Business Case and Intervention Summary
ARIES: 203925 (QUEST document number: 3923151)
Intervention Summary
Title: Preventing Recourse to Unsafe Abortion – supporting locally led initiatives.
What support will the UK provide?
This business case contributes to implementing the UK commitment to put women and girls at the heart of our development
assistance, as set out in DFID’s Business Plan 2011 – 2015. In particular this investment will address the marginalised and
underfunded issue of preventing recourse to unsafe abortion.
The UK will provide £3.0 million over 4 years to the Safe Abortion Action Fund (SAAF), a worldwide multi-donor funding mechanism
that supports in-country initiatives that tackle unsafe abortion and improve access to comprehensive safe abortion services including
post abortion family planning. It provides small flexible grants to non-governmental organizations (NGOs) for locally led policy and
advocacy initiatives as well as innovations in service delivery and research to the poorest and most marginalised.
2012/13 - £600,000
2013/14 - £950,000
2014/15- £1 million
2015/16 - £450,000
The latest round of SAAF’s programming and funding (Round 2 (2011 – 2014)) started in mid-2011. Securing multi-year funding
from DFID, alongside other donors will, in addition to ensuring full funding of Round 2, enable SAAF to launch a competition for
Round 3 (2013 – 2016) funding. Experience from both Rounds 1 and 2 have demonstrated a strong demand for funding. Our
support will help prevent 500,000 women from risking their lives by recourse to unsafe abortion and contribute to an improved policy
environment in 30 countries.
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Why is UK support required?
To achieve Millennium Development Goals (MDGs) 3 and 5 of improving maternal health, promoting gender equality and
empowering women it will be necessary to tackle unsafe abortion, which every year is responsible for 13% of maternal deathsi and
is estimated to leave a further 8.5 million women permanently injuredii. Much of this burden falls on young women and girls in the
developing world. Improving access to safe abortion saves maternal lives and reduces ill health without increasing overall abortion
rates.iii It can also result in economic and social benefits such as reducing out of pocket healthcare costs and allowing continued
education. While family planning reduces recourse to unsafe abortion it does not eliminate all unintended pregnancy.
As one of the few donors with a clear policy on safe and unsafe abortion (see box 1) the UK is well placed to continue its leadership
role in this area following the successful establishment of the Safe Abortion Action Fund (SAAF). Addressing unsafe abortion will
help realise the vision of DFID's 'Choices for women' Frameworkiv, aligns with commitments made by the UK in the 1994
International Conference on Population Development (ICPD), and resonates with the theme of women’s and girl’s empowerment as
outlined in DFID’s strategic vision for women and girls: stopping poverty before it startsv.
Box 1: UK’s Policy Position on Safe and Unsafe Abortion in developing countriesvi
Women and adolescent girls must have the right to make their own decisions about their sexual and reproductive health and well-being, and
be able to choose whether, when and how many children to have. DFID does not support abortion as a method of family planning – indeed
we are working to increase access to modern methods of family planning (which would ultimately reduce demand for abortion).
Safe abortion reduces recourse to unsafe abortion and saves maternal lives. We do not enter the ring on the rights and wrongs of abortion,
but in countries where abortion is permitted, we can support programmes that make safe abortion more accessible. In countries where it is
highly restricted and maternal mortality and morbidity are high, we can help make the consequences of unsafe abortion more widely
understood, and can consider supporting locally led processes of legal and policy reform.
Reducing unsafe abortion requires the development of a conducive legislative, policy, service delivery and cultural environment at
the local, national and international levels. Innovation is needed to test service delivery models to reach the most vulnerable women
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and girls. In addition, measures are needed to strengthen the evidence base around reducing recourse to unsafe abortion as, due to
the sensitive and often clandestine nature of abortion, knowledge is limited.
For such change to happen, it is important that the issue of unsafe abortion is locally owned. Supporting local organizations that are
at the crossroads between communities, health providers and governments can be an effective way to complement the work being
done by governments or international NGOS. Unfortunately, in the current international funding context, financial support to address
unsafe abortion is scarce, particularly for smaller local organizations which cannot access international funding mechanisms. DFID
support for such a funding mechanism to support locally driven policy, legislative and social change, as well as research and
innovation, would therefore meet an important need and help maintain progress towards MDGs 5 and 3 by reducing recourse to
unsafe abortion.
What are the expected results?
Funding of the Safe Abortion Action Fund (SAAF) is proposed as the most appropriate and cost effective arrangement for delivering
support that enables local NGOs and Community Based Organisations (CBOs) to implement small scale, locally relevant and
innovative programmes to address unsafe abortion within their own context. Three key reasons are proposed: 1) proven track
record; 2) good Value for Money (VfM) and 3) a high score in the DFID project completion report in 20111.
The results are delivered through locally led NGO initiatives and, given the competitive nature of the scheme, the balance between
advocacy, policy and service delivery results may vary between funding rounds. Exact results will be dependent on the types of
projects funding through Round 3. However, based on the results delivered in Round 1 (complete) and predicted in Round 2 (in
progress) it is expected that Rounds 2 and 3 will deliver the following results to which DFID will contribute 25% of investment:
 500,000 women and girls receive comprehensive abortion care (CAC) or post abortion-care (PAC).
 An increase in uptake of post abortion family planning from 27% to 65%.
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SAAF achieved good results across its four outputs, and has effectively taken on board the 2009 evaluation recommendations for both management and project implementation. The project purpose scored ‘2’ –
likely to be largely achieved’.
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 Abortion issues are more publicly visible and/or steps are taken to improve national, federal or local legislation in 30 countries.
 National/local policy frameworks, guidelines on safe abortion are developed and/or implemented in 30 countries.
The SAAF logical framework is jointly developed and agreed by the SAAF secretariat, board and fund donors. DFID will monitor
progress according to the indicators and milestones included in that framework. The results framework is expected to be finalised
and approved at the forthcoming SAAF Board meeting in June 2013. Milestones and targets will be adapted, to include Round 3
results, once the competitive and contracting processes for Round 3 funding have been completed (by last Quarter of 2013).
Current commitments to SAAF over the next three years from Denmark, the Netherlands and an anonymous donor amount to
US$9.5m. In addition SAAF are currently in discussion with Norway (who, with DFID, is a long standing donor to the fund) to secure
funding of $5.4m, also over 3 years. The DFID burden share is estimated at no more than 25%. Securing both Norwegian and DFID
funding would lead to a substantial increase in expected results and secure funding for Round 3.
Business Case
Strategic Case
A. Context and need for a DFID intervention
Context
Unsafe abortion hinders development
There is increasing recognition by the international community that efforts to combat maternal mortality must address unsafe
abortion. The UN Secretary General’s Strategy for Women and Children explicitly includes safe abortion services as one of the
interventions to address maternal mortality (with the caveat “where not prohibited by law”) vii. In October 2011, a landmark report on
the right of everyone to the enjoyment of the highest attainable standard of physical and mental health was submitted to the UN
General Assembly by Anand Grover, the UN Special Rapporteur on the Right to Health that included specific reference to the issue
of abortion as a human rights issue. “Criminal laws penalizing and restricting induced abortion are the paradigmatic examples of
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impermissible barriers to the realization of women’s right to health and must be eliminated. These laws infringe women’s dignity and
autonomy by severely restricting decision-making by women in respect of their sexual and reproductive health.”viii
To achieve Millennium Development Goals (MDGs) 5 and 3 of improving maternal health, promoting gender equality and
empowering women it will be necessary to tackle unsafe abortion and its consequences. Despite recent progress, the world is
currently off target on MDG 5ix and some of this can be attributed to unsafe abortion, which every year is responsible for 13%
(47,000) of maternal deathsx and is estimated to injure 8.5 million womenxi. The health impacts of unsafe abortion also fall
disproportionately on women in poorer countries as 98% of unsafe abortions take place in the developing worldxii. Addressing unsafe
abortion would therefore do much toward improving maternal health (MDG 5).
The burden of unsafe abortion extends beyond direct health impacts on individual women and girls. The economic consequences,
for example, are substantial: it has been estimated that every year unsafe abortion costs healthcare systems in developing countries
between $375 million and $838 millionxiii. In addition, out of pocket healthcare expenses for individuals and their families may amount
to a further $600 million annuallyxiv. These costs represent a major economic burden for already impoverished individuals, families,
communities and nations. Given the physical and psychological impacts of unsafe abortion it is also probable that the practice has
detrimental effects on the educational, economic and social participation of women and girls. Impacts such as these will slow
progress towards MDG 3 and are also likely to indirectly hinder the achievement of the MDGs to eradicate extreme poverty and
hunger, and to reduce child mortality, MDGS 1 and 4.
Nevertheless there has been progress in reducing the consequences of unsafe abortion: while the estimated number of unsafe
abortions has increased from 19.6 million in 2003 to 21.6 million in 2008, deaths have fallen from 56,000 to 47,000 over the same
period. It is likely that this decrease in deaths can be attributed to both improved safety of available methods of abortion e.g. medical
abortion, as well as concerted effort by many organisations to improve access to quality post-abortion care (to address complications
of unsafe abortion) which has been supported by the UK and others.
Improving access to family planning and safe abortion reduces unsafe abortion
There is a strong link between unmet need for modern family planning and abortion xv and it has been estimated that 3 out of 4
unsafe abortions could be prevented altogether by addressing the unmet need for family planningxvi.However, even where effective
contraception is available and widely used the rate of abortion declines but nowhere has it reached zero - there are a number of
reasons for this. First, and most importantly, millions of people either do not have access to modern contraceptives or do not have
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adequate support to use them. Second, no method of contraception is 100% effective. Third, high rates of violence against women,
including in the home and during armed conflicts, lead to unwanted pregnancies. Fourth, many women feel they are too young or too
poor, for example, to raise a child. In addition, in situations where there is a rapid transition from high to low fertility there may initially
be a rise in abortions if family planning services cannot keep pace with the growing demand for modern contraceptive methods xvii. .
Regional analysis of safe and unsafe abortion shows that many women and girls will chose an induced abortion when faced with an
unplanned pregnancy – irrespective of legal conditions xviii While the legal status of abortion and the risk of death or ill health
following an abortion are not perfectly correlated, it is well documented that maternal death and ill health tends to be high in
countries and regions with restrictive abortion laws, and tend to be extremely low when laws are liberal and safe services are
availablexix.
