppement French Development Agency acquired immune deficiency syndrome Appui Institutionnel du Ministre de la Sant de la Coopration Technique Belge Institutional Support to the Ministry of Health of the Belgian Technical Cooperation Action for West Africa Region II (USAID-funded project) Centrale dApprovisionnement en Mdicaments Essentiels Center for Essential Medicines Supply Campagne pour lAcclration de la Rduction de la Mortalit Maternelle en Afrique Campaign to Accelerate Reduction of Maternal Mortality in Africa community-based distribution Centre de Formation et de Recherche en Matire de Population Center for Training and Research in Population Material civil society organization Dclaration de Politique de Population Population Policy Declaration Demographic and Health Survey Direction de la Sant Maternelle et Infantile Directorate of Maternal and Child Health Family Health International family planning Facult des Sciences de la Sant Faculty of Health Sciences government of Benin human immunodeficiency virus LInstitut National Mdico-Social National Institute of Medico-Social L'Institut National de la Statistique et de L'conomie National Institute of Statistics and Economy International Planned Parenthood Federation intermediate result Institut Rgional de Sant Publique Regional Institute of Public Health intrauterine device Japanese International Cooperation Agency monitoring and evaluation Ministre de la Sant Ministry of Health nongovernmental organization Projet d'Appui la Sant Maternelle et Infantile Support for Maternal and Child Health Project Plan National de Dveloppement Sanitaire National Health Development Plan Protection Familiale
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Repositioning Family Planning in Benin: A Baseline

PSI RH SNSPSR SO TAC TFR UNDAF UNFPA UNICEF USAID WAHO WHO

Family Protection Population Services International reproductive health Stratgie Nationale pour la Scurisation des Produits en Sant de la Reproduction National Strategy for the Security of Reproductive Health Products strategic objective Tableau dAcquisition des Contraceptifs Table of Contraceptive Procurement total fertility rate United Nations Development Assistance Framework United Nations Population Fund United Nations Childrens Fund United States Agency for International Development West African Health Organization World Health Organization

vi

INTRODUCTION
Demographic pressures and lack of progress toward the Millennium Development Goals have encouraged countries and donors to take a new look at family planning. Since 2001, the United States Agency for International Development (USAID), the World Health Organization (WHO), and other important partners have joined with national governments in sub-Saharan Africa in an initiative to raise the priority for family planning (FP) programs, known as repositioning family planning. The initiative was established to ensure that family planning remains a priority for donors, policymakers, and service providers in sub-Saharan Africa in an era when HIV, malaria, and tuberculosis programs dominate the global health agenda and receive a majority of the resources. Although family planning is one of the most cost-effective, high-yield interventions for improving health and accelerating development, West Africa is lagging behind all other regions in FP use. With an average of 5.5 children per woman, the region has one of the highest fertility rates and fastest growing populations in the world. High fertility leads to many unplanned pregnancies that pose serious health risks for mothers and children. In Francophone West Africa, approximately two women die from maternal causes every hour (WHO, 2012a), and one child under age five dies every minute (UNICEF, 2011). There is substantial demand for family planning in Francophone West Africa. In six of the nine countries recently surveyed, an estimated one-third or more of currently married women have an unmet need for family planning (see Figure 1).
Figure 1. Unmet Need for Family Planning
40 35 30 25 20 15 10 5 0 32 35 28 27 29 24 22 16

Percent of Women

29

Source: Most recent Demographic and Health Survey data (retrieved from http://www.statcompiler.com/).

Community-based programming is showing promise for expanding access to family planning. Many African countries have community-based programs to provide contraceptive methods and information to under-served groups, such as rural residents and the urban poor. There are vast regional inequalities in access to and use of contraceptives between urban and rural populations, with rural populations almost always having fewer options. Bringing FP services into communities is an important strategy to improve access to family planning and satisfy unmet need.
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Repositioning Family Planning in Benin: A Baseline

Several models for the provision of community-based services have been tested successfully in the region. In Francophone Africa, community-based distribution (CBD) for family planning has been identified as an underutilized strategy to reach women in rural areas. Family planning is just one of the many health services that use CBD, and community health worker training and supervision usually is integrated with these other services (child health services, malaria and diarrhea prevention and treatment, acute respiratory infections treatment, vaccinations, neonatal care, prenatal care, safe motherhood, as well as information on these and other health issues). Currently, in most Francophone West African countries, community health workers offer only condoms, refills on oral contraceptives, and referrals. The goal of USAIDs Repositioning Family Planning initiative is to increase political and financial commitment to family planning in sub-Saharan Africa, which will lead to expanded access and help meet womens stated desires for safe, effective modern contraception. The initiative has identified three key approaches or intervention areas for achieving this goal: (1) advocating for policy change; (2) strengthening leadership; and (3) improving capacity to deliver services (USAID, 2006). At the February 2011 Ouagadougou conference on Population, Development, and Family Planning: The Urgency to Act (http://www.conferenceouagapf.org/), the eight participating Francophone countries drafted action plans for repositioning family planning and appointed focal persons to spearhead implementation of these plans. 1 At a September 2011 conference in Mbour, Senegal, on civil society involvement in family planning, additional focal persons were named from civil society organizations (CSOs), and the action plans were refined further. CBD features prominently in the action plans. While many activities are underway to reposition family planning, most countries lack a mechanism for assessing the success of their efforts (Judice and Snyder, 2012). In 2011, in response to this gap, the MEASURE Evaluation Population and Reproductive Health project developed a results framework to assess efforts to reposition family planning. The Framework for Monitoring and Evaluating Efforts to Reposition Family Planning can be used by international donors, governments, and health programs to evaluate their efforts; identify gaps in strategies to reposition family planning in countries; and inform funding decisions, program design, policy and advocacy, and program planning and improvement (Judice and Snyder, 2012). After MEASURE Evaluation conducted an initial pilot test in Tanzania, the USAIDfunded Health Policy Project adapted and pilot tested the framework in Togo and Niger. 2 The purpose of this study in Benin, undertaken by the Futures Group for the William and Flora Hewlett Foundation in 2011, was to apply the framework and conduct an in-depth assessment of policies related to family planning. This report presents the results of this application, which can serve as a baseline for future assessments.

The eight countries are Benin, Burkina Faso, Guinea, Mali, Mauritania, Niger, Senegal, and Togo. The results of the pilot test and assessment of policy and operational barriers to CBD in Niger and Togo also are available (visit www.healthpolicyproject.com).
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BACKGROUND: BENIN
Located in West Africa, Benin is one of the worlds poorest countries, with an average gross national income per capita of US$1,580 in 2010 (World Bank, 2012). Three in four of Benins people live on less than US$2 per day (World Bank, 2012). Rural residents are more likely to be poor: 41 percent of rural residents and 27 percent of urban residents were classified as being below the poverty line in 2006 (Guengant et al., 2011). Economic growth has been improving, with annual increases of 3 percent or more in the gross domestic product between 2001 and 2010 (World Bank, 2012). Benins current population is estimated at 9.4 million people (Haub and Kaneda, 2012). The most recent national census, conducted in 2002, recorded a population of 6,769,914 people (Geohive, 2012). Benins population continues to grow rapidly; it is projected to grow to 13.5 million people by 2025 and 23.3 million by 2050 (Haub and Kaneda, 2012). According to the analysis done by Guengant and colleagues (2011), Benins population in 2050 could grow to 21 or 28 million people, depending on the rate of population growth. About one in four (24%) of Benins people live in urban areas (Haub and Kaneda, 2012), and these areas are growing rapidly (Guengant et al., 2011). Benin has a very young population, with 44 percent of its people younger than 15 years old (Haub and Kaneda, 2012). In Benin, rates of maternal and child mortality have declined dramatically over the past decade (Hogan et al., 2010; Rajaratnam, 2010), although they remain very high (see Box 1). A woman in Benin has a one in 53 risk of dying from maternal causes, according to World Health Organization (WHO, 2012a). One in 10 infants dies before his/her first birthday (UNICEF, 2011). Fortunately, most children who survive their first year will also reach age five. Most women have access to maternity care. Nine in 10 (88%) women received prenatal care from a health professional and nearly four in five (78%) births took place at a health facility, according to the 2006 Demographic and Health Survey (DHS) (GOB/INSAE and Macro International, 2007).

