Project Title: Prevention of Maternal Death from
Unwanted Pregnancy (PMDUP)
Date started: July 2011
Date review undertaken: August - September 2012
Introduction and Context
What support is the UK providing?
DFID is providing £67 million over five years to a consortium of organisations led by
Marie Stopes International (MSI) and including Ipas, DKT and Options to develop
and implement the Prevention of Maternal Death from Unwanted Pregnancy
(PMDUP) programme in 14 countries across two regions; Africa and Asia.
The programme builds on the assumptions that:
 A decrease in unsafe abortion (and better treatment of complications from unsafe
abortion) will save women’s lives and decrease morbidity;
 An increase in use of family planning (FP) will increase contraceptive prevalence
and prevent unintended pregnancies;
 An approach which integrates regional and country level advocacy with service
delivery will support countries to identify unsafe abortion as a public health issue
and, where requested, improve their policy and regulatory framework for safe
abortion.
The programme aims to reduce death and injury from unsafe abortion and increase
contraceptive use, thereby improving maternal health, in nine countries in Africa
(Ghana, Ethiopia, Zambia, Zimbabwe, Sierra Leone, Malawi, Nigeria, Democratic
Republic of Congo (DRC) and South Sudan) and five countries in Asia (Bangladesh,
India, Burma, Pakistan and Afghanistan). The programme works by:




Ensuring that fewer women, especially marginalised and young women, have
recourse to unsafe abortion and that more women can access modern FP
methods;
Providing nearly 5,500 more service delivery sites including community based
services;
Improving health worker capacity through training over 7,400 health care
workers in post abortion care and where permitted, comprehensive abortion
care, and FP methods;
Supporting locally led changes to the regulatory and/ or policy environments
for abortion services in selected countries and in the Africa region
DFID is the sole funder of this programme.
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What are the expected results?
The results for this programme are estimated using MSI’s Impact Estimator model
which links programme service delivery volumes to outcomes. As with any model,
these results will be approximate. The expected results for the five outcomes are:





19,046 maternal deaths averted in the programme period and beyond;
2.87 million unsafe abortions averted;
2.53 million unintended pregnancies prevented;
2.99 million disability adjusted life years averted;
11.1 million couple years of protection (CYPs) generated by family planning
services
in addition to institutionalised and sustainable attention at the national level to ensure
access to safe abortion and family planning.
The MSI Impact Estimator model has recently been revised to reflect latest
international data. While the expected number of services to be delivered under this
programme has not changed, the programme’s outcome results have been reestimated accordingly at the following values:





18,829 maternal deaths averted in the programme period and beyond;
3.17 million unsafe abortions averted;
5.66 million unintended pregnancies prevented;
4.03 million disability adjusted life years averted;
10.9 million couple years of protection (CYP) generated by family planning
services.
For the purposes of this first annual review the original results and corresponding
logframe milestones have been used in all reporting and analysis. Subsequent
reviews will use the latest impact estimator model.
What is the context in which UK support is provided?
DFID’s support for PMDUP will help meet Millennium Development Goal 5a (reduce
maternal mortality by three quarters by 2015).
Unsafe abortion is one of the major causes of maternal mortality, responsible for an
estimated 13% of the annual 358,000 maternal deaths globally; an additional 8.5
million women suffer injury, illness or disability as a result of unsafe abortion.
Abortion is legal (in certain circumstances) in 13 of the 14 PMDUP programme
countries1. Even where abortion is illegal or allowed on restricted grounds, unsafe
abortion and miscarriages will occur, and post abortion care is needed to address life
threatening complications. Reducing women’s recourse to unsafe abortion and
providing family planning to avoid further unintended pregnancy is therefore a public
health priority.
PMDUP will help achieve MDG 5 by increasing family planning use and reducing
maternal mortality in each participating country. In selected countries and in line with
DFID’s policy position on safe and unsafe abortion PMDUP will support locally led
efforts towards policy and regulatory reform.
1
Abortion is illegal in the Democratic Republic of Congo
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Section A: Detailed Output Scoring
Output 1: Fewer women (especially marginalised and young) have recourse to
unsafe abortion and fewer women have an unintended pregnancy.