Improving access to safe abortion reduces recourse to unsafe abortion. A review of legal status of abortion, levels of unsafe abortion
and abortion related deaths in 160 countries found that where the law allows abortion on broad indications, there was little (if any)
unsafe abortion and few maternal deaths due to the complications of abortion. However where the law is restrictive levels of unsafe
abortion and abortion related maternal mortality increase greatlyxx. Fear of legal consequences can drive women not only to seek a
clandestine unsafe abortion but may also prevent them from seeking post-abortion care in the event of a complication. An estimated
15- 25% of women in need of treatment for complications following an illegal abortion do not seek carexxi
Project data from Ethiopia and Cambodiaxxii, two of the countries that have recently expanded access to safe abortion, strongly
suggests that there is less recourse to unsafe abortion when a safe alternative is available and accessible to all:
 In 2006 the health bureau in Ethiopia’s Tigray Region began working with IPAS (an international non-government
organisation) to implement and document changes in abortion services and use in 50 facilities. Within 18 months there were
increases in the availability of and use of safe abortion services. This was accompanied by significant decreases in the
number of women presenting with abortion related complications – suggesting that fewer women were resorting to dangerous
abortion methods. Notably the uptake of modern family planning methods following a safe abortion also increased (from 31%
to 78%)xxiii.
 In Cambodia, from 2005 – 2010 health providers were trained in the provision of safe abortion and efforts made to increase
the quality and availability of safe abortion. An IPAS survey of providers from 188 facilities in 2005 and 205 facilities in 2010
found that fewer women were severely ill and that no women died of complications of unsafe abortion in 2010. Again these
findings suggest that there was reduced recourse to unsafe abortion once safe abortion was accessible.
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In settings where abortion is legally available but where safe services have not been made accessible there is still recourse to
unsafe abortion. For example in India abortion was legalised on all grounds in 1971 but inadequate implementation of safe services
means that unsafe abortion is still commonplace. In several countries that have recently made legislative changes (e.g. Nepal,
Cambodia, South Africa, Ethiopia) uneven distribution of services for example in rural areas means that for some population
groups unsafe abortion remains the normxxiv.
Improving access to safe abortion does not increase overall abortion rates
Improving access to safe abortion does not increase overall abortion rates. A newly published report on global abortion levels and
trends shows that abortion rates are lower in sub-regions characterised by liberal abortion laws compared to sub-regions dominated
by restrictive abortion lawsxxv. Western Europe, has the lowest abortion rate in the world (12 abortions per 1000 women of
reproductive age) because in most countries abortion law is liberal and quality services are accessible, provided as part of
comprehensive reproductive health care, including contraception. In addition, some countries with a long history of access to safe
abortion and complete data on use of abortion services including Denmark, Finland, Italy and Japan have demonstrated steady
declines in abortion ratesxxvi - likely in part due to increased access to and use of modern contraception. This underlines the
importance of improved access to safe abortion in the context of improved access to other essential reproductive health services
such as family planning.
Need for a DFID intervention
Actors and architecture
A limited amount of funding for safe abortion comes from a small number of private US foundations and some European donors
(Nordic states, UK and Netherlands). USAID, one of the largest SRH donors, does not fund safe abortion due to the Helms
Amendment to the US Foreign Assistance Act. In addition, funding for safe abortion has been negatively affected by the economic
downturn in recent years.
The safe abortion development architecture is well defined. There are a handful of international NGOs working to improve the global,
regional and national legislative, policy and service delivery environment. Notably these include Guttmacher Institute which is mainly
focused on research and monitoring of abortion incidence in partnership with the World Health Organisation and on research and
data on prevalence and IPAS: a US based INGO that works through regional and national fora and bodies (e.g. the African Union,
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International Federation of Gynaecologists and Obstetricians) and concentrates on policy influence/enabling establishment of
evidence based services when law/policy changes. There are also key INGOs who engage in expanding access to service delivery
through their own clinic networks and through their links with the public and private sectors e.g. Marie Stopes International (MSI) and
the International Planned Parenthood Federation (IPPF). The key UN agencies that work to reduce recourse to unsafe abortion are
WHO and UNFPA.
It is increasingly recognised that indigenous organisations, often quite small NGOs or CBOs, play a very important role in shaping
the national and sub-national policy and service delivery environments – including in generating national support for legislative
change and identifying & filling gaps in service provision (e.g. second trimester abortion; access for vulnerable groups). For example
the recent shifts in Sierra Leone and Malawi have been led by local voices; in Uruguay legislative change was the consequence of
innovative work by two local organisations. However there are very few channels through which local organisations key to catalysing
such change can access funding. The SAAF, a multi-donor fund was established in 2006, at DFID request, to fill this gap in the
architecture.
Why DFID intervention is justified
DFID’s Business Plan 2011 – 2015 commits us to ‘lead international action to improve the lives of girls and women’ This includes
action to improve reproductive and maternal health as elaborated in DFID’s December 2010 Framework for Results for
Reproductive Maternal and Newborn Health Framework for Results (FfR RMNH ).This framework outlines how DFID will do more of
what works, focusing on value for money, but also innovate, evaluate and continue to learn – in every area of the continuum of care
including improved access to safe abortion.
DFID as one of the very few donors that supports improved access to safe abortion is an acknowledged leader and key donor in this
neglected area of maternal health. Our willingness to tackle this neglected issue makes it one of our strengths, which was widely
acknowledged by stakeholders in a DFID consultation held from July – October 2010, “Choice for women: every pregnancy wanted,
every birth safe” to shape the UK policy and new business plan on reproductive, maternal and newborn care in the developing world.
DFID’s position is consistent with the Cairo Programme of Action (POA) agreed at the 1994 United Nations International Conference
on Population and Development.
DFID already has strong links with key international actors working to reduce recourse to unsafe abortion. Through our Regional,
Civil Society and United Nations and Commonwealth Departments we already support the major INGOs and UN agencies that lead
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on this agenda, for example:

Both MSI and IPPF are recipients of Project Partnership Arrangements;

DFID provides core funding to both UNFPA and WHO.
In addition, DFID is represented on the SAAF Board and has funded this initiative since its inception in 2006 until the end of Phase 1
in 2011. DFID funding has totalled £5.3 million broken down as follows: £4 million 2007/08 – 2008/09 (£3.0 m general unallocated
and £1.0 m Africa specific), £900,000 2009/2010 (South Asia specific) and £400,000 2010/11 (general unallocated). DFID is not
currently funding work to support initiatives by local NGOs and CBOs and given the increasing relevance of work at this level this
represents a gap in our portfolio that this business case seeks to address.
The continuing and increased involvement of the UK in reducing recourse to unsafe abortion is in line with our policy, will help lever
political and financial support from elsewhere, and will help counter increasingly organised international opposition to progressive
references to sexual and reproductive health and rights that has led to:
1. Very difficult negotiations on SRHR language during the recent 57th Commission on the Status of Women (CSW) and failure
to agree conclusions at the 56th CSW) in 2012.
2. Removal of language around reproductive rights during the Rio+20 negotiations.
3. No clear consensus from the EU on reproductive rights.
These trends threaten to undermine hard won gains for reproductive rights at every level – from negotiations around UN resolutions
and conventions, and the Post 2015 MDG framework, to national government’s priorities in policy and programming.
B. Impact and Outcome that we expect to achieve
Through funding and supporting small scale and locally led but context relevant and often innovative interventions, we expect to
achieve the outcome of ‘locally led changes to the legislative, policy and service delivery environment for safe abortion’.
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Based on the experience of Round 1 (complete) and Round 2 (in progress) it is expected that DFID investment (25%) will
substantially contribute to the following results at outcome level2:
 500,000 women and girls receive comprehensive abortion care (CAC) or post abortion-care (PAC).
 An increase in uptake of post abortion family planning from 27% to 65%.
 Abortion issues are more publicly visibility for abortion and/or steps are taken to improve national, federal or local legislation in
30 countries.
 National/local policy frameworks, guidelines and/or protocols on safe abortion are developed and/or implemented in 30
countries.
Less unsafe abortion will lead to a reduction in abortion complications and thus less maternal ill health and fewer deaths (impact).
However, due to the nature of this investment – multiple small investments, large emphasis on changes to the enabling environment
including legislative and policy change combined with the significant challenges in measurement3 of safe and unsafe abortion it is not
possible to quantify impact in terms of number of lives saved. The table below presents some of the available evidence to support
our assumption that improved access to safe abortion leads to fewer maternal injuries and deaths. Additional studies to support this
assumption are noted in the strategic case.
Unsafe
abortion
leads
maternal deaths and injury
to Unsafe abortion is a major cause of maternal mortality, responsible for an estimated 13% of all maternal
deathsxxvii In addition; every year an estimated 8.5 million women suffer injury, illness or disability, as a
result of unsafe abortionxxviii.
Note results for Round 3 will be dependent on the types of projects funded. The competition for proposals is expected to be launched in
the second Quarter of 2013 and milestones/targets will be reviewed once funding is awarded (by last Quarter 2013),
2
The measurement of abortion is a particularly difficult task because of its sensitivity and, in many countries its illegal status. Few
developing countries have scaled up access to safe abortion services in the public health system and even where this has occurred health
statistics on service provision are often incomplete. As a consequence there is little direct evidence of the impact of improved access to
safe abortion on health outcomes and abortion rates. In addition, compared to other areas of health, funding for research on abortion is
limited. However there is a growing body of research that strongly suggests that access to safe abortion saves lives and reduces illhealth, does not increase overall abortion rates and reduces recourse to unsafe abortion
3
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Improving access to safe In countries where access to safe abortion has improved, complications resulting from unsafe abortion
abortion through changes to the and abortion related maternal mortality can fall rapidly:
enabling environment reduces
maternal ill health and deaths.
In South Africa where the abortion law was liberalised in 1997, the annual number of abortion related
maternal deaths fell by 91% between 1994 and 1998-2001xxix.In addition the incidence of infection from
abortion, often a consequence of unsafe abortion, decreased by more than half between 1994 and 19982001.xxx
In Nepal, where abortion was made legal on broad grounds in 2002, abortion related complications
appear to be declining. Abortion related complications fell from 54% to 28% of all maternal illness treated
at facilities in eight districts between 1998 and 2008/2009xxxi.