Box 1. Maternal and Child Health Indicators Maternal mortality ratio: 350 deaths per 100,000 births Lifetime risk of maternal death: 1 in 53 women Infant mortality rate: 107 deaths per 1,000 births Mortality rate for children under 5: 115 deaths per 1,000 births
Sources: WHO, 2012a; and UNICEF, 2011.

Key Health and Literacy Indicators Total fertility rate: 5.7 children per woman Contraceptive prevalence rate: 17% Unmet need for family planning: 30% Women who received prenatal care from a health professional: 88% Births taking place at a health facility: 78% Children under age five underweight: 18% Women ages 1549 literate: 28% Men ages 1549 literate: 55%

Source: GOB/INSAE and Macro International, 2007.

Couples in Benin continue to have large families. The 2006 DHS reported a total fertility rate (TFR) of 5.7 children per woman, a slight increase over the 5.6 rate recorded in the 2001 DHS (see Box 1). Half of all women ages 2049 have given birth before age 20 (GOB/INSAE and Macro International, 2007). An analysis of the data from the 1996, 2001, and 2006 DHS rounds concluded that fertility had declined little in the early 2000s (Machiyama, 2010). However, Guengant and colleagues (2011) estimated the TFR to be 5.5 children per woman in 2010, and Haub and Kaneda (2012) estimated the TFR to be 5.4 children per woman in 2012. When asked about their ideal number of children, married women said they wanted to have an average of 5.2 children, while married men expressed a desire for 6.9 children, according to the 2006 DHS (GOB/INSAE and Macro International, 2007).
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Repositioning Family Planning in Benin: A Baseline

Among married women ages 1549, 17 percent reported using a contraceptive method, according to the 2006 DHS. Traditional contraceptive methods were popular, with 11 percent of women using them7 percent used periodic abstinence and 4 percent used withdrawal. Six percent of married women used modern contraceptive methodsmainly injectables, the pill, and male condoms. Of those married women who are not using any contraceptive method, nearly half (46%) said they intend to use contraceptives in the future; half of these women (49%) indicate they prefer injectables (GOB/INSAE and Macro International, 2007). Among married women ages 1549, 18 percent wanted to space future births by at least two years, and 12 percent wanted to limit future births but were not using any method of family planning. Accordingly, 30 percent of women are considered to have an unmet need for family planning (GOB/INSAE and Macro International, 2007).

Benins Health System


Benins government spent 4.1 percent of its gross domestic product on health in 2010; the annual per capita expenditure for health is US$15. According to WHO, foreign assistance accounted for 36 percent of total health expenditures in 2010 (WHO, 2012b). Compared with other countries in the region, Benin has relatively high use of health services, such as antenatal care, delivery, and treatment of tuberculosis. Nevertheless, it has a critical shortage of health professionals, with less than one physician per 10,000 people and an average of about 8 nurses and midwives per 10,000 people (WHO, 2012b) (see Box 2). Existing health workers mostly are clustered in urban areas, with few of them located in rural areas. Similarly, there are few hospital beds available at five beds per 10,000 people (WHO, 2012b).
Box 2. Ratio of Health Professionals to Population Doctors Nurses and Midwive Hospital beds 0.59:10,000 in 2008 7.7:10,000 in 2008 5:10,000 in 2010
Sources : WHO, 2012b.

FRAMEWORK FOR ASSESSING THE REPOSITIONING FP INITIATIVE


The overall strategic objective (SO) of the Framework for Monitoring and Evaluating Efforts to Reposition Family Planning (hereafter referred to as the M&E Framework) is Increased stewardship of and strengthened enabling environment for effective, equitable, and sustainable FP programming. Under the SO, there are three illustrative indicators:
1. Instances of a government-led council, coalition, or entity that oversees and actively manages the

FP program
2. Instances of documented improvement in the enabling environment using a validated instrument 3. Evidence of FP policies implemented and resources allocated, and subsequently used in relation

to the same FP policy Each IR has specific indicators that contribute to overall achievement of the IR (see Figure 2).
Figure 2. Results Framework for Strengthening Commitment to and Increased Resources for Family Planning

SO: Increased stewardship of and strengthened enabling environment for effective, equitable, and sustainable FP programming

IR1: Resources for FP increased, allocated, and spent more effectively and equitably

IR2: Increased multisectoral coordination in the design, implementation, and financing of FP policies and programs

IR3: Policies that improve equitable and affordable access to high-quality FP services and information adopted and put into place

IR4: Evidence-based data or information used to inform advocacy, policy dialogue, policy development, planning, resource allocation, budgeting, program design, guidelines, regulations, and program improvement, and management

IR5: Individual or institutional capacity strengthened in the public sector, civil society, and private sector to assume leadership and/or support the FP agenda

Source: Judice and Snyder, 2012.

Repositioning Family Planning in Benin: A Baseline

Methodology
After the M&E Framework was field tested in Tanzania in 2011 and finalized, staff of the USAID-funded Health Policy Project, implemented by Futures Group, reviewed the tools developed for Tanzania and subsequently adapted them for use in West Africa and translated them into French. The project team then tested the M&E Framework in Togo and Niger. In preparation for application of the M&E Framework with Hewlett Foundation funding, Futures Group proposed a revised methodology for working in six countries of Francophone West Africa. 3 Futures Group first assembled a team of four people to test a more participatory and interactive methodology in Mali. Based on the successful results, the team decided to use the Mali methodology for the five remaining countries. For Benin, the Futures Group team reviewed policies, strategies, program materials, and other information related to the framework indicators. Some documents were found online or in electronic format, but many were available only in hard copy and thus were not accessible until arriving in country. In preparation for the meeting, the team identified three key documents translated into French to use for the working meeting:
1. 2. 3.

Framework for Monitoring and Evaluating Efforts to Reposition Family Planning Explanation of Indicators Semi-structured Interview Guide, to serve as background

Futures Group team collaborated with the Directorate of Maternal and Child Health (DSME) of Benins Ministry of Health (MS) to conduct a one-day technical meeting with 11 family planning stakeholders. The ministry was keen to take the lead in this exercise and called the meeting. It sent the documents noted above, along with the invitations for the working meeting, to approximately 25 people identified by contacts as key actors in repositioning family planning in Benin. Stakeholders invited included the four Repositioning Family Planning focal persons designated during the 2011 regional conferences, government officials, representatives of international and national nongovernmental organizations (NGOs) and other partners, and donors. The Futures Group team then prepared a detailed agenda for the working meeting, developed two PowerPoint presentations, and made hard copies of the background documents for use during the meeting. The MS took additional ownership in this effort by conducting parts of the meeting. Both presentations, as well as the documents, will used for the working meetings for the remaining countries. The meeting, held on March 7, 2012, consisted of a presentation on challenges and opportunities in family planning in the Francophone West Africa region, an orientation to the M&E Framework, group work to inform each of the IRs and indicators, and reporting out on each of the indicators. The indicator table was filled out as the meeting progressed. The group identified seven people who had information to contribute but had not attended the meeting; the Futures Group team made arrangements to interview them before leaving Cotonou. The meeting concluded with several recommendations for the government and its technical and financial partners to strengthen efforts to reposition family planning in Benin. Table 1 provides a breakdown of the contacts by affiliation and sex, including participants at the meeting and those subsequently interviewed.

The six countries are Benin, Burkina Faso, Guinea, Mali, Mauritania, and Senegal.

Framework for Assessing the Repositioning FP Initiative

Table 1. Affiliation and Sex of Contacts in Benin


Sex
Men Women Total

Government Officials
2 2 4

Donors
3 4 7

NGOs
4 3 7

Total
9 9 18

Following the meeting, the Futures Group team drafted a complete indicator table and sent it to the participants for their feedback. The team then incorporated the additional input into the table and drafted this report on the Benin application (see Annex 2 for the final indicator table).
Ethical Considerations

The protocol and data collection instruments for both components of this study were submitted to the Futures Group Research Ethics Committee and were deemed exempt from review by an Institutional Review Board.

Study Limitations
Not all people identified as key actors in family planning were available for the meeting or for interviews. Good data were extremely hard to come by. Despite these limitations, this study provides an important baseline for repositioning family planning in Benin.

