Family Planning Outreach Programme in
Tanzania
Business Case
June 2011
Table of Contents
Acronyms ................................................................................................................... 3
Intervention Summary ............................................................................................... 5
A. What support will the UK provide? ..................................................................... 5
B. Why is UK support required? ............................................................................. 5
C. What are the expected results? ......................................................................... 6
Strategic Case for Family Planning Outreach Programme in Tanzania ..................... 7
A. Context and need for DFID intervention ............................................................. 7
B. Impact and Outcome ........................................................................................ 11
Appraisal Case......................................................................................................... 11
A. Determining Critical Success Criteria (CSC) ................................................... 11
B. Feasible options ............................................................................................... 13
C. Appraisal of options ......................................................................................... 18
D. Comparison of options: .................................................................................... 23
E. Measures to be used or developed to assess value for money ....................... 28
Commercial Case .................................................................................................... 29
A. Procurement/commercial Requirements .......................................................... 29
B. Indirect procurement ....................................................................................... 29
Financial Case ......................................................................................................... 33
A. Costs ................................................................................................................ 33
B. Types of Funding ............................................................................................. 33
C. Payment procedures ........................................................................................ 33
D. Monitoring and Reporting on Expenditure ....................................................... 34
Management Case................................................................................................... 35
A. Oversight.......................................................................................................... 35
B. Management .................................................................................................... 37
C. Conditionality ................................................................................................... 40
D. Monitoring and Evaluation ............................................................................... 40
E. Risk Assessment ............................................................................................. 43
F. Results and Benefits Management .................................................................. 44
ANNEXES:
ANNEX 1: Climate & Environment Assurance Note ............................................ 45
ANNEX 2: Climate & Environment Checklist ...................................................... 46
ANNEX 3: Project logframe ................................................................................. 49
Acronyms
ADS
AIDS
AM
A/OTAR
BCC
CBM
CIB
CIDA
CO2
COTAR
CPR
CSC
CYPs
DALYs
DFID
DMOs
DPs
FBO
FP
GAAP
GOT
HIV
HQ
IC
I/E
IEC
IP
IRR
KPIs
IUDs
JSI
KFW
LAPM
MCH
MDGs
MDT
M&E
MIS
MOHSW
MKUKUTAII
MOU
MSI
MST
MTEF
NFP CIP
NGOS
NPV
OMB
Automated Directive System
Acquired immune deficiency syndrome
Activity Manager
Agreement Officers’ technical representative
Behaviour change communication
Community-based mobiliser
Contract Information Bulletins
Canadian International Development Agency
Carbon dioxide
Contract Officer Technical representative
Contraceptive prevalence rate
Critical Success Criteria
Couple Years of Protection
Disability Assisted Life Years
Department for International Development
District Medical Offices
Development Partners
Faith-based organisation
Family planning
Generally Accepted Accountancy Principles
Government of Tanzania
Human Iimmune deficiency virus
Headquarters
MSI Impact Calculator
Income/expenditure
Information, Education, and Communication
Infection prevention
Internal Rate of Return
Key performance indicators
Inter-uterine device
John Snow International
German Development Agency
Long-acting and permanent methods (of FP)
Maternal and child health
Millennium development goals
MSI Medical development team
Monitoring and evaluation
Management information system
Ministry of Health and Social Welfare
Tanzanian poverty reduction strategy
Memorandum of Understanding
Marie Stopes International
Marie Stopes Tanzania
Medium-term expenditure framework
National family planning costed implementation plan
Non-governmental organisation
Net Present Value
Office of Management and Budget
PPA
PFM
PMP
PSI
QTA
RCHS
REDD
RH
SIFPO-MSI
SORP
SRH
SWAP
TDHS
USAID
VCT
VFM
Programme Partnership Agreement
Performance and financial management
Performance Management Plan
Population Services International
Quality technical assessment
Reproductive and Child Health Services
Reducing emissions from deforestation & degradation
Reproductive health
Support for international FP-MSI
Statement of recommended accounting practice
Sexual and reproductive health
Sector-wide approach
Tanzanian Demographic and Health Survey
US Agency for International Development
Voluntary counselling and testing (for HIV)
Value for money
Intervention Summary
What support will the UK provide?
The UK will provide £8 million over four years (2011-2015).
Why is UK support required?
Maternal mortality is high in Tanzania reflecting a health system with inadequate health
personnel and a lack of adequately equipped and supplied health facilities in reasonable reach
of every woman who experiences difficulties when giving birth. In addition, the demand for
family planning is not being met. There is international consensus that reducing maternal
mortality requires: a) emergency obstetric care 24/7; b) skilled attendance at birth; and c)
access to family planning and safe abortion (Campbell et al, 2006).
Increasing access to family planning could reduce maternal mortality in Tanzania by as much
as one third by reducing the number of births and a woman’s exposure to the risk of dying. In
addition, family planning increases birth spacing between children, which has a positive effect
on outcomes for both the child born and the older sibling. In Tanzania, it has been found that
one in four currently married women of reproductive age want to space or limit births but are
not currently using any family planning (FP)i. Tanzania’s family planning programme has
stalled and without it, the MDGs cannot be met. Access to family planning is lower in rural
areas than urban and rural women are less likely to be using contraceptives. Poor women
are much less likely to be using family planning than rich ones. Interventions are needed that
raise awareness of family planning which include education about FP services, how to access
them, use of more effective contraceptive methods, as well as dispelling rumours and myths to
reduce barriers. The majority of Tanzanian women are becoming pregnant early, with over half
of women already mothers by the age of 20ii.
DFID partnered with USAID to purchase £6.5m in contraceptive commodities in 2011. In a
second phase of support, DFID Tanzania proposes to work again in partnership with USAID
(providing VFM, see strategic case) to deliver an additional 2.7 million couple years of
protection (CYPs)1 to rural women through rural family planning outreach services in 12
regions across Tanzania. The support required to revitalize national family planning efforts will
be considerable and the public sector efforts have stalled over the last 10 years. The private
sector (including not-for-profit and faith based) is a critical partner in Tanzania and provides 32
percent of contraceptive services in the country, with even higher levels in the rural areasiii.
Family planning services are provided by mobile teams of trained providers through an
existing health facility, in areas with limited FP services. Mobile outreach has great potential
for reaching women who otherwise would not have access to contraceptives of their choice,
particularly long acting and permanent methods.
1
CYPs means couple years of protection. A “CYP” is the amount of contraception necessary to protect one couple for
one year. The term "CYP" reflects contraceptive distribution and is a way to estimate coverage but not actual use or
impact. The CYP calculation provides an immediate indication of the volume of programme activity.
Considering the constraints that the Ministry of Health and Social Welfare’s (MoHSW) finds to
fully providing family planning services across the country, DFID has seized the opportunity to
work with the private sector to provide mobile outreach services. The programme has
identified a unique private sector partner, Marie Stopes Tanzania (MST) and will leverage their
existing outreach programmes to expand coverage and access to quality family planning
services in underserved areas. MST extends FP services to the rural poor by sending clinical
teams to rural government health facilities. All MST outreach services are provided free of
charge. In addition, MST works with communities before the medical teams arrive to ensure
that the communities are prepared and women understand their family planning options.
MST will work in partnership with the MOHSW service provider. MST is working with MoHSW
to establish a National Outreach Working Group to map the regions, districts and sites where
all partners work to minimise duplication and maximise coverage.
The beneficiaries of the programme will be poor, rural women who have not had reliable
access to a range of effective family planning in the past.
What are the expected results?
The impact of this programme is to contribute to achieving MDG5 and reduce maternal
deaths, which is in line with DFID’s Business Plan action 5.2 to lead international action to
improve maternal health. This will mean 1,528,000 pregnancies, approximately 134,000
abortions (many of which would have been unsafe), and 5,116 maternal deaths averted. The
DALYs saved amount to 659,000.
The outcome of the project will be to increase use of family planning through outreach
services. These will increase coverage of family planning services and women’s access to
reproductive health care. This project will increase the availability and use of contraceptives
and will provide 2.7 million CYPs over the life of the project for poor, rural women in Tanzania.
The project has four outputs as follows:
a. Increased access to quality family planning services
b. Increased equal opportunity to obtain FP services (free at the point of delivery)
c. Increased knowledge of, changed attitudes towards, and positive behaviours to
family planning
d. Improved cost effectiveness in the delivery of family planning services
Not intervening would mean that many women would not have access to family planning
beyond the local public sector facility or private facilities. Use of family planning in Tanzania
would remain low and women would continue to use less effective methods, meaning
maternal mortality would be less likely to be reduced.
Strategic Case for Family Planning Outreach Programme in
Tanzania
A. Context and need for DFID intervention
Rationale
This intervention will contribute to DFID’s objectives on reducing maternal and infant mortality
(action 5.2. in the DFID 2011-15 Business Plan). It will deliver DFID Tanzania’s commitment
under the Country Operational Plan to promote choice for women over whether and when they
have children and provide 2.7 million Couple Years of Protection (CYPs) over four years.
Providing rural women with family planning outreach services will decrease maternal and infant
mortality.
Context
High maternal mortality. Maternal and infant mortality remain high in Tanzania, especially in
rural areas. The maternal mortality ratio is 454 deaths per 100,000iv live births (2010). This is
down from 578v (2005) which may indicate that maternal mortality is beginning to decline but
maternal mortality is still unacceptably high and very difficult to accurately assess. Maternal
health is affected by the poor coverage, low quality staff, and inequitable access to health
services, early age of first pregnancy and high unmet need for contraception. Access to family
planning services is critical to Tanzania’s development. Without it, the Millennium Development
Goals (MDGs) cannot be met. There is now international consensus that reducing maternal
mortality requires a) access to emergency obstetric care 24/7; b) skilled attendance at birth; and
c) access to family planning and safe abortion vi. Each intervention reduces maternal mortality
by approximately one third.
Family planning saves lives. International evidence shows that, by reducing the number of
births, the number of times a woman is exposed to the risk of mortality from pregnancy related
causes is reduced. One third of the total maternal deaths can be attributed to non-use or lack of
availability of contraceptionvii. Family planning also enables both the youngest and oldest
women, for whom pregnancy and childbirth is most risky, to either delay or limit childbearing. In
addition, family planning can help a woman space her births. Increased birth intervals have a
positive effect on outcomes for both the child born and the older siblingviii.
High unmet need for family planning in Tanzania. In Tanzania lack of family planning is a
problem. It has been found that one in four currently married women of reproductive age want to
space or limit births but are not currently using any method of family planning ix. This is called
‘unmet need’ for contraception and implies that there is a high demand for family planning by
women in Tanzania that is not being met by current services. This means that one in four
currently married Tanzania women has an unmet need for family planning and the unmet need
is higher for rural women. While 70% of urban currently married women’s demand for family
planning is satisfied, this is true for only 53% of rural currently married women. x Reasons for
unmet need are generally lack of knowledge, difficult access to supplies and services, financial
costs, and fear of side effectsxi.
Knowledge of family planning in Tanzania is high. Knowledge of family planning in
Tanzania is high with virtually all men and women able to name at least one modern method
regardless of marital status and sexual experiencexii. Whilst Tanzanian women know about
family planning, they still lack all of the knowledge they need. There is a need for the provision
of education on family planning services and how to access them, the use of more effective
contraceptive methods, as well as dispelling rumours and myths to reduce barriers.
Family size remains high and use of contraception is increasing only slowly. In spite of
the level of knowledge and expansion of family planning services, contraceptive prevalence has
grown slowly over the past 20 years, while fertility has virtually stagnated. The total fertility rate
(the average number of live births per woman based on current fertility trends and derived from
the Tanzania Demographic and Health Surveys) was 6.3 in 1992, 5.6 in 1999, 5.7 in 2005 and
5.4 todayxiii. Use of modern contraception has risen from 7% in 1992 to 27% in 2010 but is
making only a small impression on family size. Early marriage and early age at first birth means
that 21% of 17-year-old and 39% of 18-year old women are either pregnant or already
mothersxiv. This indicates ineffective use of family planning as well as a lack of access to
services.
The situation is worse for women in rural areas. About 75% of Tanzanians (33.8 million
people) live in rural areas where family sizes are much bigger and contraceptive prevalence
lower. Poor rural women need access to good family planning services but their only option is
the public sector programme, which is not always able to deliver the services they need. The
national programme is faced with commodity shortages, a human resource crisis, dwindling GoT
resources and conflicting priorities, combined with insufficient education and promotion. The
Development Partners (DPs), including earlier DFID support through USAID, is helping revitalize
and strengthen the national public sector programme but more must be done immediately to
ensure family planning access for marginalized and underserved populations.
Table 1: Total fertility rate and contraceptive prevalence by urban and rural, Tanzania 2010.