Output 1 score and performance description: A+ Output moderately exceeded
expectation
Overall good progress has been made in increasing the use of post abortion care
(PAC) and, where permitted, comprehensive abortion care (CAC) as an alternative to
unsafe abortion. Excellent progress has been made in the number of family planning
services provided. The programme exceeded the annual milestones for three of the
four output indicators and attained 91% of the milestone for the fourth indicator.
There is evidence that the programme is reaching young and marginalised women
(characterised as poorer clients) with 72% of Marie Stopes International’s (MSI)
overall client base living on less than $2.50 per day, 27% on less than $1.25 per day
and about 30% of clients across both organisations being under 25 years of age2.
There is an intrinsic tension between the programme aim of reaching marginalised
and young people and ambitious milestones. This may be resolved through
developing a performance indicator within the programme’s logframe to measure and
monitor access by these priority target groups.
Progress against expected results:
Indicator 1.1: Increased number of women who choose to use post abortion care,
and, where permitted, comprehensive abortion care services as an alternative to
unsafe abortion through MSI (excluding Burma and Malawi).
Achieved 111% of the milestone but with substantial variations across the countries
with five of the 12 countries (that is, excluding Malawi which does not provide any
services and Burma), not achieving their milestones.
Indicator 1.2: Increased number of women who choose to use post abortion care,
and, where permitted, comprehensive abortion care services as an alternative to
unsafe abortion through Ipas monitored sites.
Achieved 119% of the milestone with variations across the range of countries.
Indicator 1.3: Number of FP services provided to women through MSI/Ipas
Achieved 164% of the milestone with four Asian countries contributing an additional
910,228 services over and above their first year milestones. The reasons for higher
than anticipated level of services include an underestimate of demand for FP. In
some contexts there was greater than anticipated demand from women for continued
use of short term FP rather than switching to longer acting methods. For example in
Ethiopia a change in strategy at the government's request has contributed to more
effective distribution of short term methods through community based providers as
opposed to the original strategy of mini-centres which support delivery of longer2
Percentage of clients aged under 20, percentage aged under 25 and percentage of clients living on
under $1.25 are based on results from exit interviews in 2011 in countries where at least one channel
included in the exit interview is funded by PMDUP. These countries are: Ethiopia, Ghana, Pakistan,
Sierra Leone, Zimbabwe and Burma. For the percentage of clients living on under $2.50 a day, data was
available for (and total average based upon) the following PMDUP countries where at least one delivery
channel was funded by PMDUP: Ethiopia, Ghana, Pakistan and Sierra Leone.
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acting methods.
Indicator1.4: Percentage of post abortion / comprehensive abortion care clients who
receive a Family Planning method.
Not achieved. The programme achieved 91% of the milestone. The calculation of this
indicator averages out the results from ten countries in which MSI is implementing
PMDUP, seven of which also have data from Ipas. In these seven countries the
results are weighted by the number of services provided by each agency during year
one. Data on this indicator is currently not available for Burma and Malawi (no
service provided), Afghanistan, South Sudan, and DRC. The average percentage of
women receiving a FP method on this basis is 60% against a milestone target of
66%.
Recommendations:

DFID and PMDUP to explore developing a performance indicator within
the programme’s logframe to measure and monitor access by poor and
marginalised groups.
Impact Weighting (%): 20%
Revised since last Annual Review? No – this is the first annual review.
Risk: High
Revised since last Annual Review? No – this is the first annual review.
Output 2: Increased choice of sites for post abortion care and where permitted
comprehensive abortion care provided as an alternative to unsafe abortion and for
modern FP services.
Output 2 score and performance description: A+ Output moderately exceeded
expectation
The programme has exceeded both of the milestones for this output. Only two
country programmes attained less than 90% of their anticipated numbers of new sites
(South Sudan (MSI) and India (MSI)). In total 2,021 new sites were added in year
one, 24% of which (482) were Ipas intervention sites in the public health sector. The
programme has thus increased the choice for clients seeking family planning, post
abortion care and, where permitted, comprehensive abortion care.