ASSESSMENT FINDINGS
This section presents the findings from the pilot test of the M&E Framework. The findings are presented according to the SO indicators and intermediate results, as delineated in the framework. Annex 2 summarizes the findings in table format.

SO: Increased Stewardship of and Strengthened Enabling Environment for Effective, Equitable, and Sustainable FP Programming
Indicator 1: Instances of a government-led council, coalition, or entity that oversees and actively manages the FP program

Several groups can be used to lead discussions and FP actions in Benin, as indicated by the existence of an FP department within the DSME at the MS. In addition, after the Mbour, Senegal, conference for CSOs, DSME designed a Roadmap for Family Planning. A few publications, including the Population Policy Declaration (DEPOLIPO), clearly identify the option of curbing population growth through family planning. Yet, these successes need to be consolidated to reach the operational objectives, as noted by the donors who acknowledge and accept the leadership role of the DSME. The civil society initiatives also indicate a desire to support family planning through concrete action led by associations such as the Association Bninoise pour le Bien Etre Familial (ABPF). ABPFs action plan commits the association to including and incorporating family planning through its membership in the Coalition of Civil Societies for Family Planning, which has an action plan financed by the Hewlett Foundation. This coalition includes about 30 organizations and has a governing board. Representatives of several donors, including USAID, the United Nations Population Fund (UNFPA), and WHO, have stated that the coalition leadership needs to be more assertive.
Indicator 2: Evidence of documented improvement in the enabling environment for family planning using a validated instrument

Data from two validated instruments are available to assess the enabling environment for family planning in Benin. The Family Planning Program Effort Scores were developed as an international measure to gauge key areas of each countrys FP program. The scores are based on the average scores submitted by 1015 local experts on 30 indicators related to policies, services, evaluation, and access to FP methods. Benins score has fluctuated greatly in the past decadefirst rising sharply from 30.3 in 1999 to 53.4 in 2004 and then declining markedly to 35.1 in 2009 (Ross and Smith, 2010). As the highest score is 100, the scores also indicate considerable room for improvement in Benin. The Contraceptive Security Index uses a rating system that assigns points to 17 indicators related to the supply chain, finance, the health and social environment, access to FP, and use of FP. The scores for Benin were 43.8 in 2003, 48.8 in 2006, and 47.7 in 2009, out of a possible 100 points (USAID | DELIVER, 2003, 2006, 2009). These scores indicate a relatively low level of contraceptive security, with no improvement since 2006. Policymakers and program managers need to increase their efforts to ensure that adequate contraceptive supplies are widely available. There is clearly a favorable environment, evident by the Policies, Norms, and Standards on Reproductive Health; the National Policy for Reproductive Health 20112016; the National Strategy for the Security of Reproductive Health Products (SNSPSR) 20112016, followed by the Operational Plan; a National Strategy for Repositioning Family Planning in Benin; and ABPFs Reproductive Health Policy. The principal FP declarations and publications (policies, laws, and strategies) generally rely on information coming from reliable sources. The main information sources for Benin FP indicators are health statistics and Demographic and Health Surveys. These data support the emerging role for family
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Assessment Findings

planning in various national-level instruments. The team also noted that civil society actions, which promote family planning, also rely on the data provided by Demographic and Health Surveys.
Indicator 3: Evidence of FP policies implemented, resources allocated, and subsequently used in relation to the same FP policies

In May 1996, DEPOLIPO 19962016 was adopted. This document takes into account all potential population and development interactions. Accordingly, this declaration includes policies targeting education, health, fertility, migration, environment, and gender concerns among various cohorts (young, old, handicapped); acquiring knowledge; raising public awareness of socioeconomic and demographic issues; increasing life expectancy (from 54 years in 1992 to 65 years in 2016); and promoting a sensible fertility. This set of policies was evaluated in 2003 and, following the gaps identified, reviewed in 2006. The new set of policies kept the objectives and strategies of the first set but initiated a few changes in how the policies were formulated and retained quantitative indicators to measure to what extent the objectives were achieved. Benin adopted the Reproductive Health Law in January 2003. This law was drafted to fill the legal vacuum regarding sexual and reproductive health and to amend the Act of 1920 that banned family planning. Based on the principles adopted at the 1994 International Conference on Population and Development held in Cairo, the RH Law guarantees the right of individuals and couples to reproductive health, equitable access to reproductive healthcare, and respect for the physical integrity of women and girls, including the elimination of female genital cutting, rape, sexual abuse, and incest. In Benin, family planning is part of the reproductive health policy and the improvement of healthcare. Promotion of family health was included in the Policy and Strategy for Health Sector Development 2002 2006, which was adopted in November 2002. An evaluation in mid-2005 concluded that the strategies adopted to promote family health were weak. Consequently, a new plan, the National Plan for Health Development (PNDS), was designed for 20092018. It is based on the performance of the health system, which offers equitable, high-quality healthcare for all segments of the population. Taking into account the real impact of the 3.25 percent annual population growth rate in 2002 and its consequences for the socioeconomic sector, the 20092018 PNDS includes plans to create institutional systems in support of reproductive health. Programs and initiatives in this plan focus on promoting basic hygiene and sanitation, supporting reproductive health, combating diseases, and strengthening human resources in the health sector. Reproductive health is sub-divided into two programsreducing maternal and neonatal mortality and reducing mortality among infants and youth. Both programs incorporate general and specific programs. Specific objectives to meet needs in obstetrical and neonatal emergency care incorporate the objective of increasing contraceptive prevalence from 7 percent in 2001 to 15 percent in 2016. The law pertaining to sexual and reproductive health (Law 2003/03, dated March 3, 2003) acknowledges that equality between men and women regarding rights and dignity in reproductive health is fair. It also includes the principle of self-determination regarding marriage and procreation. Another document Policies, Norms, and Standardswas adopted in 1998. This document outlines objectives for (1) reducing maternal, infant, and child mortality; (2) urging young men and women to adopt sensible sexual behaviors; and (3) encouraging men to support reproductive health (RH) programs. Starting with the 2006 Road Map for the African Union, Benin also designed a National Strategy to Reduce Maternal and Neonatal Mortality between 2006 and 2015. This strategy presents less ambitious objectives than those listed in the previous PNDS regarding maternal and neonatal mortality rates. Contraceptive prevalence is noted as an indication of impact, but quantitative objectives are not stated. Finally, SNSPSR 20062015 stresses the need to provide high-quality, reliable, and safe RH products; efficient management of commodities; RH services offered in an integrated way, seven days a week, to
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Repositioning Family Planning in Benin: A Baseline

meet increased demand; transparent financing; long-term sustainable provision; and transparent oversight and management. Funds for family planning are used to purchase contraceptive methods, support logistics systems, and provide refresher training on family planning for health workers. Benin has qualified health professionals in the field of reproductive health. DSME has a unit responsible for human resources. The big challenge is the equitable distribution of staff, especially in areas difficult to access and rural areas. Elsewhere, in health centers, qualified staff are able to prescribe contraceptives and oversee FP services. Civil society or private sector representatives, including such local NGOs as ABPF, Association Bninoise pour le Marketing Social et la Communication pour la Sant (ABMS), and the West Africa Health Organization (WAHO) have underscored line items to indicate that funding is devoted to providing contraceptive supplies.

Intermediate Result 1: Resources for Family Planning Increased, Allocated, and Spent More Effectively and Equitably
The M&E Framework lists the following four indicators related to resources for family planning: IR1.1: Total resources spent on family planning (by source and activity/program area) IR1.2: Number of new financing mechanisms for family planning identified and tested IR1.3: Total resources allocated to family planning (by source and activity) IR1.4: New and/or increased resources are committed to family planning in the last two years The Futures Group team was unable to identify the total resources spent or allocated for family planning in Benin. The team did identify several partners supporting family planning, such as UNFPA and USAID, as well as several bilateral agreements and international NGOs. During 20092011, USAID has provided about US$3 million annually for family planning programs; for 2012, USAID increased this amount to US$4 million. USAID supports the Integrated Family Health Project.