TANZANIA
Urban
Rural
Total Fertility Rate (average family size)
3.7
6.1
Contraceptive Prevalence Rate, modern
methods (%), married women
34%
25%
Per cent of family planning demand that is
70%
53%
satisfied
Source: TDHS, 2010
Family planning outreach works.
Mobile outreach service delivery can be defined as family planning services provided by a
mobile team of trained providers, from a higher-level health facility to a lower-level facility, in an
area with limited or no family planning or health services xv. Research on utilisation data strongly
suggests that outreach can play an important role in expanding access to modern
contraceptives.xvi Outreach ensures a range of contraceptive methods, particularly permanent
and long acting methods such as IUDs, injectables and implants become more accessible to all
women, particularly those in rural and remote areas.
DFID can fill a niche: Partnering with USAID. DFID is not active in the health sector in
Tanzania, however it is responsive to needs that can not be met by Government or other
Development Partners. DFID Tanzania funded a project at the end of 2010 that will improve
women’s access to a range of contraceptives through the health clinics and centres across
Tanzania by providing 1,250,000 women with long-term methods of family planning. This
project (Phase 1), carried out with USAID Tanzania filled the gap in the FP supply chain for
implants and injectables. DFID Tanzania proposes to work again in partnership with USAID on
this Phase 2 family planning outreach expansion. There are a number of different entities in
Tanzania that are working on family planning and USAID funds many of them. USAID has
decades of experience in family planning programme delivery. It is also considered to be the
leader of the development partners working in family planning in Tanzania, thereby ensuring
that the monitoring and supervision is well coordinated.
NGO partners. There are three NGOs in Tanzania (Marie Stopes Tanzania, Engender Health
and Population Services International (PSI)) that are working on family planning outreach. MST
has the widest coverage and longest experience, particularly with long-acting and permanent
methods and is a major provider of family planning services in Tanzania. Engender Health is an
international organisation that provides training for MoHSW service providers on long-acting and
permanent methods and also supports the MoHSW to run some outreach family planning
services. PSI has recently started outreach in 10 regions, offering short and long-term methods,
but not permanent, family planning methods. It also supplies family planning commodities and
some training on short and long-term methods to faith-based organisations (FBOs) and private
dispensaries.
The need is such that it cannot even be met with all three NGOs continuing to work on family
planning outreach. As coordination is important, MST is working with MoHSW to establish a
National Outreach Working Group as a sub-group of the National Family Planning Technical
Working Group. This group will meet monthly to map the regions, districts and sites where the
three organisations work in order to minimise duplication and maximise coverage. It will also
standardise outreach documentation (e.g. consent forms, client registers and records) and
coordinate training schedules.
Beneficiaries. The beneficiaries of the programme will be poor, rural women who have not had
reliable access to effective family planning in the past.
Delivery. This programme will channel funds through USAID based on an agreed MOU and will
expand the mobile outreach approach to every region in Tanzania. This partnership will ensure
procurement and monitoring and evaluation follows strict procedures, with joint processes
occurring at key points throughout the programme.
Evidence
Health benefits of family planning. There is a wealth of strong evidence that the health
benefits of family planning to women and their children are multiple. Unfortunately, pregnancy
and childbirth are risky. In developed countries, 1 in 7,300 women will die in childbirth or from
pregnancy–related causes. In Tanzania, the chances of dying in childbirth are 1 in 25xvii. And
most of these deaths are preventable. Internationally, if every woman had the number of
children she wanted when she wanted them, maternal mortality would drop by one thirdxviii.
This is because there are safer times to be pregnant (between 18 and 35 rather than earlier or
later) and spacing and limiting births reduces risks. There are also benefits to the children of
birth-spacing. Babies born less than two years after their older sibling are twice as likely to die
before they reach their first birthdays as those born more than three years apart xix. When
women are unable to practise family planning, they have unintended pregnancies. Unintended
pregnancies are more likely to end in abortion. In Tanzania, where abortion is illegal under most
circumstances, this is likely to be unsafe and extremely risky for women. Recent estimates
suggest that approximately 19% of Tanzania’s maternal mortality is due to unsafe abortion xx.
Family planning can avoid many of these unintended pregnancies in the first place.
Evidence shows more of a lack of quality services than lack of physical access.
Internationally, lack of physical access and distance from services is less often cited as a reason
for non-use by women and men in need of family planningxxi. Cross-national studies of survey
data demonstrate that use of contraceptive methods falls only modestly with increasing distance
or travel time to the nearest source of contraceptionxxii. Cleland et alxxiii suspect that ‘if lack of
physical access is not such a severe barrier as is sometimes claimed, perhaps poor quality of
services is the more important constraint’. Access to government health services in most rural
areas in Tanzania is limited to a dispensary, which usually can offer short-term family planning
services but is unlikely to have the capacity to provide the more effective long-term and
permanent methods.
Long-acting and permanent family planning methods are more effective. Contraceptive
effectiveness is a measure of the success of typical use of a method. It incorporates efficacy
(how well a method works when used consistently and correctly) with ease of compliancexxiv.
No modern contraceptive approach is 100% perfect in reducing unwanted pregnancies but in
general, long-acting methods are the most effective (>99% protection against pregnancy over a
year of use). An advantage of these methods is that they are independent of the user once
initiated and are the most effective contraceptives (between 3 and 60 times more effective than
short acting methods during a year of typical use). Yet, despite these advantages, they are
often difficult for clients to access and are not used as widely as other methods, particularly in
Africaxxv.
Family planning is good value for money. At a global level, the Guttmacher Institute has
undertaken research which demonstrates that increasing the coverage of modern family
planning methods is a highly cost effective interventionxxvi. They calculate that meeting the
need for family planning methods for 818 million women in developing countries would cost:



$ 28 to avert an unintended pregnancy
$ 3050 to save the life of a woman or newborn
$ 62 to save a DALY (women and newborns combined)
Putting this in the context of other common health care interventions in developing countries
they demonstrate that such a cost-benefit figure represents relatively good value for money:
Table 2: DALY costs by intervention
Intervention
Insecticide-treated bed nets
Malaria prevention for pregnant women
Tuberculosis
treatment
(epidemic
situations)
Modern contraceptive methods
Antiretroviral therapy (Africa)
BCG vaccination of children
Oral rehydration therapy
Cholera immunisation
Cost per DALY saved in US$
13-20
29
6-60
62
252-547
48-203
1268
3516
Furthermore the Guttmacher Institute in 2009 demonstrated that in Sub-Saharan Africa,
providing modern contraceptives to all women who need them would more than pay for itself,
saving $1.30 in the cost of maternal and newborn care for each dollar invested.
Method Mix. Women’s preference for spacing births versus limiting their total number of births
influences their choices of contraceptive methods. Those wanting to stop childbearing are likely
to use one of the most effective methods while those wishing to postpone a birth choose among
short-acting reversible methods.xxvii It is well documented that a family planning programme
must offer the full range of methods to all womenxxviii.
Social impact. Community-based outreach services have proven most useful in rural
communities where there is limited access to other services and have been successful in raising
contraceptive use.xxix Having control over their reproductive lives is a crucial element in
women’s empowerment and gender equity. Women’s ability and willingness to pay fees for
family planning depends on many factors, including economic conditions, how high fees are set,
whether clients see an associated improvement in the quality of services, and even the type of
contraceptive for which the fee is charged.xxx There is concern that charging fees will be an
economic barrier to services for poor people, especially for women who have less control over
household resources than men.xxxi Those most likely to be affected by user fees are rural
residents, for whom targeted assistance may be required to maintain contraceptive use. xxxii
B. Impact and Outcome
The impact of this programme is to contribute to achieving MDG5 and reduce maternal deaths,
which is in line with DFID’s Business Plan action 5.2 to lead international action to improve
maternal health. This will mean 1,528,000 pregnancies, approximately 134,000 abortions (many
of which would have been unsafe), and 5,116 maternal deaths averted. The DALYs saved
amount to 659,000.
The outcome of the project will be to increase use of family planning through outreach services.
This project will increase the availability and use of contraceptives and will provide 2.85 million
couple years of protection (CYPs) over the life of the project for poor, rural women in Tanzania.
The project has four outputs as follows:
a. Increased access to quality family planning services
b. Increased equal opportunity to obtain FP services (free at the point of delivery)
c. Increased knowledge of, changed attitudes towards, and positive behaviours to family
planning
d. Improved cost effectiveness of delivery of family planning services.
Appraisal Case
A. Determining Critical Success Criteria (CSC)
Each CSC is weighted 1 to 5, where 1 is least important and 5 is most important based on the relative
importance of each criterion to the success of the intervention.
Table 3: Critical Success Criteria
CSC
Description
Weighting (1-5)
1
Ensures reliable supply of effective family planning
5
services
2
Reduces cost barriers to family planning through free
4
3
services
Increases knowledge of and demand for family planning
4
B. Feasible options
There are three options to consider based on the programme objectives to expand family planning
outreach services free of charge to rural women across Tanzania:
1. Do nothing to support family planning services to rural women across Tanzania
2. Support the delivery of family planning services through Government systems
3. Support the delivery of family planning services through private sector/NGOs.
Option 1: Do nothing additional in family planning beyond the support DFID is already providing
with contraceptive commodities. Other development partners and some NGOs are already
supplying some limited outreach services in rural Tanzania (although coverage is insufficient,
particularly in rural communities). There would continue to be high unmet need for family planning
in Tanzania.
Option 2: Working through Government systems. The public sector is currently delivering some
short-term family planning methods through its local public health clinics;however, long-acting and
permanent methods are not generally available. Contraceptive commodity stock-outs are
frequent and the public sector is faced with many competing priorities as well as a human
resource crisis.
Option 3: The private sector/NGO delivery of family planning services. It can deliver the short
term high impact results, particularly for rural poor women who currently have little or no access to
family planning services. There are currently three organisations within this option that are
providing family planning services in rural Tanzania. These include options 3A. Marie Stopes
Tanzania (MST); 3B. Population Services International (PSI); and 3C. Engender Health.
 3A. MST extends family planning services to the rural poor by sending outreach clinical
teams to rural government health facilities. Travelling in 4x4 vehicles, teams of four carry
the supplies necessary to deliver long acting and permanent family planning methods.
These include tubal ligations, vasectomies, inter-uterine devices (IUDs) and contraceptive
implants as well as the full range of short-term methods. MST currently has 14 outreach
teams: three of which operate out of Dar es Salaam; the rest are based in Mtwara, Mbeya,
Makambako, Iringa, Same, Arumeru, Karatu, Monduli, Kahama, Mwanza and Musoma.
Each outreach team consists of a surgeon, two nurses and a driver. Nationally, teams are
grouped into three zones with Outreach Team Leaders reporting to field-based Zonal
Coordinators who in turn report to Dar es Salaam. All outreach services are provided free
of charge. MST’s outreach services reach more than 95% of districts country-wide.
 3B. Population Services International (PSI). PSI has been doing social marketing of
contraceptives in Tanzania since 1993 with good sales and a wide range of products
available for sale to private sector providers (they do not provide services themselves).
They currently offer condoms, oral contraceptives, IUDs, and injectables. One of PSI’s
current main priorities is to strengthen the skills of private sector family planning providers.
This programme is supported by KfW funding and is expected to end within the next three
years. The geographic focus of this programme is linked to a viable business model and is
located in peri-urban and urban areas.
 3C. Engender Health. Engender Health gives family planning technical support to the
MOHSW as part of the Tanzania ACQUIRE project which ‘works to advance the
availability, quality, and use of reproductive health and family planning services throughout
the country’. They aim to increase the availability of long-acting and permanent methods in
Tanzania as well as implement communications campaigns to increase awareness of more
effective family planning methods. In addition, they are building the ability of health
personnel to advocate for and deliver high quality family planning services. Engender
Health’s FP project was created and funded by USAID and is scheduled to end in 2012.
Impact Appraisal
Social Impact:
This programme is designed to meet the needs of poor rural women. If women can control their
fertility, we seexxxiii:
Table 4; Benefits of Family Planning
Outcome
Improved women’s education
Reason
Girls can stay in school and finish their
educations
Increased
female
labour
force Family sizes smaller, giving women increased
participation
flexibility to work
Increased political participation
Women have more freedom to participate in
society
Higher status for women
Women are not always pregnant and have
increased control over their lives
Increased family well-being
Mother has survived to care for her family and
is less likely to suffer post pregnancy illness.
Increased child well-being
More resources, time and income for each
child and longer birth intervals lead to
improved child health.
Lower infant and maternal mortality
Births to women too young, too old or who
have already had many children would be
avoided.
In addition, society can see:
Outcome
Reduced public-sector spending on health
Reason
Healthier mothers and babies and reduced
fertility means reduced demand on
maternity, neonatal and paediatric facilities
Reduced public-sector spending on Reduced fertility means reduced numbers
education, water and sanitation
of students and increased investment in
each
Improved productivity and higher income, More people in working age population
greater savings and investment
with fewer children to support
Potential for faster economic growth
Working population has fewer children to
support
Reduced pressure on natural resources Fewer people to be sustained by the land
and biodiversity
(currently 80%) and natural resources
such as wood fuelxxxiv.