In Guyana, admissions for septic, incomplete abortions to the capital’s largest maternity hospital fell by
41% within six months of liberalisation of the abortion law in 1995xxxii.
.
Appraisal Case
A. What are the feasible options that address the need set out in the Strategic case?
Theory of Change
This business case proposes to provide support to locally led initiatives that reduce recourse to unsafe abortion and improve
access to safe abortion including post abortion family planning information and services.
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Fig 1 - Theory of Change: Preventing recourse to unsafe abortion – supporting locally led initiatives
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The Theory of Change in Fig 1 and narrative below describe the context and main challenges to preventing recourse to unsafe
abortion through support for locally led action and initiatives; the primary causal pathways for the intervention proposed to address
this and the evidence for hypotheses and assumptions made.
The contextual issues and challenges outlined in Figure 1 are summarised below:
a) High levels of unintended pregnancy: Every year there are around 80 million unintended pregnancies. It is estimated
that about four in ten pregnancies worldwide are unintended. This proportion is considerably higher in South America and
Southern African where 60% of pregnancies are unintendedxxxiii. This reflects barriers to accessing family planning
information, services and access to modern contraceptive supplies; lack of attention to adolescent sexual and reproductive
health and rights and high levels of violence against women and girls (VAWG) including sexual violence – all and a
combination of these factor can lead to unintended pregnancy.
b) Unsafe abortion is commonplace and dangerous: Nearly half of the 44 million abortions that are performed each year
are unsafe, and nearly all unsafe abortions (98%) occur in the developing world. Globally, complications from unsafe
abortions account for an estimated 13% of all maternal deaths. However, in some settings abortion related complications
cause a very high proportion of maternal deaths. For example in Kenya, prior to recent legislative changes, it was
estimated that 25% of maternal deaths are abortion relatedxxxiv. Young women are at particular risk. For example, in Africa
a quarter of all those who have an unsafe abortion are adolescent girlsxxxv and about half of the 20,000 Nigerian women
who die from unsafe abortions each year are adolescents. In addition, unsafe abortion is a significant cause of ill-health.
Estimates for 2005 (most recent available) indicate that 8.5 million women annually experience complications from unsafe
abortion that require medical attention; 3 million do not receive the care they need.
c) Multiple barriers and taboos limit access to safe services: abortion is a sensitive, often polarising, issue that is
culturally and politically taboo in many settings. For example debate around abortion threatened to de-rail recent
constitutional processes in Kenya. That abortion is taboo often leads to a lack of accurate information about the nature and
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size of the problem as well as the consequences of unsafe abortion. Legal, policy and service delivery frameworks and
guidance often severely limit access to safe abortion – but as noted above this does not prevent women and girls from
seeking abortion. Even where national legislation enables abortion provision (and there are very few countries in which
abortion is totally banned) policy interpretation (e.g. provision only by doctors who are rarely present in rural areas; or
provision only with husbands consent) and lack of information to women may severely limit service provision and access.
For example one study in Zambia, a country with a progressive legal framework that allows abortion for a range of
indicators, found that few people were aware of the law, that most considered abortion to be illegal and immoral but would
support improved safe services – as the study investigators noted ‘ these seemingly incongruent positions are in line with a
social norm to report believing that abortion is immoral even if it does not reflect a more nuanced belief about the need for
women to have access to appropriate care‘xxxvi
Access to funding, especially for local organisations, is limited: as noted above (see ‘actors and architecture’) there
are very few donors willing to provide funding on this issue; and it is rare for developing country governments to allocate
any resources to this politically taboo subject. Most available funding is channelled to key international organisations
working to reduce recourse to unsafe abortion. Yet local organisations are often a key, if not the only, actor willing and able
to work on this issue. For example in one very insecure setting a local organisation4, responding to demand for information
has established a helpline operating in a range of local languages providing information about unsafe abortionxxxvii. In such
a situation where security is very volatile the role of local organisations is particularly important.
DFID is already strongly engaged in efforts to improve access to family planning and address VAWG for example the UK
committed an additional £516 million over eight years towards the Family Planning 2020 Summit goal. In addition DFID is funding
interventions to address the social and cultural barriers to improving sexual and reproductive health and rights. The latter are
summarised in the Strategic Vision for Women and Girls One Year On report, and include the DFID Nike Foundation partnership
and Girl Hub projects in Rwanda, Ethiopia and Nigeria, a programme to delay age of marriage and a new ‘demand side’ challenge
fund in Ethiopia, the safe spaces for adolescent girls in Zambia, and a programme to meet wider education and health needs of
adolescent girls in Ghana. DFID’s support to UNFPA’s core funding contributes to UNFPA’s wider role on family planning,
promoting reproductive rights and addressing issues such as VAWG, specific needs of adolescents, female genital cutting and
HIV prevention.
4
Neither country or organisation are named in order to protect the security of staff.
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This business case focuses on reducing recourse to unsafe abortion following an unintended pregnancy. In order to address
these challenges we propose that by providing a means of funding and support to local organisations they will generate context
specific, locally relevant and innovative projects that improve the enabling environment to tackle unsafe abortion and improve
access to safe abortion. We have evidence that there is a demand for such funding. The experiences of SAAF (currently the only
funding mechanism that local organisations can apply to for work on unsafe abortion) demonstrate that there is a strong demand –
to date there have been two calls for proposals. Both rounds were significantly over subscribed with fundable proposals 5 and there
was good global spread in the proposals submitted (with the exception of the Arab world).
The key hypothesis in the theory of change is that the provision of funding and support to local organisations will result
in activities that are responsive to the local context, innovative and influential in informing and enabling change.
Evidence to support this hypothesis is limited and confined to case studies but growing. For example:
In Burundi a local organisation, Association Burundaise pour le Bien Etre Familial, conducted a study that demonstrated how lack
of training for providers and poor availability of medical abortion drugs were contributing to unsafe abortion. Building on a longterm relationship with the Ministry of Health, the organisation was successful in advocating for the integration of a key training
module on post-abortion care as part of strategic plan of the National Reproductive Health Programme. Moreover, Misoprostol
was added on the national essential medicine list and on the national post-abortion care protocols.
The Kenyan Reproductive Health and Rights Alliance (RHRA) has been a key player in raising the profile of unsafe abortion and
developing initiatives that contributed to changes in legislation. For example one very innovative approach taken by RHRA in
partnership with the Kenyan Human Rights Commission was a mock tribunal of abortion aimed at raising awareness of the
negative consequences of criminalisation of abortion in Kenya. The event included testimonies from four women who have
undergone unsafe abortion and from doctors and nurses, audience engagement followed by feedback rights experts acting as
‘Judges’. The event generated significant national and international press interest and raised the profile of the issue
considerablyxxxviii.
In the Philippines local organisations are playing a very important role in getting and keeping issues of unsafe abortion on the
5
Assessed by the SAAF Technical Review Panel, a highly reputable group of experts in the field of safe abortion.
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public’s and policy maker’s agendas – despite a very conservative environment. One local organisation (now turned political
party), Gabriela-Negros, produced a national qualitative study – leading to enormous controversy and discussion – on the state of
abortion in the country and followed this up with an advocacy to campaign to ensure that study to ensure that findings were widely
disseminated. Another local organisation (that requests anonymity) ), is working with local advocacy networks and organising
forums such as policy roundtables to lobby for a broad sexual and reproductive rights agenda including issues such as sexuality
and sexual rights, adolescent pregnancy and unsafe abortion. Such work is influential in shaping the advancement of the
Philippines Reproductive Health Bill.
Two key assumptions are that:
Firstly, that local actors and action are supported by the work of international actors. For example an account of processes and
actors that enabled access to safe abortion, to the extent allowed by law, in Brazil notes how the key roles of local actors –
notably the women’s rights movement and obstetrician-gynaecologists – was legitimised by internationally led activities such as
Latin American Regional meetings on the subject held by the International Federation of Obstetricians and Gynaecologists xxxix. In
Burkina Faso collaboration between the local Institut Supérieur des Sciences de la Population and key international actors in
abortion research such as the Guttmacher institute led not only to excellent locally owned research outputs but it helped build the
in-country capacities for further research and studies on abortion and broader SRHR issues. The World Health Organisation has
recently updated and published technical and policy guidelines for safe abortion – setting international standards to support and
guide locally led work. Whilst conservative opposition to improved access to safe abortion remains strong and the number of
donors supporting such activities is low those donors and the key international agencies working on this issue are very committed
to continued action and this assumption is considered to be valid. One risk to remain alert for is the increasing ‘projectisation’ of
funding (as opposed to more flexible core funds) that reduces international agencies flexibility to respond to opportunities and
needs that are generated by local action.
Secondly, that supported activities are occurring in an context where there is attention to the underpinning issues of women’s and
girl’s empowerment and improved access to sexual and reproductive health information, services and supplies – in particular
family planning to prevent unintended pregnancy. As noted above, DFID and others are addressing these through other
programmes and partners, especially with the UNFPA, national governments and non-state sector to improve access to family
planning and other reproductive health commodities, enable quality service delivery, build informed demand, address social and
cultural barriers to access, and strengthen accountability.
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In order to enable efficient and effective delivery of the intervention(s) and maximise achievement of results there are a number of
key factors that will need to be in place:
a) Ability to generate/identify local initiatives that address policy/legislative change; research and innovation and/or improved
service delivery environment.
b) A demonstrated ability to build alliances and networks.
c) A commitment to meeting the needs of the poorest and most vulnerable women and girls.
d) Evidence that work on safe/unsafe abortion is placed within the broader context of work to improve SRHR including access
to family planning to prevent unintended pregnancy.
The following options for funding have been identified:
1. FUND SAAF: SAAF is a well-established international, multi-donor fund that provides small grants to NGOs and CBOs working
to reduce recourse to safe abortion. The SAAF secretariat is hosted by the International Planned Parenthood Federation (IPPF).
2. VIA ADDITIONAL EARMARKED RESOURCES TO UNFPA: UNFPA the lead UN agency working for the achievement of
sexual and reproductive health and reproductive rights guided by the ICPD Programme of Action and MDG framework. The
agency already works on a number of neglected/sensitive issues such as female genital cutting (FGC) at the international and
national level.
3. OR TENDER: Select, by competitive tender, an organisation to host and administer a funding mechanism for reducing recourse
to unsafe abortion.
