Type of Review: Project Completion Review
Project Title: Ipas Regional Programme to Increase Women’s Access to
Reproductive Health Services in Sub-Saharan Africa
Date started: October 2007
Date review undertaken: February 2013
Introduction and Context
What support did the UK provide?
DFID funded Ipas to deliver a Regional Programme to increase women's access to reproductive health
services in sub-Saharan Africa. The programme worked to strengthen regional organisations and
networks to advocate for safe abortion care1, produce advocacy and policy relevant research, and
have a positive impact at country and regional levels on policy change and service delivery capacity for
safe abortion care.
This programme was originally approved for £6.5 million over five years. Three supplements to
enable enhanced work under the programme brought total DFID support to approximately £12.9
million2.
What were the expected results?
The expected outcome of this programme is “to improve women's access to quality comprehensive
abortion care (CAC) in sub-Saharan Africa.”
The impact this programme contributes to is to “reduce maternal mortality and morbidity due to unsafe
abortion”, and the impact indicators3 were:
 Annual deaths due to unsafe abortion in Africa to fall from 36,000 (2003) to 23,000 (2012)
 Number of African countries that have expanded legal indications for abortion (during the
life of the programme): 4 (by end-March 2013)
What was the context in which UK support was provided?
Unsafe abortion accounts for a significant proportion of maternal deaths: 13% of maternal deaths
worldwide according to World Health Organisation estimates. Between 2003 and 2008, the annual
number of induced abortions in Africa rose from 5.6 million to 6.4 million. In the region approximately
14% of maternal deaths (29,000) were due to unsafe abortion in 20084 and 1.7 million women are
1
Safe abortion care represents a package of services that includes safe elective abortion, treatment of complications of unsafe abortion, and
postabortion contraception and other reproductive health care
2 The original end date for the grant was 30 September 2012; in early 2012 a no-cost extension was granted through 31 March 2013.
Accordingly, throughout this review, the Target and Actual dates are indicated as 2013.
3
These results are not directly attributable to Ipas or its partners
4
World Health Organization (WHO), Unsafe Abortion: Global and Regional Estimates of the Incidence of Unsafe Abortion and
Associated Mortality in 2008, sixth ed., Geneva: WHO, 2011.
1
hospitalized annually for complications5. In Sub-Saharan Africa, postabortion and safe abortion
services (where legal) are hard to access and are of poor quality.
Problems with quality and access are common to other maternal health issues – delays in
treatment, shortage of trained health workers, low access to facilities and supplies, use of unsuitable
procedures and high cost of medical care. However, the added complication of stigma and silence
makes it even more difficult for women to access safe abortion services and exacerbates the poor
treatment that women receive in health facilities. Poor and excluded women and young women are
least likely to be able to access safe services.
There is evidence to show that legal change can reduce recourse to unsafe abortion – improving
conditions for women seeking safe abortion services and post abortion care, and therefore reducing
abortion-related deaths. In South Africa, for example, the abortion law was liberalized in 1997, and the
number of women who died every year from unsafe abortions fell by 91% between 1994 and 2001. In
addition to legal reform, actions that can reduce deaths from unsafe abortion6 include:
 Improved access to a range of family planning methods
 Better access to post abortion care and improvements in Post-abortion Care (PAC) quality (e.g.
shifting from use of dilatation and curettage, D&C, to manual vacuum aspiration [MVA] and/or
misoprostol)
 Health system readiness to provide services – ensuring standards and guidelines, trained
health workers and sustainable supplies of MVA and medical abortion drugs.
The regional context has changed since the start of the programme – in part because of the
programme itself. External reviews of the programme commissioned by DFID in 2009 and 2012
identified increased regional awareness of the issues around unwanted pregnancy and unsafe
abortions, with marked shifts in some countries. Kenya adopted a new constitution in 2010 that
includes abortion-related provisions – an important change that can be expected to have regional
influence. A number of countries in the region have committed resources to safe abortion care, and
access to services is gradually increasing. There is an ongoing shift in the type of services accessed,
especially as misoprostol (used in postabortion care and for medical abortion) is increasingly available
in a number of countries; in Latin America and South Asia there is evidence for the potentially
transformative impact of the advent and increased use of medical abortion. The evidence base on
abortion has also improved, alongside improvements in African researchers’ capacity for and interest in
conducting abortion-related research. However, while restrictions on abortion have decreased in some
countries, in others the barriers to safe abortion remain or have increased through more restrictive
application of laws, lack of training for providers, and ongoing or increased validation of abortion
stigmatisation.
DFID support to this programme was provided in the context of increasing DFID support to
reproductive, maternal and newborn health (RMNH). The UK’s ‘Framework for Results’ for
improving RMNH was published in 20107. This stated that the UK would do more to remove barriers
that prevent access to quality RMNH services, and to expand the supply of quality services. This has
included increased support to family planning and work to reduce recourse to unsafe abortion,
including in the Africa region.
In July 2011 DFID published a Practice Paper on Safe and unsafe abortion. This states that, ‘we
do not promote abortion as a method of family planning and neither condone nor support any
organisation that promotes abortion as a means of family planning… Women should not face death or
disability when they decide to have an abortion. To reduce deaths to women from the complications of
unsafe abortion we support the prevention of unsafe abortion as part of broader public health efforts to
improve sexual and reproductive health. We support programmes that make safe abortion more
accessible in countries where it is permitted. We can help make the consequences of unsafe abortion
5
Singh S, Hospital admissions resulting from unsafe abortion: estimates from 13 developing countries, Lancet, 2006,
368(9550):1887– 1892.
6
Facts on abortion in Africa, Guttmacher Institute. January 2012
7
DFID Reproductive, Maternal and Newborn Health Framework For Results, Choices for Women: planned pregnancies, safe
births and healthy newborns, December 2010 www.dfid.gov.uk/Documents/.../RMNH-framework-for-results.pdf
2
more widely understood in countries where it is highly restricted. We can also consider supporting civil
society-led processes that enable legal and policy reform’8.
Ipas is a global nongovernmental organisation, founded in 1973, dedicated to ending preventable
deaths and disabilities from unsafe abortion. It has it’s headquarters in North Carolina, USA and
offices in 14 countries.