Political / Institutional Impact
The programme recognises that family planning is a sensitive political topic and requires careful
negotiation and discussion with government counterparts. The MKUKUTA II (poverty reduction
strategy for Tanzania) clearly states that population growth must be addressed in order to reach
the GoT’s goals of becoming a middle income country by 2025. The Tanzanian Government is
committed to National Family Planning; its plan and its costing (NFP CIP) is a serious exercise
that is comprehensive. That it is yet to be funded from the health sector basket fund shows a
series of competing priorities in the sector. Funding for malaria and HIV are also important and
have eclipsed family planning in recent years. The Ministry has many competing priorities and
would be happy to see a variety of current and possibly new DPs help to fund contraceptive
commodities. So far, Government commitment has come in fits and starts but has not recently
been fully sustained.
The Ministry of Health and Social Welfare (MOHSW) is the ultimate authority on family planning
and reproductive health in Tanzania. Along with the Development Partners Group, the MOHSW
decides how much of the SWAP and Basket Funding go to FP and RH. The hierarchy in the
MOHSW includes the Principle Secretary and then the Chief Medical Officer, offering overall
technical direction. Below him is the Director of Preventative Service, followed by the
Reproductive and Child Health Services (RCHS) branch. The head of this unit is developing the
RH programme to satisfy the unmet need. However, the RCHS continues to face financial and
procurement constraints from a variety of sources. There is no line item in the National Budget,
no guarantee that a portion of basket funds is earmarked for the purchase of contraceptives, no
assurance of funding release once funds are allocated for commodities, little diversification of
funding sources for contraceptives and a laboriously slow procurement process once funds are
issued. The national Contraceptive Security Committee is addressing these critical policy issues
that will require continued advocacy in the months and years to come. In 2010, DFID gave funds
to fill a commodity gap but those funds were not intended to build capacity. When the
Government is responsible for buying the most popular methods and is not fully committed to the
programme, the likelihood of stock-outs and shortfalls increase, making the family planning
programme more vulnerable.
An examination of the MTEF funding trends over the past seven years reveals that the family
planning allocation and expenditure was functioning well before 2006. Since that year, however,
irregularities have appeared showing a lagging commitment. Conditions for full transformation
may not yet be present in the Ministry and the presence of competing factions implies that the
managerial and organisational capacity is not yet sufficiently strong for change to take place.
USAID has conducted extensive dialogue with the GoT to improve the supply gaps and a written
commitment has been provided. To address these concerns, DFID is building on the success of
the USAID funded programmes and using DFID’s support on PFM to improve release of
Government’s stated budget allocations.
Environmental and climate change effects
The proposed project is likely to have a potentially substantial positive environmental impact and
a limited direct detrimental environmental impact. See Annex 1 & 2 for the full climate change
assurance note.
Positive environment impact. There is a significant benefit associated with higher uptake of
family planning services and smaller family sizes which relates to climate change and pressure on
natural resources. Increased contraceptive use should result in a lower fertility rate, which in turn
results in slowed population growth. Tanzania’s current 45 million people are currently projected
to grow to 67 million by 2025.xxxv Population growth is a major contributor to environmental
degradation. As populations grow, settlements expand and encroach on natural habitats, often
leading to habitat loss. They also put pressure on natural resources, such as water and
ecosystem services. As an example, by 2015, population growth will mean that Tanzania’s per
capita water resources could fall below 1,700 m 3 per person: the definition of water scarcity.
Population growth will also lead to environmental degradation through the demand for additional
goods and services, which are particularly important due to the strong urbanisation trends in
Tanzania. Potential increasing demand for energy and transport will also have an impact on
increased use of fossil fuels, potentially doubling greenhouse gas emissions over the next twenty
years, as well as increasing urban air pollution and congestion. Fewer people generate less
green house gases which are the main determinant of adverse climate changes.
Population growth and increasing urbanisation are key factors as well as climate change in
determining future economic costs. These rapid demographic changes will be important in future
impacts, adaptation and emissionsxxxvi. In fact in a recent paper produced by climate change
experts at the Centre for Global Development, family planning was identified as the best buy for a
single intervention to reduce green house gasesxxxvii. If family planning is combined with girls’
education there are even more significant gains, as the table below shows in terms of the number
of tonnes of CO2 saved for $1 million invested. It has been argued that the combination of family
planning and girls’ education would be a better investment than the UN Reducing Emissions from
Deforestation and Forest Degradation (REDD), which aims to spend $30 billion a year on
incentives for developing countries to reduce deforestation and forest degradation.”xxxviii
Table 5: Saving CO2 emissions by development intervention
Intervention
Family planning
combined
Tonnes of CO2 saved
&
girls'
education
250,000
Family planning alone
222,222
Girls education alone
100,000
Reduce slash and burn of forests
66,667
Pasture management
50,000
Geothermal energy
50,000
Energy efficient buildings
50,000
Pastureland afforestation
40,000
Nuclear energy
40,000
Reforestation of degraded forests
40,000
Plug-in hybrid cars
33,333
Solar
33,333
Power plant biomass co-firing
28,571
Carbon Capture and Storage (new)
28,571
Carbon Capture and Storage (retrofit)
26,316
It should be noted that, while increased contraceptive use will reduce population growth, caution
should be practised in using this argument without stressing the importance of voluntary family
planning to allow women to meet their reproductive desires. The health benefits to women alone
(e.g. the reduction in maternal mortality) are adequate argument to the provision of good family
planning services.
Potential detrimental environmental impact. There are two possible detrimental effects that
this programme might have on the environment:


The release of carbon dioxide through transport of the outreach teams to each region for
the regular visits; and
Waste generated as a result of used contraceptive commodities.
The programme will attempt to minimise any negative impacts on the environment. The number of
teams and visits made each year will be relatively few and the overall impact from the vehicle
emissions is likely to be minimal. Waste disposal will follow carefully-designed protocols.
It is on this basis that the programme’s likely impact on climate change and the environment has
been categorised as “B”: medium/manageable potential risk, with good opportunity for
improvement.
Table 6: Evidence rating and climate change and environment category
Option
Evidence rating
Climate
change
and
environment category (A,B,C, D)
1 Do nothing
Medium
C
2 Go through MOT
Medium
C
3 Use an NGO
Strong
B
C. Appraisal of options
This appraisal is split into two parts. First, the three high level options to support family planning
service delivery are examined. In the second part, we examine in more detail the choices under
option three (Private sector NGO delivery of rural outreach services).
Part One: Examining the high level options.
Table 7: Appraisal of options – Part One
Option
1. Do
nothing
Benefits
Costs
(Quantitative
and Qualitative)
(Quantitative and Qualitative)
No commitment
cost to DFID
Negative benefit: Negative
impact on health indicators set
out in the strategic case.
Risks and
assumptions
Risk: Tanzania’s
high maternal
mortality persists
High
Risks: Little
political will to
sustain changes.
Medium
Poor rural women will continue
to have little access to family
planning even when they would
use it if it were available.
2. Work
Resource cost:
through
£8m
Government
Systems
Staff-intensive
policy work in
health
Positive benefits: System
strengthening creates potential
for reforms being sustained
beyond DFID funding.
Public sector facilities are able
to deliver short-term family
planning methods such as
condoms and pills.
Negative benefits: Immediate
programme service delivery
impact cannot be found by
working through Government
systems
Commodity stock-outs and a
lack of medical staff continue to
dog the effective delivery of a
full range of family planning
options. This means that
Key evidence
(including
rating)
The level of
fiduciary risk for
funding through
GoT systems was
assessed as
substantial in
DFID’s May 2010
Fiduciary Risk
Assessment,
albeit noting that
specific risks for
the health sector
were not
assessed in detail
Contraceptive
Tanzania’s
poor maternal
health statistics
well
documented by
TDHS
and
other
international
sources.
Government
spending data
over
time
shows current
lack
of
commitment.
Political
analysis shows
GOT still happy
to
lean
on
donor
support.xxxix
3.Work
through an
NGO
Resource cost:
£8m
MOU with
USAID
Low
management
costs for DFID
women receive prescriptions
and need to buy their family
planning through a private
source. There is some
evidence of unofficial payments
for ‘better service’ but this is
primarily anecdotal.
commodity stock
outs
Positive benefits:
High/immediate impact means
that current high rural unmet
need is met quickly (until GoT
services are stronger)
Risks: USAID
policy changes;
GOT ceases to
support NGO
activity.
Negative benefit: No support to
GoT systems to incentivise
systemic change. (USAID and
other donors working here.)
Assumptions:
Assumption:
Public sector
services will grow
stronger over
time and be able
to serve rural
communities
High.
See strategic
case.
NGO capacity
GOT continues to
welcome private
sector NGO
support to
supplement
public sector
family planning
delivery
Option 1: The “do nothing” option would have a negative impact on health indicators set out in
the strategic case above.
Option 2: Working through Government systems. DFID is already supporting the Tanzanian
Government through budget support. However, dealing with these deep-seated and complicated
issues of the low capacity and commitment of GoT staff, inadequate health staff and weak central
commodity logistics represents work in progress. Meanwhile, women in rural Tanzania need the
full range of family planning options immediately and can’t wait while the public sector
programmes are being strengthened. Immediate programme service delivery impact cannot be
found by working through Government systems. System strengthening has been ongoing for 15
years and the system still experiences regular stock-outs.
Option 3: The private sector/NGO delivery of family planning services. It can deliver short term
high impact results, particularly for rural poor women who currently have little or no access to
family planning services. There are currently three organisations within this option that are
providing family planning services in rural Tanzania. These include options 3A. Marie Stopes
Tanzania (MST); 3B. Population Services International (PSI); and 3C. Engender Health.
Part One: Conclusion of High Level Options
If poor, rural Tanzania women need family planning services immediately, this programme should
aim to deliver rapid effects to poor populations rather than to wait to drive fundamental reforms
within the health system. DFID is currently already providing long term systematic support to the
health sector through the GBS mechanism and the institutional support for improvements in public
sector family planning services is already taking place—but not quickly enough.
For this reason, Option three is being chosen. Within option three there are three additional
options which will be examined in the next section. Part two will examine these options to
determine the best delivery mechanism for the outreach programme to be funded as well as the
best value for money.
Part Two: Examining Option Three (Options 3A, 3B, and 3C).
Appraisal of feasible NGO options
Table 8: C. Appraisal of options – Part 2
Option
MST
Costs
(Quantitative and
Qualitative)
£8 million
Benefits
(Quantitative and Qualitative)
Positive benefits:
Long experience in delivering rural
outreach family planning services
in Tanzania
Risks and
Assumptions
Evidence
Risks: NGO
remains strong
and is
supported by
HQ
High:
Outreach network can deliver a full
range of contraceptive methods.
Cost per CYP demonstrates value
for money
Outreach services are provided
free of charge
PSI
£8 million
Positive benefits:
Long experience in Tanzania in
social marketing
Beginning work in rural family
planning outreach in limited rural
areas of Tanzania
Can deliver some temporary family
planning methods more cheaply
than MST
Assumptions:
MOH continues
to collaborate
with private
sector family
planning service
delivery
Risks: NGO
remains strong
and is
supported by
HQ
Assumptions:
FBOs continue
Good
evidence that
MST has
successfully
delivered
CYPs via
family
planning
outreach
servicesxl.
High:
Good
evidence that
PSI can
successfully
deliver family
planning via
social
marketing
and
Negative benefits:
to work with PSI
outreachxli
Risk: NGO
remains strong
and is
supported by
HQ
Low:
Can’t currently deliver full mix of
methods, including both temporary
and long term methods through
outreach.
Not set up as a service provider
per se
Engender
Health
Positive benefits:
£8 million
Good experience in improving
public sector rural outreach of
family planning.
Good capacity building of GoT staff
on outreach service delivery
Negative benefits:
No direct outreach service
delivery—instead works with public
sector to deliver services.
Assumptions:
GOT public
sector continues
to collaborate
with NGO
Evidence of
public sector
improvement
harder to
demonstrate.
Work of the
Acquire
project. xlii
The Engender Health programme
will end in 2012.
Additional information on organisations carrying out rural outreach in Tanzania
Delivering through Marie Stopes Tanzania (MST). MST already has 20% market share of
Tanzania’s family planning programme. These services are mostly delivered through a network of
13 static clinics located throughout Tanzania in urban and peri-urban areas. While these clinics
are popular and covering their costs, they are not located in areas easily accessible to rural
women. This is why MST also began to offer free outreach services in rural areas.