4. DO NOTHING COUNTERFACTUAL
This would mean no funding from DFID for locally led initiatives to address unsafe abortion. However, there is a risk that a DFID
decision not to fund such activity would send a negative message at a time when sensitive issues, in particular abortion, remain
difficult on both national and international agendas. For example, the poor CSW 2012 outcome, the run-up to ICPD+20 and the
post 2015 MDG discussions, in which the UK intends to play a key role.
Design options considered and not taken forward include; providing additional resources through sector budget support at country
17
level or delivery of a safe abortion programme, by DFID, in 2 to 3 countries. Sector budget support is not a viable option, as it
would only apply to certain countries, and the restrictive legal and policy environment would make it unlikely that tackling unsafe
abortion would be identified as a priority issue. Delivery of country level safe abortion programming, by DFID, was also rejected on
the basis that it is less likely to enable a locally driven approach to changing the enabling environment and DFID working directly
on these issues would restrict our investment to countries where there is already a more progressive legislative environment for
safe abortion. Neither approach would provide the reach that a grant mechanism (SAAF or tender) or UN programme could
achieve.
B. Assessing the strength of the evidence base for each feasible option
There is a large body of high quality evidence that points consistently to the negative impact that unsafe abortion has on maternal
health. In addition there is a smaller but growing body of moderate quality evidence that consistently suggests that improving
access to safe abortion does not increase overall abortion rates but does improve maternal health outcomes. We therefore
suggest that the evidence for intervention versus no intervention is strong. In addition, although there is a smaller body of lower
quality (largely case study) evidence it comes from a range of countries and consistently suggests that local organisations play a
key role in catalysing change in the enabling environment. There is, however, as outlined in the table below, much less evidence
of limited strength (project evaluations and reports) to guide choice of intervention to reach those local organisations with funding.
Option
1
2
3
Evidence rating6
FUND SAAF – Medium to limited
UNFPA – None
Tender – None
As already noted above, the measurement of unsafe abortion is challenging because:
 Abortion is a sensitive issue about which there is often considerable stigma.
 Abortion is highly restricted in many countries.
 Few developing countries have scaled up access to safe abortion in their health systems.
 Even where safe abortion is widely available health statistics on this topic are often incomplete.
6
Based on How to Note, Assessing the Strength of Evidence, Feb 2013.
18
In addition much of the focus on the proposed intervention is change in policy and the broader enabling environment. Such
outcomes are difficult to attribute; there can be a considerable time lag between intervention and outcomes; and the contribution
of particular interventions is often non-linear.xl
Two external evaluations that included document reviews, field visits and interviews with a range of stakeholders, including
primary stakeholders confirm the ‘added value’ of SAAF and provide evidence of the fund’s track record in identifying, funding and
supporting local organisations to deliver an improved enabling environment for safe abortion and to reduce recourse to unsafe
abortion. The evidence for Option 1 is therefore assesses as medium to limited
There is no evidence available to support Options 2 and 3.
Option 1 would include funding for local/national research that would help strengthen the evidence base around reducing recourse
to unsafe abortion. This might also be the case for options 2 and 3 depending on how they were conducted. All three options
would be subject to the usual monitoring and evaluation undertaken by DFID and in partnership with other donors.
What is the likely impact (positive and negative) on climate change and environment for each feasible option?
Categorise as A, high potential risk / opportunity; B, medium / manageable potential risk / opportunity; C, low / no risk /
opportunity; or D, core contribution to a multilateral organisation.
The direct climate and environment risks are primarily associated with emissions derived from travel and in particular international
travel. It is likely that option 1 will have the lowest impact on emissions because the grant recipients are not likely to have
significant international travel and work primarily in their own countries. Whilst there may be some emissions associated with
travel to meetings for review of proposals, it should be possible to minimise these and to maximise the use of video and
teleconferencing for meetings, and using emails to see comments and approvals. As a consequence this option is considered to
have low risks and given a C. It is important, however, to ensure that SAAF does make every effort to limit international travel and
use communications to reduce carbon footprints.
The other two options potentially will have greater emissions as they are less clearly based on funding local organisations in
developing countries and in both cases may lead to more international travel. This would be more likely for option 2, but for both
options we could anticipate a demand for more international travel to develop projects. As a consequence both are given a B.
19
There are unlikely to be direct environmental risks from this project as it focuses on research, advocacy and policy work. There
are downstream issues on managing medical waste from improved abortion services, although these are not likely to be
significantly greater than those associated with unsafe abortion services (and arguably lower).
There are relatively limited climate and environment opportunities from the programme. There may be some benefits from
reduced pressure on resources from women being able to access safe abortion services, but these are limited. The main way to
reduce such pressures will be through family planning. As a consequence each option is categorised as a C for opportunity.
Options
Risks and impacts
Opportunities
1. SAAF
C
C
2. Funding UNFPA
B
C
3. Tender
B
C
C. What are the costs and benefits of each feasible option?
Option 1, the SAAF, occupies a unique niche and has the comparative advantage as the existing mechanism to deliver these
results. The other organisational options are unlikely to be as effective. The likelihood of effectiveness in delivering the planned
results is assessed using five criteria (A-E) that need to be met in order for results to be delivered (the key factors outlined above).
In addition, the options are assessed against three indicators of economy and efficiency (F- H): programme management and
delivery, administrative/overhead costs and ability to leverage funding. Overall, Option 1 offers the best value for money, and is
likely to be more cost effective in terms of its ability to deliver the expected results at a lower cost. In particular, the role of IPPF as
hosting organisation offers value for money.
Since it is difficult to identify quantifiable metrics with which to measure many of these parameters, a qualitative approach has
been taken. A 1-5 scale has been used with 1 being the worst and 5 being the best. The table below summarises the comparison
between options and includes, in the last column, an assessment against the three Value for Money (VfM) ‘Es’ – Economy,
Efficiency and Effectiveness. Criteria D specifically looks at the ‘4th E’ – Equity. A written narrative accompanies the table and
explains the thinking underpinning the analysis. Given the qualitative nature of this analysis a formal sensitivity analysis is not
appropriate.
Criteria
1 SAAF
2 UNFPA
3 Tender
Assessment against 3 ‘Es’
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A
B
C
D
E
F
G
H
Ability to generate/identify
local initiatives that address
policy/legislative
change;
research
and
innovation
and/or
improved
service
delivery environment
Systems in place to enhance
grantee capacity to deliver
and report results
Proven ability to develop
alliances and partnerships for
safer abortion
Commitment to reaching the
poorest
and
most
marginalised
Track record of working
within the broader context of
SRHR
Track record of delivering and
managing funding to local
initiatives
Administrative, overhead and
initial start-up costs
4
2–3
3
SAAF likely to be more
effective
3
2
2-3
SAAF likely to
effective
3-4
2
3
SAAF likely to be slightly
more effective
4
2
4
SAAF or tender are likely to
be equally effective
5
5
5
Each option likely to be
equally effective
5
2
3
SAAF likely to be more
effective
4
2
2
SAAF likely to be more
effective
2
2
SAAF likely to be more
effective
£3.0m
£3.0M
Track record of leveraging 4
funding for work on safe
abortion
Additional contribution from £3.0 m
DFID required for results
be
most
The counterfactual would not generate any initiatives and thus is given the lowest score (1) throughout (with the exception of
21
criteria G – which scores 5 as there would be no costs). As discussed earlier in this business case there are few donors who
invest in this area of work and without funding by DFID it is highly unlikely that any supplier will generate additional funds for an
initiative of this type. Given the credibility of and confidence already generated in SAAF, as well as its successful engagement with
all the major suppliers in this area (a number of whom sit on the SAAF Board) there is no appetite among donors to create a
another grantee funding mechanism for local initiatives that reduce recourse to unsafe abortion.
Criteria A: Ability to generate/identify local initiatives that address policy/legislative change; research and innovation
and/or improved service delivery environment
Option 1, SAAF, scores highly (4). SAAF has a proven track record in attracting and supporting locally led initiatives. Funding
rounds are project driven with calls for proposals for specific in country initiatives followed by a competitive assessment process.
Round 1 attracted 172 proposals and funded 50 projects in 35 countries; Round 2 attracted 166 proposals, of these 105 were
considered of high enough quality for funding but due to resource constraints 35 in 26 countries are currently being funded. An
external evaluation in 2009 noted that many of the grantees were new actors to the issue – i.e. SAAF is expanding the numbers of
organisations working on abortion. There is very good global reach – to date of the 85 projects funded; 38 are in Africa, 18 in Asia,
23 in Latin America and the Caribbean with the remaining in Eastern/Central Europe. Because SAAF takes a portfolio approach
there is greater opportunity to support high risk/high reward projects without incurring high risk across the entire portfolio.
SAAF projects cover all three areas flagged in criteria a, for example:
Research: In Cote d’Ivoire the Association Ivoirienne pour le Bien Etre Familial undertook and disseminated (including at
regional conferences) a survey looking at attitudes and practices relating to family planning, unintended pregnancy and abortion
among private providers. Gathering local information and presentation of the evidence led to the development and adoption of
new guidelines for provider training in post abortion care in Burundi.
Improving Service Delivery: In Darfur a SAAF project supported the creation of a network of providers offering post-abortion
care in Darfur. In a very restrictive environment, the network is a supporting entity for providers to meet, receive technical updates,
exchange experiences and develop referral networks. It is also being used as a platform to engage actively in advocacy activities
such as ensuring SRHR commodities security, the inclusion of post abortion care in the medical schools’ curriculum or policy
change around the midwives’ provision of family planning services
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Policy/legislative advocacy: Using innovative advocacy approaches that used new technologies to reach young people SAAF
grantee Mujer y Salud in Uruguay) led the campaign for the legalisation of abortion in Uruguay, central in bringing abortion into
the election campaign in 2010. At the end of 2011, the Uruguayan Senators passed a law legalising abortion up to 12 weeks on
demand.
Option 2, UNFPA, was given a low (2) to medium (3) score. Whilst UNFPA has a strong ability to leverage support and influence
the agency does not have mechanisms to take a locally driven approach working with small local organisations and initiatives.
Funding UNFPA in this area may help the agency to increase its reach on safe abortion. However, it is challenging for UNFPA to
push the agenda where Government partners are in opposition of change. As a consequence funding would only apply to certain
countries that are unlikely to be those with more restrictive policy and legislative environments where we would wish to ensure
attention.