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Assessment Findings

Table 2. USAID Funding for Family Planning in Benin, 20092012


Years, thousands USD 2009
1,467 449 584 100 100

N
3.1.7.1 3.1.7.2 3.1.7.3 3.1.7.4 3.1.7.5 6.1 Professional Development & Learning for 3.1.7 6.2 Administration & Operations for 3.1.7 TOTAL

Sub-Element
Service Delivery Communication (family planning) Policy Analysis and System Strengthening Health Governance and Finance (family planning) Host Country Strategic information Capacity (family planning) Family Planning and Reproductive Health

2010
1,474 326 625 125 100

2011
1,474 323 622 125 100

2012
1,600 390 1,360 200 100

150

100

100

100

Family Planning and Reproductive Health

150 3,000

200 3,000

250 2,994

250 4,000

Source: USAID, 2012.

UNFPA is funding the MS to implement a five-year project to reduce maternal mortality during 2009 2013. Key components that relate to family planning are Collaboration with NGOs to provide community-based FP services and FP services for youth; Advocacy with traditional opinion leaders and parliamentarians to reposition family planning; Revision of the workplan for the SNSPSR; Integration of family planning into maternal health services; and Strengthening of the capacity of health providers, development of a policy on human resources on maternal and reproductive health, and implementation of this policy. The 2010 budget for this project is US$2.9 million (UNFPA, 2010). UNFPAs contributions to family planning, besides providing an expert seconded to DSME, include 13 computers, seven video projectors, a supervisors car, contraceptive products, and five anatomical models to be used during demonstrations of the insertion and removal of intrauterine devices (IUDs). WHO provided additional funding of US$100,000. WAHO provided US$108,000 for capacity building and US$79,000 to buy contraceptive products and FP supplies. At the working meeting to collect information for the framework, participants indicated that partners are ready to finance family planning in Benin. This is also confirmed by the support for family planning provided by partners to CSOs such as ABPF and ABMS.

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Repositioning Family Planning in Benin: A Baseline

ABMS, with Dutch funding, is promoting family planning through donations of sterilizers, trays, tongs, and other supplies to more than 50 private clinics. ABPF has received contraceptive supplies financed by the International Planned Parenthood Federation (IPPF) and the Interchurch Organization for Development Co-Operation. WAHO also has contributed US$108 million to capacity building and US$79 million to purchase contraceptive products and FP instruments.
Table 3. ABPBF Expenditures for Contraceptive Commodities, 20082010
Year
2008 2009 2010 Total

Amount (US$)
2,553 10,073 20,300 32,926 Source: ANBEF, 2011.

New donors, such as UNFPA, USAID (ABMS, PISF), ABPF, and Plan Benin have emerged during 2011 and 2012. Moreover, statements favorable to family planning are noticeable, such as DSMEs announcement to provide 10,000,000 CFA to buy contraceptives and 5,000,000 CFA to monitor FP activities. The Netherlands allocated US$250,000, USAID provided US$4 million, UNFPA donated US$1 million for RH commodities, and the Muskoka Initiative donated US$700,000. Benin receives other regular donations through the Agence Franaise de Dveloppement (AFD)/Projet d'Appui la Sant Maternelle et Infantile (PASMI)/Volet PF, Japanese International Cooperation Agency (JICA), WAHO, Plan Benin, ABMS, ABPF, and Appui Institutionnel du Ministre de la Sant de la Coopration Technique Belge (AIMS/CTB). The Futures Group team has identified new financing mechanisms from the Netherlands, Muskoka Initiative (French government), and IntraHealth.

Intermediate Result 2: Increased Multisectoral Coordination in the Design, Implementation, and Financing of FP Policies and Programs
This IR assesses the extent to which various disciplines, such as health, education, agriculture, and the environment, as well as the public and private sectors, are involved in FP policymaking and implementation. In general, the Futures Group team found numerous examples of multisectoral coordination, which will be reported under the various sub-IRs.
IR2.1: Evidence of FP programs incorporated into national strategic and development plans

Family planning is incorporated into the PNDS 20092018; DEPOLIPO 19962016; Policies, Norms and Standards 1998; SNSPSR 20062015; and the National Policy for Reproductive Health 20112016 (see Box 3). The Futures Group team did not receive any documents that highlight family planning.

12

Assessment Findings

Family planning is taken into account in various national programs, but it is often subsumed under the key mandate of each program. For example, in the MS structure, family planning is incorporated into the work of the Maternal and Child Health Service under the DSME, the Planning Service for Adolescent and Youth Health, and the Nutrition Service. As a result of this structure, family planning is given lower priority than the focal issue of each service, even if it clearly is important to those national programs.
IR2.2: Evidence of governments engaging multiple sectors in FP activities

Box 4: Key National Policies and Plans that Include Family Planning National Plan for Health Development (20092018) Population Policy Declaration (19962016) Policies, Norms, and Standards (1998) National Strategy for the Security of Reproductive Health Products (20062015) National Policy for Reproductive Health (20112016)

The government has engaged the following sectors in family planning: health, education, rural development, gender, food and nutrition, and social protection. After the 2011 Mbour conference for CSOs working in family planning, DSME designed the Roadmap for Family Planning. This roadmap is the central framework for all FP actors (state, donors, civil society). It includes a provision for setting up the National Commission for Policy Dialogue among Researchers and Decisionmakers on Reproductive Health. DSME also has engaged the National Commission on Human Resources and Population, the National Institute for the Promotion of Women, and the Ministry of the Family and National Solidarity.
IR2.3: Evidence of multisectoral structures that are established or strengthened to promote FP policy

As previously mentioned in Indicator 1 above, DSME is the main body that coordinates multisectoral planning of FP activities. Several donor representatives said that they would like DSME to be more active and initiate more activities. Nevertheless, key informants praised several initiatives: Establishment of a National Panel for Family Planning that includes institutions, NGOs, and technical staff of the MS; Setting up of the multisectoral committee to reduce maternal and neonatal mortality; Creation of the Committee for the Security of Reproductive Health Supplies (not yet established); Creation of the Centre de Formation et de Recherche en Matire de Population (CEFORP), a research center that provides a framework for reflection and information exchange regarding population and FP issues; and Creation of the new Coalition of Civil Society Organizations to Promote Family Planning, launched by IntraHealth with Hewlett Foundation funding.
IR2.4: Evidence of government support for private sector participation in family planning

The government includes NGOs, civil society groups, and private providers in advisory groups and consultative meetings. For example, the ABMS collaborated with the MS to set up Protection Familiale (ProFam), a private sector network under the Franchise Sociale des Produits et Services de SR. Through this network, clinics sign agreements to promote contraceptive products. The government also provides tax relief for the importation of contraceptive products, which supports NGOs working in FP/RH. Several NGOs have signed agreement protocols in this regard, such as the collaboration with DSME through the Center for Essential Medicines Supply (CAME) for the management of contraceptives.

13

Repositioning Family Planning in Benin: A Baseline

Declarations, such as the one legalizing FP activities over the entire country, also attest to DSMEs support for the private sector. Finally, ABPF, one of the main organizations promoting family planning, is acknowledged as an organization serving the public good.

Intermediate Result 3: Policies that Improve Equitable and Affordable Access to High-Quality FP Services and Information Adopted and Put into Place
IR3.1: Existence of national or subnational policies or strategic plans that promote access to FP services and information

Benin has several policies that promote access to FP services and information. The National Policy for Reproductive Health 20112016 provides the framework for FP programs. Family planning is included in the Minimum Package of Services that the government requires each health facility to provide. The National Strategy for Repositioning Family Planning provides an opportunity to gather data on family planning. The most recent PNDS for 20092018, which resulted from an assessment of the previous plan and the former DEPOLIPO, took into account the question of data pertaining to family planning as part of reproductive health data needs. Other policies and strategic plans that support family planning include the following: National Plan for Health Development Policies, Norms, and Standards on Reproductive Health, including family planning Operational Plan for Reproductive Health 20112016 National Strategy for the Security of Reproductive Health Products Operational Plan for the Security of Reproductive Health Products National Strategy for Repositioning Family Planning National Strategy to Reduce Maternal and Neonatal Mortality National Bidirectional Strategy to Integrate Family Planning/STI/HIV/AIDS ABPF Reproductive Health Policy National Communication Plan to Reduce Maternal Mortality Actions implemented on the basis of these policies and plans include the following: Promotional FP activities at all levels of the health system Initiative to promote family planning in a few communities Free FP Week Training of journalists in family planning Campaign to encourage men to become involved in family planning Advocacy among community leaders regarding family planning Research on the needs, demand for, and acceptance of family planning at the community level
IR3.2: Existence of national or subnational policies or strategic plans that promote access to FP services and information for under-served populations

