October 2012

REPOSITIONING FAMILY PLANNING IN MAURITANIA

A Baseline

This publication was prepared by Modibo Maiga and Aissatou Lo (consultant) of Futures Group.

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

Repositioning Family Planning in Mauritania: A Baseline

OCTOBER 2012
This publication was prepared by Modibo Maiga and Aissatou Lo (consultant) of Futures Group.

CONTENTS
Acknowledgments .................................................................................................................. iv Abbreviations ............................................................................................................................v Introduction ...............................................................................................................................1 Background: Mauritania ..........................................................................................................3 Mauritanias Health System ...................................................................................................................... 3 Maternal and Child Health ........................................................................................................................ 4 Community-based Distribution of Contraceptives.................................................................................... 5 Framework for Assessing the Repositioning FP Initiative........................................................6 Methodology ............................................................................................................................................. 6 Study Limitations ...................................................................................................................................... 8 Assessment Findings .................................................................................................................9 SO: Increased Stewardship of and Strengthened Enabling Environment for Effective, Equitable, and Sustainable FP Programming .............................................................................................................. 9 Intermediate Result 1: Resources for Family Planning Increased, Allocated, and Spent More Effectively and Equitably .................................................................................................................. 11 Intermediate Result 2: Increased Multisectoral Coordination in the Design, Implementation, and Financing of FP Policies and Programs ............................................................................................ 14 Intermediate Result 3: Policies that Improve Equitable and Affordable Access to High-Quality FP Services and Information Adopted and Put into Place ...................................................................... 17 Intermediate Result 4: Evidence-based Data or Information Used to Inform Policy Dialogue, Policy Development, Planning, Resource Allocation, Budgeting, Advocacy, Program Design, Guidelines, Regulations, and Program Improvement and Management ........................................... 20 Intermediate Result 5: Individual or Institutional Capacity Strengthened in the Public Sector, Civil Society, and Private Sector to Assume Leadership and/or Support the FP Agenda ......................... 22 Recommendations for Repositioning FP in Mauritania ........................................................25 Annex 1: Workshop Participants and Persons Interviewed .................................................27 Annex 2: Repositioning Family Planning Results and Indicators for Mauritania ................28 References and Additional Resources..................................................................................36

iii

ACKNOWLEDGMENTS
The authors would like to thank Margot Fahnestock, Program Officer, of the Global Development and Population Program at the William and Flora Hewlett Foundation for her collaboration, ideas, and funding for this work. We also thank our colleagues at the Health Policy Project: Elizabeth McDavid, for her instrumental management support, practical suggestions, and technical expertise (we especially appreciate her tireless work in assisting with the scope of work, protocol and methodology, hiring of consultants, and conceptualization and writing of the report); Karen Hardee, for her support of all aspects of the study from the questionnaire design to report writing; and Cynthia Green, for her invaluable contributions to the report. The authors particularly thank Nicole Judice, who supported the development and pilot testing (in Tanzania) of the Framework for Monitoring and Evaluating Efforts to Reposition Family Planning and provided our study team with technical assistance related to the framework. We also thank Laura McPherson and Sandra Duvall for their insights, and Lori Merritt, Molly and Jim Cameron, and Sarah McNabb for their editing of the report. The authors are also grateful to Dr. Mahfoud Ould Boye, head of the National Reproductive Health Program (PNSR) in Mauritania and Mrs. Fatimetou Mint Moulaye, Maternal and Child Health Program Coordinator, and Dr. Amadou Racine Kane, former Action for West African Region (AWARE) II local consultant. These experts provided essential assistance and facilitated our work by securing meetings with the main FP stakeholders, including PNSR staff, donors, civil society organizations, and important leaders at all levels. Finally, we thank Mr. Brahim Ould Ahmedou, Association Mauritanienne pour le Bien Etre Familial (AMPF) Executive Director, and Mrs. Salla NDoungou Ba, Coordinator of the National Council to Combat AIDS and Sexually Transmitted Infections, for providing valuable information for this study.

iv

ABBREVIATIONS
AFD AMPF ASFM ASMAGO AWARE II CAMEC CBD CHW CNLS-IST CNSS CSLP CSO DHS DPS DSSP DPCIS DPES DRAS FP FPE IPPF IR IUD MAED MDG M&E MICS MS UM NGO ONS PHC Agence Franaise de Dveloppement French Agency for Development Association Mauritanienne pour le Bien Etre Familial Mauritanian Association for Family Planning Association des Sages-Femmes de Mauritanie Mauritanian Midwives Association Association Mauritanienne des Gyncologues et Obsttriciens Association of Mauritanian Gynecologists and Obstetricians Action for West African Region II (USAID-funded project) Centrale dAchat des Mdicaments Essentiels et Consommables Central Purchasing of Essential Drugs and Supplies community-based distribution community health worker Conseil National de Lutte contre le Sida et les Infections Sexuellement Transmissibles National Council to Combat AIDS and Sexually Transmitted Infections Caisse de Securit Sociale National Social Security Agency Cadre Stratgique de Lutte contre la Pauvret Strategic Framework for the Fight against Poverty civil society organization Demographic and Health Survey Direction de la Protection Sanitaire Directorate of Sanitary Protection Division des Soins de Sant Primaire Division of Primary Health Care Direction de la Planification, Coordination et de lInformation Sanitaire Directorate for Planning, Coordination, and Health Information Document de Politique conomique et Sociale Document of Economic and Social Policies Direction Rgional de lAction Sociale et de la Sant Regional Directorates of Health family planning Family Planning Program Effort (Index) International Planned Parenthood Federation intermediate result intrauterine device Ministre des Affaires Economiques et du Dveloppement Ministry of Economics and Development Millennium Development Goal monitoring and evaluation Multiple Indicator Cluster Survey Ministre de la Sant Ministry of Health Mauritanian Ouguiya (currency) nongovernmental organization Office Nationale de la Statistiques de la Mauritanie National Statistics Office primary healthcare v

Repositioning Family Planning in Mauritania: A Baseline

PMTCT PNDS PNP PNP/SR PNSR PSSPSR RH SNIM SNIS SO TFP UNFPA USAID WHO

prevention of mother-to-child transmission Plan National de Dveloppement Sanitaire National Health Development Plan Politique Nationale de Population National Population Policy Politique Norme et Protocole en Sant de la Reproduction Policies, Norms, and Standards in Reproductive Health Programme National Sante de la Reproduction National Reproductive Health Program Plan Stratgique de Scurisation des Produits de la Sante de la Reproduction Strategic Plan for RH Products Security reproductive health Societ Nationale Industrielle et Miniere National Mining Industry Company Service National de l'Information et des Statistiques Sanitaires National Service of Health Information and Statistics strategic objective technical and financial partner United Nations Population Fund United States Agency for International Development World Health Organization

vi

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

29

32

35 28 27 29 24 22 16

Source: Demographic and Health Survey data (accessed at: http://www.statcompiler.com/).

Community-based programming is showing promise for expanding access to family planning. Many African countries have community-based programs to provide contraceptive methods and information to under-served groups, such as rural residents and the urban poor.

Repositioning Family Planning in Mauritania: A Baseline

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

The eight countries are Benin, Burkina Faso, Guinea, Mali, Mauritania, Niger, Senegal, and Togo. The results of the pilot test and assessment of policy and operational barriers to CBD in Niger and Togo also are available (visit www.healthpolicyproject.com).
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BACKGROUND: MAURITANIA
Mauritania is a Sahelian country located in northwest Africa with approximately 592 km of coastline on the Atlantic Ocean. The country is mostly desert, with the exception of the fertile Senegal River valley and grazing lands in the north. It is divided administratively into 13 regions, 54 departments, and 216 communes. Based on its steadily improving economy, Mauritania is now ranked as a lower middle-income country. Over the past two decades, the government has adopted vigorous economic reforms. Its gross national product (GNP) grew by 5 percent annually in 2010 and 2011, and its gross national income was US$2,410 per person in 2011, outstripping neighboring countries (World Bank, 2012). Its economy increasingly is based on industry and services, with iron ore as a major export. With the recent discovery of oil and other minerals, Mauritania has good prospects for continued economic growth. Nevertheless, the country imports most of its food, and its coastal fish production is threatened by over-exploitation. Many Mauritanians remain poor. Two in five (42%) of its people live below the poverty line (World Bank, 2012). Its agricultural sector is vulnerable to drought; thus, Mauritania depends heavily on food imports (70% of its food) and is very vulnerable to rising world prices for staple commodities. Many of its people have little or no education. Of adults age 15 and older, 50 percent of females and 65 percent of males were considered to be literate in 2009 (World Bank, 2012). According to the United Nations Human Development Index, Mauritania ranks 159th out of 187 countries based on life expectancy, educational attainment, and standard of living (UNDP, 2011a). Mauritanias population has quadrupled in size since independence, growing from 860,000 people in 1960 to 3.3 million people in 2010 (lOffice National de la Statistique de la Mauritanie, 2012). Its current population is estimated to be 3.6 million people (Haub and Kaneda, 2012). Its population is growing at 2.4 percent annually and is projected to double by 2050 (Haub and Kaneda, 2012). Factors driving rapid population growth are (1) the large proportion of young people, with 40 percent of its population under age 15; and (2) large family size, with an average of 4.5 children per woman (Haub and Kaneda, 2012). Mauritania is urbanizing rapidly, with 42 percent of its people living in urban areas. Half of all urban dwellers live in the capital, Nouakchott (Guengant et al., 2011).

Mauritanias Health System

Mauritanias health system is governed by the Decree n 90/2011/PM of May 2011, which established the allocations of the Ministry of Health (MS) and the organization of its central administration. The health system is managed and coordinated by the MS central administration through its directorates, services, and programs. The health system administration is decentralized at intermediate levels through Regional Directorates of Health (DRAS) and, at the operational level, through district health teams.
Box 1: Ratio of Health Professionals to Population, 2004 Doctors: 0.11 per 1,000 people Nurses: 0.64 per 1,000 people
Source: WHO, 2006.

Over the past 20 years, Mauritania has made significant investments to improve its health infrastructure. The government spent US$43 per person on health in 3

Repositioning Family Planning in Mauritania: A Baseline

2010 (World Bank, 2012). Despite these efforts, the distribution of health services is uneven across the country, with limited access to healthcare in suburban populated areas and remote and desert regions. One in four people (25%) live more than 5 km from a health facility (WHO, 2009). The National Health Development Plan (PNDS) 20112020 states that the country has 18 hospitals, 530 health centers, and 67 health posts. Despite efforts over the past 20 years to increase the number of health workers, Mauritania still needs many more health workers to meet WHOs recommended ratio of 2.28 health professionals per 1,000 people. In 2004, there were 0.11 doctors per 1,000 people and 0.64 nurses per 1,000 people (WHO, 2006) (see Box 1). Besides the public health system, other health providers are the health systems run by the military, social security, and the private sector. The private health sector has developed gradually but is now well integrated and coordinated with the public sector (MS, 2005). Many private health providers are located near mining companies. In Nouakchott and Nouadhibou, the two main urban areas, private sector facilities consist of 15 medical and surgical clinics, 47 medical consulting offices, 37 dental offices, 15 primary healthcare stations, 118 pharmacies, and 280 shops that sell pharmaceutical products.