Option 3, tender, scored medium (3). The tender process would be designed to enable DFID to purchase a programme that
fulfilled the requisite parameters. However, there are no mechanisms/agencies other than IPPF who already host SAAF who can
demonstrate a track record in generating locally led work of this type, so any other tenderer is likely to need to start from scratch
establishing new systems and processes. In addition, there are a limited number of suppliers available who are able and willing to
engage in work on safe abortion and most of those are already engaged with SAAF (e.g. the mechanism is hosted by IPPF; MSI
and IPAS both have membership on the SAAF Board) so there is a risk creating tensions between the existing SAAF and a new
grant making mechanism.
Criteria B: Systems in place to enhance grantee capacity to deliver and report results
Option 1 scores a good (3) on systems in place to enhance grantee capacity to deliver and report results as this is a central plank
of SAAF’s strategy. Engagement of this type is purposely kept light touch to maintain a balance between fund efficiency,
effectiveness and non-direct project costs. Achieving the correct balance remains an on-going challenge but one that the SAAF
secretariat and board are actively committed to achieve. Currently SAAF operates in four languages for all communications with
grantees (including at tender and proposal assessment stage) – this is recognised as a core strength (by grantees and external
evaluators) and enables engagement with a broader base of grantees. In addition, SAAF provides some targeted assistance and
capacity building to support Grantees in some key areas (e.g. proposal development when basic approaches are sound but
production of proposal weak; monitoring and reporting results) through the technical expertise of its technical review panel (TRP)
23
and their networks. SAAF actively encourages inter project learning and sharing through its virtual community of grantees, by
showcasing well developed projects and through a two yearly regional conference for grantees and ex-grantees.
Option 2 scores low (2) on systems in place to enhance grantee capacity to deliver and report results. It is a role and strength of
UNFPA to support national governments to deliver sexual and reproductive health information, services and supplies – and to
enable national partners to report on these results. However, it is not UNFPA’s mandate or strength to provide such capacity
building to small local organisations – systems would need to be developed to do so. There is also concern that encouraging such
engagement by UNFPA would dilute the agencies’ ability to work in other key areas such as high level advocacy and influencing.
Option 3 scores a low to good (2-3) on this criteria. Whilst the tendering process would be designed to identify an organisation
with strengths in this area, these may be unproven and it is likely that systems would take time to establish.
Criteria C: Proven ability to develop alliances and partnerships for safer abortion
Option 1, SAAF is given a good (3) to high (4) score. The 2009 external evaluation reported good networking between SAAF
grantees in some countries but recommended that greater attention was given to this area. Subsequently, the SAAF secretariat
has supported grantees and ex-grantees to build alliances and network in a number of ways including through a dedicated
password protected virtual community on the SAAF www; regional meetings each 2 years for networking and exchange of
information and learning; and supporting grantees with very innovative or widely relevant projects/results to present these at
international/regional conferences/meetings. The secretariat has maintained a minimum level of staff which has limited SAAF’s
ability to influence and network with the wider international community for safe abortion but the mechanism has been represented
and profiled at key events such as Women Deliver Conference in 2011 – however this is an areas that can be strengthened and
has been flagged at recent Board discussions.
Option 2, UNFPA, is given a low (2) score. UNFPA has a proven and strong track record in developing alliances and partnerships
in a range of areas – for example for reproductive health commodity security. However, there are sensitivities for a UN agency –
even UNFPA with a mandate for universal access to sexual and reproductive health and reproductive rights – robustly engaging
on politically sensitive issues. As such it is our assessment that the agency is unlikely to actively pursue the development of
strong alliances and partnerships on this issue.
Option 3 would exhibit a medium (3) degree of building alliances and engaging new partners because new organisations may
24
become involved through the tendering process. However it takes time to develop alliances, partnerships and processes to
maintain these so there may be some lag time while a new programme starts up.
Criteria D: Commitment to reaching the poorest and most marginalised
Option 1, SAAF, scores highly (4) on accessing the poorest and most marginalised. SAAF funding criteria establish that grantees
must be from countries that are included in the DAC list for ODA. Priority will be given to the poorer countries, with 50% of the
funds going to the least developed and other low income countries. In addition, all proposals must demonstrate how they address
the needs of the poor, vulnerable, hard to reach, including young people
Option 2, UNFPA, scores good (3) on accessing the poorest and most marginalised given the agencies strong commitment and
track record in addressing the needs of vulnerable population groups – for example adolescents. However, a higher score is not
given as, in countries where there are not wide legal indications for safe abortion, it may be – given the UN is a membership
organisation – difficult for UNFPA to engage in and fund local actions that challenge the legislative, policy and service delivery
environment.
Option 3 scores highly (4) on accessing the poorest and most marginalised as the tendering process would be designed to ensure
that funding was only provided to a supplier committed to reaching the poor.
Criteria E: Working with the context of broader SRHR
All three options score excellent (5). UNFPA and SAAF have a demonstrated track record and commitment to SRHR and placing
any work within this context. DFID would be able to ensure this was the case for any new organisation awarded DFID funds.
Criteria F:Track record of delivering and managing funding to local initiatives
Option 1, SAAF, has an excellent (5) track record of programme delivery and management in this area that is demonstrated by
two successful external evaluations since SAAF’s inception in 2006. In 2009 DFID commissioned an external review on behalf of
all the donors to evaluate the relevance, effectiveness and efficiency of the SAAF and IPPF’s administration of the fund. The
evaluation found that the grant mechanism was sound and efficient; that most funded projects reached the majority of their
25
objectives and that the majority of evaluated projects (20% of all funded projects) would be self-sustaining at the end of funding.
The evaluators also made detailed recommendations, all were analysed and discussed by the SAAF Board and the majority were
implemented to further improve SAAF effectiveness. In 2011, an impact assessment of ‘SAAF added value’ commissioned by
NORAD, concluded that; SAAF is non-bureaucratic, transparent and flexible; it lacks high transaction costs and draws on
southern expertise’. In addition the SAAF secretariat has demonstrated great sensitivity in managing what, for many small
organizations in restrictive settings, are ‘risky’ issues – for example using protected passwords on the SAAF www to maintain
confidentiality and still enabling networking.
Option 2 has a limited (2) track record of programme delivery and management in this area. UNFPA has not undertaken
programmes of this sort and there are challenges for UNFPA, as a UN agency working with Governments, in advocacy around
unsafe abortion, particularly in restricted settings. There are also concerns that encouraging UNFPA to engage in delivering and
managing funding to local initiatives would dilute the agencies upstream work.
Option 3 has scored a good (3) for track record of programme delivery and management in this area as a tender process would
be designed to attract and identify organisations with experience in managing small grants. However, it is less likely that they
would have a track record on small grants for work on safe/unsafe abortion (a highly sensitive area of work that requires a high
level of vigilance to protect grantee identify and security in many settings) and there is likely to be a lagtime whilst grant making
and management systems are designed and established.
Criteria G: Administrative, overhead and initial start-up costs
The SAAF already exists as a reliable, functioning mechanism with an effective Secretariat and Board. The SAAFs administrative
costs have been maintained at a low level of approx. 8% (including overhead costs) – in large part due to the hosting of the
secretariat within IPPF and the benefits this brings in minimising costs whilst still being able to access a range of expertise
(management, finance etc) on site. The SAAF secretariat is expanding slightly to reflect higher levels of work that an increasing
number of donors (many with individual funding criteria) and evaluation recommendations (e.g. to increase efforts to enhance
grantee capacity) and as such operating costs may increase though are expected to remain relatively modest. SAAF therefore
scores low (4) on this criteria.
Both Option 2 UNFPA and Option 3 tender score a high (2) level of administrative, overhead and initial start-up costs. There
would be costs incurred in setting up a new grantee mechanism by any supplier who won a tender. Equally there would be risks of
26
duplication given that other major safe abortion donors, bilateral and foundation, are already investing in SAAF. In addition
UNFPA charges an additional 7% as a cost recovery fee, in addition to programme operating costs. There would also be a cost to
undertake and manage a tendering process with Option 3. It is likely that we could expect administrative, overhead and start-up
costs in excess of 15% for both Options 2 and 3.
Criteria F: Track record of leveraging funding for work on safe abortion
Option 1, SAAF is given a high (4) score. Despite the very challenging funding environment for safe abortion and limited number
of donors SAAF has managed to secure funding from a range of sources. The SAAF Board have a fundraising strategy which
appears to be demonstrating progress with two new donors recently brought on board - nearly $5 million additional funding from
the Netherlands, which is a new donor. The fund has also recently secured funding from an anonymous donor. In addition,
Denmark, one of the donors who started up the fund in 2006, has re-joined with a multi-year commitment. Whilst these may seem
like modest achievements this progress must be viewed as good in the context of the current economic climate and the paucity of
donors who are willing to fund safe abortion. The fund does not score higher as demand for funding continues to outstrip available
resources.
Option 2, UNFPA, is given a medium (3) score as, although the UNFPA has a strong track record in generating funding from a
range of donors, for the reasons provided in criteria a, above, it is challenging for UNFPA to channel this funding to improve
access to safe abortion.
Option 3, tender, scores low (2) given that it is likely that any new awardee would be embarking on such work for the first time and
is unlikely to be able to leverage funding from other donors as a ‘DFID project or contract’ would not have the same legitimacy as
the existing multi-donor SAAF.
Overall costs
The overall cost for all three options is £3m. However, Option 1, due to lower administration and overhead costs, and no start-up
costs, would be able to provide a higher proportion of funds as grants to local organisations compared to Options 2 and 3. The
counterfactual would incur no overall cost.
D. What measures can be used to assess Value for Money for the intervention?
27
Economy and efficiency
Indicators that will be used to assess economy and efficiency include maintenance of SAAF administrative and overhead budget
under 10%; and timeliness of approval of proposals and disbursement and expenditure of SAAF funds to grantees and SAAF
‘reach’ evidenced by type and regional spread of proposals received and projects funded in Round 3.