All of Benins important policy documents aim to create an enabling environment for achieving the Millennium Development Goals, combating poverty, and promoting sustainable and sustained economic growth for the people of Benin. The Program Development Strategies 20062011 and the Strategic Plan for Growth and Poverty Reduction 20072009 have replaced the Poverty Reduction Strategy 20032005.
14

Assessment Findings

As many inhabitants of Benin are classified as poor or vulnerable (67% of rural residents and 55% of urban dwellers), they experience difficulties in meeting their vital needs, such as health. The indicators presented in this report show that health needs are not entirely met. To fill this gap, the government of Benin and its partners led an ongoing study regarding ways to take gender equity into account in the strategic documents of the health sector, in particular those for reproductive health. The government also has a strategy that takes into account RH problems specific to teenagers and youth. In addition, ABPF has a policy for meeting the reproductive health needs of adolescents and youth. Other innovations, such as the Advanced Strategy for Reproductive Health Care, also are significant insofar as they allow FP programs to reach the most vulnerable groups.
IR3.3: Documentation of instances in which a formal implementation or operational directive or plan is issued to accompany a national or subnational FP policy

During the various meetings and interviews, most respondents could cite at least a few guidelines or plans that accompany national FP policies. They noted that implementing instructions or operational guidelines can be found in the National Policy for Reproductive Health 20112016 and SNSPSR 20062015. Additionally, the National Strategy for Repositioning Family Planning, an Operational Plan for Reproductive Health, and an Operational Plan to Reduce Maternal and Neonatal Mortality also support family planning. Among NGOs that promote family planning, ABPF has an annual budget plan that takes family planning into account.
IR3.4: Evidence that policy barriers to access to FP services and information have been identified and/or removed

Until 2003, the Law of 1920 banned provision of FP services throughout Benin. This law was struck down in March 2003 with passage of Law 2003/03. Key informants have reported greater participation of community leaders in FP activities during awareness campaigns led by various entities advocating for the promotion of family planning.
IR3.5: Evidence of the implementation of policies that promote FP services and information

This topic has been covered in previous sections under IR2 and IR3.

Intermediate Result 4: Evidence-based Data or Information Used to Inform Policy Dialogue, Policy Development, Planning, Resource Allocation, Budgeting, Advocacy, Program Design, Guidelines, Regulations, and Program Improvement and Management
This IR assesses the extent to which policies and programs are grounded in data and information to ensure a sound rationale for selecting the program strategies, activities, and other elements.
IR4.1: Evidence of data or information used to support repositioning FP efforts

Family planning trends and programs in Benin are assessed through the important data provided by various surveys such as DHS and the activity reports of FP institutions. The existing data provide information on topics such as the number of FP products distributed, the number of new contraceptive users, the number of contraceptive users who have discontinued use of specific methods, former FP providers, new FP providers per health center, visits to health facilities for FP services, the level of acceptance of family planning, the level of coverage for specific commodities, the attitudes of health providers regarding long-term contraceptive methods, and the RH needs of teenagers and youth.

15

Repositioning Family Planning in Benin: A Baseline

The DHS provides the contraceptive prevalence rate according to the various methods and the unmet need for family planning. The Roadmap for Family Planning used DHS data to establish its targets. Several donors, including USAID, the government of France, UNFPA, and WHO, have a focal person to follow progress and support FP repositioning in Benin. These agencies follow FP issues closely and greatly support the application of the roadmap.
IR4.2: Evidence of international FP best practices incorporated into national health standards

Protocols for family planning services have been revised, based on common components in the new WHO guidelines.
IR4.3: Evidence of a defined and funded research agenda in family planning

Benin has designed a National Policy on Reproductive Health; one of its general objectives is to involve more men in family planning. MS official

The Futures Group team was unable to find evidence of an FP research agenda, nor of funding allocated to FP research. Research and training centers and the two main CSOs (ABMS and ABPF) implement a few research activities but not on a large scale or with an FP focus.
IR4.4: Evidence of in-country organizational technical capacity for the collection, analysis, and communication of FP information

Similar to the finding from IR4.3, the Futures Group team concluded that there is little technical capacity to collect, analyze, and disseminate FP information. In theory, the FP service of the DSME has enormous capacity to lead research programs, given the existing synergy and the multisectoral coordination with which it is credited. In practice, however, DSME does not implement or oversee research. ABPF has strengthened its capacity for monitoring and evaluation and data dissemination after an evaluation highlighted this issue.

Intermediate Result 5: Individual or Institutional Capacity Strengthened in the Public Sector, Civil Society, and Private Sector to Assume Leadership and/or Support the FP Agenda
IR5.1: Evidence of entities provided with donor assistance that demonstrate capacity to independently implement repositioning FP activities

Based on interviews with representatives of partners, government, donors, and NGOs, the Futures Group team concluded that NGOs work harder than the MS to reposition family planning, even though the FP Department of the DSME is recognized as having a leadership role in repositioning family planning. Local CSOs, such as ABPF, ABMS, and OSV/JORDAN, have led activities to reposition family planning. At the national level, ABMS provides IUDs to women during the immediate postpartum period and to women without children. Population Services International (PSI) supports a network of 100 private clinics that offer only long-term methods.
IR5.2: Evidence of government departments or other entities established or strengthened to support the FP agenda

DSME was created with a clear mandate and well-defined responsibilities. It is the governmental entity that supports the FP agenda. It centralizes all of the initiatives taken by the institutions that deal with family planning by taking their activities into account via reports regularly submitted to it. With the creation of the National Panel for Family Planning, it now organizes the framework for FP discussions
16

Assessment Findings

and reflections. It is actively involved with other ministries regarding all issues pertaining to family planning in Benin. There is thus a need for the DSME to capitalize on available data and publish relevant data. The DSME is also involved in training and supervision. The various regions must continue to provide feedback to the DSME, taking all of the information into account to better reposition family planning. The annual review of the Table of Contraceptive Procurement (TAC) is entirely under the DSMEs supervision to ensure that supply meets demand. A network of parliamentarians in support of population and development has been created.
IR5.3: Evidence of targeted public and private sector officials, faith-based organizations, or community leaders publicly demonstrating new or increased commitment to family planning

In Benin, a few people who publicly show their support for family planning can be considered champions. The Minister of Health has discussed family planning on the following occasions: Launch of the Campaign to Accelerate Reduction of Maternal Mortality in Africa (CARMMA) in September 2010 and the relaunch of CARMMA activities in December 2011 Awareness session for community leaders held at the town hall of Cotonou Launch of the campaign to involve men in family planning on March 25, 2010 Benin leaders also made a commitment to participate in the United Nations Secretary Generals Initiative for Womens and Childrens Health in September 2010. They endorsed the following actions: Provide a complete intervention kit for reproductive health by 2018 Increase the contraceptive prevalence rate from 6.2 percent to 15 percent Design new strategies regarding sexual and reproductive health services targeting teenagers
IR5.4: Number of regional/national centers or collaborations for shared education and research in family planning

The Futures Group team did not identity a reference center focused solely on family planning. However, participants in the working group said that several centers are designing training modules or encouraging research on family planning: the Institut National Mdico-Social (INMES), CEFORP, Facult des Sciences de la Sant (FSS), and Institut Rgional de Sant Publique (IRSP).