The work funded by DFID under this programme was part of Ipas’s broader efforts in the Africa
region supported by other European and foundation donors. DFID’s contribution averaged 28% of
Ipas’s total funding for the region in Ipas fiscal years 2008-2012 (not including certain headquarters
management and technical support costs).
Section A: Detailed Output Scoring
Output Description
Outputs substantially exceeded expectation
Outputs moderately exceeded expectation
Outputs met expectation
Outputs moderately did not meet expectation
Outputs substantially did not meet expectation
Scale
A++
A+
A
B
C
Outcome Description
Outcome substantially exceeded expectation
Outcome moderately exceeded expectation
Outcome met expectation
Outcome moderately did not meet expectation
Outcome substantially did not meet
expectation
Output 1: To build an enabling regional environment in sub-Saharan Africa for access to
safe abortion
Output 1 final score: A+
Performance description: Ipas worked effectively with a range of stakeholders to build a common
understanding of the health issues around unintended pregnancy and unsafe abortion and to
encourage influential institutions and networks not only to incorporate the issue of abortion into their
own agendas but also to take or promote meaningful action on the issue.
Two external reviews commissioned by DFID (2009, 2012), and reports from Ipas, document evidence
of:
 Relevant regional actors (such as the African Commission on Human and Peoples’ Rights,
ACHPR, and the African Union) demonstrating high level of ownership of and commitment to
the programme objectives.
 Improved ability to speak about unsafe abortion and access to safe services without stigma in
the region (including policy fora, media and society at large)
 Country level leaders – including health ministers, heads of state, and parliamentarians –
having been exposed to multiple and repeated messages about the importance of addressing
unsafe abortion in a range of regional fora (African Union, ECSA – East Central and Southern
Africa health community, WAHO – West African Health Organisation, ACHPR – African
Commission on Human and Peoples’ Rights, UNECA – UN Economic Commission for Africa).
 Ipas-led regional meetings or initiatives resulting in processes to improve policies and practices
8
DFID Safe and unsafe abortion Practice Paper, July 2011. http://www.dfid.gov.uk/Documents/publications1/pol-2010-
safe-unsafe-abort-dev-cntries.pdf
3

on safe abortion in a number of countries.
Effectively supporting dissemination of WHO’s new safe abortion technical and policy guidance
in the Africa region, and including ‘preventing unsafe abortion’ as a thematic emphasis in
WHO’s new Regional Agenda for Accelerating Universal Access to Sexual and Reproductive
Health.
The 2012 review recommended that Ipas adopt more methodological documentation of the outcomes
of regional work (including region-to-country influence; declarations and commitments; regional
champions; opportunities seized). Ipas reporting outlines engagement with key regional partners, and
results; it is expected that a new monitoring and evaluation system that Ipas are implementing will help
ensure this work and related outcomes are captured in a more structured way in future. Reviews and
feedback from DFID health advisers recognised consistent and concerted efforts by Ipas
representatives to attend regional meetings, to network on a continuous basis, and to organise
technical meetings for regional networks and institutions that raised awareness and understanding of
the issues at both regional and country levels.
Final results: Targets for all three indicators for this Output were achieved or exceeded.
Indicator 1: Number of African regional institutions addressing safe abortion:
2007 Baseline:
3
2013 Target:
8
2013 Actual:
8 (cumulative)
Ipas supported the following 8 regional institutions to address safe abortion: the African Union; the
African Commission on Human and Peoples’ Rights (ACHPR); United Nations Economic
Commission for Africa (UNECA); West African Health Organisation (WAHO); East Central and
Southern African Health Community (ECSA -HC); WHO-AFRO; UNFPA Africa Regional Office;
FIGO Working Group on Prevention of Unsafe Abortion. Ipas support included contributions to
meeting declarations, speeches, raising awareness among leaders, internal training and values
clarification or action planning, and reports. Inclusion of unsafe abortion in the agendas and activities
of these organisations will feed into regional accountability mechanisms. For example, Ipas obtained
official Observer status at ACHPR and responded to requests to build the capacity of commissioners
and staff to hold countries accountable to global commitments in reproductive health. The Ipas Africa
Alliance has become a key partner for the African Union in work on reproductive health and rights –
and a major recent AU workshop produced recommended actions and policy revisions for promotion of
sexual and reproductive health and rights, including access to safe abortion, in AU member countries.
Indicator 2: Number of African regional networks mobilised to advocate and act on safe
abortion.
2007 Baseline:
1
2013 Target:
8
2013 Actual:
9 (cumulative)
Ipas organised a number of regional workshops and fostered ongoing formal and informal regional
networks with lawyers, parliamentarians, regional high-level SRHR champions, obstetriciangynecologists; midwives; medical abortion advocates, journalists, women’s groups and youth leaders,
including medical students.
Ipas has linked in with regional and international meetings of the International Confederation of
Midwives (ICM) and nurse-midwives convened by ECSACON; the International Federation of
Gynaecologists and Obstetricians (FIGO), and the African Network on Medical Abortion (ANMA),
and the Federation of African Medical Students’ Associations (FAMSA), sponsoring the
attendance of key individuals from numerous countries and building support for the programme’s
objectives.
Ipas has also built capacity and supported women’s networks, including the Gender is My Agenda
Campaign (GIMAC), FEMNET (Africa Women’s Development and Communications Network),
Solidarity for African Women’s Rights (SOAWR) and the International Community of Women
4
living with HIV and AIDS (ICW), and women lawyers’ organisations: WiLSA, WiLDAF and FIDA.
Regional training workshops for journalists have also been held, and Ipas regularly participates in
other networking events, ensuring that abortion is addressed, most recently the IPPF-sponsored
Reproductive Health Advocacy Network of Africa, co-chaired in its first year by the Ipas Ghana
Country Director.
Regional workshops and related advocacy activities successfully increased participants’ understanding
of issues related to unsafe abortion, as well as their commitment to addressing them. For example a
July 2012 workshop convened twenty lawyers and reproductive health champions from ten countries,
covering human rights instruments, laws affecting abortion access, how to draft laws without barriers to
safe abortion, and working with the judiciary to protect sexual and reproductive health and rights.