MST already extends family planning services to the rural poor by sending clinical teams to rural
government health facilities. Sixty per cent of Marie Stopes Tanzania clients receive services via
outreachxliii. Teams carry the supplies necessary to deliver long-acting and permanent family
planning methods as well as the full range of short-term methods. MST prioritises long-acting and
permanent methods for rural areas because most government facilities already provide short-term
contraceptive methods.
MST outreach team visits are planned in coordination with local government authorities and are
scheduled and geographically targeted to extend coverage in areas where service provision is
limited. Teams work closely with government staff and local communities to transform existing
government and community buildings into sterile surgical environments in which to deliver longacting and permanent method services which are generally unavailable in these facilities. MST
teams carry a buffer stock of family planning commodities in case of government facility stockouts to ensure the full range of methods are available. All MST outreach services are provided
free of charge.
As part of their outreach programme, MST works in communities before the medical teams arrive
to ensure that the communities are prepared. This work with communities has been shown to be
crucial to the efficient delivery of outreach services. With current resources, MST is unable to
reach all wards in every district and many sites receive only one visit per year. This low frequency
of visits reduces the cost-effectiveness of informing women about their family planning options
and disappoints many women who are keen to use family planning.
Population Services International. PSI social marketing in Tanzania provides male and female
condoms, injectables and oral pills. Social marketing programmes complement static clinic and
outreach family planning programmes by giving women and men additional outlets to obtain
family planning or sexual health protection. As family planning use increases, the variety of
places for people to obtain contraceptives becomes increasingly important. In addition, one of
PSI’s current main priorities is to strengthen the skills of private sector family planning providers.
PSI has also built networks of faith-based organisations (FBOs) in 38 districts across 10 regions
and they coordinate their work with the local district health officials. PSI provides training in family
planning and post-abortion care to the FBOs and supplies them with contraceptive methods. PSI
outreach nurses provide long-term contraceptive methods and the FBO provides short-term
methods. They do not provide permanent family planning (male or female sterilisation). PSI has
begun minimal outreach teams in the last six months that spend one day at each FBO every
quarter to expand the FBO services for that day. PSI does not yet have data for the cost of its
2010 outreach couple years of protection.
It is likely that PSI is able to deliver some methods of contraception at equal or lower cost than
MST. For example, socially marketed oral pills and condoms are delivered more cheaply than
contraceptives delivered by clinical staff. This is in great part because users have already been
counselled on contraceptive choices and are simply restocking their preferred method when
buying socially marketed options.
However, PSI is currently unable to provide the full range of family planning services required in
an outreach programme as they do not provide permanent methods of family planning. The
reproductive health needs of women vary a great deal making the social cost to women for being
unable to access the full range of contraceptive options high. A wide range of methods increases
user satisfaction and enhances the status of the family planning programme as well as increasing
contraceptive prevalencexliv. Ideally, clinical family planning outreach and social marketing of
contraceptives should complement one another. This is only possible, however, when women
already have regular sustainable access to a full range of family planning services.
Engender Health’s approach invests in the long term sustainable method of building up the
public sector services to deliver family planning services. They assist the public sector in carrying
out outreach services. They do this by training MOH staff on long-acting and permanent methods
of family planning, encouraging family planning outreach events; and sometimes providing staff to
provide family planning methods. They work in close consultation with district authorities who
determine where outreach events are held. This system operates in 70 districts across all
regions. Engender Health’s family planning activities in Tanzania are implemented under a
USAID support project, “Acquire Tanzania”, which is due to end in 2012.
D. Comparison of options:
The same weighting is used as for CSC above. The score ranges from 1-5, where 1 is low
contribution and 5 is high contribution, based on the relative contribution to the success of the
intervention.
Table 9: Analysis of options against Critical Success Criteria (CSC)
Option 3A (MST)
Option 3B (PSI)
Critical Success Criteria
Weight Score Weighted Score Weighted
(1-5)
(1-5)
Score
Score
1 Ensures reliable supply of family
5
5
25
4
20
planning methods
2 Reduces cost barriers to family
4
4
16
2
8
planning through free services
3
Increases knowledge of and
4
3
12
4
16
demand for family planning
Totals
12
53
11
44
Option 3C (Eng H)
Score Weighted
Score
3
15
4
16
4
16
11
37
Option Selected
Based on this analysis and the desired outcome of this programme (to increase use of family
planning in Tanzania), the selected option is Marie Stopes Tanzania (MST) as it is the only
organisation that can currently deliver the full range of family planning outreach services.
The choice of option three is made also with the consideration that the close coordination of both
Engender Health and MST with district authorities helps to ensure that activities are
complementary and coverage is not duplicated. District health officials are aware of the
partnerships between PSI and the FBOs and are informed of the outreach schedule. As MST
plans all outreach activities with DMOs in each district, their coordination should ensure that there
is no duplication of service provision.
Description of the selected option
The Marie Stopes Tanzania Family Planning Outreach Programme delivers mobile integrated FP
and HIV services to poor women and men in rural areas. The programme will provide 12 outreach
teams to regions across Tanzania including Morogoro, Singida, Zanzibar/Pemba, Rukwa, Katavi,
Kagera, Simiyu, Geita, Dodoma, Mbeya, Shinyanga, and Kigoma.
Family Planning Outreach. These mobile teams will increase access to quality family planning
services for underserved women that are free at the point of delivery. The teams comprise a
surgeon, three nurses and a driver for Mainland Tanzania, travelling in an equipped four-wheel
drive vehicle. These teams set up mobile surgeries in local government health facilities. As an
island, Pemba requires a different service delivery model whereby a trained FP nurse will be
based permanently in Pemba to deliver ongoing services and coordinate monthly visits by
Zanzibar/Dar outreach teams. The nurse will use three-wheeled auto-rickshaws for local transport
and visiting outreach teams.
Training. Four clinical training sessions will be conducted each year in the region for MST
service providers (20-40 participants each). These will cover topics such as different FP methods,
infection prevention, VCT and FP/HIV integration. There will also be four management training
sessions each year and additional training (four in year 1 and two in subsequent years) on
information/technology and reporting. Where relevant, MOHSW facilitators, curricula and
assessments will be used.
Increasing demand for FP. Behaviour change communication (BCC) approaches will be based
on MST’s BCC Strategy and will include radio broadcasts, community events and information,
education and communication (IEC) products. In addition, most communities have volunteers who
have been trained in health education or community mobilisation called community-based
mobilisers (CBMs). In this programme a network of CBMs will receive specific training on
promoting FP/VCT within the community. There will be an emphasis on working out how to best
reach young people (funded by AusAID). The revised demand generation strategy (funded by
CIDA) will reflect these new approaches for attracting youth.
M&E. Evidence of the effectiveness of using CBMs is lacking and this programme has
incorporated research into this issue as part of the design. Project teams will also be included in
three annual quality-of-care studies using mystery clients, exit interviews and assessment of
complication and discontinuation rates, as well as an annual clinical quality technical assessment.
Theory of Change
The programme will have an impact upon women’s reproductive health directly (through delivery
of family planning outreach to rural and remote areas) as well as indirectly (though building
demand for family planning and providing research and understanding to strengthen the provision
and acceptance of family planning services in Tanzania).
Will increased access, equity, and behavior changed lead to increased use of
contraception? One of the most well known examples of an intervention to increase
contraceptive prevalence through both stimulating demand and increasing supply is the Matlab
experiment in Bangladesh. xlv Nearly two decades after the programme was begun, exposure to
the programme was associated with a statistically significant 13% reduction in fertility. xlvi
MOBILE ACCESS: Mobile outreach service delivery has potential for meeting the unmet need for
a range of contraceptive methods. Evidence from a recent systematic review suggests that
outreach in an effective and acceptable way of increasing access to contraceptives, particularly
injectables and long-acting and permanent methods.xlvii
EQUITY: Enabling women to have choices in their lives, especially the right to determine the
number, timing and spacing of their children free of discrimination, coercion or violence is key to
women’s empowerment and gender equality. xlviii Evidence has shown that those most likely to be
affected by user fees are rural residents, for whom targeted assistance may be required to
maintain contraceptive use.xlix
BEHAVIOUR CHANGE: Analysis of DHS data in the late 1980s shows that one of the most
frequently reported reasons for not using modern methods of contraception was a lack of accurate
information about different contraceptive methods, how to use them, and potential side effects. l A
systematic review of media campaigns from 1970-1999li drew the following conclusions: a) family
planning campaigns can generate an immediate demand for family services; b) exposure to
family planning messages through mass media campaigns is associated with approval of family
planning, partner communication about fertility and family planning, and increased contraceptive
use; and c) exposure to general and targeted mass media messages about family planning
influences social norms through stimulating group, interpersonal and spousal communication,
thereby indirectly affecting reproductive behaviours.
Further details on the selected option
Environmental considerations
MST complies with Marie Stopes International (MSI) and MoHSW guidelines on infection
prevention (IP) which include strict protocols on disposal of domestic and clinical waste as well as
procedures for disinfection, cleaning and sterilisation. Clinical staff receive IP training every year.
IP is included in annual independent external inspections by both MoHSW and MSI. In 2011, with
anticipated funding from CIDA, MST will develop and implement an organisational policy on
environmental sustainability. As funding for the programme is through USAID Tanzania, they
have provided full assurance to DFID Tanzania that the environmental issues of this project have
been fully considered. http://www.access.gpo.gov/nara/cfr/waisidx_06/22cfr216_06.html lists the
environmental procedures for USAID and a copy of the local environmental impact mitigation plan
is on file within USAID Tanzania. USAID is required to conduct an annual report on environmental
issues for their projects. The last environmental review for USAID on Family Planning was
conducted in June 2010.
Economic Appraisal
This section presents an economic appraisal on the selected option.
MST outputs and outcome data. The following table presents monetised health benefits that
will result from the programme. These have been calculated using MSI’s Impact Calculator.
Based on regional research data, the impact calculator estimates the potential cost savings to the
health system, families and communities from preventing unsafe abortions and maternal deaths.
As this data is regional, it is assumed that it is applicable to the specific Tanzanian context. In
reality, this is the best data, at present. Some background about how a Couple Year of Protection
is calculated and costed is given first.
How is a CYP calculated?
The CYP is calculated by multiplying the quantity of each method distributed to clients by a
conversion factor, to yield an estimate of the duration of contraceptive protection provided per unit
of that method. The CYP for each method is then summed for all methods to obtain a total CYP
figure. CYP conversion factors are based on how a method is used, failure rates, wastage, and
how many units of the method are typically needed to provide one year of contraceptive protection
for a couple. The calculation takes into account that some methods, like condoms and oral
contraceptives, for example, may be used incorrectly and then discarded, or that IUDs and
implants may be removed before their life span is realized.
What is the total cost of a CYP?
To calculate the cost of a CYP, it is necessary to add up all the components required in the supply
line. At its simplest, there is:
a) the cost of the commodity;
b) the price for procurement and logistics;
c) the price to advertise or market the services; and
d) the cost of the service delivery.
Commodity and shipping costs. Determining the price of a commodity for one CYP in
Tanzania is a complicated undertaking with many suppliers, commodities and prices. All products
cost different amounts to ship and store. The method mix (which type of contraceptives a woman
uses) fluctuates year to year. Ultimately, the price of a ‘commodity CYP’ (including the costs for a
and b in the list above) is going to be a rough estimate at best without going through a
tremendous exercise to obtain a more exact estimate.
In consultation with USAID and the JSI Deliver project, a conservative rough estimate for a
commodity CYP in Tanzania has been estimated at £4. This includes the average price of all
contraceptive commodities plus shipping and storage, weighted by the proportion of women who
use them. If anything, this amount (£4) is an over-estimate so it is conservative.
Table 10. Some example CYP costs in Tanzania (commodities only)
Method
Oral contraceptives
Depo provera
injectable
Copper T 380-A IUD
Female condoms
CYP per unit
15 cycles per CYP
4 doses per CYP
Cost per method
$0.25
$1.13
Cost per CYP
$3.75
$4.52
3.5 CYPs for each
IUD inserted
120 units per CYP
$0.49
$0.14
$0.55
$66.00
Service delivery (including marketing) costs. The unit cost of a CYP for 2010 for MST was
£5.35. This includes all of MST’s costs in marketing and delivering a wide variety of maternal,
sexual and reproductive health services so it is an extremely generous outside estimate. It does
not include the cost of the commodity itself as MST uses commodities from the Tanzania central
stores so the costs of procuring the contraceptives has already been covered by the Tanzanian
Government and their DPs.
Therefore, the full estimated cost for a CYP delivered by MST using Government-funded
contraceptives would be £9.35. This is a combined figure that includes the £4 commodity cost
estimate and the MST unit cost per CYP for 2010.