17

RECOMMENDATIONS FOR REPOSITIONING FAMILY PLANNING IN BENIN


Benin has made considerable progress in creating a more enabling environment for family planning. Nevertheless, much still remains to be done to strengthen ongoing activities for repositioning family planning. According to respondents, the present environment offers opportunities for actions that would not have been possible just a short time ago. Participants at the working meeting made recommendations that relate to each of the IRs:
IR1: Resources for family planning increased, allocated, and spent more effectively and equitably

The government should increase resources for family planning and ensure that funds are granted and spent more efficiently and equitably. The government should give special attention to the establishment and maintenance of a budget line to purchase contraceptives. Ensuring a secure supply of reproductive health products including contraceptives is fundamental to the repositioning of family planning. The government should assess the need for family planning at the national level, assess the potential funding available with regard to projects and programs, and define the FP gaps so as to share the data during discussions with donors. The MS should create a sub-account for expenditures in RH and maternal and child health to enable a more efficient implementation of RH activities, especially family planning.
IR2: Increased multisectoral coordination in the design, implementation, and financing of FP policies and programs

The government should increase multisectoral coordination in the design, implementation, and financing of policies and programs pertaining to family planning. The MS should strengthen the National Panel on Family Planning, increase its multisectoral dimension, and ensure that it functions effectively. The MS should reinforce the capacity of the National Panel on Family Planning by adding members with communication and development expertise.
IR3: Policies that improve equitable and affordable access to high-quality FP services and information adopted and put into place

The MS should revise the Policies, Norms, and Standards or establish new directives to contribute more effectively to repositioning family planning by providing guidelines on task shifting, community-based provision of oral contraceptives and injectables, and standards for community health workers. The MS should adopt and implement policies that expand equitable and affordable access to all high-quality FP services and data on FP programs. The MS should make documents pertaining to FP policies and strategies more user-friendly and design additional documents if needed. The MS should design and implement an integrated communication plan for family planning. The MS should make the committees on the Reduction of Maternal and Neonatal Mortality and on Security of Reproductive Health Products functional.

18

Recommendations for Repositioning Family Planning in Benin

The MS should train and maintain a media group pertaining to family planning and RH to assist the DSME in its policy implementation. DSME should create an Internet site.
IR4: Evidence-based data or information used to inform advocacy, policy dialogue, policy development, planning, resource allocation, budgeting, program design, guidelines, regulations, and program improvement, and management

Public and private agencies working in family planning should use reliable data to inform policy dialogue, policy design, planning, funding allocation, budgets, advocacy, program design, guidelines, regulations, and improvement of FP programs and management. The MS should finance operational FP research and disseminate the research results regarding the best FP practices to agencies working in family planning. The MS should elaborate on and apply an FP research program. The MS should strengthen the capacity of DSME staff in M&E and data management. Implementing agencies should broaden the approach of the social franchising network to include RH services within the public health sector.
IR5: Individual or institutional capacity strengthened in the public sector, civil society, and private sector to assume leadership and/or support the FP agenda

Public and private agencies working in family planning should strengthen individual and institutional capacity within the public sector, civil society, and private sector to build the next generation of leaders and broaden support for FP programs. The MS should design an integrated workplan that takes into account interventions of all partners around national objectives. Public and private agencies working in family planning should identify and nurture FP champions.

19

ANNEX 1: PERSONS INTERVIEWED


Name
Modibo Maiga Dr. Olga Agbohoui-Houinato Dr Gaston D. Ahounou Madame Baba-Moussa Ramatou

Title
Sr. Technical Advisor, Policy Director of Maternal and Child Health Head of Family Planning Service Member

Affiliation
AWARE II MS/DSME Ministry of Youth and Adolescent Health Network of African Women Ministers and Parliamentarians UNFPA UNFPA ABPF ABPF USAID/Benin SR/ABMS/PSI Association des Gyncologues et Obsttriciens du Bnin DSME UNFPA CAS/SPE/DSME, IFSAJ/MS ABPF HOMEL/FSS WHO MS

Diene KEITA Dr. Amar MSamed lemine Edgard F. Odjo Cledjo Gdon D. Djissa Dr. Milton B. Amayun, MD, MPH Ayivi Prudencia Dr. Ewagnigon Emmanuel

Representative Focal Point Executive Director Focal Point, National MAJ Family Health Team Leader Coordinator Obstetrician/Gynecologist and member, Association of Gynecologists and Obstetricians Department Head, Contraceptive Logistics Technical Advisor Manager Monitoring and Evaluation Manager Obstetrician/Gynecologist Pediatrician, Head of Evaluation Project Administrator

Zohou Alimatou Mboza Mbassi Dossou Constance ne Gnonloufoun Moussa Ibrahim Hounkpatin Benjamin Gbenon Dina Radji Siuradjou

20

ANNEX 2: REPOSITIONING FAMILY PLANNING RESULTS AND INDICATORS FOR BENIN


Repositioning FP Results and Indicators for Benin
Indicators Information Indicator Source

Strategic Objective: Increased stewardship of and strengthened enabling environment for effective, equitable, and sustainable FP programming 1: Instances of a government-led council, coalition, or entity that oversees and actively manages the FP program 2: Evidence of documented improvement in the enabling environment for family planning using a validated instrument DSME designed a Roadmap for FP. The Coalition of Civil Societies for Family Planning has been formed. Key informant interviews

There is clearly a favorable environment, evident by the Policies, Norms, and Standards on RH including FP; the National Policy for RH 20112016; the National Strategy for the Security of RH Products, followed by an operational plan; a National Strategy for R epositioning FP in Benin; and ABPFs RH policy. National Policy for RH 20112016; National Strategy for the Security of RH Products; National Strategy for Repositioning FP; and an Operational Plan to Reduce Maternal and Neonatal Mortality.

Family Planning Effort Scores 1999, 2004, 2009 Contraceptive Security Index 2003, 2006, 2009 Questionnaire developed with partners Key informant reporting on evaluations of projects Quarterly reports from the different districts and regions RH norms and standards

3: Evidence of FP policies implemented, resources allocated, and subsequently used in relation to the same FP policies

IR1: Resources for family planning increased, allocated, and spent more effectively and equitably IR1.1: Total resources spent on FP (by source and activity/program area) IR1.2: Number of new financing mechanisms for FP identified and tested Data on total expenditures are not available. However, data on expenditures were provided by USAID, UNFPA, PISF, ABPF, Plan Benin, WAHO, and Muskoka Initiative/UNFPA. Netherlands, Muskoka Initiative (French government), and IntraHealth Spreadsheet provided by USAID

Key informant interviews and public advertising

21

Repositioning Family Planning in Benin: A Baseline

Indicators
IR1.3: Total resources allocated to FP (by source and by activity)

Information
Financial, material, and humanitarian resources are diverse: UNFPA (UNFPA-funded expert based at DSME)13 computers, 7 video projectors, one supervisors car, contraceptive supplies, and 5 anatomical models to give demos on IUD insertion and removal. Funding for ABMS. Netherlandsgift of clinical material (sterilizers, trays, tongs, and other supplies) for more than 50 private clinics. IPPFprovided contraceptive products to ABPF. Interchurch Organization for Development Cooperation donated contraceptive products to ABPF. WAHOUS$ 108,000 for capacity building and US$79,000 to buy contraceptive products and FP supplies. WHO$100,000 drawn from the extra funding.

Indicator Source
Key informant interviews and public advertising

IR1.4: New and/or increased resources are committed to FP in the last two years

New donors such as UNFPA, USAID (ABMS/PISF), ABPF, and Plan Benin have emerged during 2011 and 2012. Moreover, statements favorable to FP are noticeable, such as the announcement by DSME of 10,000,000 CFA to buy contraceptives and 5,000,000 CFA to monitor activities; the Netherlands for US$250,000; USAID for US$4 million; UNFPA for US$1 million to secure RH products; and $700,000 from the Muskoka Initiative. There are other regular donations through AFD/PASMI/Volet PF, JICA, WAHO, Plan Benin, ABMS, ABPF, and AIMS/CTB.

