October 2012

REPOSITIONING FAMILY PLANNING IN GUINEA

A Baseline

This publication was prepared by Elizabeth McDavid of Futures Group.

Photo credit (cover): Elizabeth McDavid Suggested citation: McDavid, E. 2012. Repositioning Family Planning in Guinea: 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 Guinea: A Baseline

OCTOBER 2012
This publication was prepared by Elizabeth McDavid of Futures Group.

CONTENTS
Acknowledgments .................................................................................................................. iv Abbreviations ............................................................................................................................v Introduction ...............................................................................................................................1 Background: Guinea ................................................................................................................3 Framework for Assessing the Repositioning FP Initiative........................................................6 Methodology ............................................................................................................................................. 7 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 .................................................................................................................. 10 Intermediate Result 2: Increased Multisectoral Coordination in the Design, Implementation, and Financing of FP Policies and Programs ............................................................................................ 12 Intermediate Result 3: Policies that Improve Equitable and Affordable Access to High-Quality FP Services and Information Adopted and Put into Place ...................................................................... 14 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 ........................................... 16 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 ......................... 17 Recommendations for Repositioning FP in Guinea ..............................................................19 Annex 1: Persons interviewed ................................................................................................21 Annex 2: Repositioning Family Planning Results and Indicators for Guinea ......................22 References and Additional Resources..................................................................................31

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ACKNOWLEDGMENTS
The author thanks the William and Flora Hewlett Foundation, and particularly Margot Fahnestock, Program Officer, Global Development and Population Program, for providing Futures Group with the funding, support, and guidance for this activity. Many colleagues at Futures Group also deserve thanks: Karen Hardee, for her support of all aspects of the studyfrom the questionnaire design to report writing; and Cynthia Green, for her invaluable contributions to the report. The authors also 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 for all of her insights. Gratitude also goes to Dr. Mamadi Kourouma, National Director for Family Health and Nutrition, and his colleagues, Dr. Madina Rachid, Division Chief, Reproductive Health, and Dr. Maimouna Diallo, head of Maternal and Infant Health and Family Planning, who provided assistance and facilitated the work by calling a meeting of all partners in family planning. In addition, the authors thank Moustapha Diallo, Director of EngenderHealth/Guinea, and his team for their invaluable logistical and administrative support in Guinea.

iv

ABBREVIATIONS
AIDS AGBEF ASFEGMASSI acquired immune deficiency syndrome Association Guinenne pour le Bien Etre Familial Guinean Association for Family Welfare Association des Femmes de Guine pour la Lutte contre les Infections Sexuellement Transmissibles y Compris le Sida Association of Guinean Women Fighting against Sexually Transmitted Infections, including AIDS Association des Sages-Femmes de Guine Midwives Association of Guinea community-based distribution Cellule de recherche en sant de la reproduction en Guine Unit of RH Research in Guinea (NGO) community health worker Demographic and Health Survey Direction Nationale de la Sant Familiale et de la Nutrition Directorate of Family Health and Nutrition Division de la Sant de la Reproduction Division of Reproductive Health family health family planning Guinean franc gross national income in purchasing power parity human immunodeficiency virus International Conference on Population and Development International Planned Parenthood Federation intermediate result intrauterine device monitoring and evaluation maternal and child health Millennium Development Goal Ministre de la Sant et de lHygine Publique Ministry of Health and Public Hygiene nongovernmental organization Plan National de Dveloppement Sanitaire National Health Development Plan Les Politiques, Normes et Protocoles Policies, Norms, and Protocols Politique Nationale et le Programme de Sant de la Reproduction National Policy and Program for Reproductive Health Population Reference Bureau repositioning family planning Recensement Gnral de la Population et de lHabitat National Census of Population and Housing reproductive health strategic objective United Nations Population Fund United States Agency for International Development World Health Organization
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ASFEGUI CBD CERREGUI CHW DHS DNSFN DSR FH FP GF GNI PPP HIV ICPD IPPF IR IUD M&E MCH MDG MSHP NGO PNDS PNP PNSR PRB RFP RGPH RH SO UNFPA USAID WHO

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 (FP). 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 FP programs, known as repositioning family planning (RFP). 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 regions in its 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, 2012), 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 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 32 35 28 27 29 24 22 16

Percent of Women

29

Source: Most recent 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.

Introduction

There are vast regional inequalities between urban and rural populations in access to and use of contraceptives, with rural populations almost always suffering from fewer options. Bringing FP services into communities is an important strategy for improving access to family planning and satisfying unmet need. Several models for the provision of community-based services have been successfully tested in the region. In Francophone Africa, community-based distribution (CBD) for family planning is generally not well developed and is identified as an underutilized strategy for reaching 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 and refills on oral contraceptives and referrals. 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 and help meet womens stated desires for safe, effective modern contraception (USAID, 2006). 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. 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 RFP and appointed focal persons to spearhead implementation of these plans. 1 At a conference on civil society involvement in family planning in September 2011 in Mbour, Senegal, additional focal persons were named from civil society organizations and the action plans were further refined. CBD features prominently in the action plans. While many activities are underway to reposition family planning, most countries lack a mechanism to assess the success of their efforts (Judice and Snyder, 2012). 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). In 2012, the Futures Group applied the framework to assess Guineas 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.