Table 11: Estimated Reproductive Health Impact for 4-Year Outreach
Project: Marie Stopes Tanzania*
YEAR
Impact measures
CYPs
£/impact
measures
£9.35
401,625 757,350
2,673,675 (£5.35
757,350 757,350
+£4)
142,362 268,454 268,454 268454 1,527,813 £16 ($24)
1
2
3
4
TOTAL
97,281
183,444 183,444 183,444 947724
Pregnancies averted
Births averted
Maternal
deaths 769
averted
Unsafe
abortions 20,168
averted
99,047
DALYs saved
£26
1449
1449
1449
5116
38,081
38,081
38,081
134,411
£4886
£186
659,372
£38 ($57)
186,775
186,775 186,775
*These figures have been determined using the MSI Impact Calculator.
Even at the maximum total estimates, this investment still demonstrates (very) good value for
money. The Guttmacher Institute estimates that averting a pregnancy world-wide, on average,
costs $28 while this programme is promising a cost of $24.. Modern contraceptives are estimated
by Guttmacher Institute to cost $62 per DALY saved world-wide while this programme promises
£38 ($57). Given that these family planning costs are for rural outreach (one of the most difficult
ways to deliver a full range of clinical services), these represent extremely good value for money.
Whilst the MSI Impact Calculator was deemed appropriate to determine the impact measures in
table 11, its methodology was not considered to be sufficiently robust to conduct a fuller costbenefit analysis that would determine NPVs and IRRs.
E. Measures to be used or developed to assess value for money
Value for Money
Programme Scale. The role of programme size is important to consider in assessing costeffectiveness. Larger programmes, such as this in Tanzania, benefit from economies of scale in
procurement and so unit costs decline as the number of contraceptive users increase. It follows
therefore that average costs decrease as fixed costs from training and from information, education
and communication programmes are distributed over more units.
Mode of service delivery: There is no data on services delivery mode for Tanzania alone and
there is no data on rural outreach. However the table below, using cost data shows how the
mode of service delivery influences the estimated cost per output based on analysis from SubSaharan Africalii. MST outreach CYPs will be competitive with these figures. MST is also in the
process of refining their CYP unit costs and defining them as, for example, the cost of a CYP from
the static clinics or an outreach CYP. MST will be working with DFID and USAID during this
programme to refine these estimates. A preliminary estimate for an outreach CYP by MST is
£3.43 demonstrating that the estimates in Table 11 are very conservative.
Table 12: Family planning service delivery methods by cost
Mode of service delivery
Social marketing
Community-based distribution
Clinics
Clinics with community-based distribution
Cost per
(US$)
15.95
20.32
16.65
8.02
CYP
As the programme already has a number of VfM metrics available – for example costs regarding
the mode of delivery in the above table and the impact costs in table 2 above, the programme will
focus on monitoring these costs with the view of assessing where VfM gains can be achieved.
Currently, MST has committed to reducing the cost of the CYPs it delivers for outreach
programmes from £3.43 in year 1 to £2.94 by year 4, by improving efficiency, utilising new
technologies and exploiting economies of scale. This commitment will be monitored through the
programme’s logframe.
Commercial Case
A. Procurement/commercial Requirements
The activities of this family planning outreach programme will be procured indirectly, through
USAID. USAID currently has a global agreement with Marie Stopes International (MSI) and
USAID/Tanzania will put the DFID support into this already functioning award to ensure
effective and immediate implementation of the programme, as the mechanisms for funding
MST directly would delay the initiation of activities. MST is a not-for-profit organisation which
is part of MSI which operates in over 38 countries worldwide. This programme is for both
programming and commodities and will use USAID procurement policy and guidelines. There
is no direct procurement in this programme by DFID.
DFID
MOU
USAID
Contractual
Agreement
MST
B. Indirect procurement
A. Why is the proposed funding mechanism/form of arrangement the right one for
this intervention, with this development partner?
DFID Tanzania has not been active in the health sector but has been supporting the sector
where there are gaps in provision that can not be filled by other partners. In 2010, DFID
Tanzania decided to respond to a contraceptive shortage with support to the Tanzanian
family planning programme. However, as there was no dedicated DFID health adviser or
administrative support to supervise such a programme, it was decided to provide the
required resources through USAID—the donor in Tanzania who has the most experience in
family planning, using a Memorandum of Understanding (MOU). It is intended that this
collaboration is continued for the family planning outreach programme.
This programme reaches the most remote and rural areas across Tanzania. With this level of
geographic dispersal, DFID would be unable to deliver the interventions directly. By
partnering with USAID, DFID Tanzania is able to deliver improved results in CYPs and
reduced maternal and child deaths. USAID Tanzania has the history, staff, engagement with
the MoHSW and robust management, monitoring and supervision systems to deliver the
expected results.
USAID has been through a formal open and competitive bid and award process with MSI..
USAID Tanzania has a formal project management protocol that assures the necessary
support and oversight. The activities proposed here fit into USAID’s larger programme.
DFID will be contributing its support through a pooled funding arrangement with USAID as
the lead donor. By providing DFID’s support through a pooled funding mechanism, USAID's
existing agreements and conditions which set out their agreements with MSI/MST will be
followed. This includes the need for annual payments at the start of the programme and the
use of the SIFPO mechanism, which is not a cost reimbursable agreement.
In order to mitigate fiduciary risk, as part of our agreement, we will receive quarterly reporting
on usage of funds from USAID. The current agreement between USAID and MSI/MST will
come to an end in the second year of the FP programme, which will give us an opportunity to
assess/review this arrangement with USAID at the mid point of the programme.
The indirect procurement component of the programme will be managed under an MOU with
USAID, who will enter into a contractual agreement with MSI and MST and is appropriate for
the following reasons:



It provides effective means of reducing the management burden to DFID that would be
imposed through the use of commercial contracts;
It enables existing activities by USAID and MST to be harnessed and expanded through
the provision of additional resources to these organisations; and
The use of USAID to manage this programme including financial management,
procurement management, M&E and reporting provides better value for money under the
current DFID environment of doing more development work with less resources.
These instruments will deliver value of money through the assets that both USAID and MST
will bring to the programme. These include technical expertise in family planning,
contraceptive commodities procurement, distribution, utilisation and safe disposal and ability
to expand quickly. USAID provides the monitoring of the programming and robust
procurement procedures. In addition, with an MOU with USAID there are very strong and
transparent organisational and financial management processes. As there is currently an
existing central agreement between USAID and MSI, there is no anticipation in delays of
disbursement of funds to MST from USAID, once the MOU between DFID and USAID is
finalised. If, during the course of implementation, it would be considered beneficial (and
better VFM) to adjust these funding arrangements, it is agreed that funding could be
adjusted, by mutual agreement between DFID and USAID.
It has been agreed that USAID will not charge a management fee for this service, therefore
representing good VFM for DFID. USAID will require £20,000 per year of the programme to
cover a percentage of supplementary supervisory staff and administrative costs (i.e. 1% of
the total DFID contribution).
The potential financial risks of using these instruments (as opposed to commercial contracts)
will be mitigated through the use of annual tranche releases to USAID, including quarterly
progress and financial reports that are reviewed by programme staff, to ensure that the
services provided are appropriate and of high quality.
The programme will procure goods and services from this partnership using USAID’s
procurement mechanisms and delivery channels. DFID have reviewed the procurement
strategy of USAID and find that it is robust and rigorous and focused on achieving the best
VFM. USAID will also conduct cross-checking on the prices of goods and services against
those of similar inputs in Tanzania and the region, when goods are being purchased as part
of their procurement procedures. Cost consideration is also part of an award negotiation and
will be a key activity in selecting the next tender. Value for money is a key element in this
process.
B. Value for money through procurement
At a global level, USAID is known for having robust mechanisms in place to ensure good
value for money. DFID Tanzania’s experience of working with USAID at country level has
been excellent. DFID Tanzania has already twice worked with USAID through an MOU to
provide health services to Tanzania: to support the hang-up malaria bednet campaign for
children under five in 2009 (£800,000) and to fill the gap in the supply chain for the purchase
of contraceptive commodities in 2010 (£6.5 million). Both of these programmes have
performed well and highlight the strong effectiveness of USAID’s management capacity.
Although not directly funding MST, DFID has also assessed the VFM for procurement of
MST. The recent process by which MSI received its PPA concluded that MSI is a wellmanaged organisation. Marie Stopes Tanzania as an organisation states that its financial
and management systems enable it to provide robust and transparent management of the
outreach programme for which it will be responsible.
USAID has an existing agreement with MSI that was competed globally. The Support for
International Family Planning (SIFPO-MSI) project is a five-year global cooperative
agreement (2010-2015) with Marie Stopes International (MSI) with a $40m ceiling. Through
the SIFPO-MSI Project, Marie Stopes International and its partners will work to dramatically
increase access to and utilization of voluntary, high-quality family planning services around
the world. MSI’s partners on the project are EngenderHealth, International Center for
Research on Women, International HIV/AIDS Alliance, and the Population Council. USAID is
funding MST through this mechanism with both core funds as well as approximately
$200,000 per year over the next four years at the country level . USAID plans to match their
flow of local funds with those of DFID in this agreement through the central mechanism.
Control of administrative costs: MST will develop an annual workplan and objectives for
key performance indicators that will be approved by USAID and reviewed by DFID Tanzania.
On a quarterly basis, they will provide an overview of key activities and outputs to USAID
and DFID. This report will also include financial data and updates on key indicators. USAID
Tanzania staff meet regularly with implementing agencies and the annual planning and
quarterly reporting are a formal part of the project management process, as detailed in the
Agency’s formal policy directives and guidelines.
VFM in purchase of programme goods: MST procurement policy and guidelines set out
organisational procedures for procuring goods, and services globally, however this does not
apply to all procurement as MSI only procure internationally above certain thresholds. MST
carries out local procurement where this is considered best value for money, and follows
similar tendering procedures for all items beyond a certain value. All procurement will be
required to fulfil USAID’s standards and procedures. MST does not have a global purchase
agreement but MSI has a recommended specific model of vehicle for outreach. MST can
purchase through them or can manage the tendering process (preferred). MST has already
discussed with USAID a waiver in order that MST can buy the standard Toyota model
outreach vehicle. The waiver process is part of the USAID procurement policy and
guidelines. The follow-on tender will have the same guidelines and procurement policies.
Effective financial audits and accountability: MST, as part of MSI, complies with relevant
legal and accounting requirements (UK Generally Accepted Accountancy Principles GAAP,
the Companies Act 2006 and the Statement of Recommended Accounting Practice charity
SORP). As a locally registered NGO, Ernst and Young do MST’s annual audit in Tanzania.
MST is also included in the global MSI audit conducted in London. MST has documented
financial and procurement procedures to which it adheres, with monthly accounting reports
which are reviewed at country level and then sent to MSI HQ for review. This includes I/E
reports for all projects. As well as an annual audit by a local audit firm, MST is audited
annually by MSI’s regional audit team and is part of MSI’s annual global audit. In 2008,
when a new Country Director and Finance Director joined MST, a range of new controls
were introduced to ensure better financial management. MST also complies with all donor
audit requirements. MST received a qualified audit in 2007 that resulted in widespread
changes of staff and procedures in Tanzania and all recommendations were implemented. A
further detailed audit was conducted by CIDA in 2008 and was unqualified and has remained
so for each subsequent audit. This shows that there are good and effective controls for
MST’s country programmes including budget monitoring and financial controls.
Partnership with USAID. The partnership with USAID/ Tanzania will also serve to mitigate
further any fiduciary risk. USAID’s regulation and policy guidelines are rigorous. Prior to
making the central award, the contracting office made a Pre-Award Responsibility
Determination. MSI passed the final determination on this award and fully satisfied the
Agency that they had the capacity to adequately perform on the award in accordance with
the principles established by USAID and the US Office of Management and Budget (OMB).
A positive responsibility determination means that they possess or have the ability to obtain
the necessary management competence to plan and carry out the assistance programme to
be funded, and that the applicant will practice mutually agreed upon methods of
accountability for funds and other assets provided by USAID.
Financial Case
A. Costs
The expected cost of the family planning outreach programme is £8 million over four years. This
is complementary to the support already provided for contraceptive commodities provided by
DFID in December 2010.liii The approximate breakdown of these costs by year is as follows:
Table 13: Programme costs by year
2011/12
2012/13
2013/14
£2,300,000 £2,000,000 £2,000,000
2014/15
TOTAL
£1,700,000 £8,000,000
The approximate allocation of funds to individual components of the programme will be as
follows:
Table 14: Budget by intervention
Category
ACCESS: Expansion of services
EQUITY: Service Delivery
Behaviour change communications
Cost-effectiveness evaluation
Monitoring and evaluation
MST Program and operations salaries
MST operating costs
MSI technical oversight
MSI programme support and Operations (NICRA)
TOTAL
Amount
1,195,710
2,461,553
711,233
335,069
151,565
1,361,665
497,561
222,168
1,059,210
7,995,735
Percentage
15.0%
30.8%
8.9%
4.2%
1.9%
17.0%
6.2%
2.8%
13.2%
100.0%
B. Types of Funding
All required resources will be programme funds—which will cover procurement of goods and
services. This is part of the budget allocated within the Operational Plan for DFID Tanzania
covering F/Ys from 2011/12 up to 2014/15.