Maternal and Child Health

Despite reductions in child mortality rates over the past two decades, Mauritanias health indicators remain poor. One in 10 children do not live to reach their fifth birthday, as reflected in a child mortality rate of 111 deaths per 1,000 births. This rate is nearly three times the MDG for 2015, which is to reduce the child mortality rate to 41 deaths per 1,000 births. Deaths of infants under age one also remain high at 75 deaths per 1,000 births (UNICEF, 2011). Mauritania is making steady progress in reducing maternal deaths, but its maternal mortality ratio of 510 deaths per 100,000 births is still high (WHO, 2012a)more than double the target of 232 per 100,000 births set for the 2015 MDGs (African Development Bank, 2010). A Mauritanian woman has a 1 in 44 lifetime risk of maternal death (WHO, 2012a). More Mauritanian women are obtaining antenatal care and delivering in health facilities. According to the 2011 Multiple Indicator Cluster Survey (MICS), 86 percent of pregnant women received antenatal care from a trained health professional (UNICEF and UNFPA, 2012), up from 81 percent in the 2007 MICS (UNICEF and ONS, 2008) and 65 percent in the 20002001 Demographic and Health Survey (DHS) (ONS and ORC Macro, 2001). In 2011, two-thirds (67%) of births were attended by a trained health professional (UNICEF and UNFPA, 2012), up from 61 percent of births in 2007 (UNICEF and ONS, 2008) and 57 percent in 20002001 (ONS and ORC Macro, 2001). In 2007, 29 percent of births were delivered by a traditional midwife; 7 percent by a parent, friend, or other person; and nearly 3 percent had no assistance (UNICEF and ONS, 2008). The urban/rural differential is striking: in 2011, 91 percent of urban women were assisted at delivery by a trained health professional, compared with 51 percent of rural women (UNICEF and UNFPA, 2012). Increasingly, more births are taking place in a health facility. In 2011, 65 percent of births took place in a health facility (UNICEF and UNFPA, 2012), up from 48 percent of births in 2007just four years earlier (UNICEF and ONS, 2008).

Background: Mauritania

Besides pregnancy and maternity care, other factors that contribute to high maternal mortality are the low level of education, insufficient geographic access to health services in general, and low use of reproductive health (RH) services, especially in remote desert regions and densely populated urban poverty areas. The situation is aggravated by harmful traditional behaviors and practices, such as early marriage, early and late childbearing, closely spaced pregnancies, and unsafe abortions. Use of contraception is increasing slowly. The 2011 MICS reported that 11 percent of married women were using modern contraceptive methods (UNICEF and UNFPA, 2012), up from the 8 percent of women using modern methods and 1 percent using traditional methods reported in the 2007 MICS (UNICEF and ONS, 2008). The most recent DHS, conducted in 20002001, reported that in 2000, 5 percent of married women were using a modern contraceptive method and 3 percent were using traditional methods (ONS and ORC Macro, 2001). Urban women are much more likely to use a modern contraceptive method than rural women. The 2007 MICS found that 14 percent of married urban women were using a modern method, compared with 3 percent of married rural women. Contraceptive use rises as womens educational attainments and income levels increase (UNICEF and ONS, 2008). Factors affecting contraceptive use are religious beliefs, unavailability of contraceptive products at service delivery facilities, inadequately trained health providers, insufficient communication between providers and clients, lack of champions supporting family planning at the national and local levels, and weak civil society engagement in advocacy and service delivery for family planning in the context of persistent pro-natalist attitudes nationwide. Unmet need for family planning has risen sharply in recent years. About three in seven (37%) married women would like to space or limit births but are not using any contraceptive method, according to the 2011 MICS (UNICEF and UNFPA, 2012). In contrast, the 2007 MICS reported that 25 percent of married women had an unmet need for family planning. Of the married women surveyed in the 2007 MICS, 16 percent wished to delay their next birth at least two years, and 9 percent wished to limit future births. Unmet need for family planning is slightly higher in urban areas than in rural areas and among women in their prime childbearing yearsages 2034 (UNICEF and ONS, 2008). Besides pregnancy and delivery complications, the main factors affecting maternal and child health are malnutrition, HIV and AIDS, and malaria and other endemic tropical diseases (UNICEF and ONS, 2008). Inadequate clean water and poor sanitary facilities also contribute to the spread of disease. Four in 10 Mauritanians do not have access to clean drinking water, and more than half (52%) do not have adequate sanitation facilities, according to the MICS 2007 (UNICEF and ONS, 2008).

Community-based Distribution of Contraceptives

Mauritania began community health services in the early 1980s with community health agents delivering primary healthcare services, mainly in the southern river valley regions. It created hundreds of village health units. However, this program foundered due to lack of a national community health strategy and adequate funding, and the government ended it in the mid-1990s. Problems included agents that were not well supervised and supported, resulting in a decline in their motivation, and an inadequate drug distribution system. Today, village health units are supported by nongovernmental organizations (NGOs). The MS has not yet attempted to set standards for these units and has not incorporated them into the health system. Since May 2000, 545 village health units have been established throughout the country (MAED, 2011).
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Repositioning Family Planning in Mauritania: A Baseline

FRAMEWORK FOR ASSESSING THE REPOSITIONING FP INITIATIVE

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

FP program 2. Instances of documented improvement in the enabling environment, using a validated instrument 3. Evidence of FP policies implemented and resources allocated and subsequently used in relation to the same FP policies Each IR has specific indicators that contribute to overall achievement of the IR (see Figure 2).
Figure 2. Results Framework for Strengthening Commitment to and Increased Resources for Family Planning
SO: Increased stewardship of and strengthened enabling environment for effective, equitable, and sustainable FP programming

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

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

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

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

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

Source: Judice and Snyder, 2012.

Methodology
After the M&E Framework was field tested in Tanzania in 2011 and finalized, Futures Group staff reviewed the tools developed for Tanzania and subsequently adapted them for use in West Africa and

Framework for Assessing the Repositioning FP Initiative

translated them into French. The Futures Group then tested the M&E Framework in Togo and Niger with funds from the USAID-funded Health Policy Project. In preparation for the application of the M&E Framework with Hewlett Foundation funding, Futures Group proposed a different methodology for working in six countries of Francophone West Africa. In Mali, a four-person Futures Group team tested a more participatory and interactive methodology, which produced excellent results. The change in methodology consisted of holding a meeting of stakeholders and collecting information to complete the framework questionnaire as a group, rather than conducting individual interviews and then compiling the findings. After holding the initial meeting, the team then filled out missing or incomplete information through interviews with key informants. This new methodology was more efficient in terms of gathering the necessary information and helped to identify topics for which more information was needed. After the Mali application, the Futures Group team decided to continue to use the Mali methodology for the five remaining countries. A Futures Group staff member, Modibo Maiga, and a local consultant, Aissatou Lo, conducted the study. Field work took place in Mauritania during July 1218, 2012. In Mauritania, the team reviewed policies, strategies, program materials, and other information related to the framework indicators. The team found some documents online or in electronic versions, but many were available only in hard copy, and the team reviewed these after arrival in country. The MSs National Reproductive Health Program (PNSR) assisted the Futures Group team in conducting a one-day working meeting with FP stakeholders. The MS/PNSR issued invitations to the meeting and 24 people attended. The team identified meeting participants with assistance from Dr. Mahfoud Ould Bah, Director of the MS/PNSR, and Dr. Racine Kane, the former Action for West African Region (AWARE) II consultant in Mauritania; and through documents related to the FP program. The key informants included three of the four focal persons for the Repositioning Family Planning Initiative, government and donor focal persons identified and nominated at the Ouagadougou FP conference in February 2011, and CSO representatives who had been identified at the Mbour, Senegal, conference for CSOs in September 2011. In preparation for the meeting, the Futures Group team identified three key documents and translated them into French for use at the working meeting:
1. Framework for Monitoring and Evaluating Efforts to Reposition Family Planning document 2. Explanation of Indicators 3. Semi-structured Interview Guide (to serve as background)

The team prepared and distributed hard copies of the key documents, as well as two PowerPoint presentations, for use during the working meeting. The MS/PNSR took additional ownership of this effort by conducting parts of the meeting. Both presentations, as well as the documents, will be used for the working meetings in the remaining countries. The meeting began with a presentation on challenges and opportunities for family planning in the Francophone West Africa region and an orientation to the M&E Framework, followed by group work on the indicators and reporting on them. Meeting participants identified some experts who did not attend the meeting, and the Futures Group team made separate arrangements to interview them. The meeting
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Repositioning Family Planning in Mauritania: A Baseline

concluded with several recommendations for the government and donors, known as technical and financial partners (TFPs), to strengthen efforts to reposition family planning in Mauritania. Once the Futures Group team produced a draft of the indicator table (see Annex 2), the team distributed it to the working meeting participants for their feedback; three people provided additional input. Additional interviews were conducted during July 1317, 2012, with PNSR staff, the Executive Director of the Association Mauritanienne pour le Bien Etre Familial (AMPF), the Coordinator of the National Council to Combat AIDS and Sexually Transmitted Infections, and a former AWARE II consultant. During August, email exchanges continued with various key informants. Once the team obtained feedback from the participants, the team drafted the report. All together, the Futures Group team obtained information from 24 people, including participants at the meeting and those interviewed subsequently (see Table 1). Table 1 provides a breakdown of the sector affiliation and sex of the contacts in Mauritania, including meeting participants and those interviewed subsequently.
Table 1. Affiliation and Sex of Key Informants in Mauritania
Sex
Men Women Total

Government Officials
4 8 10

Donors
2 0 2

Cooperating Agencies and CSOs

8 2 10

Total
14 10 24

Ethical considerations

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

Study Limitations
Not all people identified as key actors in family planning were available for the stakeholders meeting or interviews. Despite these limitations, this study provides an important baseline for repositioning family planning in the country. The invitations were sent to participants without the background documents, creating a need to spend more time with key stakeholders to complete data collection. A major constraint was the frequent rescheduling of interviews with some key informants, such as PNSR and United Nations Population Fund (UNFPA) staff. Nevertheless, the deep knowledge and dedication of key stakeholders, such as the PNSR MCH Program Coordinator, the former AWARE II consultant, and the AMPF Executive Director, contributed greatly to filling information gaps. The team spent considerable time conducting web searches to obtain some information about the involvement of other sectors in family planning.