Progress against expected results:
Indicator 2.1: Increased number of MSI sites (static clinics, etc.) enabling women to
choose post abortion care, and where permitted comprehensive abortion care
services as an alternative to unsafe abortion and modern methods of FP.
Achieved 113% of milestone with the majority of countries being within 20% of their
original targets. A revised strategy in Ethiopia led to the initial milestones being
substantially exceeded; expanded outreach has also been successful in Ghana.
Elsewhere, for example in India, changes in the process for licensing clinics has
meant that progress has been slower than anticipated, however the programme is
continuing through other delivery channels to ensure that overall delivery is not
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compromised.
Indicator 2.2: Increased number of Ipas intervention sites enabling women to choose
post abortion care, and where permitted comprehensive abortion care services as an
alternative to unsafe abortion and modern methods of FP
Achieved 144% of milestone. Opening facilities ahead of schedule in Bangladesh,
Nigeria, Ethiopia and India has contributed to the higher than anticipated
achievement in year one.
Recommendations:
 There are no recommendations specific to this output.
Impact Weighting (%): 20%
Revised since last Annual Review? No – this is the first annual review.
Risk: Medium
Revised since last Annual Review? No – this is the first annual review.
Output 3: Improved capacity of the health sector which enables women to access
post abortion care, and where permitted comprehensive abortion care services
provided as an alternative to unsafe abortion and to choose modern methods of FP
Output 3 score and performance description: A+ Output moderately exceeded
expectation
All three indicator milestones have been achieved and the programme has
contributed to improved capacity in the health sector through the training of 2,158
health workers during the first year of the programme and through helping to ensure
high quality through the monitoring of quality standards. Quality assessments were
undertaken in the public health facilities in four of the Ipas supported countries and
ten MSI programmes (outreach and static centres).
Progress against expected results:
Indicator 3.1: Number of health workers trained enabling women to choose post
abortion care, and where permitted comprehensive abortion care services provided
as an alternative to unsafe abortion and/ or modern methods of FP.
Achieved 137% of milestone: a total of 2,158 health workers were trained. Milestones
were achieved in all countries except Afghanistan (achieved 91%), DRC (89%) and
MSI India (11%). In India there were delays in receiving government accreditation of
a training centre. MSI in Bangladesh, Ethiopia and Nigeria opted to train more than
the anticipated numbers of health workers in year one (and set up more sites). In
addition, higher than anticipated performance by Ipas in Bangladesh and Nigeria has
contributed to the attainment of the milestone.
Indicator 3.2: Percentage of Ipas facilities where manual vacuum aspiration and/or
medical abortion availability, where permitted, meets the quality standard (as
appropriate per setting).
Achieved 148% of milestone. This indicator is calculated through the averaging of
data from four countries (Nigeria, Zambia, Ethiopia and Bangladesh). Bangladesh
attained 100% of the standards at all centres. Data is not collected in three
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countries; Ghana, Pakistan and India.
Indicator 3.3: Percentage of facilities reaching minimum service quality standards.
Achieved 117% of milestone. The calculation is an average of all MSI and Ipas sites
which have submitted data and where MSI have undertaken their quality assessment
process. A total of 10 countries have been considered, seven of which have no Ipas
data. The average percentage of facilities attaining the minimum standard for year
one is 88%, two countries were below 70%, four were in the bracket 80-89% and five
scored over 90%.
Recommendations:

PMDUP to ensure that quality standards and quality assessment
processes are in place, in particular for social franchisees, and that these
standards and processes are communicated to relevant stakeholders.
Impact Weighting (%): 20%
Revised since last Annual Review? No – this is the first annual review.
Risk: Medium
Revised since last Annual Review? No – this is the first annual review.
Output 4: Locally led changes to the national and regional environment on safe
abortion and modern FP services
Output 4 score and performance description: A+ Output moderately exceeded
expectation.
There is good evidence that the programme has achieved the aim of supporting
locally led changes through the provision of capacity building support to 88
organisations in nine countries and to collaborating partners and those involved in
the regional work in Africa. The programme has supported and/or facilitated ten
changes in policy or regulations during its first year.