There are no contingent or actual liabilities.
C. Payment procedures
Funds will be disbursed according to the terms of the MOU between DFID and USAID, which is
expected to have an annual disbursement schedule. USAID will then fund MST and supervise
the programme and provide report back to DFID every quarter. Reports will be available 30 days
after the end of each quarter. USAID and DFID are currently using this mechanism for other
activities to mutual satisfaction.
If there are policy changes for USAID that make their administration of this family planning
contract untenable, and therefore could not guarantee that the funds would be released in a
timely manner to ensure delivery of the programme, DFID will consider the option of directly
funding MST during the course of the four year period. While this is unlikely the fact remains that
family planning is a contentious issue in American politics and a different presidential
administration could have implications for USAID and its administration of family planning
projects.
If the programme is terminated early, through no fault of the implementing partners, USAID,
following its procurement policy and guidelines, will give back any unspent funds to DFID, who
then could either choose to enter into a direct agreement with the implementing partner, or
reimburse the suppliers for any costs they have already incurred or that will be necessarily
incurred (and the supplier can’t be expected to avoid or recover).
D. Monitoring and Reporting on Expenditure
USAID will monitor expenditure. MST will submit an annual audited account. It should be noted
that this will not correspond with DFID’s annual programme evaluation as it will be done on
MST’s financial year end which is calendar year. As USAID, CIDA and DFID are all funding the
MST family planning outreach programme in Tanzania, regular meetings will be held with all
partners through a joint steering committee. The reporting will be a single process, with updates
as required.
MSI will present an annual audit as part of being the prime partner on the SIFPO award. As a
recipient of other donor funding, MSI conducts an external annual audit of all programmes and
makes that available to donor partners.
Whilst primary accountability for DFID funds will reside with USAID through the agreed MOU,
MST will be accountable to USAID. The financial management and accounting systems and
procedures of MST are robust, especially since the overhaul of their financial auditing system
and staffing in 2008. USAID will ensure audit and pre-authorisation work so that MST continues
with unqualified audits in future.
Management Case
A. Oversight
The primary stakeholders are USAID and the private sector service delivery sector (i.e. MST),
the Government of Tanzania, poor women and also other donors such as CIDA. A technical
steering committee made up of the key donors to the MST family planning outreach programme
is responsible for overall quality control and managerial and technical oversight of the
programme. It will consist of senior representatives of DFID, USAID, CIDA, and MST and will be
chaired by USAID.
USAID will have general oversight of MST and the USAID Family Planning Adviser will
supervise MST. This will happen under the auspices of the central agreement, SIFPO-MSI
Project. The Family Planning Advisor at USAID Tanzania will serve as the local Activity
Manager (AM) for the award in Tanzania. Specific certification requirements are outlined in
USAID’s policies, Locally, the AM will:







oversee the technical activities on the ground;
develop and monitors the statement of work;;
is the Mission point of contact for visitors;
is the Partner point of contact (responding to submitted reports);
is responsible for writing up minutes for quarterly meetings and placing them on file;
is responsible for site visits and submitting reports; and
is responsible for tracking finances.
When the agreement moves to a local one, the responsibilities for management will also transfer
to the USAID Tanzania office and the AM will work to ensure that USAID exercises prudent
management over funds. Management arrangements are covered by USAID’s Automated
Directives System – which is available online at http://www.usaid.gov/policy/ads/300/ or from
DFID Tanzania. The ADS also describes the procedures, including a pre award survey necesary
for moving to a new agreement. The survey team examines the applicant’s systems to
determine whether the prospective recipient has the necessary organization, experience,
accounting and operational controls, and technical skills — or the ability to obtain them — in
order to achieve the objectives of the programme.
USAID’s Family Planning Strategy and how this programme fits.
The USAID Health and Population Office has updated its strategic vision under the BEST
programme. USAID’s Family Planning priorities include (in order of priority):
o improve contraceptive security and advocate for supportive government policies
including sufficient financing and budget line items (continued and expanding) under
the NFP CIP and fund new partnerships with private and faith- based/nongovernmental sector for commodities;
o increase access to a broad method mix (provide a regular supply of a complete range
of methods) through scale-up of outreach services under a coordinated ‘Catch-Up’
Campaign and through scale up of partnership with local faith based and private
sector partners (OUTREACH FITS HERE);
o scale up youth friendly communication and services including a focus on adolescent
pregnancy;
o broaden communication efforts to include promotion of healthy timing and spacing
o
o
o
o
and address persistent myths and misconceptions;
increase availability and skills of providers to deliver long-acting and permanent
methods and expanded access of post-partum intrauterine contraceptive device
delivery;
introduce programming to access emergency contraception and scale up postabortion care services from the current 21 districts to all 131 districts;
counsel all women and couples on the range of FP methods when accessing MCH
and HIV/AIDS services; and
initiate training and task shifting of minilaparotomy under local anesthesia to clinical
0fficers, and continued outreach services.
B. Management
Management structure within DFID: This programme will be managed by a DFID Adviser from
the MDG team, with the support of Deputy Programme Manager, based in Tanzania. She will
meet at least quarterly with the Programme Director of MST and the AM/AOTAR in USAID
Tanzania.
Quarterly or other reports on the family planning outreach programme will be shared with DFID.
Quarterly progress and financial reports will be produced as well as annual reviews. Regular
monitoring will be conducted and reports shared with DFID at least on a semi-annual basis and
a mid-term evaluation will be conducted at Year 2 of the programme as well as the final internal
evaluation. Any revision of the Key Performance Indicators will be done as part of the annual
review process and this will be linked and jointly conducted, if possible, with the other funders to
the family planning outreach programme (CIDA and USAID).
Financial reports, compliance and administrative functions will be managed by the USAID AM
and shared with the DFID adviser.
Management by USAID. Management by USAID will be as described above as mandated by
USAID regulations and policies. Additional information is provided below for financial
management, for family planning compliance, and for site visit and environmental compliance.
The Mission’s Site Visit Checklist, the Environmental Impact Evaluation and mitigation plan, The
Family Planning Compliance checklists for the Mission have all been provided to DFID for
documentation in detail of oversight procedures.
Financial oversight includes:
 Ensuring that all funding actions comply with USAID's forward funding guidelines (ADS
602, Forward Funding of Program Funds).
Reviewing the recipient's request for payments or financial reports and providing or
denying administrative approval if required by the procedures in ADS Chapter 630,
Payables Management.
Monitoring the financial status of the award on a regular basis to ensure that the level of
funding is the minimum necessary.
Developing accrued expenditures on a quarterly basis in accordance with ADS 631,
Accrued Expenditures, and instructions from M/FM or the mission controller. Reviewing
and documenting the review (for example, signing and dating a copy of the financial
report) of financial status reports for U.S. organizations with letters of credit and periodic
advance payments to monitor financial progress.
Initiating a request to the agreement officer to deobligate funds if at any point it is
apparent that the amount of available funds is more than will be necessary to complete
the cooperative agreement activities (see ADS 621 Obligations and Internal Mandatory
Reference “Deobligation Guidebook”).
Monitoring recipient compliance with the requirement for them to obtain any host country
tax exemptions for which they are eligible; and
Upon completion of the work under the award, reviewing any unliquidated obligation
balance in the award and working with the agreement officer to deobligate excess funds
before beginning close-out actions.
Site visits are an important part of effective award management because they usually allow a
more effective review of the project. When USAID makes a site visit, the AO or AOTR must
write a brief report highlighting his or her findings and put a copy in the official award file.
Family planning compliance is an area of great importance to the USG and principles of
voluntarism and informed choice guide USAID's family planning programme. These principles
are articulated in programme guidelines and a number of legislative and policy requirements
that govern the use of U.S. family planning assistance. USAID works with partners to ensure
compliance with the family planning requirements in their programmes. This is mandatory and
must be well documented and reviewed on an on-going and stringent basis.
Management within MST: The national outreach programme is within and is managed through
MST’s national management structure. The roles and responsibilities of staff involved in
programme implementation are outlined here. At Executive Management Team level, all roles
have oversight of the national programme as a whole.

Country Director – provides overall administrative, financial and programmatic leadership
and oversight; ensures cross-department collaboration and coordination in support of the
programme objectives; provides high level representation with national and international
stakeholders.

Director of Projects – line authority for the project management team as well as other senior
management staff; represents the programme to stakeholders and other national forums;
ensures compliance with requirements of individual donors, oversees programme
implementation and coordinates activities with the core business operations team.

Director of Business Operations – ensures that the service quality of all outreach teams is
aligned with MST/MSI standards, mission, and values; line authority for clinical and outreach
activities; works closely with the Director of Projects to ensure compliance in the
implementation of the clinical services. The Director of Projects and Director of Business
Operations will jointly lead the national programme, ensuring regular internal meetings and
integrated coordination as well as leading the reporting to the National Programme Steering
Committee.

Director of Finance – oversees all MST finance and procurement systems and ensures
compliance with MSI and donor requirements. Provides line management to Finance and
Procurement team.
The Heads of Department will ensure that outreach activities that fall under their departmental
function are fully integrated into a single national outreach programme.

National Outreach Manager – line manages Zonal Outreach Coordinators and Outreach
Team Leaders; coordinates all outreach activities with the Business Operations Director;
responsible for ensuring outreach teams comply with MSI operational guidelines; takes the
lead in liaising with Zonal and Regional MoHSW representatives. Will be responsible for the
annual national outreach plan.

Head of Communications – coordinates all BCC activities, including community sensitisation
events, centre demand generation (including work with Community Based Mobilisers
(CBMs)) and the development, design, production and distribution of IEC materials.

Head of M&E and Research – provides overall guidance on M&E including alignment with
MSI national standards and measures; has technical oversight for all research and
evaluation work undertaken as part of the programme. Is responsible for ensuring collection
of high quality operational data by outreach teams.

Project Manager (3) – DFID’s outreach programme will be assigned a project manager
responsible for budget control, activity planning and oversight as well as project monitoring
and evaluation; primary liaison with DFID and project stakeholders; responsible for project
reporting to DFID and other DPs as well as the organisation and delivery of other project
reports including surveys and evaluations.
In the field, the following team member will have day-to-day management responsibility for
delivery of outreach services:

Outreach Team Leader (22) - in addition to service provision, supervises outreach team
members and activities on the ground; ensures compliance with MSI/MST guidelines;
responsible for daily collection of operational data; coordinates with facility in-charges at
outreach sites.
C. Conditionality
Not applicable, as the programme does not involve financial aid to government.
D. Monitoring and Evaluation
Monitoring.
The MST monitoring information system is robust and well established within MST. MST’s MIS
can generate reliable service statistics. In addition, exit interviews will be conducted on a subset
of clients. Key data sources are as per table 14 below.
An M&E plan is currently in place to which MST is accountable to USAID. MST will submit
quarterly summary reports to USAID and DFID documenting progress against the annual
workplan, monitoring plan and logframe. The programme will be reviewed internally on an
annual basis through DFID systems. MST will provide an annual report that will provide a
narrative of achievements documented with relevant case studies as agreed. MST Outreach
teams submit monthly reports detailing their service delivery and any other activities (e.g.
demand generation, capacity building, etc.). The Outreach Coordinators do frequent field
supervisions, with other supportive supervisions from the Operations and Projects team. Clinical
quality is the responsibility of the Medical Development Team (part of Operations) and there are
annual Quality Technical Assessments involving MSI MDT from London, as part of their overall
programme in Tanzania.