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

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

The PNSR is the government-led entity that oversees and manages the FP/RH program. It is attached to the MS Cabinet but technically is placed under the Primary Health Care and Nutrition Directorate. The PNSR actively fulfills its role as the manager of the national FP program and collaborates with other MS structures, such as the Primary Health Care Division, the National Service of Health Information and Statistics (SNIS), and the National Pharmacy. Other cooperating mechanisms at the level of the MS are the Directorate for Planning, Coordination and Health Information (DPCIS), which is in charge of coordinating with TFPs in collaboration with the Directorate of Financial Affairs. The main partners providing funding and technical assistance to the MS for the repositioning of the family planning program are UNFPA, Agence Franaise de Dveloppement (AFD), the Spanish Cooperation, and WHO. Other government supporting entities include the General Directorate of Economic Policies and Development Strategies (Direction Gnrale des Politiques Economiques et des Stratgies de Dveloppement) and the National Population Committee, which is hosted by the Ministry of Economics and Development (MAED). There is also a National Reproductive Health Program Technical Committee placed under the MS/Directorate of Sanitary Protection (DPS). Ad-hoc technical committees on specific FP issues and the management of regional contraceptive warehouses are placed under the PNSR. The governments commitment to address rapid population growth through family planning is expressed in some major policy documents, such as the National Declaration of Population Policy promulgated in 1995, just one year after the International Conference on Population and Development (CIPD), and updated in 2005; the Strategic Framework for Economic Growth; the Strategic Framework for Poverty Reduction; the recently designed Framework for the Acceleration of the MDGs (March 2012); the PNDS (20112020); and the Strategic Plan for RH Products Security (PSSPSR). The institutional placement of the FP program has evolved since the mid-1980s from a Family Well-being Project (19881998) to the creation of a PNSR with more autonomy within the Directorate of Health. However, this level of autonomy, and the level of funding secured from the MS and technical partners, are not sufficiently reflected in the strength of the FP program, which has insufficient technical staff and requires capacity building in management, advocacy, coordination, communication, and monitoring. Other weak areas are policy and strategy development, contraceptive logistics and management, behavior change communication, supervision, and operational research.

Repositioning Family Planning in Mauritania: A Baseline Indicator 2: Evidence of documented improvement in the enabling environment for family planning, using a validated instrument

The main declarations and publications (policies, laws, and strategies) generally rely on information from reliable sources. The main information sources for Mauritania FP indicators are annual health statistics, the DHS (20002001 and 20032004), the Multiple Indicator Cluster Surveys (MICS 2007 and MICS 2011), the Family Planning Program Effort Scores (from 1982 to 2009), and the Contraceptive Security Index (2003 and 2006). These data support the emerging role given to family planning in various national instruments and orientations, even if it often is subsumed in more general RH or family health documents. Similar to most African and Arab countries, Mauritania has had a pro-natalist orientation because of the widespread preference for large families. Since the mid-1980s, however, the Mauritanian government has recognized that the integration of RH programs, including family planning, into its population policy strategies is indispensable for the socioeconomic development of its people. This principle was incorporated into the National Declaration of Population Policy, adopted on June 21, 1995, which states that couples should have the freedom to make decisions concerning the size of their families. Prior to this formal policy declaration, the Ministry of Islamic Affairs and Religious Education had authorized family planning in February 1997, under the category of birth spacing, to reflect the beliefs of the general population. The MS implemented the first FP program, the Bien Etre Familial (Family Well-being) Project, during 19881998. It was replaced by the National Reproductive Health Program in 1999. This favorable environment has encouraged the creation of several professional associations and NGOs that integrated FP into their activities: the Association des Sages-Femmes de Mauritanie (ASFM), founded in 1986; the International Planned Parenthood Federation (IPPF) affiliate, AMPF, founded in 1989; Association Mauritanienne des Gyncologues et Obsttriciens (ASMAGO), founded in 1998; Reseau des Maires pour la Sante de la Reproduction (Mayors Association for Reproductive Health), founded in 2010; and Reseau des Parlementaires Mauritaniens pour la Population et le Dveloppement (Network of Parliamentarians for Population and Development). The FP program has evolved strategically from a global vision of FP integration into RH services to overcome strong religious and cultural barriers from 19992002, to the integration of adolescent and youth RH and prevention of mother-to-child transmission of HIV (PMTCT) into the National Reproductive Health Strategy documents for 20032010, to the repositioning of family planning under a strategic plan for 20112015 and PSSPSR (20102015). Before the 2011 Ouagadougou FP conference, the repositioning decision was supported by information from a situational and gap analysis report and by the involvement of more actors, particularly networks of religious leaders. A recognized shortcoming in the area of policy is the failure to validate and promulgate the FP/RH Project of Law, which was finalized in 2007. The Family Planning Program Effort (FPE) Index was developed as an international measure to gauge key areas of each countrys FP program. Over the past 30 years, Mauritanias FPE score has fluctuated, rising from 3.5 in 1982 (indicating very little FP activity) to 31.7 in 1994, then dropping to 19.1 in 1999, rising again to 40.1 in 2004, and finally dropping dramatically, by half, to a score of 20.1 in 2009 (Ross and Smith, 2010). These scores reflect slow progress, especially in relation to policy and stage-setting activities, service delivery, and related activities. Since the highest score is 100, Mauritanias FPE score also indicates considerable room for improvement.

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Assessment Findings

Another index shows contraceptive security to be inadequate. Mauritanias score on the 2006 Contraceptive Security Index was 47.0 out of a possible score of 100 (USAID/DELIVER, 2006). While there has been some improvement in contraceptive security since 2003, when the score was 42.1, the 2006 score (the most recent one available) indicates a relatively low level of contraceptive security. While these measures provide a useful benchmark for assessing progress, the MS and FP partners in Mauritania do not seem to be aware of them.
Indicator 3: Evidence of FP policies implemented and resources allocated and subsequently used in relation to the same FP policies

Mauritania has no specific policies focusing exclusively on family planning, but it is treated as an integrated component of the larger RH program, which is based on some specific operational policy and planning documents, such as the National Reproductive Health Strategy Documents (19992002, 2003 2010, and 20112015). The strategic plans are funded under a Letter of Agreement (Lettre dAccord) between the government and UNFPA, as well as partnership agreements with the Spanish Cooperation, AFD, and WHO. FP funds are allocated annually according to annual plans approved by the Steering Committee (Comit de Pilotagesee IR2.2). The PNSRs annual action plans are guided by the strategic plan and integrate the district and regional-level plans and those of the CSOs involved in family planning. Other resources needed for family planning are met under the health system strengthening component of the larger RH program funded through cooperating agreements with TFPs. Resources are allocated for strengthening human resources, equipment, training, supervision, contraceptives, and logistics. The FP program is integrated into the minimum package of health services and is supposed to be implemented nationwide by all service delivery points. In reality, however, it is estimated that only approximately twothirds of service delivery points are implementing it. Key factors contributing to limited access to FP services are inadequate geographic access to services in urban poor and rural areas; staffing and equipment shortages in remote regions; small-scale use of long-term contraceptive methods; lack of private sector involvement; and lack of more aggressive implementation of such innovative strategies as using male nurses, CHWs, mobile teams, and task shifting. Since the 2011 Ouagadougou conference, the TFPs have made additional commitments to support repositioning FP activities. In particular, AFD has made a major commitment under its bilateral Forfait Obstetrical project. The new FP Action Plan currently being drafted is incorporating new data from the 2007 MICS and information from lessons learned by all implementers drawn from the 2011 situation and FP program gap analyses, as well as new FP initiatives and innovations. This latest FP Action Plan is supported by several partners, such as UNFPA, AFD, Spanish Cooperation, and WHO, as well as the AMPF, Medicus Mundi, and Medicos del Mundo NGOs. Despite these funding commitments, it is unlikely that the resources from the government and partners will be sufficient to meet the FP programs large technical assistance needs in the areas of policy and strategy development, capacity building, contraceptive logistics and management, behavior change communication, supervision, and operational research.

Intermediate Result 1: Resources for Family Planning Increased, Allocated, and Spent More Effectively and Equitably
The M&E Framework has four indicators related to resources for family planning:
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Repositioning Family Planning in Mauritania: A Baseline

IR1.1: Total resources spent on family planning (by source and activity/program area) IR1.2: Number of new financing mechanisms identified and tested IR1.3: Total resources allocated to family planning (by source and activity) IR1.4: New and/or increased resources are committed to family planning in the last two years The Futures Group team was unable to identify the total resources spent or allocated for family planning in Mauritania. Many resources allocated by international NGOs, communes, and local communities are not incorporated into the accounts of resources spent on family planning. There are no specific costing studies on FP activities, and the national budget expenditure analysis does not provide specific information on FP spending. The annual MS budget allocation to the PNSR to fund FP campaigns amounts to 34 million Mauritanian Ouguiya (UM) or US$9,795$13,061. In 2011, the MS announced the establishment of a specific budget line item for contraceptive commodities, but it has not yet allocated any funds. The MS manages funds from donors under the Sectoral Mid-Term Framework for Expenditures. UNFPA is the leading RH and FP donor; it procures all contraceptive commodities and provides most of the funds to support FP activities. In 2012, UNFPA provided US$350,000 for FP programs and US$350,000 for RH product security (see Table 2). UNFPA increased its allocations for contraceptive commodities from US$222,618 in 2009 to $321,850 in 2011 and US$350,000 in 2012. In its 20122016 program of assistance to Mauritania, UNFPA plans to allocate US$9.25 million to the RH package, which includes family planning, safe motherhood, and HIV prevention. Other financial resources for family planning come through bilateral or cooperative agreements with the AFD, the Spanish Cooperation, and a few NGOs, such as IPPF/AMPF. The amount of funding provided by the Spanish Cooperation and international NGOs Medicus Mundi and Medicos del Mondo is not available because it is not included in the PNSRs records. Under its newly funded Phase II Forfait Obsttrical Project, the AFD is providing US$85,320 for contraceptive procurement and staff training. The Forfait Obsttrical is a community mutual insurance scheme to reduce obstetrical risk and deliver quality prenatal, obstetrical, and postnatal services at service delivery points. Each client pays 5,000 UMs (about US$16.33, or 17 Euros) in advance. This risk-sharing scheme is based on the assumption that the 93 percent of women who have a normal birth will cover the cost of the remaining 7 percent of women who have birth complications (AFD, 2011). An assessment of the pilot program conducted in four sites during 20022007 found that the proportion of births attended by trained personnel doubled in the rural sites (Renaudin et al., 2008). Mauritanias government plans to extend this financing and service delivery mechanism nationwide by 2015. This will provide an opportunity for the promotion and expansion of FP services and information on a large scale. IPPF program funding to AMPF amounted to US$75,000 in 2009 and 2010 and dropped to US$62,000 in 20112012. IPPFs budget for contraceptive commodities decreased from US$23,038 in 2008 to US$7,337 in 2009, and a final amount of US$4,928 in 2010 as UNFPA took responsibility for contraceptive procurement. Since 2008, other donors have funded small projects implemented by AMPF under IPPF sponsorship, including the Quality of FP Services (US$45,000 in 2011), a mobile clinic providing long-term contraceptive methods in 42 villages (US$110,000 in 20092010), male involvement in family planning (US$16,780 in 2011), and contraceptives from UNFPA, for a total of US$186,780. In

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Assessment Findings

addition, the IPPF allocated $300,000 for health system strengthening (governance, advocacy, access, postabortion care, and M&E). ASMAGO provided 1 million UM (US$3,265) to FP programs. Under the March 2012 MDG Acceleration Initiative, the planned funding for family planning during 20122015 is 210 million UM (US$685,676 for the provision of long-term methods (implants and intrauterine devices or IUDs) and 150 million UM (US$489,769) for training health staff in RH/family planning. Other funding mechanisms from such parastatals as the National Social Security Agency (CNSS) and the National Mining Industry Agency (SNIM) are not captured by the PNSR, despite the large number of their facilities delivering FP services. Potential funding mechanisms are the development of contracting mechanisms with NGOs working on HIV/AIDS throughout the country, and the private sector for FP service delivery and promotion.
Table 2. Technical and Financial Partners Contributions to Family Planning, 20112012 (in US Dollars)
Name of Partner
Government Budget UNFPA/Program Funds

Financial Contributions
2010 12,027 350,000 2011 12,027 350,000 2012 12,027 350,000

Activity or Program Area

FP promotion weekly campaigns Institutional capacity development; training in technology and counseling; advocacy; behavior change communication; community health services; contraceptive procurement; training in CHANNEL, a logistics management software; medical equipment procurement; support for supervision; MICS Contraceptive procurement and security FP information and service delivery; contraceptive procurement from IPPF and UNFPA Quality of FP services; mobile clinic with service delivery in 42 villages; male involvement in family planning

UNFPA/Contraceptive Procurement AMPF/IPPF

359,884 78,000

321,850 65,000

350,000 65,000

AMPF/Small Projects

55,000

71,780

Sources: PNSR, UNFPA, AMPF; Estimated from UNFPA RH Funding Table. Country Program (CP) Performance Summary. UNFPA Report 2010 .