The country reviews in Pakistan and Sierra Leone gave the opportunity to discuss
the impact of the PMDUP programme under this output and the feedback was
generally very positive: representatives from the organisations being supported
indicated that the support facilitated locally led change and that Ipas’s expertise and
access to global evidence and learning had generally led to more wide-ranging
changes.
Progress against expected results:
Indicator 4.1: Locally led changes in policy, and regulatory environment that reduce
restrictions in access to safe abortion and to FP services and supplies.
Achieved. The actual result exceeded the target (of seven changes in five countries
and two regional changes in Africa) by an additional three changes and in an
additional country: that is, 10 changes in six countries and two regional changes in
total.
Indicator 4.2: Number of local and regional organisations/networks whose capacity is
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built to support locally led advocacy and community efforts to reduce recourse to
unsafe abortion and increase access to modern FP.
Achieved 101% of milestone. The programme worked with a total of 88 local and
regional organisations and networks. The majority of the country programmes
achieved their targets and all came within 20% of doing so.
The reviews in Pakistan and Sierra Leone reviewed the effectiveness of the capacity
building and the management of this aspect of the programme through discussion
with representatives from organisations/networks involved in the programme. In both
instances the representatives indicated that the capacity building programmes and
support received is appropriate and valuable.
Recommendations:

There are no specific recommendations however it is noted that the
complexity of the indicator may in future lead to problems with clarifying
the level of achievement should one or two of the three variables not be
met.
Impact Weighting (%): 30%
Revised since last Annual Review? No – this is the first annual review.
Risk: Medium
Revised since last Annual Review? No – this is the first annual review.
Output 5: Evidence-based practice and innovations shared to increase women’s
choice and access to post abortion care and where permitted comprehensive
abortion care and modern FP
Output 5 score and performance description: A+ Output moderately exceeded
expectation.
The programme exceeded the milestone whilst spending 40% of the allocated
budget. This is due to payments for some activities for year two outputs slipping into
year two of the programme.
Progress against expected results:
Indicator 5.1: Examples of evidence-based practices disseminated to influence
programmatic decision making e.g. peer reviewed articles, workshops, case studies,
tools
Achieved. A total of 15 evidence-based practices were disseminated by the
programme in year one.
Recommendations:

None under this output.
Impact Weighting (%): 10%
Revised since last Annual Review? No – this is the first annual review.
Risk: Low
Revised since last Annual Review? No – this is the first annual review.
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1. Progress and results
1.1 Has the logframe been updated since last review? Yes
The model for estimating outcome level indicators has been updated to reflect latest
international data – see Introduction and Context section.
1.2 Overall Output Score and Description: A+
The PMDUP programme has been very successful in its first year and exceeded the
almost all of its milestones. In some areas the performance has been exceptional
and close to being scored at A++, however there is variation of achievement across
countries. Milestones may have been set cautiously in some programme areas to
reflect the uncertainties of the new programme, of the new partnership and of
working in new locations. This review has assessed the programme design and
implementation as generally strong and internal risks appear to be well monitored
and managed. The flexibility of the design appears to contribute to the programme’s
success. There is scope better to define the expectation around access for
marginalised and young women.
The risk of changes in the operating environment exists in all country contexts with
some changes unpredictable. The programme benefits from substantial experience
within both main partners and their respective connections and is well placed to
respond to change. It is possible that changes may result in the programme failing to
meet its outcomes in some countries.
Notwithstanding some minor issues, the partnership between MSI, Ipas and DKT
appears to be effective and contributing positively to programme performance. There
is scope at country level to define and improve the effectiveness of the partnership
between MSI and Ipas.
1.2 Direct feedback from beneficiaries
As part of this annual review, in-depth reviews in Pakistan and Sierra Leone provided
some scope to discuss the programme with beneficiaries however the opportunities
were limited by the time available. The actual number of women who provided
feedback was not adequate to make the information meaningful in the context of the
annual review however the feedback was very positive. Women using a clinic in
Sierra Leone stated that the access to post abortion care was a vital and much
valued service particularly for young women who are at the highest risk of unintended
pregnancy and recourse to unsafe abortion.
As a matter of routine, MSI undertakes client satisfaction exit surveys at its clinics.