Table 15: Key Monitoring Data Sources
Data collection
approach
Tanzania
Demographic
and
Health
Survey
Method
Frequency
Sampling
Content
Responsible
Household
survey
Every
years
Nationally
(and
regionally)
representative
sample of approx
10,000
households,
clustered
in
approx
500
sample
points
across Tanzania
Mainland
and
Zanzibar.
fertility
levels
and
preferences; family planning
use; reproductive, child and
maternal health; nutritional
status of young children and
women; childhood mortality
levels; ownership and use of
mosquito
bednets;
prevalence and treatment of
childhood illness; fistula,
domestic
violence,
knowledge and behaviour
regarding HIV/AIDS; and
maternal mortality
National
Bureau
Statistics
MST
routine
service delivery
data
Routine
data
(registers)
Daily
records,
collated
monthly
All clients
sex; age; first-time FP/MST
clients; source of referral; FP
method; VCT
Training reports
Activity
report
Ad hoc
N/A
participants;
objectives;
content; facilitators; training
methods; evaluation; preand post-training test scores
MST
operations
(in the field)
and MIS (at
support
office) teams
Training
facilitator/s
5
of
Exit interview
Facilitybased
client
survey
Annual
KAPB survey
Communit
y-based
household
survey
Every
years
Quality technical
assessment
Facilitybased
audit
Annual
2
30+% of teams
randomly
selected;
all
consenting clients
interviewed
on
survey days
Clustered
(representative
sample size to be
calculated
dependent
on
survey design)
service
utilisation;
client
profile (including modelling to
identify poverty status of
woman); client satisfaction
MST
research
team
knowledge,
attitudes,
behaviours and practices
relating
to
reproductive
health and family planning
MST
research
team
Up to 3 teams
purposively
selected; rotated
annually
client
focus;
infection
prevention;
emergency
preparedness;
clinical
technical and counselling
quality
MST
and
MSI medical
development
teams
USAID Tanzania has formalized monitoring and evaluation plans as part of their approach for
Managing for Results. The Mission rigorously and systematically assesses progress towards
desired results using a results framework and performance management plan (PMP). USAID
also requires portfolio reviews for investments and partnerships, field visits, data quality
assessments, evaluations and quarterly and annual reports. All partners would have a PMP,
which measures output and outcome levels and are gender sensitive. The central agreement’s
PMP is on file at headquarters and with a new local award, the PMP will be developed and
managed from USAID Tanzania. USAID/Tanzania’s Mission Order for Performance Monitoring
and Evaluation Framework has been made available to DFID.
Evaluation and lesson learning.
MST is currently beginning Family Planning outreach with three different donors and is looking
to test some different outreach models. There is currently one key evaluation question and MSI
is considering other evaluation questions in consultation with all the donors funding outreach:

Do community-based mobilisers represent good value for money in increasing demand for
family planning?
Are Community-based mobilisers in rural areas good VFM?
As part of its commitment to cost-effectiveness, MST wants to ensure that its standard package
of demand generation activities offers best value for money. MST currently has conflicting
evidence on the effectiveness of Community-based Mobilisers (CBMs). On the one hand, MST’s
own analysis of referral methods show that word-of-mouth via a known community member is
the most common method of referral for MST clients. On the other hand, an initial investment in
CBMs in 2010 had no major impact on service delivery use. It is costly to train, motivate and
coordinate CBMs but such an investment could be justified if it resulted in much greater demand
for FP services.
There is a growing national interest in the use of CBMs. The national CBM network, coordinated
by MoHSW, has collapsed through lack of funding but following a recent study, the Department
for Reproductive Health has stated an interest in relaunching the national network. Many NGOs
in the health sector have developed their own CBM networks in recent years. A CBM Technical
Working Group, of which MST is a member, has been formed to coordinate national efforts.
Within this national context, MST’s analysis will have national relevance and be able to inform
the model of relaunch chosen by the MoHSW.
The funding of outreach by three donors will provide a control opportunity. Outreach teams
funded by CIDA and AusAID (in 11 regions) will have only what the national programme
provides: mass communication approaches e.g. local radio, towncriers, and community infotainment events to generate demand for FP services. The DFID sites (in 12 regions) will have
the national programme mass communication approach as well as a network of trained
community based mobilisers (CBMs) to generate demand.
Rather than develop its own network of CBMs, MST will work with other partners that have
CBMs focusing on services other than family planning. A baseline mapping exercise will be
carried out to identify existing CBM networks in the regions where DFID-funded teams are
working and MST will offer FP-specific training to existing CBMs.
How the evaluation will be used:
An evaluation of this approach would yield important information for Tanzania and, perhaps,
other African countries. Results from the question will help to determine whether CommunityBased Mobilisers are worth further investment in Tanzania. As these CBMs can be used for
more than family planning information, the results for this line of enquiry could inform more than
the family planning community.
E. Risk Assessment
The key risks for the family planning outreach programme are:
Table 16: Assessment of risks
Risk Description
Impact
on
Success
(L,M,H)
H
Probability
of
Occurring
(L,M,H)
L
Mitigating Actions
Monitoring
Mechanism
MSI headquarters responded quickly
to replace the head of the programme
and other implicated staff. While there
were no prosecutions, the organisation
went through a careful review of its
procedures and a new head came in
2008. Subsequent audits have been
unqualified CIDA assisted MST in this
reorganisation and is content that MST
is now a reliable organisation and is
continuing their funding.
USAID is also doing robust audit and
pre-authorisation work to ensure that
MST remains with unqualified audits in
the future.
USAID will be
monitoring
MST.
MST
systems
in
place including
monthly
accounting
reports which
are
reviewed
by at country
level and then
sent to MSI HQ
for review. As
well
as
an
annual audit by
a local audit
firm, MST is
audited
annually
by
MSI’s regional
audit team and
are
part
of
MSI’s
annual
global audit.
USAID
will
oversee
and
Director of MST
Business
Operations
responsible for
monitoring
USAID
will
oversee
and
Director of MST
Projects
responsible for
monitoring
USAID
will
oversee
and
Director of MST
Operations will
monitor
Risk
1
Fiduciary risk:
irregularities
identified in past
audit (in 2007)
could be repeated
in the future and
affect
implementation
Risk
2
Implementation
risks:
MOHSW
change
guidelines
for
outreach
service
provision
L
M
USAID and MST are active members
of government working and technical
groups and committees
Risk
3
Inadequate support
from GOT health
authorities
L-M
M
Develop MOUs with health authorities
for outreach services; undertake
consultative meetings with health
authorities at all levels to galvanize
support and ownership
Risk
4
Irregular
or
inadequate
commodity supply
M-H
M
Risk
5
Clinical
incident
results in injury or
death of client
L
M
Member of contraceptive security
working group; emergency purchase
of FP commodities; FP commodities
buffer supplies in stock; clients can
use alternatives (but this is not
optimal)
Clinical standards in place; regular
QTA and monitoring visits; Medical
Assessment Team review takes place
quarterly
Risk
Political risks:
M
M
DFID will consider the option of
USAID
will
oversee
and
Director of MST
Operations will
monitor
DFID
will
6
Risk
7
US
Government
political
change
makes funding of
family
planning
impossible
Change of provider
by USAID during
course of support
L
M
directly funding MST during the course
of the four year period.
monitor policy
changes within
USAID
DFID will consider the option of
directly funding MST or to remain
funding through MSI
DFID will keep
in close contact
with USAID
F. Results and Benefits Management
Milestones against indicators are set out in the programme logframe in Annex 1.
The economic appraisal quantifies expected results in the increase of CYPs over the course of
the programme.
This programme will improve the women’s access to reproductive health services and it is
expected that 2.7 million CYPs will be achieved, leading to the aversion of 1,528,000
pregnancies, approximately 134,000 abortions (many of which would have been unsafe), and
5116 maternal deaths. The DALYs saved amount to 659,000.
ANNEX 1: Climate & Environment Assurance Note
Intervention Details
Title
Family Planning
Outreach in Tanzania
Home Department
DFID Tanzania
Budget
£8,000,000
Responsible Officers
Title
Project Owner
Climate Change and
Environment Advisor
Name
Tanya Zebroff
Magdalena Banasiak
Department
DFID Tanzania
DFID Tanzania
Category
B - the intervention has
climate and
environmental
relevance. It has
potential for positive
impact.
Sensitivity Analysis
The outcomes are expected to
tackle climate change and
reduce vulnerability by reducing
population growth. There will be
some moderate vehicle use in
service delivery.
(Climate and
Environment checklist,
outlined in Annex B of
the how to note, has
been completed for this
category B intervention
and any additional
climate and environment
opportunities and risks
have been incorporated)
The impact of the project on
climate change and
environment will be positive.
Climate & Environment
Measures agreed
No
Climate & Environment
Measures in log-frame
No
Appraisal
Success Criteria
Impact of CC on the
intervention
None
Impact of
Environment on the
intervention
None
Impact of the
intervention on
climate change
- reduces CO2
emissions
- increases CO2
emissions
Impact of the
intervention on
Environment
- Opportunity to achieve
MDG7
Management
Risks and opportunities
defined
Yes, the opportunities
are integral to the
intervention.
SIGNED OFF BY:
Magdalena Banasiak, DFID Tanzania Climate and Environment Adviser
DATE: 31 May, 2011
ANNEX2: CLIMATE AND ENVIRONMENT CHECK LISTS
Impact of Climate Change on Intervention
Positive
Opportunity for economic growth through development and
dissemination of technologies
Opportunity for job creation
Increased revenue generating opportunities
Opportunity for new agriculture and livelihood options
Negative
In a climate sensitive area?
In an area subject to frequent climatic shocks / variability
(floods/droughts/temperature)
In an area where climate change could lead to conflict
Community has poor capacity to deal with or adapt to climate
change or shocks
Programme dependant on specific climatic condition
(agriculture, aquaculture)
Climate sensitive policies / laws / regulations result in social /
development impacts
Y/N
Impact of Environment on Intervention
Positive
Dependant on environment / natural resources for success
Good governance of natural resources would improve likelihood
of success
Improved revenue generating opportunities
Improved environmental management could increase the
number of benefits from intervention
Environmental management offers peace-building opportunities
Y/N
Detail
Measure
Detail
Measure
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Negative
Dependant on environment / natural resources for success
In an area subject to environmental degradation?
In an area subject to frequent environmental shocks
Community lack capacity to deal with environmental
degradation or shocks
Community dependant on natural resources, which will be
affected by the intervention for their livelihoods
Property / land-rights are not well defined / governed
Environmental policies/laws/regulations result in social /
development impacts
In an area where natural resources are a potential source of
conflict
N
N
N
N
N
N
N
N
Impact of Intervention on Climate Change
Positive
Increases mitigation capacity
Reduces Co2 emissions
Y/N
Detail
Measure
N
Y
Reduces population growth
Increased contraceptive
prevalence rate will result in
eventual population stablisation
(see table 5)
Provides an opportunity to achieve low-carbon development?
Negative
Increases CO2 emissions
N
Some vehicle use for
outreach (minor)
Unnecessary
Decreases mitigation capacity
Does not support low-carbon development
N
N
Impact of Intervention on Environment
Positive
Depends on natural resource use for its success
Y/N
Detail
Measure
Y
N
Opportunity for improved environmental management
Opportunity to achieve MDG7
N
Y
Opportunity for co-financing of environmental management
Negative
Depends on natural resource use for success
In an environmentally sensitive area
Causes direct and significant impact on environment
Risks causing significant negative impact on environment
N
Impact of Intervention on vulnerable Communities
Positive
Opportunity to reduce the vulnerability of communities to
climate change?
Y/N
Detail
Measures
Y
Fewer people mean that
communities are less
vulnerable
Increased contraceptive
prevalence rate will result in
eventual population stablisation
Opportunity to build the capacity of communities to adapt to
climate change?
Opportunity to build the resilience of communities to climate
change?
Opportunity to mitigate climate change impacts for a
community?
Negative
Reduces adaptive capacity of a community to climate change
Reduces resilience of a community to climate change
Increases vulnerability of communities to climate change?
Reduces capacity of a community to mitigate climate change
N
As above.
As above.