Indicator 3: Number of focus countries where regional inputs have stimulated action
2007 Baseline:
4
2013 Target:
12
2013 Actual:
12 (cumulative) - plus contribution in 3 additional countries in
Francophone west Africa
The two external reviews document country action following on from regional processes in Ethiopia,
Nigeria, Zambia, Malawi and Kenya. In addition Ipas reports indicate that regional events and
capacity building over the lifetime of the programme have also stimulated or helped maintain action in:
Ghana, Uganda, Senegal, Tanzania, Mozambique, Sierra Leone and South Africa. Activities in
three other Francophone countries were also reported in 2009 (though these have been more
challenging for sustained Ipas support with available resources).
Examples of regional work stimulating country action include supporting regional workshops (Kenya in
2007 and Senegal in 2008) on WHO’s Strategic Approach to strengthening sexual and reproductive
health policies and programmes – helping lead four countries (Malawi, Senegal, Sierra Leone, Zambia)
to conduct national strategic assessments of unsafe abortion. In 2012 Ipas convened a study tour to
Ethiopia for delegations from three countries (Malawi, Mozambique, Sierra Leone) considering
reforming their abortion laws, to share Ethiopia’s experience of legal reform. Delegates have since
contributed to momentum for legal reform in each of these countries.
Impact Weighting (%): 30%
Revised since last Annual Review? No
Risk: Low
Revised since last Annual Review? No
Output 2: National strategies, policies and plans implemented to advance access to safe
abortion
Output 2 final score: A+
Performance description: Ipas’ approach for decreasing deaths from unsafe abortion relies on the
interplay between policy, advocacy and service delivery work – each of which reinforces the other.
Related work includes strategic assessments, research, development of standards and guidelines and
codes of conduct for health professionals, supporting local advocacy efforts for legal reform, service
delivery, community sensitisation and mobilisation, sensitisation and support to professional
associations, lawyers and media.
Feedback from DFID health advisers and the two external reviews validates that key stakeholders see
5
this approach as valuable at country level. For example, in Kenya Ipas supported the policy process
through the drafting of Kenya’s 2010 constitution, and subsequently contributed to development of new
evidence-based national standards and guidelines for safe abortion care (launched October 2012).
These guidelines will support health care providers, relevant authorities, and civil society in ensuring
that Kenyan women can access abortion-related care in compliance with the new expanded provisions.
Ipas has been most active in the following 12 countries under this grant, supporting local partners:
Nigeria, Ghana, Ethiopia, Zambia, Malawi, Senegal, Mozambique, Tanzania, Uganda, South
Africa, Kenya and Sierra Leone. Less extensive work has also taken place in Mali, Burkina Faso,
Benin, Sudan and Botswana over the lifetime of the project. Additional countries have been reached
through MVA distribution (and although MVA distribution is not explicitly included in the logframe, one
DFID country adviser highlighted the value of a regional programme being able to respond flexibly to
support implementation of countries’ plans, in this case to sustain provision of postabortion care).
Final results: Two targets exceeded (number of countries with legal reform or protection efforts and
financial commitments); significant progress toward the third (number of countries with abortion-related
regulations and guidelines).
Indicator 1: Number of countries where regulations and guidelines are adopted by government,
disseminated and implemented.
2007 Baseline:
3
2013 Target:
12
2013 Actual:
9 (with progress anticipated in three others) (cumulative)
Overall during this programme, with input from Ipas the following 9 countries have completed and
operationalised standards and guidelines either for postabortion care (PAC), medical abortion, or
comprehensive abortion care (CAC): Ethiopia, Ghana, Zambia, Benin, Mali, Nigeria, South Africa,
Uganda and Kenya. Additionally, in Malawi, Standards and Guidelines are completed (the process of
being approved by the government is ongoing) and the Burkina Faso standards and guidelines are
awaiting approval. Ipas is discussing plans for review of standards and guidelines with stakeholders in
Sierra Leone.
Indicator 2: Number of countries where additional resources committed by relevant health
authorities.
2007 Baseline:
1
2013 Target:
10
2013 Actual:
11 (cumulative)
Governments in Ghana, Malawi, Ethiopia, Mozambique, Tanzania, Uganda, South Africa, Nigeria,
Zambia, Kenya, and Sierra Leone have all committed resources to safe abortion or PAC through the
purchase of MVA kits or medical abortion (MA) supplies, personnel working on research (magnitude,
strategic assessments and operational research) or the use of public health personnel and space in
public facilities to provide services. PAC or Comprehensive Abortion Care (CAC) has been included in
several countries’ health plans (e.g. CAC services are included in Ethiopia’s annual woreda-based
planning for health facilities), and since July 2011 seven countries have procured MVA using their
UNFPA funds.
Indicator 3: Number of countries where government and civil society partners sensitised and
engaged in efforts towards legal reform and protection of existing indications.
2007 Baseline:
2
2013 Target:
8
2013 Actual:
12 (cumulative)
Ipas partners in the following 12 countries have been active in legal reform or protection of existing
legal indications for abortion through the support of Ipas: Nigeria, Ethiopia, South Africa, Kenya,
Zambia, Senegal, Mozambique, Malawi, Sierra Leone, Ghana, Tanzania, and Uganda.
Ipas has supported these processes through the sensitisation and support of medical professional
6
associations, lawyers, journalists, women’s groups, youth groups, parliamentarians and government
officials. In addition to educating and informing members of these constituencies about the need to
address unsafe abortion, Ipas has also helped foster and support advocacy coalitions. For example,
Ipas supported members of the Kenya Reproductive Health and Rights Alliance and other Kenyan
advocates through the constitutional review process, including to address stringent anti-abortion
provisions that had been introduced in the draft constitution.
Impact Weighting (%): 50%
Revised since last Annual Review? No
Risk: Medium
Revised since last Annual Review? No
Output 3: Regional research consortium study findings used regionally and nationally to
support advocacy, policy change and improved services
Output 3 final score: A+
Performance description: This Output focused on producing policy-relevant research supporting
activities and results in Outputs 1 and 2, through a regional research consortium.