Median satisfaction scores across 10 dimensions of service quality were in excess of
80% with the lowest score for waiting times and the highest score for service prices.
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1.4 Summary of overall progress
In its first year of operation, the PMDUP programme has achieved, and in most
instances surpassed, output and outcome milestones for year one. Specific
modelled results include3:
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2,305 maternal deaths were averted, just under the target of 2,350 for year
one and a shortfall of 2% against the year one milestone.
352,696 unsafe abortions and 390,810 unintended pregnancies were
prevented, surpassing annual milestones by 6% and 10% respectively.
1,712,513 couple years of protection were achieved, surpassing the year one
milestone by 10%.
Although overall outcome and outputs have been achieved and exceeded under
PMDUP, the results from the Africa region have been lower than projected in year
one and Asia has exceeded year one milestones. In Africa maternal deaths averted
were 63% of target (significantly up from 17% at six months) while unintended
pregnancies prevented were 88% of target (up from 25% at six months). This is
mainly because of operational delays in conflict-affected countries and the need to
recall an inferior misoprostol product. However, results in the last six months of year
one have significantly improved compared to the first six months. This faster pace in
Africa is expected to continue in year two, given the solid foundation that has been
established. This foundation includes a wide range of health facilities and trained
health providers with increasing commitment and capacity to provide family planning,
post abortion care, and where permitted, comprehensive abortion care services. This
foundation was achieved, in part, through adaptive programming by Marie Stopes
International and Ipas, in response to evolving environments.
1.5 Key challenges
The key challenges to the achievement of overall results identified through the
annual review process are:
Changes in the operational context: there have been some changes in the operating
environments in some PMDUP countries since the programme design. These include
instances of worsening security, for example in Pakistan and Nigeria and some
contexts where price inflation has had an impact, such as South Sudan. PMDUP
programme managers have responded flexibly by adjusting implementing strategies
to minimise impact on service delivery. For example, in Nigeria PMDUP has
relocated some activities. In South Sudan, higher than expected costs and
deteriorating security has required an uplift to the budget, drawing on the programme
contingency budget.
Changes in the policy context: in some countries the policy environment has become
less favourable for the PMDUP programme. For example changes in Zambia, has
delayed implementation. Safeguarding favourable policy whilst supporting policy
development in more restrictive settings has required constant attention.
Weak health systems: PMDUP has been designed to respond to prevailing country
operating contexts and some health system impediments can only be
accommodated, rather than resolved, especially in respect of PMDUP’s work in and
with the public sector. Issues faced range from a lack of Human Resources for
Health (HRH) and their mal-distribution to commodity stock outs, equipment
shortages and weak data collection related to poor Health Management Information
Systems (HMIS). Challenges also exist in the private sector in relation to basic
operating conditions and capacities. Various mitigation measures have been applied
3
Estimates based on Impact Estimator 1.2 (the published log frame)
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but have not completely addressed low achievement in some countries in year one.
Progress, especially in Africa, will be closely monitored in year two and
implementation strategies adjusted as needed.
Access to quality inputs: Quality input issues range from training to the quality of
commodities. For example, the training for Afghanistan providers had to be relocated
to India where trainers and case load were available; an initial batch of trainees were
trained as trainers-of-trainers and subsequently were able to provide the training to a
number of providers in Afghanistan. In Sierra Leone, misoprostol had to be
withdrawn after inferior quality was detected by MSI delaying programme
implementation.
1.6 Annual Outcome Assessment
Good progress has been made towards attainment of year one outcome level
indicators indicating significant steps have been made to in reducing and preventing
deaths as a result of unintended pregnancy. The table below provides a summary of
the achievements against the year one milestones. The programme has achieved all
indicators except the number of maternal deaths averted which was missed by only
2%.
As indicated in the table below the Africa region has generally not attained its
anticipated milestones and the achievement of the programme targets is
underpinned by higher than expected levels of performance in Asia. The
performance in Africa in the second six months of year one was a marked
improvement over the first six months and it is expected that this positive trend will
continue.