Reducing numbers of people Increased contraceptive
means MDG7 is more
prevalence rate will result in
attainable. Also reducing
eventual population stablisation
pressure on natural resources
such as forest, land and water
N
N
N
N
N
Y
N
N
N
N
Annex 3: Project logframe
PROJECT NAME
IMPACT
Family Planning Outreach Programme In Tanzania
To contribute to
achieving MDG5 and
reduce maternal deaths
Impact Indicator 1
Maternal mortality ratio
(national)
Baseline
2009/10
Planned
Milestone
1 (end yr
1)
Milestone 2
(end yr 2)
Milestone
3 (end yr
3)
Target (2015)
265/100,000liv
454/100,000
Achieved
Source
TDHS 2010 (baseline) and 2015 (target)
Impact Indicator 2
Contraceptive
Prevalence Rate
(modern methods;
married women: national
and disaggregated by
region and age)
Baseline
2009/10
Planned
Milestone
1 (end yr
1)
Milestone 2
(end yr 2)
Milestone
3 (end yr
3)
27.40%
Target (2015)
34.80%
Achieved
Source
TDHS 2010 (baseline) and 2015 (target)
OUTCOME
To increase poor
women's use of family
planning through rural
outreach
Outcome Indicator 1
Couple years of
protection delivered by
project
Baseline
Planned
0
Milestone
1 (end yr
1)
402,000
CYPs
Milestone 2
(end yr 2)
1.16 million
CYPs
Milestone
3 (end yr
3)
1.91 million
CYPs
Target (end of
proj)
Assumptions
2.67 million
CYPs
There are no major natural
disasters, conflict or
political instability;
Access and quality of other
maternal health services
(ANC, EMOC, etc)
continue to improve
Milestone
3 (end yr
3)
Target (end of
proj)
Achieved
Source
Routine service delivery data from MST HMIS
Outcome Indicator 2
Baseline
Milestone
1 (end yr
1)
Milestone 2
(end yr 2)
Project's contribution to
national CPR
Planned
0
0.20%
0.40%
0.65%
0.90%
Achieved
Source
INPUTS (£)
Routine service delivery data from MST HMIS; calculation using MSI
REACH calculator
Govt (£)
Other (£)
Total (£)
DFID SHARE (%)
DFID (£)
INPUTS (HR)
8,000,000
DFID (FTEs)
10%
OUTPUT 1
ACCESS: Increased
access to quality family
planning/VCT services
Output Indicator 1.1
Number of FP/VCT
clients served by project
Baseline
Planned
0
Milestone
1 (end yr
1)
68,000
clients
Milestone 2
(end yr 2)
196000
clients
Milestone
3 (end yr
3)
324000
clients
Target (end of
proj)
Assumption
453000 clients
Milestone
3 (end yr
3)
600
Target (end of
proj)
Supplies of FP and VCT
commodities are
consistent and high
quality;
Adequate support from
GOT health authorities
No major changes in MOH
guidelines for outreach
service provision
Milestone
3 (end yr
3)
80%
Target (end of
proj)
Achieved
Source
Routine service delivery data from MST HMIS
Output Indicator 1.2
Number of service
providers (MST and
MOH) trained in quality of
care according to MSI
partnership global
standards
IMPACT WEIGHTING
(%)
Baseline
Planned
0
Milestone
1 (end yr
1)
200
Milestone 2
(end yr 2)
400
800
Achieved
Source
Training reports
Output Indicator 1.3
Baseline
40%
Percentage of project
Planned
N/A
Milestone
1 (end yr
1)
60%
Milestone 2
(end yr 2)
70%
90%
clients who report they
would refer MST services
to a friend among the
target group
INPUTS (£)
Achieved
Source
RISK RATING
Exit interviews with clients
DFID (£)
Low-medium
Govt (£)
Other (£)
Total (£)
DFID SHARE (%)
Milestone 2
(end yr 2)
Milestone
3 (end yr
3)
30%
Target (end of
proj)
Milestone
3 (end yr
3)
22.50%
Target (end of
proj)
Milestone
3 (end yr
3)
12.50%
Target (end of
proj)
INPUTS (HR)
DFID (FTEs)
OUTPUT 2
EQUITY: Increased
equal opportunity to
obtain FP/VCT services
Output Indicator 2.1
Proportion of project
clients who live below
$1.25 per day
Baseline
Planned
N/A
Milestone
1 (end yr
1)
20%
25%
37.60%
Assumptions
Current trends in economic
development continue;
Achieved
Source
Exit interview assessments
Output Indicator 2.2
Proportion of project
clients who are aged
below 25 years
Baseline
Planned
N/A
Milestone
1 (end yr
1)
15%
Milestone 2
(end yr 2)
20%
25%
Achieved
Source
IMPACT WEIGHTING
(%)
Routine service delivery data from MST HMIS
Output Indicator 2.3
Baseline
20%
Proportion of project
clients who are male
Planned
N/A
Milestone
1 (end yr
1)
7.5%
Milestone 2
(end yr 2)
10%
15%
Achieved
Source
RISK RATING
INPUTS (£)
Routine service delivery data from MST HMIS
DFID (£)
Govt (£)
Low
Other (£)
Total (£)
DFID SHARE (%)
Milestone 2
(end yr 2)
Milestone
3 (end yr
3)
Target (end of
proj)
Assumptions
30% increase
over baseline
Socio-cultural conditions
support the conversion of
changes in knowledge and
attitudes into changed
practice in relation to
FP/VCT
INPUTS (HR)
DFID (FTEs)
OUTPUT 3
BEHAVIOUR:
Increased knowledge
of, changed attitudes
towards, and positive
behaviours to FP/VCT
Output Indicator 3.1
% of target group who
can cite at least 2
benefits of birth spacing
Baseline
Planned
Milestone
1 (end yr
1)
TBD at
baseline
15%
increase
over
baseline
Achieved
Source
KAPB survey included in project baseline, mid-term and end-line evaluations
Output Indicator 3.2
% of men who oppose
the use of FP by their
wife
Baseline
Planned
Milestone
1 (end yr
1)
TBD at
baseline
Milestone 2
(end yr 2)
Milestone
3 (end yr
3)
7.5%
decrease
against
baseline
Target (end of
proj)
15% decrease
against
baseline
Achieved
Source
IMPACT WEIGHTING
(%)
KAPB survey included in project baseline, mid-term and end-line evaluations
Output Indicator 3.3
Baseline
30%
Proportion of clients who
are first time users of FP
Planned
N/A
Milestone
1 (end yr
1)
17.50%
Milestone 2
(end yr 2)
20%
Milestone
3 (end yr
3)
22.50%
25%
Achieved
Source
INPUTS (£)
Target (end of
proj)
Routine service delivery data from MST HMIS; exit interviews
RISK RATING
Medium
DFID (£)
Govt (£)
Other (£)
Total (£)
DFID SHARE (%)
Milestone 2
(end yr 2)
Milestone
3 (end yr
3)
£3.00
Target (end of
proj)
Assumptions
£2.94
No significant economic
shocks, run-away inflation
or exchange rate crises
that lead to unexpected
increases in costs
INPUTS (HR)
DFID (FTEs)
OUTPUT 4
EFFICIENCY:
Improved costeffectiveness of
delivery of quality
FP/VCT services
Output Indicator 4.1
Cost per CYP
(cumulative)
Baseline
Planned
£3.43
Milestone
1 (end yr
1)
£3.43
£3.29
Achieved
Source
MST SUN financial reporting system; Routine service delivery data from MST HMIS
Output Indicator 4.2
Cost per service
(cumulative)
Baseline
Planned
£21.79
Milestone
1 (end yr
1)
£21.79
Milestone 2
(end yr 2)
£19.45
Milestone
3 (end yr
3)
£17.68
Target (end of
proj)
£17.33
Achieved
Source
IMPACT WEIGHTING
(%)
MST SUN financial reporting system; Routine service delivery data from MST HMIS
Output Indicator 4.3
Baseline
10%
Average Quality
Planned
technical assessment
Achieved
74%
Milestone
1 (end yr
1)
80%
Milestone 2
(end yr 2)
85%
Milestone
3 (end yr
3)
90%
Target (end of
proj)
90%
MST remains a wellmanaged NGO with strong
financial policies
RISK RATING
(QTA) score for project
teams
Source
INPUTS (£)
MSI/MST QTA report
DFID (£)
INPUTS (HR)
DFID (FTEs)
Govt (£)
Low-medium
Other (£)
Total (£)
DFID SHARE (%)
i
TDHS (2010).
ibid
iii ibid
iv Tanzanian Demographic and Health Survey (TDHS), 2010.
v ibid
vi Campbell, O, and W Graham (2006) Strategies for reducing maternal mortality: getting on
with what works. Lancet 368: 1284-99.
vii Cleland, J, S Bernstein, A Ezeh, A Glasier and J Innis. (2006) Family Panning: The
unfinished agenda. Lancet 368: 1810-1820.
viii Rutstein, S (2005) Effects of preceding birth intervals on neonatal, infant and under-five
years mortality and nutritional status in developing countries: evidence from the demographic
and health surveys. International Journal of Obstetrics and Gynaecology 89 (supplement 1):
S7-S24.
ix TDHS, 2010.
x TDHS (2010).
xi DFID Evidence Paper (2010) Improving Reproductive, maternal and Newborn Health:
Reducing Unintended Pregnancies: Evidence Overview. A Working Paper version 1.0.
xii TDHS (2010).
xiii ibid
xiv Ibid
xv Solo, J (2008). Family planning in Rwanda: How a taboo became priority number one.
North Carolina: IntraHealth. Reference In Speidel et al (2008) Making the case for US
international family planning assistance.
xvi USAID (2010) Community Based Family Planning. Technical Update No 8: Mobile
Outreach Services Delivery.
xvii World Health Organisation (2007) Maternal Mortality in 2005. Estimates developed by
WHO, UNICEPF, UNFPA and the World Bank.
xviii Cleland, J (2006) Op cited.
xix Population Reference Bureau (2009) Family planning Saves Lives.
xx The National Road Map Strategic Plan to Accelerate Reduction of Maternal,
Newborn and Child Deaths in Tanzania 2008 – 2015 (2008).
xxi Cleland (2006) Op cited.
xxii Tsui, A (1992) Service proximity as a determinant of contraceptive behaviour: evidence
from cross-national studies of survey data. In Phillips, J and J Ross, Editors. Family planning
programmes and fertility. Oxford: Clarendon Press: 222-258.
xxiii Cleland (2006) Op cited.
xxiv Tsui, A, McDonald-Mosley, and E Burke (2010) Family planning and the Burden of
Unintended Pregnancies. Epidemiology Review April 32(1): 152-74.
xxv Singh, s et al (2009) Adding it up: the benefits of investing in sexual and reproductive
healthcare. UNFPA: Guttmacher Institute.
xxvi Ibid.
xxvii Ibid
xxviii Contraceptive Method Mix (1994) Geneva: World Health Organisation.
xxix Cleland et al (2006).
xxx Janowitz B et al (1999) Issues in the financing of family planning services in sub Saharan
Africa. Research Triangle Institute: Family Health International.
xxxi Langer, A et al (2000) Health sector reform and reproductive health in Latin America and
the Caribbean: strengthening the links. Bulletin of the WHO 74: 667-676.
xxxii DFID Evidence paper (2010) Improving Reproductive, Maternal and Newborn Health:
Reducing Unintended Pregnancies: Evidence Overview.
xxxiii Guttmacher Institute (2009) Adding it Up. New York: Guttmacher Institute
xxxiv Assessment of Linkages Between Population Dynamics and Environmental
Change in Tanzania, Ndalahwa F. Madulu, Institute of Resource Assessment, University of
Dar es Salaam, Tanzania AND Examining the inter-linkages of population growth, poverty, and
natural resources in Tanzania, Ayoub Ayoub, University of Nevada
xxxv 2010 World Population Data Sheet. Washington, DC: Population Reference Bureau.
ii
xxxvi
The Economics of Climate Change in the United Republic of Tanzania. Global Climate
Adaptation Partnership. Final Draft 2010
xxxvii
Wheeler D and Hammer D, The Economics of Population Policy For Carbon Emissions Reduction in
Developing Countries. Centre for Global Development Working Paper 22.9 November 2010
xxxviii
http://www.owen.org/blog/4105 last accessed 17th November 2010
xxxix MOHSW correspondence with USAID, May 2010
xl USAID (2010) Community Based Family Planning. Technical Update Number 8: Mobile
Outreach Service Delivery.
xli Discussions with USAID and PSI Tanzania.
xlii http://www.engenderhealth.org/our-work/major-projects/acquire-tanzania.php
xliii USAID (2010) Community Based Family Planning. Technical Update Number 8: Mobile
Outreach Service Delivery.
xliv Contraceptive Method Mix (1994) Geneva: World Health Organisation.
xlv Pritchett, L (1994) Desired fertility and the impact of population policies. Population
Development Review 20: 1-55.
xlvi Sinha, N. (2003) Fertility, child work and schooling consequences of family planning
programs : evidence from an experiment in rural Bangladesh. Gender Discussion Paper.
Available at: www.econ.yale.edu/growth_pdf/cdp867.pdf.
xlvii USAID (2010) Community-based Family Planning. Technical Update No. 8: Mobile
Outreach Service Delivery.
xlviii DFID (2010) Improving Reproductive, Maternal and Newborn health: Reducing
Unintended Pregnancies: Evidence Overview. A Working Paper.
xlix Puri, M et al (2007) Examining out-of-pocket expenditures on reproductive and sexual
health among the urban population of Nepal. Population Review 47: 50-66.
l Sedgh, G et al (2007) Women with an unmet need for contraception in developing countries
and their reasons for not using a method. Occasional Report. New York: Guttmacher
Institute.
li Hornik, R and E McAnany (2001) Mass media and fertility change in Casterline J, editor.
Diffusion processes and fertility transition: selected perspectives. Committee on Population,
National Research Council. Washington, DC: National Academy Press.
lii Levine R, Langer A, Birdsall N. et al. 2006 Contraception. Chapter 57. In: Jamison, D.T.
et.al. Disease Control Priorities in Developing Countries. 2nd Edition. The World Bank and
Oxford University Press (2006)
liii DFID Tanzania provided £6.5 Million, using the same funding mechanism of an MOU
through USAID, to fill the supply chain gap on contraceptive commodities (implants and
injectables). The CYPs that have been calculated for this support will be included in the
logframe for this programme and will be jointly reported on, to avoid any double-counting.
Further detail on how the double counting of CYPs is being addressed is included in the M&E
section of the Business Case.
liv This is the target from GoT and we consider it to be highly ambitious, but prefer to use GoT
targets where available.