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Repositioning Family Planning in Mauritania: A Baseline

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

Box 2: Key National Policies and Plans that Include Family Planning The Strategic Framework for Poverty Reduction (20062010) Document of Economic and Social Policies: DPES (20112015) National Health Development Plan (PNDS 20112020) National Reproductive Health Strategy Documents (19992002; 20032010; 2011 2015) Declaration of National Population Policy (1985 and 2005) Strategy for Accelerated Growth and Sustainable Development (2007 and 20222015) Road Map for the Acceleration of Maternal and Newborn and Child Mortality Reduction (20062015) Strategic Framework for the Acceleration of the MDGs (2012) Policies, Norms, and Standards in Reproductive Health (2009) Strategic Plan for RH Products Security (20092015) Strategic Framework for HIV/AIDS and STIs

Key national strategy documents constitute the references for national health policies, including family planning (see Box 2): the Declaration of Population Policy (1995); and the two iterations of the Strategic Framework for Poverty Reduction (20012005 and 20062010), which mention increased and equal access to primary healthcare for all within a 5 km radius of a health facilityparticularly the poorest segments of the population. This document was followed by the 20112015 Document of Economic and Social Policies (DPES), which provides a rationale for the prioritization of social sectors, including health, education, and womens development. The Strategic Framework for the Acceleration of Achieving the MDGs also includes repositioning family planning as a priority intervention. This initiative was inspired by the Presidents engagement in March 2012 and aims at investing more government resources to accelerate progress toward meeting the MDG indicators by 2015. The PNDS (20112020) clearly refers to the implementation of high-impact activities, including repositioning family planning. It also includes a clear result indicator for the FP program by 2015: % of women in reproductive age requesting and using a family planning method (MS, 2011). The Road Map for the Reduction of Maternal and Neonatal Mortality (20062015) also mentions family planning.

The National RH Strategy Document (20092013) targets such strategic priorities as safe motherhood, repositioning family planning, developing youth and adolescent sexual and reproductive health, and addressing sexually transmitted infections in the framework of RH programs. In sum, family planning clearly is mentioned in national strategic and development plans, but the nature of its integration into RH programs is hindering its full development as a program. 14

Assessment Findings IR2.2: Evidence of governments engaging multiple sectors in FP activities

The Mauritanian government has set up coordination mechanisms to engage multiple sectors in FP activities. These mechanisms include the following: Multisectoral Population Committee, managed by MAED, that functions only on an ad hoc basis Multisectoral Committee for the Reduction of Maternal, Neonatal, and Child Mortality, led by the MS/DPS Technical and Financial Partners Group, coordinated by MS/DPCIS, that monitors the implementation of the PNDS Steering Committee, managed by the PNSR, that meets twice annually to review the FP/RH program (committee includes staff from the PNSR, MS/DPS, SNIS, National Council to Combat AIDS and Sexually Transmitted Infections (CNLS-IST), MAED, Ministry of Social, Child and Family Affairs, partners, and one NGO representative) The RH Security Committee, which meets every six months The PNSRs multisectoral approach is more visible during the preparation of annual FP campaigns, with the involvement of two parastatal organizations (SNIM and CNSS) and CSOs, such as the Association des Imams et Erudits de Mauritanie (Imams/Ulemas Network for Family Planning/Birth Spacing), Le Reseau des Maires pour la Sante de la Reproduction (Mayors Association for Reproductive Health), and Le Reseau des Journalistes en Population (the Journalists Network for Population). Nevertheless, the PNSR and all other stakeholders recognize that these national multisectoral coordination mechanisms do not function adequately. The PNSR is not yet coordinating programs effectively with CSOs and the private sector. The few CSOs working in family planning also lack a mechanism for coordination. The PNDS (20112020) has an innovative approach to involve CSOs and the private sector in preventive health services and promotion through contracting out services. A few NGOs and associations are actively involved in pilot testing the Strategic Plan for RH Products Security; they also were active in developing the post-Ouagadougou Action Plan for repositioning family planning.

Box 3: Existing Laws and Conventions for the Involvement of NGOs and the Private Sector in FP Policy National STI/HIV&AIDS Multisectoral Plan (20112015) Partnership and Contractualization Guide between Ministry of Health and NGOs (2002) RH Product Security Technical Committee Reports

All parties express the desire for more organized and active involvement from CSOs and the private sector, but they recognize that the small number of groups working in family planning have limited organizational capacity and so cannot yet be full partners in FP programs. The weaknesses that affect their participation in existing coordination mechanisms are insufficient technical staff to network with other groups and lack of effective leadership. CSOs need dedicated leaders capable of bringing their voices to the partnership table.

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Repositioning Family Planning in Mauritania: A Baseline IR2.3: Evidence of multisectoral structures that are established or strengthened to promote FP policy

The PNSR is fully responsible for the development, coordination, and monitoring of FP policies; implementation devolves to the DRAS that support the district operational level. The PNSR hosts a technical committee that meets on an ad hoc basis to prepare FP/RH plans and technical documents. These documents are validated by a steering committee comprising PNSR managers and partners, which meets every six months. The newly established RH Commodity Product Security Committee meets every six months at the PNSR. The National Strategy for Reproductive Health Commodity Security was adopted in 2009, and a procedural manual has been developed. These documents were disseminated to all levels of the health system and all partners. A pharmaceutical law, including RH commodities, has been adopted and a draft law on RH is under review. However, the PNSRs multisectoral coordination function is not reinforced and decentralized at the regional and district levels. Multisectoral coordination could be more effective with the active involvement of other sectors, such as Reseau des Parlementaires Mauritaniens pour la Population et le Dveloppement (Network of Parliamentarians for Population and Development), additional TFPs and international NGOs, and parastatals implementing FP activities (SNIM and CNSS), coupled with more community participation. There is no organized network of CSOs for the promotion of FP/RH, but Association des Imams et Erudits de Mauritanie (Imams/Ulemas Network for Family Planning/Birth Spacing), Le Reseau des Journalistes en Population (Network of Journalists for Population and Development), and Le Reseau des Maires pour la Sante de la Reproduction (Mayors Association for Reproductive Health) are particularly active in advocacy and promotion of family planning to raise political awareness further and combat sociocultural and religious barriers. The Thematic Group on Family Planning, created after the 2011 Ouagadougou Family Planning Conference, was very active in the elaboration of the post-Ouagadougou Family Planning Plan of Action and remains available for consultations with PNSR.
IR2.4: Evidence of government support for private sector participation in family planning

There is a favorable environment for the participation of the private sector in family planning and a recognized role for CSOs in development work, as affirmed by the PNDS 20112020 policy declaration, which states that the private sector needs to be involved in partnership with other service providers to improve access to FP services and information (MS, 2011). The government offers easy methods for the procurement of recepisses (receipts) from CSOs, and the regulations to set up NGOs are not burdensome. The PNSR provides ad hoc financial support to NGOs for some activities, particularly during FP campaigns. Since 1989, AMPF, the IPPF affiliate, has been the second largest FP service provider in the country (after the MS). It covers five of the 13 regions in the country, with fixed service delivery and education centers and a mobile team for remote areas. AMPF coordinates its interventions at the regional level with the DRAS, local NGOs, health worker networks, and women and youth groups. The for-profit private health sector (clinics and pharmacies) is not officially involved as a partner in FP programs. The PNSR needs to tap into the opportunity offered by this growing sector for the expansion of the FP program.

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Assessment Findings

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

Many national policies and strategies are references for the priority given to the promotion of improved access to FP services and information. Since 2005, increased FP awareness among policymakers has been reflected in new policy documents. Among them are the National Health and Social Development Policy (20052015); the PNDS (20112020); the Reproductive Health Strategic Plan (20122015); the Road Map for the Acceleration of the Reduction of Maternal, Newborn, and Child Mortality (20062015); the Policies, Norms, and Standards (PNP 2009); the Reproductive Health Products Security Plan (2009); and the Annual Health Expenditures Plan under the Sectoral Mid-term Framework for Expenditures. In addition to these plans and strategies, the FP/RH political environment has been consolidated by the existence of a National Population Policy, first elaborated in 1995 and updated in 2005, and a National Gender Strategy (2008), which integrated an FP/RH component and the adoption of specific laws regarding RH and HIV and AIDS in 2007. Despite this important list of policy and strategy documents and plans, one of the major policy issues hindering the full development of FP programs is the delay in adopting the RH Law and other policy-related documents that would facilitate a stronger government response to the needs of individuals and couples to access affordable, equitable, and high-quality FP services and information. The RH Law was drafted in 2007, but the National Assembly has not yet voted on it.
IR3.2: Existence of national or subnational policies or strategic plans that promote access to FP services and information for under-served populations

Box 4: Youth and Adolescent Policy and Strategy Documents National Youth Policy (2004) Policies, Norms, and Standards for Youth RH Services (PNP/YRH, 2009) Youth and Adolescent Reproductive Health Strategy (2005) Collection of legislative documents and regulations on reproductive health and family planning

Several documents show through the following that underserved populations and specific groups are recognized in strategic plans that promote access to FP services and information (see Box 4):

The integration of youth and adolescent RH and PMTCT into the National Reproductive Health Strategy for 20032010 (with its three priorities: reduction of maternal and perinatal mortality, birth spacing, and youth reproductive health) The existence of a National Youth Policy (2004), a Youth and Adolescent Reproductive Health Strategy (2005), and the Policies, Norms, and Standards for Youth RH Services that have been integrated into the National RH Policies, Norms, and Standards document, last revised in 2009 The district and regional plans and NGOs five-year strategic plans and annual plans also are integrated into PNSRs plans.