Data from, USAID, UNFPA, ABPF

22

Annex 2: Repositioning Family Planning Results and Indicators for Benin

Indicators

Information

Indicator Source

IR 2: Increased multisectoral coordination in the design, implementation, and financing of FP policies and programs IR2.1: Evidence of FP programs incorporated into national strategic and development plans Population and FP issues are a major concern of key policy documents, which include FP indicators. BENIN ALAFIA 2025 Strategic Plan for Growth and Poverty Reduction 20112015 PNDS 20092018 Package of Interventions for High Impact Triennial Development Plan 2010 2012 COMPACT/PTF-Gouvernement UNDAF 20092013 IR2.2: Evidence of governments engaging multiple sectors in FP activities The government has engaged the following sectors in FP: health, education, rural development, gender, food and nutrition, and social protection. Design of a Roadmap for FP National Commission for Dialogue between Researchers and Policy makers on Reproductive Health National Commission for Human Resources and Population National Institute for the Promotion of Women Ministry of Family and National Solidarity Key informant interviews Panel meeting report Interministerial decree Ministerial decree Ministerial decree N203/MEMS/DGM/VR-UNB du 17/04/1989 Workplan Key informant interviews Contraceptive Security Plan Roadmap for Family Planning Ministerial decree Decree 2009-728 dated 31/12/2009

IR2.3: Evidence of multisectoral structures that are established or strengthened to promote FP policy

The DSME has been strengthened by several new committees: National Panel on Family Planning with institutions, NGO, technical services of the MS Multisectoral Committee for the Reduction of Maternal and Neonatal Mortality (implemented) Committee for Securing Products of Reproductive Health (not implemented) CEFORP CSO Coalition for the Promotion of Family Planning

23

Repositioning Family Planning in Benin: A Baseline

Indicators
IR2.4: Evidence of government support for private sector participation in FP

Information
ABMS, in collaboration with the MS, is designing the Social Franchise for RH Products and Services in the private sector (ProFam network) Tax relief for the importation of contraceptive products Collaboration of DSME and CAME for the management of contraceptives Legalization of FP activities on a national scale Acknowledgement of ABPF as an organization serving the public good

Indicator Source
Private clinics and ABMS Agreement NGO/Government Contract DSME/CAME Law 2003/03 dated 03/03/2003 Decree

IR 3: Policies that improve equitable and affordable access to high-quality FP services and information adopted and put into place IR3.1: Existence of national or subnational policies or strategic plans that promote access to FP services and information Policies, Norms, and Standards National Reproductive Health Policy 2011 2016 National Strategy for the Security of Reproductive Health Products Operational Plan for the Security of Reproductive Health Products Documents cited under Information (on the left) Key informant interviews

National Strategy for Family Planning National Strategy for Repositioning Family Planning National Strategy to Reduce Maternal and Neonatal Mortality National Bidirectional Strategy to Integrate FP/STI/HIV/AIDS ABPF RH Policy IR3.2: Existence of national or subnational policies or strategic plans that promote access to FP services and information for underserved populations Ongoing study on taking gender/equity into account in the strategic documents of the health sector, and of RH in particular Strategy taking into account the FP problems specific to teenagers/youth Policy on Reproductive Health of Adolescents and Youth (ABPF) National multisectoral strategy Policy on Reproductive Health of Adolescents and Youth (ABPF)

24

Annex 2: Repositioning Family Planning Results and Indicators for Benin

Indicators
IR3.3: Documentation of instances in which a formal implementation or operational directive or plan is issued to accompany a national or subnational FP policy

Information
Operational Plan for Reproductive Health 20112016 Operational Plan for the Security of Reproductive Health Products National Strategy for Repositioning FP in Benin Operational Plan to Reduce Maternal and Neonatal Mortality Annual plan with budget for ABPF

Indicator Source
Documents cited under Information (on the left) Annual Budget Plan/ABPF

IR3.4: Evidence that policy barriers to access to FP services and information have been identified and/or removed IR3.5: Evidence of the implementation of policies that promote FP services and information

Termination of the 1920 law forbidding the provision of FP services Increased participation of community leaders in FP activities

RH Law 2003/03 dated March 2003 Reports on awareness campaigns and activities by various entities

CARMMA Implementation of postabortion health services at HOMEL, CUGO, and other entities

IR 4: Evidence-based data or information used to inform advocacy, policy dialogue, policy development, planning, resource allocation, budgeting, program design, guidelines, regulations, and program improvement, and management IR4.1: Evidence of data or information used to support repositioning FP efforts Mid-term review of the National Strategy to Reduce Maternal and Neonatal Mortality Data from the DHS and program reports for FP indicators, such as the number of FP products distributed, the number of new contraceptive users, the number of contraceptive users who have discontinued the use of specific methods, former FP providers, new FP providers per health center, visits to health facilities for FP services, the level of acceptance of FP, the level of coverage for specific commodities, the attitudes of health providers regarding long-term contraceptive methods, and the RH needs of teenagers and youth Design of an Action Plan 2011 2015 Lists of health statistics DHS Report TRaC FP (ABMS) Report (ABPF) Report Focus on Providers (ABMS)

25

Repositioning Family Planning in Benin: A Baseline

Indicators
IR4.2: Evidence of international FP best practices incorporated into national health standards IR4.3: Evidence of a defined and funded research agenda in FP IR4.4: Evidence of incountry organizational technical capacity for the collection, analysis, and communication of FP information

Information
Protocols for family health services revised based on the new WHO directives

Indicator Source
Document on protocols for family health services Document on coverage of STI/HIV/AIDS

No program, but some research done in research and training centers and by ABMS and ABPF

Little technical capacity to collect, analyze, and disseminate data ABPF has strengthened its capacity for M&E

Statistical data on FP services

IR 5: Individual or institutional capacity strengthened in the public sector, civil society, and private sector to assume leadership and/or support the FP agenda IR5.1: Evidence of entities provided with donor assistance that demonstrate capacity to independently implement repositioning FP activities IR5.2: Evidence of government departments or other entities established or strengthened to support the FP agenda CSOsABPF, ABMS, and OSV/JORDAN conduct FP activities ABMS provides IUDs PSI supports a network of 100 private clinics Statutes and rules Activity reports Activity report (ABMS)

DSME, FP Service National Panel on FP Annual review of the TAC A network of parliamentarians in support of population and development has been created

FP Decree Activity report Report on the review of the acquisition chart Deputy Lon BIO BIGOU (activity report provided by the network)

26

Annex 2: Repositioning Family Planning Results and Indicators for Benin

Indicators
IR5.3: Evidence of targeted public and private sector officials, faith-based organizations, or community leaders publicly demonstrating new or increased commitment to FP

Information
Speeches by the Minister of Health: Launch of CARMMA in September 2010 and the relaunch of CARMMA activities in December 2011 Awareness session for community leaders held at the town hall of Cotonou Launch of the campaign to involve men in FP on March 25,,2010

Indicator Source
Calendar of the ceremony Commitment in Benin

Benins commitment to participate in the United Nations Secretary Generals initiative for Women and Childrens Health in September 2010 Benins commitments to the global strategy: Provide a complete RH intervention kit by 2018 Increase the contraceptive prevalence rate from 6.2% to 15% Design new strategies on sexual and RH health services for teenagers FP training modules Research themes

IR5.4: Number of regional/national centers or collaborations for shared education and research in FP

INMES, CEFORP, FSS, IRSP

27

REFERENCES AND ADDITIONAL RESOURCES


AWARE II. 2011. Summary of Policy Barriers in AWARE II Focus Countries and Actions to Be Taken. Unpublished. AWARE II. 2011. Analysis of Barriers to Policy Implementation in AWARE II Focus Countries. Unpublished. AWARE II. 2011. Project Baseline Survey: Summary Analytical Report. Unpublished. Cross, H., K. Hardee, and N. Jewell. 2001. Reforming Operational Policies: A Pathway to Improving Reproductive Health Programs. POLICY Project Occasional Paper. Washington, DC: Futures Group, POLICY Project. Geohive. 2012. Benin Population Statistics [2002 census data from Institute National de la statistique et de lAnalyse Economique]. Retrieved from http://www.geohive.com/cntry/Bnin.aspx. Government of Bnin (GOB ). 2011. Feuille de Route pour la Planification Familiale. GOB. 2010. Programme National de Sant de la Reproduction 20112015. Cotonou: GOB. GOB. 2010. Stratgie de Croissance pour la Rduction de la Pauvret (SCRP) 20112015. Cotonou: GOB. GOB/Institut National de la Statistique et de l'Analyse conomique (INSAE) avec la Collaboration du Programme National de Lutte contre le Sida (PNLS) Cotonou, Bnin and Macro International Inc. 2007. Enqute Dmographique et de Sant 2006. Calverton, MD: INSAE and Macro International. GOB/Ministre de la Sant (MS). 2008. Acceptabilit de la Planification Familiale au Bnin. Cotonou: GOB. GOB/MS. 2010. Annuaire Statistique. Cotonou: GOB. GOB/ MS. 2010. Cadre de Dpenses Moyen Terme (CDMT) 20102012 du Ministre de la Sant.Government of Bnin and United Nations System. 2009. Plan Cadre des Nations Unies pour lAssistance au Dveloppement du Bnin (UNDAF 20092013). Retrieved on September 6, 2012 from http://www.bj.one.un.org/IMG/pdf/UNDAF_BNIN.pdf. Guengant, Jean-Pierre, Yarri Kamara, Nicholas De Metz, and Kolad Okoudjou. 2011. Comment Bnficier du Dividende Dmographique? La Dmographie au Centre des Trajectoires de Dveloppement dans les Pays de lUEMOA: Country Analysis: Bnin. Haub, Carl, and Toshiko Kaneda. 2012. World Population Data Sheet 2012. Washington, DC: Population Reference Bureau. Hogan, Margaret, Kyle Forman, Mohsen Naghavi, Stephanie Ahn, Mengru Wang, et al. 2010. Maternal Mortality for 181 Countries, 19802008: A Systematic Analysis of Progress towards Millennium Development Goal 5. Lancet 375: 16091623. Judice, N., and E. Snyder. 2012. Framework for Monitoring and Evaluating Efforts to Reposition Family Planning. Washington, DC: Futures Group. Accessed at: http://www.cpc.unc.edu/measure/publications/SR-12-63
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References and Additional Resources