The SAAF’s operating model relies on a staff of 2.2 FTE, providing administrative, strategic and technical support to the Board
and the grantees and oversees the financial management of the fund. IPPF’s hosting role provides a robust and cost efficient
arrangement for financial management and administrative costs, delivering savings compared with costs for a similar independent
structure. Civil Society Department have carried out a due diligence check for IPPF, the managing and fiduciary agent responsible
for the SAAF. The findings provide confidence that IPPF has strong and efficient mechanisms in place for monitoring and
evaluating, focusing on results and delivery, and ensuring good Value for Money and transparency in all decision making. In
addition the 2009 external evaluation of the fund mechanism, commissioned by donors, reported that t IPPF had performed well in
terms of the efficiency and effectiveness of the fund, with only a few easy-to-resolve start-up issues.
We will continue to review if investment of SAAF is delivering Value for Money in terms of economy and efficiency through
assessing:
 Timeliness of disbursement and expenditure of SAAF funds to and by grantees.
 Efficiency in administration of the call for proposals, review of proposals and awarding of grants for Round 3
 SAAF ‘reach’ as demonstrated by the regional spread of proposals received and funded in Round 3
 Level of administrative and overhead a budget
In addition, building on available data and tools (such as MSI’s IMPACT calculator) we will work with SAAF to develop a means of
estimating health system savings delivered as a result of services provided. We will aim to have this in place to assess cost
savings generated by service delivery initiatives funded in Round 3.
Effectiveness
We will continue to assess the effectiveness of SAAF in delivering the outputs of increased awareness, improved knowledge and
local service delivery initiatives. We will assess progress, according to achievement of milestones and targets against the
following marker indicators:
28
 Number of countries where NGOs achieve shared positions/consensus on approach to abortion law or policy reform
 Number of research/studies conducted and Number of official documents citing/including (these new) research results
 Number of staff trained in new abortion technologies and techniques (MVA and MA)
We will also assess how outputs are collectively leading to achievement of the programme outcome locally led initiatives
addressing barriers to safe abortion. This will be assessed by reviewing achievement of milestones and targets for outcome level
indicators:
 Number women and girls receive comprehensive abortion care (CAC) or post abortion-care (PAC).
 Proportion of women and girls in receipt of CAC/PAC who take up a method of family planning
 Number of countries where there is increased public visibility for safe abortion and/or steps taken to improve legislative
frameworks and
 Number of countries where improved national/local policies, guidelines and/or protocols are developed/implemented.
SAAF has a good track record of delivering on outputs during Round 1 – reports are received from grantees and results are
collated by the secretariat and presented in an annual report to donors. As the mechanism has evolved more emphasis has been
placed on improving grantee monitoring and reporting of results. Where needed, support, for example using members of the
SAAF TRP (who are based in the region), can be provided to enhance grantee capacity to monitor and report results. This type of
support will be developed further during Round 3. Results presented by the grantees will be verified and further explored during
an external evaluation in 2014.
E. Summary Value for Money Statement for the preferred option
The SAAF is an existing and successful partnership with a robust track record in attracting, assessing and funding proposals for
locally led initiatives through a transparent and competitive process. The SAAF has also been shown, through two external
evaluations, that it can deliver results. It is hosted by IPPF – an organisation with a strong track record of working with DIFD and
for which due diligence reports provide confidence in its approach to ensuring good value for money. It is our assessment that
funding SAAF provides the best value for money for DFID funding.
The level of funding at £3m is assessed to be the best price to enable SAAF, alongside the funding of other fund donors (including
forthcoming Norwegian funding) to successfully manage third round of funding whilst ensuring that DFID’s burden share is
29
proportionate. It is estimated that the DFID burden share will be approx. 25%. This is considerably lower that our past share of
SAAF funds, demonstrating the funds success in leveraging funding and diversifying its donor base. However, this level of funding
still demonstrates the importance DFID places on improving women’s and girl’s lives by reducing recourse to unsafe abortion and
the paucity of donors willing and able to fund in this area.
The majority of the £3m fund – 86% - will be disbursed as grants to local organisations for initiatives that improve the enabling
environment to prevent recourse to unsafe abortion. All grants are awarded following a widely published call for proposals (in four
languages) and a rigorous competitive process with every proposal that meets basic criteria reviewed by SAAFs TRP. The SAAF
Board make final funding decisions. A further 5.5% of funds is allocated for monitoring, evaluation and support to grantees (e.g.
grantee networking), the remaining 8.5% is for administration, overheads and contingency.
Commercial Case
Indirect procurement
A. Why is the proposed funding mechanism/form of arrangement the right one for this intervention, with this
development partner?
The programme will be funded through a Memorandum of Understanding (MOU) with IPPF on behalf of SAAF. This is according to
DFID blue book instructions when directing funding to an international non-governmental organisation such as IPPF. The MOU will
specify the purpose to which DFID funds will be used and the schedule of disbursements. The MOU will also provide for DFID to
modify or terminate its financial support if any changes occurred, which in the opinion of DFID, impair significantly the development
value of the project. DFID has funded IPPF on behalf of SAAF since its inception in 2006. As demonstrated to date, IPPF has a
proven record of accountability and the technical and administrative competence to host the SAAF. IPPF which houses SAAF,
itself is in receipt of DFID Programme-Partnership Agreement (PPA) funding and DFID has already undertaken a due diligence
assessment of IPPF. A particular area of concern was to strengthen the contractual relationship between IPPF with subcontractor
grant-holders, such as SAAF grantees. However, this issue has subsequently been satisfactorily resolved with a change of
procedure/wording in IPPF contracts so they meet DFID standard requirements.
The funding mechanism for SAAF is already well-established (since 2006) and has proved to be a robust, reliable mechanism with
30
individual agreements between IPPF and the NGO/CBOs concerned with a good record of performance and of accountability,
hence the reason for continuation of use of this mechanism.
B. Value for money through procurement
SAAF operates in much the same way as DFID’s own NGO challenge fund in that organisations are invited to bid for funds via a
competitive process. The grants themselves are not large (under US$ 300,000 over two years). SAAF is already established,
therefore there are no further start-up costs and the overhead costs currently stand at a competitive 8% per annum . SAAF also
has a track-record of proving and managing grants to a range of CSOs/CBOs and has robust systems in place to manage grants
through the Secretariat which minimises the administrative burden upon DFID, including performance monitoring and external
evaluation.
SAAF is designed to remove the administrative burden from DFID dealing directly with a large number of in-country NGO’s/CBO’s
around the world but it has to be attractive to the small NGO’s working in this area. The selection process for SAAF funding is via a
competition, with country based NGOs/CBOs asked to make proposals against agreed criteria which have been agreed by DFID
and the SAAF Board and which are outcome focused. Part of the assessment of the proposals by the SAAF’s Technical Review
Panel (TRP) is the encouragement of innovative approaches and value for money. Previous funding rounds have been
oversubscribed and proposals received and eventually funded have been of high quality.
Financial Case
A. What are the costs, how are they profiled and how will you ensure accurate forecasting?
SAAF is a multi-donor supported fund. It is currently supporting 35 second round projects at an expected cost of US$ 17.561 m for
the period 2013 – 2016. The Round 2 expenditure profile is estimated as follows:
Total Expenditure
2013 - US$ 8,526 million
2014 - US$ 5,884 million
2015 - US$ 2,653 million
2016 - US$ .514 million
SAAF Board has approved the work plan and budget and previous experience has shown that budget and forecasting are
31
extremely accurate based on a compilation annual progress and financial reports from existing projects. The budget is finely tuned
to balance funds immediately available and against the expectation of funds being made available in the future from donors whilst
maximising the amount of projects supported. Of the funding currently available to SAAF, Round 2 project activities for the year
2011 were fully funded, with a funding gap opening in the latter half of 2013 onwards. This requires additional funding from donors
to fully fund all 35 second round projects to completion. In addition, SAAF hope to initiate a Round 3 in 2013 which requires
additional funding. The DFID contribution of £ 3.0 million is designed to partially fill this gap, support the requirements of SAAF
against other known donor contributions being available in 2012 and 2013 to meet the shortfall in funding and to allow Round 3
project funding competition. A request has also been made to the government of Norway. The UK £3.0 million will be made
available over 4 years - payment of individual tranches will be set out in the project Memorandum of Understanding (MOU).
2012/13 - £600,000
2013/14 - £950,000
2014/15- £1 million
2015/16 - £450,000
The DFID funding schedule aligns with the SAAF funding cycle to maximise the number of projects funded and provide leverage to
SAAF in raising additional contributions from other donors who might require time to pay over funds promised or need to see DFID
leadership on this issue. The major stakeholders are IPPF and the donors funding the SAAF (to date UK, Denmark, Netherlands,
Norway, Sweden, Switzerland, an anonymous donor and the Hewlett Foundation). In Round 1 of SAAF 50 NGO projects from 35
countries were funded.
B. How will it be funded: capital/programme/admin?
Funding will be provided from programme budget allocated to the AIDS and Reproductive Health Team.
C. How will funds be paid out?
In four tranches, at times agreed between DFID and SAAF. The first tranche will be delivered in approximately March 2013.
D. What is the assessment of financial risk and fraud?
32
SAAF has been in operation since 2006. Regular progress and financial reports were provided to DFID. Our assessment of
financial risk and fraud is that this is most likely to occur at country level within the individual NGOs/CBOs rather than at IPPF. The
risk of fraud and funds not used for the intended purposes is taken seriously by SAAF and IPPF, which has a Fraud Response
Strategy. This strategy covers prevention, detection and management of fraud. It aims to raise the awareness of fraud and its
prevention within IPPF and give guidance on both the reporting of suspected fraud and how any investigation would proceed. It
summarises the various controls and mechanisms that IPPF have in place to prevent and detect fraud.
To further address financial risk and fraud the Technical Review Panel (TRP) assessment of each project before implementation
includes an assessment of project sustainability. Many of the organisations and the individuals seeking funding are known to the
TRP members individually, and a judgement is made of the relative strengths of the organisations seeking funds, both technically
but also the financial viability. The global reach of SAAF whilst allowing innovation, also allows risks to be spread over a wide
number of projects. There is also wide recognition by the NGOs/CBOs of the difficulty in securing funds for this work and the
damage that could be caused by financial mismanagement to the global efforts to address abortion. This might reduce
organisational mismanagement but not individual level fraud. The SAAF have agreed that all grant recipients will provide 6 monthly
progress reports and undertake an annual audit. Failure to do so results in grant suspension. In addition 20% of fund recipients
each year will undergo visit by SAAF (secretariat including finance officer for some visits, board or TRP members).