External DFID reviews that included a special focus on Zambia and Malawi found that government
officials were aware of and used the research generated by Ipas and that it fed into policy
development and service delivery practice in both countries. In Zambia the operations research results
are in demand from government, professional groups and civil society. The magnitude study in process
in Kenya has been requested by the government and will serve as an important baseline in measuring
progress of the new indications for safe abortion. Likewise in Ethiopia the magnitude study (2008) has
been used by government and civil society in policy and programming – with particular traction since
researchers found that, three years after liberalization of Ethiopia’s abortion law, less than one-third of
an estimated 382,500 abortions annually were safe procedures performed in health facilities. The
updated Ethiopia magnitude study, currently underway, will provide critical information to assess the
impact of the government’s effort over the last few years to increase women’s access to safe abortion.
The Guttmacher Institute’s study of stakeholder perspectives in Uganda was featured in a national
workshop on unsafe abortion organized by Ipas with local partners in June 2012.
Final results: Acceleration in latter years saw Ipas exceed one target (number of studies) and meet
the other two.
Indicator 1: Number of studies designed, implemented, completed and disseminated through
publications, workshops and conferences.
2007 Baseline:
0
2013 Target:
8 studies in 7 countries
2013 Actual:
10 studies in 7 countries (cumulative)
The following 10 studies in 7 countries have been completed and disseminated, with ongoing
dissemination in a number of cases:
1) Prevalence, perceptions and experiences of unwanted pregnancy among women in slum and
non-slum settlements of Nairobi, Kenya.
2) Magnitude and consequences of unsafe abortion, Malawi
3) Documenting the health systems costs of treating complications of unsafe abortion in Malawi
4) Perceptions of policy makers towards maternal mortality and unsafe abortion in Nigeria
5) Men, women and abortion in Kenya: a study of lay narratives
6) A national assessment of the magnitude and consequences of abortion in Ethiopia
7
7) Research and advocacy on unsafe abortion in Uganda: in-depth interviews with influential
stakeholders and dissemination activities
8) Scaling up medical abortion in public sector facilities: operations research, Zambia
9) How HIV status affects unintended pregnancy and abortion experiences: new evidence from
Nigeria and Zambia
10) Expanding women’s options: scaling up medication abortion in public sector facilities in
KwaZulu Natal, South Africa
Three additional studies are in the final stages of data analysis in preparation for dissemination.
11) Costing and cost-effectiveness analysis of medical and surgical first and second trimester
abortion methods in South Africa
12) Health providers’ knowledge, attitudes and practice relating to provision of safe abortion
services in Ghana: a situation analysis following the introduction of the 2006 safe abortion
guidelines
13) The magnitude and incidence of induced and unsafe abortions in Kenya
Indicator 2: Number of countries which show evidence of awareness and use of research by
policy makers and other stakeholders.
2007 Baseline:
0
2013 Target:
7
2013 Actual:
7 (cumulative)
DFID reviews and Ipas reports offer evidence of awareness and use of (or planned use of) the
research in Zambia, Kenya, Malawi, Uganda and South Africa. Ethiopia and Nigeria have also
used research in policymaking (documented in 2009 review). In South Africa, release of results from
the consortium’s medical abortion operations research study led directly (and very quickly) to a
decision by the KwaZulu Natal Department of Health to initiate public-sector introduction of medical
abortion.
Indicator 3: Evidence of networks and capacity strengthened in the region for sharing of
knowledge and research
2007 Baseline: Regional conference in 2006 initiated process of sharing abortion
research in the region
2013 Target:
All research shared in the region and researchers networks
strengthened
2013 Actual:
Research shared (publications in African journals, stakeholder
dissemination meetings, presentations at major regional and global
conferences). Methodological skills and tools also shared. Networks
strengthened, including through African Population and Health
Research Centre (APHRC) and African Journal of Reproductive Health
(AJRH).
Results of all studies have been disseminated through numerous mechanisms, including national
dissemination workshops involving a wide range of stakeholders, publication in peer-reviewed journals
and presentations at major conferences.
The network of African abortion researchers has been strengthened through the collaborative design,
implementation and dissemination of the studies themselves, as well as through a number of specific
capacity-building exercises. These included:
 Skills-building workshops;
 Sponsoring researchers attendance at major regional conferences (for example, the Dakar
Family Planning conference and the Union for African Population Studies conference in Burkina
Faso, both in 2011);
 Publication of a report on methods for estimating abortion incidence and morbidity;
 Regular meetings of Consortium members organizations;
8


Regular publication of a Consortium newsletter and updating of its website;
Upgrading the African Journal of Reproductive Health.
Through these means, the skills, experience and commitment of the African researchers to address
abortion-related issues has increased notably. Particularly significant is increased commitment and
capacity for abortion-related research by the Nairobi-based African Population and Health Research
Center (APHRC), which previously was reluctant to address abortion and now fully embraces it (and
will take the lead role in implementation of a new DFID-funded study in Kenya on abortion magnitude
and incidence).
Impact Weighting (%): 20%
Revised since last Annual Review? No
Risk: Low
Revised since last Annual Review? No
Section B: Results and Value for Money.
1. Achievement and Results
1.1 Has the logframe been changed since the last review? No
1.2 Final Output score and description: A+ Outputs moderately exceeded expectation
1.3 Direct feedback from beneficiaries
The ultimate beneficiaries of this programme are women who have improved access to quality
comprehensive abortion care (CAC) in Sub-saharan Africa. However in the context of the programme
outputs and review, the (proximate) beneficiaries are considered to be:
 Individuals who have attended Ipas values clarification or technical training – these include
health workers, lawyers, media, parliamentarians etc.
 Government officials whose departments or institutions have benefitted from Ipas support
 Health professional associations and boards who have received technical assistance from Ipas
 Civil society organisations partnering with Ipas or receiving Ipas small grants.
 Regional organisations and networks
Previous DFID external reviews obtained direct feedback from beneficiaries through interviews with one
or more individuals from all of these groups. Comments from these reviews about Ipas and its work can
be summarised as:
 Ipas takes a low profile lead in policy processes, enabling local actors and especially
government to own and drive progress.
 Methods (such as values clarification) and technical assistance (such as standards and
guidelines drafting or training) are well respected by beneficiaries. Several interviewees
described how the values clarification exercise changed their view on abortion and converted
them into active advocates.