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Repositioning Family Planning in Mauritania: A Baseline

It is noteworthy that more and more local communities are contributing to the funding of primary healthcare, including family planning. Also, the annual plans of the Wilayas (regions) are integrated into the PNSRs annual plan. In addition, a network of centers for youth and adolescents, mostly based in urban areas, is occasionally used for the promotion of family planning, RH, and HIV prevention. These centers are managed by the Ministry of Culture, Youth, and Sports. Other government sectors that include promotion of family planning in their strategies are the Ministry of Education and the Ministry of Social, Child, and Family Affairs. Community-based distribution of contraceptives is at a nascent stage in Mauritania. Initially, NGO peer educators provided condoms at the community level as part of HIV prevention programs. In 2009, a program in 48 villages of the southern Trarza region introduced community distribution of pills, condoms, and spermicides by trained male and female community-based agents. These agents also raise public awareness about the importance of family planning, vaccinations, proper nutrition, hygiene and sanitation, malaria treatment, and drugs to combat tropical diseases. Specific needs for people living with HIV are included in the PMTCT Policy and Recommendations document, with its objective 2 to Prevent unwanted pregnancies by encouraging and offering FP methods to HIV-positive women in order to help them avoid unwanted pregnancies (MS, 2006). A few NGOs implement specific initiatives targeting vulnerable groups, such as people with disabilities, lowincome groups, and women and adolescent victims of rape, but these initiatives are small and not integrated into national intervention schemes. The lack of an aggressive strategy to engage men and other influential groups is a key factor that hinders access to FP services and information. The vast network of peer educators managed by CSOs working in HIV prevention provides an opportunity to reach more people with FP information and condoms. The fistula program and other well-developed maternal and child programs, such as the Forfait obstetrical project, also offer strong opportunities to extend FP services to targeted women and their families.
IR3.3: Documentation of instances in which a formal implementation or operational directive or plan is issued to accompany a national or subnational FP policy
Box 5: Operational Directives or Plans to Facilitate FP Policy Letter of Agreement between MS and UNFPA (2011) Verbal Note #221/21 12 from the Ministry of Foreign Affairs and Cooperation (2011) Letter of Agreement between the MS and Organon Laboratories to introduce Implanon Fatwa or legal directive of the Ministry of Islamic Affairs stipulating that Islam is not opposed to birth spacing (2001) Advocacy tool on Islam and Family Planning/Birth Spacing intended to remove religious barriers to family planning

The FP program is implemented through many directives and operational plans, such as the Family Planning National Action Plan, which integrates decentralized district and regional plans; the PSSPSR; and the action plans of development partners and NGOs. In addition, the new consolidated Family Planning Action Plan (20112015), which was prepared after the Ouagadougou and Mbour, Senegal, conferences, has been finalized.

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Assessment Findings

Other directives facilitating the implementation of the FP program are the signed Letter of Agreement between MS and UNFPA (2011) for the execution of the FP program in 39 districts; Verbal Note #221/21 12, 2011 from the Ministry of Foreign Affairs and Cooperation, authorizing UNFPA to import medical products, including contraceptive products, into the country; the Note authorizing midwives to provide family planning, which is included in the Policy, Norms, and Standards (2009); the National Supervision Guide for FP/RH activities; and the Fatwa or legal directive of the Ministry of Islamic Affairs stipulating that Islam is not opposed to birth spacing (2001). Also, the MS recently signed a Letter of Agreement with Organon Laboratories to introduce Implanon (a contraceptive implant) in two regions and authorize its sale (see Box 5).
IR3.4: Evidence that policy barriers to access to FP services and information have been identified and/or removed

A situational analysis of barriers and unmet needs related to family planning, prepared for the 2011 Ouagadougou FP Conference, has helped to clarify key issues. In 2010, UNFPA funded a study on legal, social, and cultural aspects of RH in Mauritania (Kuyu, 2010). The study concluded that negative attitudes toward family planning remain strong in Mauritania. The situational analysis identified the main factors as religious opposition, sociocultural resistance, and medical barriers (based on unnecessary restrictions that do not protect womens health, such as requiring spousal consent for a woman to obtain FP services). Another important barrier at the district level is the difficulty of setting up and delivering FP services and ensuring that service delivery is consistent throughout each district. This difficulty is reflected in the urgent need for health system strengthening, particularly in the areas of staffing, equipment, and supervision. Even with provision of contraceptives free of charge, many people still lack adequate access to FP services, since 30 percent of the people live more than 5 km from a health facility. Other vulnerable groups, such as youth and unmarried women, have difficulty in obtaining FP services that meet their needs and are provided in a supportive and nonjudgmental manner. Some health providers have negative attitudes toward family planning in general or specific methods. For example, some health providers mistakenly believe that the IUD can cause abortions, so they refuse to provide it. Other initiatives to address barriers to FP use are the following: Use of the advocacy tool developed by the AWARE II project on Islam and Family Planning/Birth Spacing in three regions in 2011 to remove religious barriers to family planning Training-of-trainers workshops on family planning conducted in 2011 by the AWARE II project The governments policy of allowing contraceptive services to be provided free of charge Integration of family planning into the training curricula of the School of Midwifery in 1993 Increased radio and TV broadcasts and debates on family planning Organization of a week-long FP campaign every year, with broad participation by CSOs The agreement between the MS and Organon Laboratories to introduce Implanon Despite the strong arsenal of policy and strategy documents and plans, a major factor hindering the full development of FP programs is the delay in approving the RH Law. This law, adopted by nine francophone African countries during 20002010, would allow a more effective response to the needs of individuals and couples to access affordable, equitable, and high-quality FP services and information.

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Repositioning Family Planning in Mauritania: A Baseline IR 3.5: Evidence of the implementation of policies that promote FP services and information

The Mauritanian government is offering FP services as an integrated component of the minimum package of services in at least two-thirds of the national public health service delivery system. However, less than half of the service delivery points provide FP services. By providing contraceptives free of charge, the government is supporting broader access to FP services and information. The MS also has begun to expand the array of FP methods available by providing long-term methods such as IUDs and implants. Currently, the MS/PNSR and its partners are pilot testing community-based provision of contraceptives and provision of long-term contraceptive methods in two regions. Once the pilot testing has been completed, it is expected that these innovations will be scaled up quickly nationally. The FP Multisectoral Working Group has organized a week-long FP campaign every year since 2003, with strong CSO participation. The campaign is based on the National Communication Plan for the Promotion of Family Planning, which was piloted by the PNSR in collaboration with other MS services and partners. In addition, the MS provides free supplies of contraceptive products to NGOs and parastatals (SNIM and CNSS). This support to the private sector shows that existing policies to promote FP services and information are being implemented. One factor affecting contraceptive supplies is that contraceptive products are not integrated into the formal drug distribution system. CAMEC (Centrale dAchat des Medicaments Essentiels et Consommables), a public institution with commercial and industrial status, is in charge of purchasing and distributing all essential drugs, including antiretroviral (ARV) drugs, for the country. However, its role in the FP program is limited to the storage of contraceptive products. Although CAMECs management system is challenged by contraceptive shortages and many other problems, there is an urgent need to integrate FP products into CAMECs mechanism. The MS is planning to ensure progressively the financial autonomy of CAMEC for the procurement and distribution of FP/RH products under the PSSPSR. It is expected that the training of CAMEC staff in CHANNEL, funded by UNFPA, will facilitate this integration and that CAMEC will assist in strengthening regional storage systems.

Intermediate Result 4: Evidence-based Data or Information Used to Inform Policy Dialogue, Policy Development, Planning, Resource Allocation, Budgeting, Advocacy, Program Design, Guidelines, Regulations, and Program Improvement and Management
IR4.1: Evidence of data or information used to support repositioning FP efforts

The PNSR and its partners use the DHS 20002001, the MICS 2007 and 2011, and SNIS annual reports as the main sources of information in supporting repositioning FP efforts. In addition to data from these sources, additional data from other ministries (economy, education, agriculture, etc.) were used to design the religious leaders advocacy tool Islam and Family Planning/Birth Spacing as well as the Argumentaire Religieux for RH/Family Planning, which was finalized with the Ministry of Islamic Affairs and used in two regions. Main strategies and plans such as the PNDS (20112020), the National Reproductive Health Strategy Documents (20112015), the National RH Products Security Strategy (20102015), and the post-Ouagadougou Family Planning Action Plan have used data from these sources and other assessment reports, including the MDG Situation Analysis 2010 report, the FP Situational Analysis, and the Analysis of the RH/Family Planning Sociocultural and Legal Environment (2010).

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Assessment Findings IR4.2: Evidence of international best practices incorporated into national health standards

The Policies, Norms, and Standards for RH were revised in 2009 to review standards and incorporate new best practices, such as the promotion of long-term FP methods at service delivery points, the introduction of injectables in community outreach services, and male involvement. The promotion of long-term methods began in 2005 with a single limited supply of IUDs and implants from UNFPA. Since 2010, Implanon has been offered in two regions. Another large-scale best practice is the promotion of dual protection through a large network of peer educators in the framework of HIV prevention by NGOs and professional associations. FP counseling and service delivery also is integrated into the PMTCT program. The PNSR encourages task shifting and training of male nurses to manage health facilities as well as the use of community health workers to provide contraceptives and information. Nevertheless, although best practices may be incorporated into national plans and norms, these actions are insufficient to support the repositioning FP initiative. The PNSR needs to improve advocacy to obtain more resources from the government and other partners to make sure that these best practices will be implemented at all of the levels cited in the RH Strategic Plan, including the private sector and community levels. Efforts to implement long-term methods and other proven best practices on a larger scale need to be strengthened.
IR4.3: Evidence of a defined and funded research agenda in family planning

There is no structured research program for family planning in Mauritania. The existing Institute of Research in Public Health does not include family planning in its research agenda. Family planning is not a high priority in the research agenda of the MS/Directorate of Planning, Cooperation and Health Information, which is in charge of implementing specific research and studies. However, many of the implemented studies and assessment activities are based on programmatic needs, and the MS shares the results with the PNSR and other stakeholders. Most of these studies are done by internal or external experts funded by UNFPA. Health training schools do generate a few FP-specific research themes and some relevant reports and dissertations.
IR4.4: Evidence of in-country organizational technical capacity for the collection, analysis, and communication of FP information

Key government structures that have benefitted from capacity building to strengthen collection, analysis, and communication of FP information are the National Statistics Office (ONS/MAED), which specializes in census and population studies; the National Service of Health Information, which produces the Annual Statistics Compendium (Annuaire des Statistiques Sanitaires); the National Directorate of Population (MAED); the PNSR, which organizes mid-term and final reviews with UNFPA and partners; and the MS annual review for all of its programs, including family planning. These structures contribute to the analysis of health information, the steering committees that oversee population and FP/RH studies (DHS and MICS), and dissemination of evaluation and assessment reports. However, the Regional Directorates of Health and district offices have a limited capacity to collect, analyze, and communicate FP information. These decentralized structures rely on decisions and directions from the PNSR.

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Repositioning Family Planning in Mauritania: A Baseline

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

With capacity-building assistance from development partners, the PNSR has acquired improved capacity in management, planning, training, supervision, and M&E. In addition, the PNSR is capable of managing contraceptive commodities. However, the PNSR needs to improve its capacity in the areas of human resource management, coordination, advocacy, and resource mobilization. Major improvements also are needed in PNSRs capacity to do program planning, budgeting, resource mobilization, and supervision of the Regional Directorates of Health and district offices. Major local NGOs, such as AMPF, SOS Peer Educators, and Sant sans Frontieres, have strong capacities to plan programs and mobilize resources, as well as implement FP programs in decentralized regions. AMPF has received technical assistance from IPPF and now can mobilize resources independently from other sources and implement repositioning FP programs.
IR5.2: Evidence of government departments or other entities established or strengthened to support the FP agenda

The Mauritanian government has created and/or strengthened many departments and other entities to support the FP agenda, as discussed in other sections of this report. Examples of these departments and other entities include the following: The MS/PNSR and its bureaus. The PNSR has a clear mandate and responsibility for the conception and development of policies and directives on family planning, coordination and monitoring of all FP activities, and coordination with all other FP implementers. Planning, implementation, coordination, and monitoring functions are decentralized to the DRAS, which ensures the implementation of family planning and all other health activities in the 13 regions of the country. National Coordination of Population Activities led by MAED. Multisectoral Committee for the Reduction of Maternal, Neonatal, and Child Mortality, led by the MS/Directorate of Health. RH Thematic Groups. Centers for Youth, created by the Ministry for Youth and Sports. Gender Directorate/Ministry of Social Affairs, Children, and Family. The Armys central directorate for health and social services. MS/Directorate of Pharmacies and Laboratories, which defines and manages the medical supply system in Mauritania. MS/CAMEC. Created in 1989 as a public establishment with industrial and commercial attributes, CAMEC is charged with the acquisition and distribution of essential drugs and supervision of regional stores, among other responsibilities.