E. How will expenditure be monitored, reported, and accounted for?
Project management and the monitoring and accounting of financial expenditure is designed to meet DFID blue book
requirements. Payments will be made in agreed tranches as specified in the MOU against the projected drawdown/need of funds.
Payment will then be made to the various NGO/CBOs who have successfully bid for funding via contracts between IPPF and the
subcontractor grant-holders. Responsibility for undertaking these tasks is devolved to IPPF on behalf of SAAF. Payments will be
made in accordance with agreed tranches and on agreed milestones being achieved. Individual country projects provide 6 monthly
reports of progress and annual audited reports, which are incorporated to make up the annual report. SAAF provides an annual
report to all donors including an account of income/expenditure. SAAF Annual Audited Accounts are prepared as part of IPPF
Annual Audited Accounts as a separate item. The DFID programme Manager and the SAAF Programme Manager are in regular
contact (quarterly) throughout the year to monitor progress, obtain a progress report and to deal with any issues arising.
Management Case
33
A. What are the Management Arrangements for implementing the intervention?
This investment will be managed by a DFID Programme Manager with technical advice and oversight from a Health Adviser, who
will also sit on the SAAF Board playing an active role in the formulation of SAAF strategy and overall policy as well as grantee
selection decisions for Round 3.
The SAAF is a multi-donor fund housed within IPPF and is governed by a Board. The SAAF Board consists of 10 representatives
from larger NGOs working in the field of safe abortion, donor governments and individuals with relevant experiences and technical
expertise. The Board provides strategic direction and oversight of the fund; sets policy and guidelines; and considers and
approves applications for funding and mobilises resources.
Day to day administration is managed by the SAAF secretariat administers the fund on behalf of the SAAF Board. The SAAF
secretariart reports regularly to the DFID programme manager throughout the year.
A Technical Review Panel (TRP) appointed by the Board (15 international experts), reviews and recommends proposals for
funding. The SAAF Secretariat formally reports to the SAAF Board on the performance and effectiveness of SAAF grants every six
months (though more regular virtual communication is maintained on an as-needed basis) and the Board reports to donors
annually. The TRP can also provide technical assistance to the grantees and monitors their activities. The eligibility criteria for
SAAF applications can be found in annex 2.
Projects will be funded for a maximum of 3 years. These projects are renewable each year based on evidence of progress,
financial compliance and management risks.
The grantee select mechanism is illustrated below. A more details description can be found in annex 3.
34
The management arrangements are designed to reduce the administrative and advisory burden on DFID and transfer these to the
SAAF Secretariat who will be responsible for the assessment of the various NGO projects to be funded, implementation and
release of funds, also monitoring and collection of data.
SAAF is designed to be a highly flexible and responsive funding mechanism with an emphasis on supporting local organisations to
develop or expand capacity and services for safe abortion. DFID provides advisory capacity during the initial bid assessment
process and is involved in the production of the SAAF annual review – as a board member. The SAAF has been functioning
successfully using this management model since 2006 and the Secretariat has been responsive to Evaluation recommendations
and Board suggestions.
35
B. What are the risks and how these will be managed?
Below is a matrix of the risks associated with this programme and how these will be managed:
Risk
Hard line movements and initiatives in opposition to
women's and girl's rights gain greater momentum and
introduce language at the international level which
further limits access to safe abortion services. (high
probability/medium impact)
Management process
Currently being monitored. DFID is active in countering this risk
e.g. through successful lobbying strategy for CSW 2013 and
close work with likeminded partners for CPD 2013.
Limited number of government able and willing to fund
this issue and low level of funding by donors limiting the
number of projects funded via SAAF. (Medium-high
probability/Medium-high impact)
SAAF has an active fundraising strategy and is successfully
attracting new donors and multiple year funding. Keep
monitoring; advocacy by DFID for these issues, ensuring part of
post 2015 development framework.
Proposed Norwegian funding to SAAF is not confirmed
(Low probability/Medium impact on portfolio; High
impact on DFID burden share in outer years)
Maintain communication with Norwegian counterparts. Continue
as above to encourage and support SAAF to maintain an active
fundraising strategy and monitor progress.
Country context changes (e.g.: conflict, change of
government) and impacts of delivery of results at
country level. (Medium probability/low impact across
portfolio though high in individual projects)
Monitored through SAAF – cannot change but spread of funding
across multiple projects and countries reduces impact.
Fraud and financial mismanagement (Low-medium
probability/medium-high impact)
Strong procedures in place to reduce fraud and mismanagement
- See section D of the financial case.
Given the sensitive nature of this work we determine the overall risk rating to be medium and direction of travel for risk to be static
to mildly increasing. We will maintain a strong working relationship with the SAAF secretariat, through DFID engagement on the
36
SAAF Board (both at formal meetings and through virtual communication between Boards) and with other SAAF donors to
continually monitor and manage risks.
C. What conditions apply (for financial aid only)?
n/a.
D. How will progress and results be monitored, measured and evaluated?
Reporting of current round projects will be continuous against the logframe. Based on experience from the operation of SAAF the
DFID SAAF Round I logframe has been improved and consolidated and has become all-encompassing for all Round II projects.
This allows common monitoring of unified results and evaluation. The log-frame is currently being finalised and is expected to be
approved by the SAAF Board by mid-2013 – significant changes are not anticipated, however there will be further completion of
baselines, milestones and targets following ongoing work with current grantees. NOTE: It has been identified that we need to
ensure vfm is maximised by maximising the ambition, SMARTness and achievement of the indicators. Milestones and targets for
Round 3 will be completed toward the end of 2013. . SAAF reports annually, to all donors, against this logframe. Project returns
are collated for the production of an annual report, the findings of which are presented at an annual meeting of the technical
committee and donors. NGOs/CBOs funded under Round II are required to produce 6 monthly reports of progress and annual
audited accounts. Failure to do so results in grant suspension.
During 2013-2015 period; the six monthly reports will collect information on challenges projects are facing and what measures are
being taken to mitigate those challenges. The format will be designed in a way so that it analysis the % progress (in case of
quantitative results) or progress in activities (in case of more abstract results) based on the previous report. This report will be
accompanied by a brief financial report outlining the funds spent to date and major areas of diversion from the budget with
explanation for these diversions.
In addition to the above arrangement, 10-20% of SAAF projects, selected firstly on needs and then randomly, may be visits by the
SAAF team or a TRP member on the basis of standard terms of reference to assess progress of implementation on the ground.
At the programme level SAAF will commission an external evaluation in 2014. Evaluation questions will include:
 What is the impact of technical support and capacity building SAAF provides to its grantees?
37



How are SAAF projects instrumental in creating change, what is the scale of SAAF impact?
How sustainable is the SAAF approach?
Feedback from project beneficiaries – immediate (where possible, the sensitivity of safe abortion issues means that women
and girls are often reluctant to be identified as beneficiaries) and potential.
In addition external evaluations may also be carried out according to individual donor needs or for any specific purpose e.g.: to
provide feedback/inputs to future strategy development. It is DFID preference to encourage and support SAAF to develop one
medium term evaluation plan (for ongoing evaluation over a three to five year period) that all donors ‘buy into’ and we will work
through the SAAF Board to achieve such a united plan.
Quest No of logframe for this intervention: 3923157 - in the future Logrframe discussions with SAAF it has been identified that
we need to ensure vfm is maximised by maximising the ambition, SMARTness and achievement of the indicators.
38
Annex 1: SAAF grant eligibility criteria
Who can be supported by SAAF?






Grantees must be from countries that are included in the DAC list for ODA (see in annexe 2). Priority will be given to the
poorer countries, with 50% of the funds going to the least developed and other low income countries.
Any non-governmental organization which has a clear management structure defined and in place, including national/local
NGOs, CBOs, research/other institutions, national/regional coalitions/networks, alliances, etc.
The primary recipient would be a national/local organization. INGOs may however have supportive role.
The organization must have required permission(s) (if applicable) to receive foreign donations.
The organization must be able to demonstrate accountability (by, e.g. identifying a specific individual as being responsible
for the project)
There must be basic financial systems in place, evidenced by financial statements, written policies and audited accounts
reports.
What type of projects can be supported by SAAF?
Any project which addresses the issue of promoting safe abortion and/or preventing unsafe abortion would be eligible for funding.
This may include the entire spectrum of activities from service delivery to advocacy for policy change.
39
To be selected projects must fulfil these essential criteria:





Projects address the needs of the poor, vulnerable, hard to reach, including young people
Projects sow the seeds of change, e.g. by bringing about a change in the operating environment through advocacy
initiatives, or establishing new, more effective ways of delivering services
Projects build capacity either in course of implementing project activities or undertaking specific capacity development
initiatives in the field of abortion
Projects are able to demonstrate sustainability of their impact/leave some footprint behind after the funding is finished
Projects working in the context of broader Sexual and Reproductive Health and Rights including access to family planning
information, services and supplies.
Priority will be given to projects also fulfilling these other criteria:
 Projects which address abortion issues in a restricted environment with inherent risks
 Projects which use innovative ways of addressing barriers /increasing access to safe abortion services
 Projects which are catalytic and increase the impact of other actors working in this field
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Annex 2: SAAF Grantee selection mechanisms
This selection follows a two-staged process: a concept note stage and a full proposal development stage.
All interested organizations are required to submit a concept note first. A template for narrative and financial sections is provided by
the SAAF Secretariat. The write up is supplemented by a few key documents highlighting the organizational, financial (e.g. last
audited accounts report) and operational background of the applicants.
All concept notes are reviewed by the Secretariat to ascertain if they fulfil the Grantee Selection Criteria. Those that do will undergo
more detailed review and scoring by an assigned TRP member from that region. The TRP member would grade the concept notes
on the following criteria (Graded on a scale of 1-5):
CONTEXT/ RELEVANCE (50% weight)
 Does the project focus on the poorest, most vulnerable and hard to reach women and girls, including young people
 Is the project idea relevant, given the country context
 Does the project work within a broader SRHR framework
IMPACT (30%)
 Does the project demonstrate sustainability of impact/long term impact
 Does the project build capacity either in course of implementing project activities or undertaking specific capacity
development initiatives in the field of abortion
 Is the project catalytic and increase the impact of other actors working in this field
41
INNOVATION and RISK TAKING (20%)
 Does the project sow the seeds of change, e.g. by bringing about a change in the operating environment through advocacy
initiatives, or establishing new, more effective ways of delivering services
 Does the project use innovative ways of addressing barriers /increasing access to safe abortion services
 Does the project address abortion issues in a restricted environment with inherent risks
All concept notes which are reviewed by TRP members are listed according to their total scores and the best ones are invited to
develop and submit a full proposal.