 Professional associations of doctors and obstetricians and gynaecologists were particularly
happy with the work that Ipas had been doing in their countries and regionally. One organisation
said that Ipas was the best “donor” that they had worked with, as Ipas had taken an effective
facilitation role in developing a code of conduct. Ipas had enabled the professional board to take
9




the lead in consultation and drafting processes.
CSOs and INGOs were on the whole happy with the mini-grants and the partnerships with Ipas.
Regional partners were happy with Ipas presentations and participation in regional events. They
were also pleased with the impact of the Ipas regional meetings and the impact this had on their
institutions.
IPPF’s Africa Regional Office mentioned how their office and the IPPF affiliates have benefited
from Ipas’s trainings and workshops, technology distribution and educational materials, citing
examples from a number of countries, including Zambia, Ghana, Kenya, Mozambique and
Ethiopia.
A 2009 direct quote from one of Ipas’ regional partners reflects Ipas’ position in the overall
landscape of work to address unsafe abortion: “I haven’t been to any country in Africa to work on
abortion that you don’t see Ipas. In advocacy and training they are the main people”.
DFID health advisers and other organisations working on reproductive health also commented on the
value of Ipas’ approach in bringing together research, policy work, and training. This was cited as
making Ipas relevant, informed, and impactful – with an ability to influence policy, based on
understanding of the situation from doing relevant research and working directly with ministries of health
and other relevant stakeholders. In addition, insofar as they work both at national and regional/global
levels, and the sensitivity of many of the issues on which they work, some of their research and policy
outputs and lesson-sharing can be considered akin to regional or global public goods.
1.4 Overall Outcome score and description:
Outcome: To improve women's access to quality comprehensive abortion care (CAC) in Subsaharan Africa.
Overall Outcome Score: A
Two of the four outcome targets are on-track to be substantially exceeded in 2013. Whether or not the
other two targets are met reflects more a shift in context than any performance shortcomings; both were
very nearly met in Ipas’ FY129. The data show that that access to comprehensive abortion care has
been increased through Ipas intervention facilities and MVA sales. The percentage of women who
receive contraception on site is an important indicator of quality of care; performance against this
indicator has been good.
In addition, it is likely that the outcome of this programme extends beyond the measures in the
logframe: they do not include services that are available throughout the continent through the
increased access to medical abortion and the wider decrease in stigma associated with induced
abortion.
Indicator 1: Number of women receiving uterine evacuation (UE) services in Ipas intervention
facilities
2007 Baseline: 45,828 (2008)
2013 Target:
120,000 (annual)
2013 Actual: 80,425 infirst 6 months Ipas’ FY13 (i.e. on track to exceed target).
FY12 actual: 102,307.
Ipas is on track to exceed the 2013 target (and almost reached the 2013 target for Ipas’ FY12, the last
year with complete data). This is despite concerns of the impact on total numbers of women reached of
i) a shifting focus of Ipas interventions to more primary level sites (lower volume, but more likely to
reach greatest need, e.g. poorest and adolescents); and ii) limited donor funding for new service
delivery sites.
Ipas’ financial and internal reporting year runs from July through June. “FY12” refers to July 2011 through June 2012. Ipas’
final reports include data for FY12 and, where available, the first 6 months of FY13 (i.e. July-December 2012)
9
10
Indicator 2: Proportion of women receiving UE services in intervention facilities who receive
contraception on site
2007 Baseline: 49% (2008)
2013 Target:
60%
2013 Actual:
75% (in first 6 months FY13; 71.4% in FY12)
The 60% target is in line with the WHO-published standard for Safe Abortion Care indicators. Ipas has
exceeded this. This reflects a priority of the Ipas comprehensive abortion care approach in all facilities,
so is likely to be maintained.
Indicator 3: Number of providers clinically trained or clinically oriented by Ipas events in
preferred methods of MVA or MA
2007 Baseline:
2,062 (annual)
2013 Target:
4,000
2013 Actual:
1,309 (first 6 months FY13; all clinical trainees >8 hours training);
3,990 in FY12.
The number of trainees has levelled off in recent years, largely due to greater emphasis on more
stringent training, follow-up monitoring and mentoring. This improvement in training and follow-up
quality is important in the context of very poor health systems and staff retention. Consequently the
target was moved from 5,500 to 4,000 after the 2011 report. Ipas report typically seeing greater training
numbers in the second half of each financial year. Over the entire programme life, 20,823 providers
were clinically trained or oriented.
Indicator 4: Number of women receiving UE through Ipas MVA distributed in Africa region
2007 Baseline:
566,650 (annual)
2013 Target:
1.7 million
2013 Actual:
350,000 (first 6 months FY13); 1.6million in FY12.
As noted in the context section, during the life of the programme there has been a shift in Africa – as
previously seen in Latin America and South Asia – towards increasing purchasing and use of medical
abortion supplies (including misoprostol alone, which is increasingly available and relatively
inexpensive). This would be expected to result in less use of MVA – and it should not be seen as a
programme failure that the number of MVA being distributed in larger-volume countries like Ethiopia,
Nigeria, and South Africa has gone down in this context. f. In the chart below, the left-most column is
East Africa, and the next column is West/Southern Africa. The green bar represents medical abortion –
approximately two-thirds of all Ipas UE procedures in East Africa used medical abortion in FY12. Also,
there tend to be peaks in purchase of MVA as countries plan procurement for more than one year (and
several larger-volume countries had large procurements in FY12).
11
1.5 Impact and Sustainability
As the 2012 review noted, progress towards the programme impact (reduction in maternal mortality and
morbidity due to unsafe abortion) is probably substantial but difficult to measure. There is strong
evidence that increased access to safe abortion services, effective postabortion care and family
planning can decrease deaths from unsafe abortion. The outcome indicators for this programme show
substantial increase in services over the lifetime of the programme, and they do not include the impact
of the increase in access to medical abortion through pharmacies and other cadres of health workers.
There is also fairly good evidence of how Ipas’s work with others has effectively supported legal change
processes and of the mutually reinforcing effects of its efforts at the national, regional and global level in
significantly improving the overall enabling environment for abortion in Africa. While attribution is
challenging, and there is a substantial time lag on availability of regional impact data, the indicators that
are available show good progress in the Africa region.