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Assessment Findings

Parastatals, such as SNIM and its clinics, and National Social Security Agency and its health facilities. Training schools, such as the medical, midwifery, and nursing schools. Networks, such as Association des Imams et Erudits de Mauritanie (Imams/Ulemas Network for Family Planning/Birth Spacing), Le Reseau des Journalistes en Population (Network of Journalists for Population and Development), and Le Reseau des Maires pour la Sante de la Reproduction (Mayors Association for Reproductive Health), and Reseau des Parlementaires Mauritaniens pour la Population et le Dveloppement (Network of Parliamentarians for Population and Development). CSOs, including AMPF and other NGOs involved in such FP campaigns as Association Mauritanienne dAide aux Malades Indigents, Association Mauritanienne pour la Sant de la Mre et de lEnfant, CARITAS, Association pour le Dveloppement Communautaire, and Sant sans Frontieres. Professional associations, such as the ASFM and ASMAGO, are involved in some advocacy activities in support of family planning. All of these groups have benefitted from some training and/or specific support in implementing specific FP activities, such as service provision, advocacy, and information and FP communication.
IR5.3: Evidence of targeted public and private sector officials, faith-based organizations, or community leaders publicly demonstrating new or increased commitment to family planning

The President of the Republic indicated his commitment to reproductive health in March 2012, when he created a Multisectoral Committee to Accelerate Achievement of the MDGs under the Cabinet. The committee is in charge of establishing a roadmap and defining needed additional resources to improve the MDG indicators by 2015. The planned funding for family planning under this initiative is 210 million UM (US$687,000) for the provision of long-term methods (implants and IUDs) and 150 Million UM (US$489,000) for health staff training in reproductive health and family planning. The training of religious leaders as champions in Mauritania has been a principal focus of the USAID Regional Project/AWARE II; UNFPA has supported the implementation of its advocacy tool in three regions. Members of Association des Imams et Erudits de Mauritanie (Imams/Ulemas Network for Family Planning/Birth Spacing) have delivered sermons in public places and in their mosques using the advocacy tool Islam and Family Planning/Birth Spacing: lArgumentaire Religieux, thus demonstrating the non-opposition of Islam to family planning. They have also appeared on radio and television. Members of professional associations have also participated in debates about family planning on radio and television, and these appearances have increased over the last year. Local FP champions have made declarations during FP campaigns, but their reach and impact are limited. FP supporters need to reinforce documentation and dissemination of these declarations to encourage other religious and community leaders to engage as champions and expand community-level advocacy activities. Strengthening emerging local FP champions, such as the members of Reseau des Maires pour la Sante de la Reproduction (Mayors Association for Reproductive Health), should be a high priority.

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Repositioning Family Planning in Mauritania: A Baseline IR5.4: Number of regional/national centers or collaboratives for shared education and research in family planning

The team did not find evidence of such centers in Mauritania. The competencies of the National Public Health Research Institute are not used for RH and family planning.

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RECOMMENDATIONS FOR REPOSITIONING FP IN MAURITANIA

Mauritania has significant opportunities for taking advantage of the favorable policy environment surrounding the finalization of the repositioning FP program, particularly the Presidents decision to commit more state resources for the initiatives so as to accelerate progress in achieving the MDGs. Strong policies are in place, and most of them have been revised recently. The active involvement of stakeholders in preparing the post-Ouagadougou conference FP Action Plan indicates that momentum to support the repositioning FP initiative is strong. The UNFPA and AFD have committed funds to expand provision of family planning, including long-term methods, in the majority of health districts. Other promising factors are the governments efforts to support womens advancement and gender equity and the progress toward gender equity in primary education enrollment. Still, it must be acknowledged that the government faces the challenge of improving its institutional and financial capacity to sustain the repositioning FP initiative. The Futures Group team has compiled the following recommendations made by the key informants during the working meeting and in subsequent interviews:
1. Improve the institutional capacity and leadership of the PNSR. The MS should provide

adequate staffing and financial resources to the FP program and strengthen the capacity of its staff, particularly in the areas of coordination, advocacy, supervision, and M&E. The MS should also instill the necessary management and leadership capacities in the Regional Directorates of Health and district offices by strengthening their planning, management, and M&E functions.
2. Increase funding for FP programs in the national budget and from donors. The

government needs to fulfill its strong commitment to improve the MDG indicators, including FP use, by increasing its budget allocation to family planning. The MS and the PNSR need to direct strong advocacy efforts for increased funding from development partners, international NGOs, and industrial and mining partners and companies. The PNSR needs to reinforce advocacy activities by engaging more CSOs and the medical and pharmaceutical private sector in family planning and RH in general. The MSs decision to open a budget line for contraceptives must be fulfilled through a progressive increase to ensure long-term sustainability. The MS must integrate contraceptive products into the national drug distribution system, and this system needs to be reinforced to meet the management requirements of the Strategic Plan for FP/RH Products Security and implement the necessary activities.
3. Strengthen multisectoral coordination of repositioning family planning. The MS needs

to strengthen multisectoral coordination at the national level and between the PNSR and other stakeholders. The partners and stakeholders expect the PNSR to lead a functioning multisectoral coordination mechanism, and this need should be met as soon as possible. Such a mechanism will help the PNSR to maintain and capitalize on the enthusiasm and motivation among stakeholders generated in the process of preparing the FP Action Plan after the 2011 Ouagadougou FP conference. Regional Directorates of Health and district offices need to strengthen their capacity to coordinate various activities, mobilize more resources, and foster community participation. Stronger multisectoral coordination will offer the opportunity to involve the many CSOs working in HIV and AIDS programs in FP/RH activities.

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Repositioning Family Planning in Mauritania: A Baseline 4. Strengthen staff capacity to manage and deliver FP services. The MS should revise its

policies, norms, and standards to incorporate the latest best practices. By using tutoring, formative supervision, exchange of experiences, and other continuing education methods, the MS should seek to improve providers attitudes toward family planning and increase their knowledge of contraceptive technology.
5. Make FP services universally available. The MS should scale up successful FP approaches,

including offering injectable contraceptives in community-based programs, particularly in suburban areas; making long-term contraceptive methods available at all health facilities; providing FP services in rural areas, using mobile teams; shifting some tasks from health professionals to trained paraprofessionals; educating males about family planning and engaging them in FP programs; promoting public-private sector partnerships; and contracting with CSOs and the private sector to extend the reach of government services.
6. Advocate for adoption of the RH Law and funding increases. FP stakeholders need to

increase their advocacy to policymakers and decisionmakers at all levels to secure passage of the RH Law and other relevant policies and raise funding for FP programs. FP stakeholders also need to strengthen the various networks, including Reseau des Maires pour la Sant de la Reproduction.
7. Cultivate and support FP champions at all levels. Advocacy by FP champions that people

know, respect, and trust is key to increasing demand for and use of FP services. Mauritania already has some champions among its religious and civil society leaders, mostly at the national level. FP stakeholders need to identify, train, and support additional championsespecially among women and youthat the national, regional, and local levels. By documenting and disseminating declarations of champions and celebrating their accomplishments, FP stakeholders can expand the group of champions and thus make advocacy initiatives more effective.

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ANNEX 1: WORKSHOP PARTICIPANTS AND PERSONS INTERVIEWED

Name
Diop Aliou Abdoul Ibrahim Ould Ahmedou Cheikh Babah Ould Ahmed Babou Melainine Moukhtar Nech Dr Mahfoud Ould Boye Dr Msamed Lemine O/ Cheikh Dr Boubacar Abdoul Aziz Abdi Abdelwaheb Lierni Galdos Thierno Ousmane Coulibaly Aichetou Mint Ahmed Dr Kane Amadou Racine Couro Kane Aicha Mint Mbareck Mariem Mint Bellahi Mimi Mint Moulaye Cherif Fatimetou Kone Mahmouden Ould Hally Zeinabou Mint Msemd Lemine Fatimetou Mint Moulaye Rajel Ould Nemi Cheftan Ould Dihah Dr. Salla Ndoungou Ba Racine Kane, Former USAID/Aware II Consultant Assistant Tech. Responsable Programme Unfpa Assistant Representative And Rh Coordinator Sfe Consultant Aaf Sfe/Ansm Sfe Sfe Sfe Unite Iec Sfe Chief Of Mch Bureau, Pnsr Deputy Coordinator Ide Sg Coordinatrice Former USAID/Aware II Consultant

Title
President Executive Director Depute D.R Coordinateur Dras

Affiliation
Sos Peer Educators Ampf Rpp.Dan Ong Suport Ms/Pnsr Rosso Oms Aecid Aecid Unfpa Dras Nktt Mauritanian Midwifery Association Nktt Pnsr Ssf Pnsr Pnsr Pnsr Pnsr Amdsfe Ms/Pnsr Pnsr Amsdfeh Cnls-Ist Aware II

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ANNEX 2: REPOSITIONING FAMILY PLANNING RESULTS AND INDICATORS FOR MAURITANIA

Indicators Information Indicator Source

Strategic Objective: Increased stewardship of and strengthened enabling environment for effective, equitable, and sustainable FP programming SO.1: Instances of a governmentled council, coalition, or entity that oversees and actively manages the FP program PNSR, attached to the MS Cabinet but technically is placed under the Primary Health Care and Nutrition Directorate PNSR Technical Committee, placed under the MS Directorate of Sanitary Protection Ad hoc technical committees on specific FP issues Regional contraceptive warehouses General Directorate of Economic Policies and Development Strategies MAED SO.2: Evidence of documented improvement in the enabling environment for FP, using a validated instrument Government official authorization of FP with birth spacing Creation of the PNSR in 1999, replacing the first program, Bien Etre Familial Creation of associations and NGOs in support of FP: ASFM (1986); AMPF/IPPF (1989); ASMAGO (1998); Reseau des Maires pour la Sant de la Reproduction (2010) Reseau des Parlementaires Mauritaniens pour la Population et le Dveloppement (Network of Parliamentarians for Population and Development) Strategic Plan for RH Products Security 2010 RH Project of Law, finalized since 2007 but not yet adopted Letter of Minister of Islamic Orientation authorizing birth spacing (February 1986) Report of the 1st national workshop for the launch of FP/BS Rcpiss authorizing creation of associations and NGOs Strategy doc/Archives PNSR SNIS/site du ministre: www.ms.mr 3: Evidence of FP policies implemented and resources allocated and subsequently used in relation to the same FP policies National Reproductive Health Strategy Documents (1999 2002, 20032010, and 20112015), with annual action plans Partnership Agreements with technical and financial partners (UNFPA, Spanish Cooperation, AFD, WHO) Convention between PNSR and NGOs (Medicus Mundi, Medicos del Mondo, AMPF). Protocol of Agreement between the MS and NGOs National FP Action Plan, post-Ouagadougou conference, with a strong representation from CSOs Lettre dAccord (Letter of Agreement) # MRT7U204/2012 between the government and UNFPA, stipulating the responsibilities of the two parties for the execution of the FP/RH program in 39 districts Arrte # 19477/MS of January 24, 2012, creating a National Reproductive Health Program to amplify the 1999 MS decision Arrte ministerial