During the proposal development stage, organizations are required to submit a proposal containing a more detailed description of
the project. The proposal should follow a set template provided by SAAF including a narrative and a financial section. If necessary,
and at the request of the organization, SAAF will provide remote support to organizations in developing proposals through external
consultants, who may be TRP members, appointed by SAAF.
The proposals are then reviewed by the SAAF secretariat to ensure that the organization demonstrates its ability to implement the
project both technically and managerially, and that the project is also financially viable. This review will consider the following
aspects of the proposal (again on a scale of 1-5)
- Does the Objectives/Outcomes/Deliverables reflect the project rationale/problem statement
- Is the implementation plan robust enough?
- Is the budget realistic?
- Is there a realistic work plan
- Are there adequate provisions in the budget for all human, technological, commodities and other needs?
- Have risks being considered? Is there a plan for their mitigation?
- Is there any sustainability plan
If a proposal is found to be weak, but relevant, the relevant TRP member will be encouraged to spend a maximum of two days with
the applicant organization to help them strengthen the proposal. SAAF would reimburse the TRP member for their input.
42
The following flow chart demonstrates the sequence of activities in the proposal selection process:
When an organization is invited to develop a full proposal, there is no guarantee of funding, and the final funding decision will be
made by the board based on TRP recommendations and scoring.
In the situation where there are more technically solid proposals than funding available, the Board will reach a decision by looking
at the following criteria:
43



Project reaching the poorest and most marginalised, including young people
Projects reaching communities where incidence of unsafe abortion on maternal mortality rate is high
Projects with the best potential for change
Support to grantees
Based on the experience to date, a section of SAAF grantees would need support at several points in developing the full proposal,
in setting up monitoring systems and baselines, in overcoming implementation barriers, in managing their grant and in reporting.
Capacity building through SAAF will be limited to general support for grant management (including financial management) and
technical support directly linked with abortion work.
General and Technical support
While it would not be possible for SAAF Secretariat to provide support to Grantees at all these points directly, the Secretariat can
identify a pool of regional consultants, either from the TRP or from other sources, and assign specific consultants to each of the
projects requiring support during the proposal development stage. If Grantees envisage that they would need support during the
implementation stage, they would be encouraged to identify local consultants and build those costs into their budgets. SAAF’s own
pool of consultants would be drawn from a global base and would include mid-level consultants experienced in developing and
implementing projects. They would be drawn from all parts of the world and would be assigned to support Grantees in their known
region. The SAAF Secretariat will also be in a position to support the grantees with grant financial management through the SAAF
financial Management Officer.
Inter-project learning and sharing
Grantees find it inspirational and useful to have a forum for sharing their successes and challenges, and the SAAF virtual
community of practice supports this. Moreover, SAAF would on one hand actively work with selected successful/well-developed
projects to create opportunities for these projects to present in various regional/global fora. In addition, SAAF would organize a twoyearly conference of SAAF grantees and ex-grantees to share the successes and challenges of their projects, strengthen
networking among SAAF grantees and ex-grantees and take home lessons learnt and best practices.
44
REFERENCES
i
WHO. 2011. Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008. Sixth edition.
Guttmacher Institute. 2012. Facts on induced abortion worldwide.
iii
Sedge G and Shah I H. 2012. Induced abortion: incidence and trends from 1995 to 2008. The Lancet published on line Jan 19th
iv
DfID. 2010. Choices for women: planned pregnancies, safe births and health newborns.
v
See: http://www.dfid.gov.uk/Site-search/?q=strategic+vision+women+and+girls
vi
SeeL http://www.dfid.gov.uk/Site-search/?q=abortion+policy
vii
United Nations Secretary-General. Global Strategy for Women’s and Children’s Health. The Partnership for Maternal, Newborn and Child Health. 2011. Available at:
http://www.un.org/sg/hf/Global_StategyEN.pdf. Accessed 24 June 2012
viii
Interim report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. A/66/254. General Assembly of the United
Nations, Third Committee. October 2011. Available at: http://daccess-dds-ny.un.org/doc/UNDOC/GEN/N11/443/58/PDF/N1144358.pdf?OpenElement. Accessed 24 June 2012.
ix
United Nations. 2012. Millennium Development Goals: 2012 progress chart.
x
WHO. 2011. Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008. Sixth edition.
xi
Guttmacher Institute. 2012. Facts on induced abortion worldwide.
xii
WHO. 2011. Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008. Sixth edition.
xiii
Vlassoff M, Shearer J, Walker D and Lucas H. Economic Impact of Unsafe Abortion Related Morbidity and Mortality: evidence and estimation challenges. Institute of Development Studies
Research report 59. December 2008.
xiv
Ibid
xv
Westoff, Charles F. 2008. A New Approach to Estimating Abortion Rates. DHS Analytical Studies No. 13. Macro International Inc.; see annex C.
xvi
Singh S, Darroch J, Vlassoff. M. Adding it up. The costs and benefits of investing in family planning and maternal and newborn health. New York, Guttmacher Institute, 2009 page 27.
xvii
Govindasamy P, Boadi E.2000 A decade of unmet need for contraception in Ghana: programmatic and policy implications. Calverton, MD, and Accra, Ghana, Macro International Inc. and
National Population Council Secretariat, cited in WHO 2011 Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008. Sixth Edition p10
xviii
Sedge G et al 2007. Induced abortion: estimated rates and trends worldwide. Lancet, 370(9595):1338-1345 and Sedge G and Shah I H. 2012. Induced abortion: incidence and trends from 1995
to 2008. The Lancet published on line Jan 19th
xix
Sedge G and Shah I H. 2012. Induced abortion: incidence and trends from 1995 to 2008. The Lancet published on line Jan 19th
xx
Berer M 2004 National laws and unsafe abortion: the parameters of change. Reproductive Health Matters 12: 1-8.
xxi
Henshaw SK, Singh S, Haas T. 1999. Recent trends in abortion worldwide. International Family Planning Perspectives 25 (1) 44 – 48.
xxii
Communications with IPAS – January 2012.
xxiii
Otsea K et al 2011. Testing the Safe Abortion Care model in Ethiopia to monitor service availability, use and quality. International Journal of Gynecology and Obstetrics 115 pp 316-321
xxiv
WHO 2011 Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008. Sixth Edition p5
xxv
Sedge G and Shah I H. 2012. Induced abortion: incidence and trends from 1995 to 2008. The Lancet published on line Jan 19th
xxvi
Sedge G et al. 2007 Legal abortion worldwide in 2008. Levels and recent trends worldwide. The Lancet ; 370:1338-45.
xxvii
WHO 2011 Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008. Sixth Edition. p 27.
xxviii
Singh S et al., Adding It Up: The Costs and Benefits of Investing in Family Planning and Maternal and Newborn Health, New York: Guttmacher Institute and United Nations Population Fund,
2009.
xxix
Jewkes R et al. 2005 The impact of age on the epidemiology of incomplete abortions in South Africa after legislative Change. British Journal of Obstetrics and Gynaecology; 112: 355-59.
xxx
Jewkes R et al.2005 The impact of age on the epidemiology of incomplete abortions in South Africa after legislative change British Journal of Obstetrics and Gynaecology 112: 355-59.
ii
45
xxxi
Pradhan A, et al.2009 Nepal Maternal Mortality and Morbidity Study 2008/2009: Summary of Preliminary Findings. Kathmandu, Nepal: Family Health Division, Department of Health Services,
Ministry of Health, Government of Nepal.
xxxii
Nunes FE and Delph YM. 1997 Making abortion law reform work: steps and slips in Gyyama. Reproductive Health Matters 9:66-76. Cited in Jewkes et al, 2005.
xxxiii Singh S et al (2010) Unintended pregnancy: worldwide levels, trends and outcomes. Studies in Family Planning 41 (4) 241-250.
xxxiv
Guttmacher Institute May 2012 Fact Sheet: Abortion and Unintended Pregnancy in Kenya
xxxv
Grimes et al. Unsafe abortion: the preventable pandemic. The Lancet, Special Issues on Sexual and Reproductive Health. October 2006, 65-76
xxxvi
Geary et al 2012 Attitudes towards abortion in Zambia. International Journal of Gynaecology and Obstetrics. 118, Supplement 2 S148 – S151.
xxxvii
Personal communication. Organisation not named for reasons of security and safety.
xxxviiixxxviiixxxviii
Personal communication and www seach for press reports.
xxxix
Faundes A, Leocadio E and Andalaft J 2002 Making Legal Abortion Accessible in Brazil. Reproductive Health Matters 10(19): 120 – 127.
xl
Jones H. 2011. A guide to monitoring and evaluating policy influence. Overseas Development Institute.
46
Acronyms
ARH CBOs CPD CSW DAC DFID EU FfR FGM ICPD ICPD+20 INGO IPAS IPPF MDGs MOU MSI MV MVA NGOs ODA POA PMDUP Rio+20 RMNH -
AIDS and Reproductive Health (Team)
Community based organisations
Commission for Population and Development
Commission on the Status of Women
Development Coordination Directorate
Department for International Development
European Union
Framework for Results
Female genital mutilation
International Conference on Population and Development (Cairo 1994)
Twenty years after the International Conference on Population and Development (Cairo 1994)
International nongovernmental organisation
International Pregnancy Advisory Service (now shortened to IPAS)
International Planned Parenthood Federation
Millennium Development Goals
Memorandum of Understanding
Marie Stopes International
Manuel Vacuum
Manual Vacuum Aspiration
Non-governmental organizations
Overseas Development Assistance
Plan of Action (from ICPD)
Preventing Maternal Deaths from Unintended Pregnancy initiative
Twenty years after Rio
Reproductive, Maternal and Newborn Health
47
SAAF SRH SRHR TRP UN UNFPA US USAID VFM WHO -
Safe Abortion Action Fund
Sexual and reproductive health
Sexual and reproductive health and rights
Technical Review Panel
United Nations
United Nations Population Fund
United States
United States Aid
Value for money
World Health Organisation
48