Impact indicators and progress:
Indicator 1: Annual deaths due to unsafe abortion in Africa
2007 Baseline: 36,000 (data for 2003)
2013 Target: 23,000
2013 Actual: Data not available; estimated 23,000 in 2010 (based on WHO maternal
deaths data), with downward trend.
Estimation of unsafe abortion mortality is made by WHO, usually every five years. The figures released
in 2011 show substantial progress in reduction in deaths, despite the accompanying increase in actual
number of induced abortions (5.6 million to 6.4 million between 2003 and 2008); based on these data, in
the Africa region approximately 14% of maternal deaths were due to unsafe abortion in 200810, with
29,000 deaths due to unsafe abortion.
The 2008 figure is the most recent WHO estimate of unsafe abortion deaths, but applying the same
proportion (14%) to latest WHO maternal death estimates (published 2012) suggests that 23,072 of
10
World Health Organization (WHO), Unsafe Abortion: Global and Regional Estimates of the Incidence of Unsafe Abortion and
Associated Mortality in 2008, sixth ed., Geneva: WHO, 2011.
12
164,800 maternal deaths in Africa in 2010 were due to unsafe abortion. Estimates from the IHME group
at the University of Washington from global burden of disease analysis also seem to suggest levels in
this range. It is likely that the number of abortion deaths in Africa has since dropped below the 2013
target in the programme logframe.
Indicator 2: Number of countries that have expanded legal indications for abortion
2007 Baseline:
0
2013 Target:
4
2013 Actual:
3 (with progress in 5 others)
The three countries with expanded legal indications were Kenya (Ipas significantly involved), Rwanda
(with limited Ipas involvement), and Mauritius (no direct Ipas involvement). Kenya approved a new
constitution with important abortion-related provisions in 2010; in 2012 Rwanda reduced criminal
penalties related to abortion, for women and providers, and legal indications for abortion were expanded
by a parliamentary vote in Mauritius.
Under this grant, Ipas has been able to respond flexibly to provide relevant support in countries as legal
reform processes arise (see Output 2, Indicator 3).
Ipas’ work has also included work to clarify the existing legal status of abortion among policy-makers
and service providers, and, where appropriate, to protect the legal status of access to safe abortion
when it is challenged. DFID health advisers and other external partners noted the value of Ipas being
able to respond flexibly to such challenges with support from this grant.
Sustainability
Important aspects of Ipas’ work that enhanced sustainability include:
 Working within and strengthening government health systems.
 Encouraging ownership by governments
 Generation of good quality evidence and germinating a culture of using evidence in policy and
practice development
 Expansion and strengthening of the group of regional and country champions
 Strengthening of regional and country networks
 Ensuring that newer areas of work, such as youth-focused work with local NGOs, are adapted to
make linkages with health systems, for example referral systems to abortion-related services.
External DFID reviews collected evidence of good commitment for the provision of safe abortion
services from the governments in Zambia, Kenya and Malawi. Ipas reports indicate additional strong
commitment from Ghana, Ethiopia and Sierra Leone. In several countries there appears to be
commitment from senior ministry of health counterparts, but political challenges in translating that
commitment to legal reform.
Ipas has resulted in sustainable changes, however, there continue to be opportunities to do more in
Africa to improve women’s ability to access safe abortion. The rise of religious fundamentalism in
some parts of the world adds further risk. Most other donors are unwilling to address this sensitive yet
important issue. The conclusions of this PCR reinforce recommendations from previous annual
reviews: mechanisms should be put in place to sustain this work, especially as it complements
other DFID support that is more service-delivery focussed and/or more country-specific.
13
2. Costs and timescale
2.1 Was the project completed within budget / expected costs: Yes
Expenditure is on track for completion by the project end-date. Financial forecasts and actual
expenditure have largely been well-aligned, with some small deviations.
(During the life of the programme, three supplements were made to enable enhanced work; the original
grant of £6.5 million was increased to £12.9 million in total).
2.2 Key cost drivers
The key cost drivers in this project were:
 Staff salaries
 Short-term staff and consultants daily rates and subsistence
 International travel and hotels
 Materials, printing and communications
There was no major increase in any of these rates over and above inflation in the relevant countries
during the grant period.
2.3 Was the project completed within the expected timescale: Y
A six-month no-cost extension (through to end-March 2013) was approved by DFID in early 2012, to
enable Ipas to continue strategic activities under the grant. Ipas have completed project activities
within this timescale.
3. Evidence and Evaluation
3.1 Assess any changes in evidence and what this meant for the project.
In 2011, new WHO11 estimates of unsafe abortion showed an increase in total unsafe abortions in
Africa from 2003 to 2008, from 5.5 million to 6.2 million, related to slow uptake of family planning,
increased number of women of reproductive age, and persistence of restrictive laws.
At the same time, the estimated case fatality rate decreased, from 650 to 460 per 100,000 unsafe
abortion procedures, indicating that progress is being made through post abortion care and safe
abortion as well as the possibility that women are obtaining access in the private sector to safer
methods such as misoprostol. This is consistent with anecdotal evidence that severe complications
are lower than they used to be in major referral hospitals.
The implication of available research is that progress has been made but further work needs to be
done to reduce the scale and impact of unsafe abortion.
Evidence generated by this programme has directly fed into programme planning and practice and has
also enabled the attainment of the outputs. At country level the generation and availability of evidence
and data has been seen to catalyse policy and implementation changes in several cases during the
programme. Ipas’s experience in this regional programme has also directly influenced design and
implementation of other DFID work on family planning and addressing unsafe abortion in Africa.
Key assumptions in the programme logframe are listed below:
 Supportive officials in regional institutions and network leadership remain in their posts during
11
Unsafe Abortion. Global and Regional Estimates of the incidence of unsafe abortion and associated mortality in 2008. WHO
2011
14




the life of the program.
Networks and institutions are able to access funds.
Targeted policymakers will respond to advocacy and evidence on unsafe abortion as a public
health and human rights issue and include access to safe abortion in strategies, plans, and
policies.
Other international partners are also active in supporting the regional efforts, including WHO,
UNFPA (especially with SRH supplies), IPPF, Marie Stopes International, and FIGO.