K4Health. No date. Elements for Family Planning Success. Retrieved from http://www.k4health.org/toolkits/fpsuccess. Leonard, Lori. No date. Comprhension des Taux de Prvalence Contraceptive Elevs dans les Zones d'Intervention des ONG partenaires de Groupe-Pivot Sant/Population. Johns Hopkins University. Machiyama, Kazuyo. 2010. A Re-examination of Recent Fertility Declines in Sub-Saharan Africa. DHS Working Papers. Calverton. MD: ICF Macro. Ministre Charg de la Coordination de lAction Gouvernementale, de la Prospective et du Dveloppement. 2001. Rapport sur lEtat et le Devenir de la Population du Bnin Cotonou. Cotonou: Ministre Charg de la Coordination de lAction Gouvernementale, de la Prospective et du Dveloppement. Ministre de la Sant (MS). 2009. Plan Stratgique de Scurisation des Produits de Sant de la Reproduction et de Programmation Holistique des Prservatifs au Bnin 20102015. Cotonou: MS. MS. 2007. Annuaire des Statistiques Sanitaires. Cotonou: MS. MS. 2007. Plan National de Dveloppement Sanitaire 20072016. Cotonou: MS. MS. 2006. Stratgie Nationale pour la Scurisation des Produits de Sant de la Reproduction 2006 2015. Cotonou: MS. MS. 2002. Politique et Stratgies de Dveloppement du Secteur Sant 20022006. Cotonou: MS. MS. 2002. Politique Nationale de la Sant de la Reproduction 20022007. Cotonou: MS. MS. 1997. Politiques, Normes, et Standards. Cotonou: MS. MS/UNFPA/USAID. 2002. Programme National de la Sant de la Reproduction. Direction de la Sant Familiale de la Sant Familiale. Cotonou: MS. Ministre du Plan et de la Restructuration Economique et de la Promotion de lEmploi. 1996. Dclaration de Politique de Population de la Rpublique du Bnin. Cotonou: Ministre du Plan et de la Restructuration Economique et de la Promotion de lEmploi. Moreland, Scott, Ellen Smith, and Suneeta Sharma. 2010. World Population Prospects and Unmet Need for Family Planning. Washington, DC: Futures Group. Ougadougou Partnership. 2012. Family Planning: West Africa on the MoveA Call to Action. Provides recommendations for advancing family planning and mobilizing political commitment and resources after the international conference on family planning in Ouagadougou, February 811, 2011. Washington, DC, USA: Population Reference Bureau. Rajaratnam, Julie Knoll, Jake Marcus, Abraham Flaxman, Haidong Wang, Alison Levin-Rector, et al. 2010. Neonatal, Postneonatal, Childhood, and Under-5 Mortality for 187 Countries, 19702010: A Systematic Analysis of Progress towards Millennium Development Goal 4. Lancet 375: 19882008. Ross, John. 2011. The Injectable Take-Off in East and Southern Africa: Is It Substitutional? Unpublished paper. Washington, DC: Futures Group, Health Policy Project.
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Repositioning Family Planning in Benin: A Baseline

Ross, John, and Ellen Smith. 2010. The Family Planning Effort Index: 1999, 2004, and 2009. Washington, DC: Futures Group, USAID | Health Policy Initiative, Task Order 1. Retrieved from http://www.healthpolicyinitiative.com/Publications/Documents/1110_1_FP_Effort_Index_1999_2004_20 09__FINAL_05_08_10_acc.pdf United Nations Childrens Fund (UNICEF). 2011. Levels and Trends in Child Mortality: Report 2011. Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation. New York: UNICEF. Retrieved from http://www.childinfo.org/files/Child_Mortality_Report_2011.pdf. United Nations Population Fund (UNFPA). 2010. Plan de Travail Annuel 2010 pour lAcclration de la Rduction de la Mortalit Maternelle. Cotonou: UNFPA. United States Agency for International Development (USAID). 2006. Repositioning Family Planning in Sub-Saharan Africa: An Issue Brief. Washington, DC: USAID. Retrieved September 6, 2012, from http://transition.usaid.gov/our_work/global_health/pop/techareas/repositioning/briefs/repo_subafr.pdf. USAID | DELIVER Project, Task Order 1. 2009. Contraceptive Security Index 2009: A Tool for Priority Setting and Planning. Arlington, VA: USAID | DELIVER Project, Task Order 1. Retrieved September 9, 2012, from http://deliver.jsi.com/dlvr_content/resources/allpubs/factsheets/CSIndex_WallChart_WebBklet.pdf. USAID | DELIVER Project. 2006. Contraceptive Security Index 2006: A Tool for Priority Setting and Planning. Arlington, VA: USAID | DELIVER Project. Retrieved September 9, 2012, from http://deliver.jsi.com/dlvr_content/resources/allpubs/factsheets/CSInde_2006_Book.pdf. USAID | DELIVER Project. 2003. Contraceptive Security Index 2003: A Tool for Priority Setting and Planning. Arlington, VA: USAID | DELIVER Project. Retrieved September 9, 2012, fromhttp://deliver.jsi.com/dlvr_content/resources/allpubs/factsheets/CSInde_2003_Book.pdf. USAID/Senegal and the Ministry of Health. 2010. Documentation du Processus de loffre Initiale de Pilules (OIP) par les Matrones des Cases de Sant, Rapport Final. Dakar: Ministry of Health. USAID/Washington. 2011. High Impact Practices in Family Planning 2011. Retrieved from http://www.usaid.gov/our_work/global_health/pop/publications/docs/high_impact_practices.pdf. World Bank. 2012. World Development Indicators Database. Retrieved from http://search.worldbank.org/data?qterm=Bnin&_type_exact=Indicators&_topic_exact%5B%5D=Educati on&_topic_exact%5B%5D=Health&_topic_exact%5B%5D=Poverty. World Health Organization (WHO). 2012a. Trends in Maternal Mortality: 19902010. WHO, UNICEF, UNFPA and the World Bank Estimates. Geneva: WHO. Retrieved September 6, 2012, from http://whqlibdoc.who.int/publications/2012/9789241503631_eng.pdf. WHO. 2012b. Global Health Observatory Data Repository: Country Statistics: Benin. Retrieved on September 11, 2012, from http://apps.who.int/ghodata/?vid=4700&theme=country#. WHO. 2005. Critres de Recevabilit pour lAdoption et lUtilisation Continue des Mthodes Contraceptives. 3me dition. Geneva: WHO. WHO, USAID, and Family Health International (FHI). 2010. Community-based Health Workers Can Safely and Effectively Administer Injectable Contraceptives: Conclusions from a Technical Consultation. Research Triangle Park, NC: FHI. Retrieved from

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References and Additional Resources

http://www.fhi360.org//NR/rdonlyres/e66buwqnetdkndytax7vlqxeknagzd6fdahemwklkxj7enfcxltd4uvkgr skee7he4mcvnh6chcteo/WHOCBAinjectablesBrief0610.pdf.

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