O1. Maternal deaths
2,305 maternal deaths averted. Achieved 98% of
averted
the milestone with significant variation between the
regions: Asia achieved 122% and Africa 63% of
their milestones respectively.
O2. Number of unsafe
352,696 unsafe abortions averted. Achieved 100%:
abortions averted
Asia 129% and Africa 65%.
O3. Number of unintended
pregnancies prevented
390,810 unintended pregnancies averted. Achieved
110%: Asia 115% and Africa 88%.
O4. DALYs averted
397,230 DALYs have been averted. Achieved
105%: Asia 117% and Africa 76%.
O5. Evidence of systemwide commitment to ensure
access to CAC/PAC/FP that
is institutionalised and
sustainable
There is evidence of a growing commitment across
both regions.
O6. Couple Years of
Protection generated by FP
services
1,712,513 CYPs generated. Achieved 110%: Asia
113% and Africa 84%.
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2. Costs and timescale
2.1 Is the project on-track against financial forecasts: Yes
Overall the programme has spent 86% of the year one forecast with outputs one, two
and three being within 5% of the forecast (under the forecast). Expenditure on output
five is relatively low at 40% of forecast although all planned activities have been
undertaken and milestones reached due to the timing of payments which contribute
to year two outputs.
2.2 Key cost drivers
During the first year, £11 million was spent; out of this total 55% was spent on
delivering services (commodities, supplies and labour) and the balance on system
support and programme management (supervision, training of personnel, health
education, monitoring and evaluation, advocacy, building and maintaining information
systems and commodity supply systems). Both categories of expenditure include
MSI-Ipas headquarter costs, which includes all systems development, technical
support including quality management and supervision which are essential for
programme performance. These costs were on average around 25% of total
expenditures in the first year. This proportion includes programme design costs and
will diminish as a proportion of total budget over time.
2.3 Is the project on-track against original timescale: Yes
Despite some delays and on-going operational issues in some country programmes
the programme as a whole is on track at the end of year one.
3. Evidence and Evaluation
3.1 Assess any changes in evidence and implications for the project.
There have been no significant changes in the evidence on which the theory of
change is based. In 2012 the World Health Organization (WHO) published the
second edition of ‘Safe Abortion: technical and policy guidance for health systems’
which will inform practice in PMDUP.
3.2 Where an evaluation is planned what progress has been made?
DFID has contracted a consortium led by London School of Health and Tropical
Medicine (LSHTM) concurrently to undertake an evaluation of PMDUP (including an
impact evaluation) this is separate to the main PMDUP programme. The evaluation
design is currently being finalised.
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4. Risk
4.1 Output Risk Rating: Medium
The programme operates a risk matrix to accommodate the varying risks across the
fourteen counties as below. During year one Nigeria has been re-categorised as
‘high probability’ (from a previous categorisation of medium) to reflect changes in the
security situation and Burma has been re-categorised as ‘medium probability’ from a
previous categorisation of ‘high probability’ on the risk matrix.
IMPACT
PROBABILITY LOW
LOW
MEDIUM
HIGH
Zimbabwe
Malawi
Afghanistan
MEDIUM
Zambia
Ghana
Sierra Leone
Burma
South Sudan
DRC
HIGH
Bangladesh
Ethiopia
India
Pakistan
Nigeria
4.2 Assessment of the risk level
The PMDUP programme has undertaken a comprehensive assessment of potential
risks identified at the design stage, their probability and potential impact. A mitigation
strategy exists for each risk. Mitigation strategies have been strengthened where
needed. These appear to be well considered and appropriate to the level and
probability of the identified risk. The overall risk level of the project is medium.
4.3 Risk of funds not being used as intended
There is very limited risk of funds not being used as intended as all implementing
partners make payments in accordance with generally acceptable accounting
procedures and DFID rules and regulations as outlined in their contracts.
Implementing partners have robust financial policies and procedures in place to
ensure that funds are used as intended. This includes an annual internal and/or
external audit programme with certification submitted to DFID in line with contractual
requirements. A due diligence check of Marie Stopes International was carried out for
DFID prior to implementation and outstanding issues were addressed.