BACKGROUND: GUINEA
Guinea ranks among the worlds poorest countries despite its wealth in natural resources, including bauxite, diamonds, gold, and iron ore, as well as potential for hydroelectric power. The World Bank estimated Guineas gross national income in purchasing power parity (GNI PPP) to be US$440 per capita per year. This is its highest GNI PPP since 1997, when it was US$490 (World Bank, 2012). The proportion of Guineans classified as poor has been increasingfrom 40 percent of the population in 1994 to 49 percent in 2002 and 53 percent in 2007. Further, in 2010, the proportion was projected to be 58 percent, according to a survey by the National Statistics Institute, Ministry of Planning and Promotion of the Private Sector (Rpublique de Guine, 2007). Guinea ranks 178 out of 187 countries in the 2011 Human Development Index (UNDP, 2011), making it one of the least developed countries in the world, based on life expectancy, educational attainment, and average income. Agriculture employs 73 percent of Guineas labor force (IFDC, 2012), and 72 percent of its people live in rural areas (PRB, 2012). Guinea is predominantly Muslim, with 24 ethnic groups. Literacy is low; 44 percent of men and 16 percent of women surveyed in the 2005 Demographic and Health Survey (DHS) were literate (DNS and ORC Macro, 2006). Malnutrition is common: two in five (40%) children under age five suffer from moderate and severe stunting, and one in four (26%) of children under five suffers from being moderately and severely underweight. More than one in eight children dies before the fifth birthday (UNICEF, 2011). Guinea has suffered from political problems and instability ever since the death of Skou Tour, the countrys first president, in 1984. It was only in 2010 that Guinea elected a civilian head of state, Alpha Cond. The most recent national census data for Guinea are from the 1996 National Census of Population and Housing (RGPH), which was based on a sample survey of households. Informants said that a census had been conducted in 2011, but the Futures Group team could find no data reporting on its findings. Guineas current population is estimated to be 11.5 million people (PRB, 2012). The most recent national DHS for which data are available was conducted in 2005 (DNS and ORC Macro, 2006). The 2012 DHS is currently underway, with field work being conducted during JuneSeptember 2012, so the results are not yet available. Guinea has been making steady progress in reducing maternal and child mortality, although the countrys overall levels remain high. Its maternal mortality ratio has declined by 50 percent in the past decade from 970 deaths per 100,000 births in 2000 to 610 in 2010 (WHO, 2012). At the current level, a woman has a one in 30 lifetime risk of dying from maternal causes (WHO, 2012). Infant and child mortality rates also have declined in the past decade, although there is still room for improvement. One in eight children dies before his/her fifth birthday, according to UNICEF data. The infant mortality rate in 2010 was 81 deaths per 1,000 births, and the mortality rate for children under age five was 130 deaths per 1,000 births (UNICEF, 2011). In 1984 Guinea had a national conference on health, at which it opted for the primary healthcare model, following the Bamako Initiative. The primary healthcare program was launched in 1988 after a first Health Development Plan was developed, covering the period 19871991. The Bamako Initiative depends on health management committees for each health facility and involves the communities as participants in managing the health of their localities. It also calls for user fees for services, which also are managed by the committees.

Background: Guinea

In 1997, a national forum on health was organized to improve the performance of the health system. At this forum, participants observed that progress achieved thus far in Guinea was due mainly to vertical programs and projects, often poorly coordinated and without a medium- or long-term vision. To correct this situation, the forum recommended the development of a national health strategy and the liberalization of contraception through the adoption of a law and subsequent implementing documents. The Reproductive Health (RH) Law was adopted in 2000, but so far no implementing documents have been developed. The forum also recommended the dissemination of information to all of the population on how to prevent unintended pregnancies and abortions, prevent HIV and sexually transmitted infections, and promote a healthy environment. The 2003 National Health Development Plan (PNDS) laid the groundwork for the forum recommendations. Its implementation has enabled 70 percent of the population to have access to a health center within 10 kilometers.