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

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Annex 2: Repositioning Family Planning Results and Indicators for Mauritania

Indicators IR1.1: Total resources spent on FP (by source and activity/program area)

Information

Indicator Source DPCIS/MS National Health Accounts, 20082010

Provisional Budget for the five-year RH Strategic Plan provided by government and UNFPA; funding allocated each year to the annual plan State Budget: providing direct funding for FP campaigns: 3 4 million UM (US$9,795$13,061) Funding from donors (UNFPA, Spanish Cooperation, AFD, WHO) managed by MS under the Sectoral Mid-Term Framework for Expenditures Funding from international NGOs (IPPF, Medicus Mundi, Medicos del Mundo) not captured by the PNSR

IR1.2: Number of new financing mechanisms for FP identified and tested IR1.3: Total resources allocated to FP (by source and activity)

Free distribution of contraceptives in public health structures Forfait Obstetrical Project: an RH financing mechanism funded by AFD; its Phase II includes FP activities

Key informants

State budget to PNSR: 34 million UM for FP campaigns UNFPA: 20102012: $350,000/Year $350,000$ for RH product security in 2012 AMPF: From IPPF for FP activities: $65,000 in 2012; other funding for FP projects has totaled US$186,780 since 2008; IPPF allocated US$300,000 for health systems strengthening AFD/Forfait Obstetrical Phase II: US$85,320 for contraceptive procurement and staff training ASMAGO: 1 million UM (US$3,265) Bilateral Spanish Cooperation and NGOs Medicus Mundi and Medicos del Mondo, not captured by PNSR

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

State budget line for contraceptives not yet funded. Increased contribution from UNFPA; decreased AMPF funding from IPPF (10%), but AMPF receives support from IPPF to access other small grants New funding from AFP/Forfait Obstetrical Phase II: US$85,320 New funding expected from the Accelerated MDG Program during 20122015: 210 million UM for long-term methods and 150 million UM for training health staff in FP/RH

Key informants Strategic Framework for the Acceleration of the MDGs 2012

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Repositioning Family Planning in Mauritania: A Baseline

Indicators

Information

Indicator Source

IR 2: Increased multisectoral coordination in the design, implementation, and financing of FP policies and programs IR2.1: Evidence of FP programs incorporated into national strategic and development plans Three key national strategy documents constitute the references for national health policies; the Strategic Framework for Poverty Reduction (20012005 and 2006 2010), which mentions access to primary healthcare (PHC), including FP; this document was superseded by the 2011 2015 DPES PNDS 20112020, which clearly refers to activities for strengthening repositioning family planning National RH Strategy 20092013 Road Map for the Reduction of Maternal and Neonatal Mortality 20062015, which has not yet been implemented RH Products Security Plan, finalized in 2010 Declaration of Population Policy (1995) Repositioning FP has been included as a priority intervention in the Strategic Framework for the Acceleration of the MDGs IR2.2: Evidence of governments engaging multiple sectors in FP activities Government has set up mechanisms to engage multiple sectors in FP activities and coordinates several committees, including the Multisectoral Population Committee; a Steering Committee that reviews the FP/RH program; the Multisectoral Committee for the Reduction of Maternal, Neonatal, and Child Mortality; and the Technical and Financial Partners Group MS has signed agreements with SNIM and CNSS for provision of PHC, including FP/RH Annual FP campaigns involve CSOs, SNIM, CNSS, and networks of Imams/Ulemas, mayors, and journalists MS/PNSR MS/DSSP CSLP DPES PNDS PNSR DPCIS/MS Ministry of Economics and Development (Brahim Vall, UNFPA)

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Annex 2: Repositioning Family Planning Results and Indicators for Mauritania

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

Information

Indicator Source Arrte and decisions specifying the functions of MS services Minutes of meetings, agendas, and calls for meetings Meeting notes Key informants Reports on FP advocacy and campaigns

PNSR is responsible for the development, coordination, and monitoring of FP policies; implementation devolves to DRAS that support the operational level PNSR hosts a Technical Committee that prepares FP/RH plans and technical documents, which are validated by the Steering Committee, comprising PNSR managers and partners; Steering Committee meets twice annually to review the FP/RH program National Strategy for RH Commodity Security has been adopted and documents disseminated to the health sector and partners RH Products Security Committee meets every six months Thematic Group on FP, created after the 2011 Ouagadougou FP conference, was very active in developing the FP Plan of Action PNSR initiates meetings with several groups during the planning for FP campaigns and specific advocacy activities; the main groups are SNIM, CNSS, Imans/Ulemas Network for Reproductive Health, Mayors Association for Reproductive Health, and Journalists Network for Population

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

Favorable environment for private sector participation in family planning and a recognized role for CSOs PNDS 20112020 policy declaration affirms that the private sector needs to be involved in improving access to FP services and information Government has mechanisms for CSOs to obtain funding, and the regulations to set up NGOs are not burdensome PNSR provides ad hoc financial support to NGOs for some activities, particularly during FP campaigns Private clinics and pharmacies are not officially involved as partners in FP programs

Review of PNDS 2011 2020 Declaration of the National Health Policy Texts and documents authorizing private sector participation MS FP Action plans; reports, meeting agendas, etc.

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Repositioning Family Planning in Mauritania: A Baseline

Indicators

Information

Indicator Source

IR 3: Policies that improve equitable and affordable access to high-quality FP services and information adopted and put into place IR3.1: Existence of national or subnational policies or strategic plans that promote access to FP services and information Relevant policies and plans are National Health and Social Development Policy 20052015; PNDS (20112020); Reproductive Health Strategic Plan (20122015); Road Map for the Acceleration of the Reduction of Maternal, Newborn, and Child Mortality (20062015); Policies, Norms, and Standards (2009); RH Products Security Plan (2009); Annual Health Expenditures Plan under the Sectoral MidTerm Framework for Expenditures; National Population Policy (2005); and National Gender Strategy (2008) PNSR manages contraceptive distribution at all levels, including the most peripheral and coordinates with the NGOs and other parastatals delivering FP services RH Law was drafted in 2007, but the National Assembly has not voted on it IR3.2: Existence of national or subnational policies or strategic plans that promote access to FP services and information for under-served populations National Youth Policy (2004) and the Youth and Adolescent Reproductive Health Strategy (2005) provide guidance for programs Youth and adolescent RH and PMTCT have been integrated into the National RH Strategy for 20032010 Youth norms and standards have been integrated into the National RH Policies, Norms, and Standards (2009) District and regional annual plans and NGOs five-year strategic plan and annual plans are integrated into the PNSRs annual plan; FP promotion is included in the strategies of the Ministry of Education and the Ministry of Social, Child, and Family Affairs Local communities are contributing to the funding of PHC, including FP, in their communes Community-based distribution of contraceptives is being piloted in 48 villages in the Southern Region of Trarza A few NGOs implement specific initiatives targeting vulnerable groups, such as people with disabilities, lowincome groups, and women and adolescent victims of rape RH Strategic Plan Strategic Plan for Reproductive and Sexual Health of Adolescents and Youth Documents, DNS/DSR PNP (2009) National strategic plans and documents CSLP Policies, Norms, and Standards (2009) Legal RH texts and laws

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Annex 2: Repositioning Family Planning Results and Indicators for Mauritania

Indicators IR3.3: Documentation of instances in which a formal implementation or operational directive or plan is issued to accompany a national or subnational FP policy IR3.4: Evidence that policy barriers to access to FP services and information have been identified and/or removed

Information

Indicator Source

FP program is implemented through many directives and operational plans, including the National FP Action Plan, the PSSPSR, and the action plans of development partners and NGOs Other directives are the Agreement Letter between MS and UNFPA (2011), Verbal Note #221 from the Ministry of Foreign Affairs and Cooperation (2011), the Note authorizing midwives to provide family planning, the National Supervision Guide for FP/RH activities, the Fatwa or legal directive (2001) stipulating the Islam is not opposed to birth spacing, and authorization to make Implanon available on the market Analysis of barriers in the FP situational analysis prepared in 2011 Study on the Legal, Social, and Cultural Aspects of RH in Mauritania Training of trainers in FP through the AWARE II project Governments policy of allowing FP services to be provided free of charge Integration of FP into the School of Midwifery training curriculum in 1993 Radio and TV messages on Family Planning/Birth Spacing Annual FP campaigns Agreement signed between the MS and Organon Laboratories to introduce Implanon PNSR reports Study report PNSR Training reports Ministerial Note on free delivery of contraceptives school curricula Agreement between the MS and Organon Laboratories

IR3.5: Evidence of the implementation of policies that promote FP services and information

FP services are integrated into the Minimum Package of Services in at least two-thirds of the national service delivery system; however, FP services are provided in fewer than half of the service delivery points FP services are free; there is no cost for contraceptives CBD has been piloted in two districts since 2010 A week-long FP campaign has been conducted since 2003 MS provides a free supply of contraceptive products to NGOs and parastatals (SNIM and CNSS) Contraceptive products are not integrated into the formal drug distribution system

PNSR: Plans and reports on training and supervision Ministerial Note FP campaigns reports

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Repositioning Family Planning in Mauritania: A Baseline

Indicators

Information

Indicator Source

IR 4: Evidence-based data or information used to inform advocacy, policy dialogue, policy development, planning, resource allocation, budgeting, program design, guidelines, regulations, program improvement, and management IR4.1: Evidence of data or information used to support repositioning FP efforts PNSR and partners use data from the DHS 20002001 and the MICS 2007 and 2011, as well as SNIS annual reports, as the main sources of FP/RH information Additional data from the ministries of economy, education, and agriculture were used to design the religious leaders advocacy tool Islam and Family Planning/Birth Spacing Argumentaire Religieux for FP/RH has been finalized by the Ministry of Islamic Affairs and used in two regions Other sources of data are strategies and plans, assessment reports, the FP Situational Analysis (2010), and the MDG Situational Analysis (2010) IR4.2: Evidence of international FP best practices incorporated into national health standards PNP document was revised in 2009 Promotion of long-term methods initiated in 2005; Implanon was introduced in two regions in 2010 Promotion of dual protection through a large network of peer educators in the framework of HIV prevention by NGOs and professional associations FP counseling and service delivery has been integrated into the PMTCT Program IR4.3: Evidence of a defined and funded research agenda in FP Existing National Institute of Research in Public Health does not include FP in its research agenda MS shares relevant studies and assessments Health training schools issue some relevant reports and dissertations Following in-country structures have benefitted from capacity building to strengthen collection, analysis, and communication of FP information: ONS/MAED specializes in census and population studies DPCIS produces the Annual Statistics Compendium MAED PNSR organizes mid-term and final reviews with UNFPA MS conducts annual review for all its programs, including FP Schma Directeur du SNIS Dissemination reports from studies and evaluations DHS Mauritanie 2005 and DHS-MICS 2007 2012 Quarterly and Annual reports from DRAS Arrte # 19477/MS of January 24, 2012, creating a National Reproductive Health Program Arrte ministerial National Institute of Research in Public Health PNSR SOS Peer Educators/ Semester Reports PNLS/PMTCT training modules PNSR/UNFPA six-month reports