4.4 Climate and Environment Risk
The PMDUP Business Case identified the potential climate change score for this
programme as ‘C’ - challenge. The relevant areas identified in the Business Case
include:
 Risks of the project: increased medical waste, increased transport (air travel
and road transport for service delivery and supervision).
 Risks to the project: conflict or humanitarian situations
 Benefits and opportunities: decreases in fertility resulting from this project
could have an impact on population growth which would slow down the
increase in emission and environmental degradation.
but with no specific action required. MSI and Ipas’s quality assurance systems
ensure safe disposal of medical waste. On transport, PMDUP partners operate
systems to minimise air and road travel and MSI has introduced a new fleet
management systems to make most effective and efficient use of vehicles.
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5. Value for Money (VfM)
5.1 Performance on VfM measures
With regard to the VfM indicators for the programme’s outcomes year one
performance compares favourably with the anticipated results which compare the
results to the original Business Case calculations and a revision of these to 2012
prices.
The cost per DALY averted of £19.78 compared to the anticipated cost of £22.41
(adjusted to 2012 prices) indicates that the programme is highly cost effective. To
contextualise this, WHO state that an intervention with a cost-effectiveness ratio less
than the national GDP per capita for each DALY averted should be considered highly
cost–effective and ratios of two and three times the GDP per capita should be
considered cost-effective. The average cost per DALY for the PMDUP programme
ranges from £10 to £110 across the four type of countries given that the GDP per
capita in DRC, one of the poorest of the countries in the programme, is US$182
(£114.6) it is clear that value for money is being achieved.
The value for money appraisal undertaken as part of the annual review estimates the
cost per CYP of £6.05 (at 2012 prices). The latter compares favourably with the
original estimate, in the business case, of £3.59 - £6.49 (at 2010 prices with the
variation depending on whether the total budget includes public sector costs, central
costs or just service delivery). As expected, Africa shows significantly higher unit cost
per generating CYP than Asia, partly explained by the higher cost base and lower
service volumes.
The first year of implementation has seen a number of unanticipated changes to the
delivery of the programme including delayed starts in some programmes and revised
strategies in others which have had an impact on both the costs and the number of
services delivered. It is too early to judge whether or not the programme is on track
to maximise value for money over the full five years. As the programme becomes
more established there will be potential for greater economies of scale.
5.2 Commercial Improvement and Value for Money (VfM)
The programme was tendered as a ‘design and build’ contract, through an open
international OJEU bidding process. To maximise the number of potential suppliers
and the effectiveness of the programme, neither the countries nor technologies and
strategies were stipulated in advance. Given that the issues that PMDUP addresses
are a specialist area, it was likely that consortia would form. Two full bids from
consortia were received and selection made on the quality and track record of the
organisations and personnel and their capacity to fulfil the TORs, in particular to go to
scale rapidly and ensure high quality service delivery. Attention was paid to VfM at
each stage in the tendering and contracting process, while recognising that unit costs
will vary in each PMDUP country. Unit costs in Asia are markedly lower in Asia than
in Africa, and in fragile and conflict affected countries where infrastructure is poor and
few existing services on which to build. Because of the strategic importance of
improved service delivery across a range of country types, the programme is not
preferentially allocating resources to the lowest cost settings.
The contract is being managed on a performance basis with quarterly payments
partly linked to performance on three key measures of progress with outputs: FP
service delivered, number of health workers trained and number of new sites added.
The contractor partners are driving improvements in VfM by deploying effective
technical assistance from HQ to improve technical, financial, quality and monitoring
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systems in country programme, to strengthen business models.
In addition MSI has introduced systems and initiatives to improve VfM at
organisational and country levels. These include specific work on: procurement and
supply chains, vehicle fleet management and VfM through its sub-contracts. Ipas
also is working to improve VfM for procurement and to maximise the programmatic
impact of any international travel.
There are a number of examples of practices which will be contributing to the overall
VfM of the programme; for example sharing vehicles when attending meetings,
undertaking joint supervisory visits, sharing training materials, best practice guides
and expertise and contacts to reduce the time and resources required to create new
documents and relationships.