Anti-choice presence at regional meetings is effectively countered by committed African
leaders.
Programme results and evidence from external reviews suggest these have held sufficiently for the
programme to have been effective. This learning has fed into design of other programmes that will be
more rigorously evaluated.
3.2 Set out what plans are in place for an evaluation.
This programme was not designed to have a rigorous impact evaluation. Substantial external reviews
were carried out in 2009 and 2012. DFID will ensure rigorous evaluation of further work on unplanned
pregnancy in the region, making links with relevant DFID-funded research.
4. Risk
4.1 Risk Rating (overall project risk): Medium
Did the Risk Rating change over the life of the project? No
The risk rating did not change over the life of the project. As part of active risk management, risks to
programme delivery were updated following the 2009 and 2012 reviews.
4.2 Risk funds not used for purposes intended
Financial controls ensured low risk of use of funds other than for purposes intended. The grant
stipulations included that Ipas submit Annual Audited Accounts to DFID. Review of audits of the Ipas
Alliance office also gave no indication that funds might have been used for anything other than the
purposes intended. Recommendations from the audits were not serious and were all addressed as
part of the financial management of the programme and other donor programmes. As well as the
Alliance office, Ipas offices in Ethiopia, Ghana, Nigeria and South Africa have been subject to annual
financial audits by local affiliates of international firms, and all have been satisfactory.
4.3
Climate and Environment Impact
The original Environmental Screening Note for the programme noted the potential environmental
benefits of:



Supporting work to address unmet need for family planning, and helping to limit burdens on
resources that may be caused by rapid population growth.
MVA can be provided at lower levels of health facility (and without electricity) – avoiding the
need for women to travel to higher level facilities for more complex clinical procedures such as
D&C.
Preventing unsafe abortion reduces the need for complex clinical interventions to address the
complications of abortion; these Have potential environmental impact (clinical waste, potential
biohazards).
15
Increased availability of medical abortion over the life of the programme is likely to have had beneficial
effect by further reducing travel and the need for more complex clinical interventions.
Possible environmental risks identified were related to clinical waste and to programme-related travel.
The Annual Review completed in February 2012 included detailed information on ways in which Ipas
has effectively mitigated possible environmental risks.
5. Value for Money
5.1 Performance on VfM measures
Empirical studies are scarce, but available evidence shows the high cost of unsafe abortion and related
morbidity and mortality to health systems in the developing world, estimated to lie somewhere between
$375 and $838 million a year12; there is scope for the programme to catalyse large reductions in these
costs. Although it is challenging to define quantitative measures of value for money for programmes
focused primarily on policy, research and advocacy.indicative analysis from the 2012 external review
suggests:



Cost of policy and advocacy work per DALY saved: A simple indicative calculation
assessed the number of DALYs saved due to UE procedures undertaken as a result of the
policy and of the service delivery work in this programme: £6.30 per DALY saved for UE
procedures as a result of MVA sold in the region, £90 per DALY saved for UE procedures in
Ipas monitored sites in their country programmes13. International benchmarks typically
consider interventions highly cost-effective if they cost less than per capita GDP per DALY
saved; GDP in programme countries ranges from approximately £300 to £1500. The costs
included in these calculations are the costs of undertaking the work in this programme;
calculations do not include the cost incurred by the public sector (human resources, supplies,
infrastructure etc)
Cost savings to public sector: Provision of safe abortion is typically less costly than post
abortion care. Ipas, in cooperation with the Ministry of Health in Malawi, conducted a cost
study, which built on the evidence of the magnitude study to encourage the public sector to
increase access to safe services. By conservative measures this found savings to the Ministry
of Health at a single hospital of approximately £32,000 per year.
The increase in results between 2008 and 2013 has been of a greater magnitude than the
increase in funds: Ipas annual expenditure for Africa during the five-year period FY2008FY2012 increased by 90%, while the number of women served in Ipas intervention sites
increased 123%. From FY2007 to FY2012, MVA distribution in Africa nearly doubled, from
22,666 to 67,047, while the numbers of health workers clinically trained or oriented increased
94% from 2062 to 3990. At the same time, Ipas-supported research and policy efforts also
had lasting results at a system level that are less-readily quantified.
Case study on costing of policy results. The external reviews raised the need for
monitoring the cost-effectiveness policy change processes. While this is very difficult, Ipas is
putting in place a new monitoring system that will track policy activities and enable costing in
future. As a case study, Ipas costed its work in Kenya that helped ensure that Kenya’s
constitution review process (December 2009 to July 2010) would protect – and ultimately
expand - legal indications for abortion. Ipas estimates that their direct cost (including staff
time) between December 2009 to July 2010 was £160,000. (Note: this expenditure clearly built
on prior investments over a number of years of Ipas presence in Kenya). Costing direct
benefits of policy change is challenging – but annual cost to public sector of abortion-related
DFID’s Working Paper: Improving Reproductive, Maternal and Newborn Health: Reducing Unwanted Pregnancies. Evidence Overview
(Version 1.0), DFID, 2010.
12
13
MSI Impact 2 - draft version, 29th Jan 2012
16
complications in Kenya can be estimated at over £1.5 million (21,000 women admitted to public
sector hospitals for abortion-related complications14, average public sector cost of $114 per
case for abortion-related illness and disability in Africa15).
5.2 Commercial Improvement and Value for Money
Ipas uses competitive quotes for most procurement of services and supplies for their programme and
this is checked by the audit process. However, the very specialised needs for short-term inputs, e.g. on
training and values clarification, means that there is not a huge pool of people with relevant skills.
Quality of consultants’ and employees’ work, though, is maintained through close monitoring of all
programme activity from the Ipas North Carolina office. The Africa Alliance office and the Ipas country
offices all have computer systems that connect project management and financial management data
directly to the US office. There are also regular visits and a clear organisational structure and
accountability.
For grants and research Ipas has a strict financial management and control system. In planning the
work Ipas takes a hands-on approach to budgeting and proposes line by line adjustments in line with
their experience of costs in the sector and the 2012 external review saw evidence of budget savings
as a result. Ipas also provides procurement training to government to ensure a sustainable good
quality supply of MVA, MA and contraceptives.