IR4.4: Evidence of in-country organizational technical capacity for the collection, analysis, and communication of FP information

However, DRAS and district offices have a weak capacity to collect, analyze, and communicate FP information

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Annex 2: Repositioning Family Planning Results and Indicators for Mauritania

Indicators

Information

Indicator Source

IR 5: Individual or institutional capacity strengthened in the public sector, civil society, and private sector to assume leadership and/or support the FP agenda IR5.1: Evidence of entities provided with donor assistance that demonstrate capacity to implement repositioning FP activities independently IR5.2: Evidence of government departments or other entities established or strengthened to support the FP agenda PNSR capacity has been strengthened in management, planning, training, supervision, and M&E; PNSR also is capable of managing contraceptive commodities Major local NGOs, such as AMPF, SOS Peer Educators, and Sant sans Frontieres, have a strong capacity to plan programs and mobilize resources, as well as implement FP programs in decentralized regions PNSR, DRAS, and districts Government programs, committees, directorates, and a laboratory led by the MS; MAED; Ministry for Youth and Sports; Ministry of Social, Child, and Family Affairs; and the National Pharmacy NGOs/CSOs Two parastatals Training schools: medical, midwifery, and nursing Professional associations: midwives and gynecologists Networks: Imams/Ulemas, journalists, parliamentarians IR5.3: Evidence of targeted public and private sector officials, FBO, or community leaders publicly demonstrating new or increased commitment to FP Expressed commitment from the President of the Republic, who created a Multisectoral Committee to Accelerate Achievement of the MDGs in March 2012. The committee is in charge of establishing a roadmap and defining needed additional resources to attain the MDGs. The planned funding for FP under this initiative is 210 million UM for the provision of implants and IUDs and 150 million UM for health staff training in FP/RH. Members of the Imams/Ulemas Network for Family Planning/Birth Spacing have delivered sermons and appeared on radio and TV Members of professional associations have participated in debates about FP on radio and TV, and these broadcasts have increased over the past year FP declarations have had limited reach and impact; FP supporters need to reinforce documentation and dissemination of FP declarations and strengthen emerging local FP champions IR5.4: Number of regional/ national centers or collaboratives for shared education and research in FP Not found Arrte and ordonnances creating PNRS, parastatals, NGOs, schools and networks Reports from these entities Plans and activity reports

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REFERENCES AND ADDITIONAL RESOURCES

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MS and UNFPA. 2008c. Rapport de lEvaluation de la Composante Sante de la Reproduction (2003 2008). MS and UNFPA. 2009. Plan Strategique National de la Sant de la Reproduction 20092013. MS and UNFPA. 2011. valuation du 6me Programme de Coopration de lUNFPA / Mauritanie. Moreland, Scott, Ellen Smith, and Suneeta Sharma. 2010. World Population Prospects and Unmet Need for Family Planning. Washington, DC: Futures Group. Retrieved August 2, 2012, from http://www.futuresgroup.com/files/publications/World_Population_Prospects.pdf. Naciri, Raba. 2008. Stratgie Nationale dInstitutionnalisation du Genre Mauritanie. Programme des Nations Unies pour le dveloppement (UNDP) et Ministre de la Promotion Feminine, de lEnfance et de la Famille. Office National de la Statistiques de la Mauritanie (ONS). 2011. Annuaire Statistique. ONS and ORC Macro. 2001. Enqute Dmographique et de Sant Mauritanie 20002001. Calverton, MD: ONS and ORC Macro. Ouagadougou Partnership. 2012. Family Planning: West Africa on the MoveA Call to Action. Provides recommendations for advancing family planning and mobilizing political commitment and resources after the international conference on family planning in Ouagadougou, February 811, 2011. Washington, DC: Population Reference Bureau. PATH. 2012. Innovative Partnership to Deliver Convenient Contraceptives to up to Three Million Women. Retrieved from http://www.path.org/news/pr120711-depo-uniject.php. Population Reference Bureau (PRB). 2009. Family Planning Saves Lives, 4th edition. Washington, DC: PRB. Renaudin P., M.O. Abdelkader, S.M.O. Abdelaziz, M.O. Mujtaba, M.O. Saleck, C. Vangeenderhuysen, and A. Prual. 2008. La Mutualisation du Risque comme Solution lAccs aux Soins Obsttricaux dUrgence. Exprience du Forfait Obsttrical en Mauritanie. Studies in Health Services Organisation & Policy 25: 93125. Retrieved October 14, 2012, from http://www.unfpa.org/sowmy/resources/docs/library/R411_Renaudin_etal_2007_Mauritania_ArtForfaitO bstetricalNouakchott_IJGO_2007.pdf. Ross, John. 2011. The Injectable Take-off in East and Southern Africa: Is It Substitutional? Unpublished paper. Washington, DC: Futures Group, Health Policy Project. Ross, John, and Ellen Smith. 2010. The Family Planning Effort Index: 1999, 2004, and 2009. Washington, DC: Futures Group, Health Policy Initiative, Task Order 1. Retrieved August 29, 2012, from http://www.healthpolicyinitiative.com/Publications/Documents/1110_1_FP_Effort_Index_1999_2004_20 09__FINAL_05_08_10_acc.pdf. Roudi, Farzaneth, and Lori Ashford. Juillet. 1996. Les Hommes et le Planning Familial en Afrique. Washington, DC: PRB.

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Some Bekoune, Sahar-Iyaon Christian. 2010. Mise en route de la DBC, November 2010. United Nations Childrens Fund (UNICEF). 2011. Levels and Trends in Child Mortality: Report 2011. Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation. New York: UNICEF. Retrieved July 24, 2012, from http://www.childinfo.org/files/Child_Mortality_Report_2011.pdf. UNICEF and Office National de la Statistique (ONS) [Mauritania]. 2008. Enqute par Grappes Indicateurs Multiples 2007: Rapport Final. (Mauritania Multiple Indicator Cluster Survey 2007 MICS). New York: UNICEF. Retrieved September 30, 2012, from http://www.childinfo.org/mics3_surveys.html. UNICEF and UNFPA. 2012. Enqute par Grappes Indicateurs Multiples (MICS) 2011: Rsultats Prliminaires. Nouakchott: UNICEF. United Nations Development Program (UNDP). 2010. Rapport sur les Progres 2010 vers lAtteinte des Objectifs du Millenaire pour le Dveloppement (OMD) en Mauritanie. Retrieved September 24, 2012, from http://www.undp.org/content/dam/undp/library/MDG/english/MDG%20Country%20Reports/Mauritania/ Mauritania_MDGReport_2010_FR.pdf. UNDP. 2011a. Human Development Report 2011. Retrieved July 12, 2012, from http://www.undp.org/content/dam/undp/library/corporate/HDR/2011%20Global%20HDR/English/HDR_ 2011_EN_Complete.pdf. UNDP. 2011b. World Development Report 2011. Retrieved from http://hdr.undp.org/en/media/HDR_2011_EN_Table1.pdf. UNDP. 2012. World Urbanization Prospects: The 2011 Revision. New York, USA. UNDP and Economic and Social Council. 2011. World Population Prospects: The 2010 Revision. New York: UNDP. UNDP-GEF Global Project. 2010. UNV workshop on Community-Based Adaption. Retrieved September 14, 2012, from http://www.undpadaptation.org/projects/websites/docs/Conferences/UNV_workshop_on_CBA_-_Logistics_2010.pdf. United Nations Population Fund (UNFPA). 1994. Confrence Internationale sur la Population et le Dveloppement (CIPD) 1994: Rapport Final. Retrieved from http://www.path.org/news/pr120711-depouniject.php. United States Agency for International Development (USAID). 2006. Repositioning Family Planning in sub-Saharan Africa: An Issue Brief. Retrieved July 23, 2012, from http://transition.usaid.gov/our_work/global_health/pop/techareas/repositioning/briefs/repo_subafr.pdf. USAID. 2011. High Impact Practices in Family Planning 2011. Retrieved July 23, 2012, from http://www.usaid.gov/our_work/global_health/pop/publications/docs/high_impact_practices.pdf.

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USAID | DELIVER PROJECT and POLICY Project. 2003. Contraceptive Security Index 2003: A Tool for Priority Setting and Planning. Arlington, VA: John Snow, Inc., USAID | DELIVER PROJECT. Retrieved July 23, 2012, from http://deliver.jsi.com/dlvr_content/resources/allpubs/factsheets/CSInde_2003_Book.pdf. USAID | DELIVER and Task Order 1 of the Health Policy Initiative. 2006. Contraceptive Security Index 2006: A Tool for Priority Setting and Planning. Arlington, VA: John Snow, Inc., USAID | DELIVER PROJECT. Retrieved July 19, 2012, from http://deliver.jsi.com/dlvr_content/resources/allpubs/factsheets/CSInde_2006_Book.pdf. USAID | Health Policy Initiative, Task Order 1. 2005. Guide pour la Rforme Lgislative et Rglementaire en Sant de la Reproduction. USAID | Health Policy Initiative, Task Order 1. 2006. Mise en uvre de la Loi sur la Sant de la Reproduction en Afrique de lOuest et du Centre, Manuel du Parlementaire. World Bank. 2011. World Development Indicators Database. Retrieved from http://siteresources.worldbank.org/DATASTATISTICS/Resources/GNIPC.pdf. World Bank. 2012. Data by Country. Retrieved September 28, 2012, from http://data.worldbank.org/country/mauritania. World Health Organization (WHO). 2005. Rapport sur la Sant dans le Monde 2005: Donnons une Chance Chaque Mre et Chaque Enfant. Geneva: WHO. WHO. 2006. Working Together for Health: The World Health Report 2006. Geneva, Switzerland: WHO. Retrieved from http://www.who.int/whr/2006/whr06_en.pdf. WHO. 2009. Profil en Ressources Humaines en Sant, Rpublique Islamique de Mauritanie. Africa Health Workforce Observatory. Retrieved on September 28, 2012, from http://www.hrhobservatory.afro.who.int/images/Document_Centre/mauritania_country_profile.pdf. WHO. 2012a. Mauritania Country Statistics. Retrieved September 28, 2012, from http://www.who.int/countries/mrt/en/. WHO. 2012b. Trends in Maternal Mortality: 19902010. WHO, UNICEF, UNFPA and The World Bank Estimates. Geneva: WHO. Retrieved July 23, 2012, from http://whqlibdoc.who.int/publications/2012/9789241503631_eng.pdf. WHO, USAID, and Family Health International (FHI). 2010. Community-based Health Workers Can Safely and Effectively Administer Injectable Contraceptives: Conclusions from a Technical Consultation. Research Triangle Park, North Carolina: FHI. Retrieved from http://www.fhi360.org//NR/rdonlyres/e66buwqnetdkndytax7vlqxeknagzd6fdahemwklkxj7enfcxltd4uvkgr skee7he4mcvnh6chcteo/WHOCBAinjectablesBrief0610.pdf.

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