5.3 Role of project partners
At the programme level the MSI and Ipas head office teams have established
effective management arrangements for PMDUP which are responsive to the
programme and each other’s requirements and needs. The level of in-country
collaboration between the two main implementing agencies is variable and to a large
part depends on the work being undertaken and the individuals involved. There is
recognition of some duplication of effort and failure to maximise opportunities to work
with higher levels of synergy and saving. It is a recommendation of the review that
there is scope to provide further clarity on the expectations of the relationship
between MSI and Ipas within countries and to identify strategies to support the
country teams in achieving this; these may include sharing success stories and
mandating the health advisers to facilitate improved relations where necessary.
5.4 Does the project still represent Value for Money : Yes – see data in 5.1 above
5.5 If not, what action will you take? N/A
6. Conditionality
6.1 Update on specific conditions
Not applicable to PMDUP
7. Conclusions and actions
The PMDUP programme has been very successful in its first year and exceeded the
vast majority of its milestones. The milestones may have been set cautiously in some
areas to reflect the uncertainties of the new programme, of the new partnership and
of working in new areas. In other areas, particularly in Africa, the milestones were
possibly over optimistic in their estimation of the time it would take to set up
operations. Programme design and implementation is generally strong and internal
risks are well-monitored and managed. Flexibility in relation to the implementation
strategies contributes to the programme’s strong performance.
The risk of changes in the external environment exists in each country and mostly
cannot be predicted. The programme benefits from substantial experience within
both main partners and their respective connections and is well placed to respond to
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change however it is possible that some changes may result in the programme failing
to meet its outcomes.
Notwithstanding some minor issues, the partnership between MSI, Ipas (and DKT)
appears to be effective and contributing positively to the programme. There is scope
at country level to define and improve the impact and effectiveness of the partnership
between MSI and Ipas.
Recommendations:
1. DFID to undertake a robust review of the trajectory of programme
performance at the end of the first quarter of year two, in particular in Africa
around any area of underperformance.
2. DFID and PMDUP to explore developing a performance indicator within the
programme’s logframe to monitor access by marginalised and young women.
3. DFID to review milestones annually to ensure that they are relevant to the
programme’s implementation in country, especially where changes to country
strategy have been made, and that the consolidated milestones reflect the
programme as a whole.
4. DFID to consider the annual review recommendations on the operation of the
Key Performance Indicator system for quarterly payment of invoices to ensure
that the basis for payment is robust.
5. DFID to consider acceleration of results or additional funding to support
expansion where there is a strong case.
6. MSI and Ipas to support their respective country teams to maximise the
benefits of joint working.
7. DFID and MSI to consider improving the flexibility of funds allocated to Ipas
policy related activities to allow them to respond rapidly to unexpected crises
and opportunities. There may be need in due course to consider if there are
sufficient funds within the programme allocated to work related to policy.
8. MSI, Ipas and DKT to develop a transition strategy to meet DFID’s policy on
reproductive health commodities.
8. Review Process
The annual review was undertaken by a team of contracted consultants comprising a
UK based reproductive health specialist (team leader) who undertook the in-depth
review in Sierra Leone, a Pakistan-based national consultant who undertook the indepth review in Pakistan and a health economist who undertook the value for money
appraisal.
The process for the global review was as follows: Review of PMDUP’s first annual review and relevant programme reports
 Interviews with representatives from MSI, Ipas and DKT at country level (a
total of 13 MSI countries, all seven Ipas countries and the Ipas regional policy
team).
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


Interviews with DFID health advisers in 12 of the 13 countries in which they
are present and with the senior regional health adviser providing support to
the Afghanistan programme.
Relevant management, programme, financial and monitoring, research and
evaluation staff at MSI and Ipas’s head and regional offices.
Review of programme data including data tracking in two countries
For the in-depth reviews additional meetings were held with key stakeholders
including, Ministry of Health staff (in Sierra Leone only). Meetings with local
district authorities, civil society and other organisations/networks being supported
by the PMDUP programme. In addition there were visits to government health
facilities and outreach programmes, meetings with health workers and with
beneficiaries through community meetings, focus groups discussions and exit
interviews at health facilities.
Findings were discussed with DFID’s PMDUP Programme Board and MSI on 18th
September 2012.
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