5.3 Role of project partners
Ipas’s principal partners in implementing this programme included national Ministries of Health;
national, regional and global civil-society organisations, including associations of health-care
professionals, advocacy groups and others; women’s groups and other community-based
organisations; and African research organisations and networks. The performance in working with and
through these partners to achieve the project outputs and outcome is described in the sections above.
Ipas also provides small grants to some of these partners, including local and community-based
organisations. The 2012 review identified potential improvements in this grantmaking; Ipas has
solidified an approach that emphasizes choices of grantees based on results of community
assessments of need and suitability of local partners, including their capacity for effective community
outreach. The 2012 review also noted that some smaller and newer areas of work with partners –
including small grants for working directly with communities and with young people – would benefit
from consideration of sustainability and measures of effectiveness. Once Ipas have established their
new monitoring system, more analysis to track the cost and effectiveness of policy change processes
(see 5.1 above) would enable refined future budgeting and planning, including to inform grantmaking
and other work with partners.
5.4 Did the project represent Value for Money : Y
The original economic appraisal for this programme gave evidence for the economic impact of unsafe
abortion and the costs to the health system. Working to improve access to comprehensive abortion
care is good value for money for women, families and the economy. This still holds for the programme.
However, there are limitations to the evidence for this assessment. At the time of the project
development no calculations of cost per DALY or cost/CYP (for the contraceptives) were undertaken,
so no comparison can be made with the original proposal. Assessment of value for money is on the
basis that project results – particularly the increase in access to CAC services – have largely met or
exceeded expectations.
Economic analysis of subsequent regional work on unintended pregnancy established that Ipas service
14
15
A National Assessment of the Magnitude and Consequences of Unsafe Abortion in Kenya, Ipas 2004
Cohen, S: Facts and Consequences: Legality, Incidence and Safety of Abortion Worldwide. Guttmacher 2009.
17
delivery work in the public sector, similar to that supported in this programme, is good value for money.
Extract from original project document
Macroeconomic impact: There is a negative impact on the nation’s economy. In the case of Uganda,
economists estimate that the lost productivity due to maternal mortality and morbidity over the ten year
period 2004-2013 at US$ 1.1 billion. Reducing material mortality and morbidity by 50 percent over that
interval would result in a net productivity gain to the Ugandan economy of approximately US$ 250
million. 16 Economic growth is also affected by the household impact of maternal health (as explained
below). The economic disadvantages imposed on the household by maternal death are likely to be
transmitted to future generations because of the impacts on girls' schooling. This, in turn, reduces the
levels of human capital in the economy and affects economic growth prospects. There are, therefore,
impacts on growth both in the present and in the future.
Meso - The cost to the health service: A global analysis by Guttmacher Institute estimates that 1.7
million African women are admitted to hospitals each year for treatment of abortion complications.
Treating complications of unsafe abortion in Africa is currently estimated to cost public health systems
in the range of $200 million to $450 million annually, depending on which of two approaches to costing
is used17. On a per-case basis, analysis by IPAS indicates that a safe, early induced abortion
performed by a midlevel provider at a primary care level in Africa is on the order of one-tenth the cost
of treating an incomplete abortion in a tertiary care facility, even when the complications are not too
severe18. In some large urban hospitals in developing countries nearly 2 out of 3 maternity beds are
taken up with cases of illegal abortion and they can consume up to half the gynaecology budget. The
health system costs of treating an unsafe abortion – in the hundreds of dollars – far exceed the per
capita health spending in African countries, which is often reported in the single digits.
6. Conditionality
6.1 Update on specific conditions
Not applicable
7. Conclusions


Results: Programme outputs moderately exceeded logframe targets. The overall outcome met
expectation: women's access to quality comprehensive abortion care (CAC) in sub-Saharan
Africa improved, and this is likely to have contributed to a significant reduction in maternal
deaths from unsafe abortion. Previous reviews confirmed that targeted results had been set at
a realistic level of expectation (or were modified where context had changed).
Costs and timescales: Additional resources were approved during the life of the programme for
enhanced work. The programme was completed at the expected cost and (following an agreed
16
Greene., M.E. & Merrick T, Poverty Reduction: Does Reproductive Health Matter? HNE Discussion Paper 33399, World
Bank, 2005
17 (See discussion of these approaches and estimates by Michael Vlassoff, The Economic Impact of Unsafe Abortion, id21
Health Focus, University of Sussex, August 2007).
18 See Heidi Bart Johnston, Maria F. Gallo and Janie Benson, Reducing the Costs to Health Systems of Unsafe Abortion: a
Comparison of Four Strategies, Journal of Family Planning and Reproductive Health Care (2007) 33(4):250-257.
18



six month extension) timescale.
Evidence and evaluation: The programme itself contributed to the evidence base on unsafe
abortion in Africa, and there is evidence that this has informed policy and programmes in
African countries. It also strengthened capacity of African researchers. While there was no
formal in-depth evaluation of the programme, the programme has directly informed plans for
evaluation of further DFID work on reducing maternal deaths from unwanted pregnancy.
Value for money: Although it is difficult to quantify the directly attributable benefits of research
and policy advocacy, the programme is very likely to have been good value for money (based
on the original economic appraisal, indicative analysis outlined above, and economic analysis
for subsequent DFID regional work on unintended pregnancy).
Ipas’ approach is particularly valued for bringing together research, policy work, and training.
This and previous reviews have noted the value of flexible support for this approach, and that it
strongly complements other DFID support that is more service-delivery focussed and/or more
country-specific. It is an important element of work to reduce recourse to unsafe abortion and
improve maternal health outcomes.
8. Review Process
The review was undertaken by DFID’s Africa Regional Health Adviser in February-March 2013.
An in-depth external annual review was undertaken by the DFID Human Development Resource
Centre in 2012, and included interviews with Ipas staff, government officials, regional champions,
representatives from regional institutions, health professionals, lawyers, media, CSOs and service
providers. It was decided that this project completion review should be a desk-based exercise,
largely drawing from the 2012 review. Additional information was gathered from DFID and Ipas
programme documentation, past annual reviews of the programme, and interviews with Ipas staff
and DFID country health advisers.
19