Box 1. Guinea Health and Education Data Married women ages 1549 currently using modern contraceptive methods: 5.7% Married women ages 1549 currently using traditional contraceptive methods: 3.4% Average births per woman: 5.7 Unmet need for FP: 21% of married women ages 1549 Women assisted during delivery by trained health personnel: 38% Women ages 1549 who have had female genital cutting (excision): 96% Children under age five underweight: 26%

Family planning began in Guinea in 1984, when the Women ages 1549 who are United Nations Population Fund (UNFPA) funded HIV positive: 1.9% integration of FP services into the government health Men ages 1549 who are HIV centers. The Association Guinenne pour le Bien-Etre positive: 0.9% Familial (AGBEF), the Guinean affiliate of the International Planned Parenthood Federation (IPPF), Women literate: 16.1% was established in 1985 to provide private sector FP Men literate: 44.1% services. After the 1994 International Conference on Source: DNS and ORC Macro, 2006. Population and Development (ICPD), UNFPA and USAID helped Guinea develop the policy, national program, and Policies, Norms, and Protocols (PNP) for FP/RH. These and other partners assisted the Ministry of Health and Public Hygiene (MSHP) to integrate FP services into the health systemespecially the health centersand began a program for the social marketing of contraceptives. Today, all Guinea health centers offer at least three methods of family planningcondoms, pills, and injectablesalthough these methods actually may not be available due to stockouts. In the community, CHWs can provide pillsboth the first prescription and the refills. This is effective, providing that stocks are sufficient and distributed in a timely manner, which is not always the case. One in five (21%) married women ages 1549 would like to space or limit births but are not using contraception. This level of unmet need for family planning is one of the lowest in the region. Guengant and colleagues (2010) report that unmet need is lowest among the poorest and least educated women. Their explanation is that women do not know about their right to reproductive health, and that social norms, such as a pronatalist tradition prior to 2000 and the high value placed on women who have many children, support large families. Guinea has prepared several action plans related to family planning. In 2008, it developed a plan to reposition family planning (20082015). At the 2010 G8 meeting held in Muskoka, Canada, the government of France pledged funds to reduce maternal and child mortality. The 2011 conferences on RFP also raised the profile of family planning. Subsequently, Guinea developed the 20122013 Family 4

Repositioning Family Planning in Guinea: A Baseline

Planning Action Plan, which supports RFP activities, as well as a 20122016 Action Plan to Accelerate Reduction of Maternal, Neonatal, and Child Mortality, based on applying the French Muskoka funds. Three priority actions are identified in the 20122013 Family Planning Action Plan:
1. Integrate CBD for injectables in four pilot sites: Kindia, Labe, Kankan, and NZerekore 2. Intensify communication and sensitization campaigns to change mens attitudes regarding

family planning
3. Implement an FP advocacy plan

The various plans need to be integrated into a single plan to guide future work. In addition, Guinea is introducing best practices, including postpartum use of long-term methods (the intrauterine device or IUD), Jadelle implant, and tubal ligation). Guinean stakeholders believe these efforts will help meet the unmet need for family planning. Several major policy issues are considered constraints to meeting the need for family planning in Guinea:
1. Weak political will and commitment among the national leadership 2. Insufficient intersectoral and multisectoral collaboration in the implementation of FP

programs and projects

3. Insufficient involvement of communities in decision making around family planning 4. Insufficient allocation of governmental financial resources to RH programs (e.g., to prevent

stockouts and make sure that a wide range of contraceptives is available at every health center) Social constraints, including customs and tradition (e.g., polygamy and female genital cutting); the low education level of women; their poverty; and the lack of mens involvement in RH decisions, play no small part in the precarious health and FP situation of the population. Guinea has many international partners willing to assist with RFP initiatives, including UNFPA, WHO, USAID (through cooperating agencies such as the USAID Maternal and Child Health Integrated Program, Faisons Ensemble, and Fistula Care), EngenderHealth, Save the Children, Plan International, KfW (the German Development Bank), GIZ (Deutsche Gesellschaft fr Internationale Zusammenarbeit GmbH), and Population Services International. Local partners include AGBEF and the Association des SagesFemmes de Guine (ASFEGUI).

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 policy Each IR has specific indicators that contribute to its overall achievement (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.

Repositioning Family Planning in Guinea: A Baseline

Methodology
After the M&E Framework was field tested in Tanzania in 2011 and then finalized, staff of the USAIDfunded Health Policy Project, implemented by Futures Group, reviewed the tools developed for Tanzania, subsequently adapted them for use in West Africa, and translated them into French. The project then tested the M&E Framework in Togo and Niger. 2 In preparation for application of the M&E Framework using Hewlett Foundation funding, Futures Group proposed a different methodology for working in the remaining six countries of Francophone West Africa. 3 Futures Group first assembled a team to test a more participatory and interactive methodology in Mali. Based on the successful results, the team decided to use the Mali methodology for the five remaining countries. For Guinea, 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 did not see them until their arrival in country. The Futures Group team collaborated with the MSHP to plan a one-day technical meeting with FP stakeholders. In preparation for the meeting, the team identified the following three key documents, which were then translated into French for use at the working meeting:
1. Framework for Monitoring and Evaluating Efforts to Reposition Family Planning 2. Explanation of Indicators 3. Semi-Structured Interview Guide (to serve as background)

The MSHP of Guinea was keen to take the lead in this exercise and called the meeting. It sent the three documents noted above, along with the invitations for the working meeting, to approximately 25 people who were identified by contacts as key actors in repositioning FP in Guinea. Invitees included the four RFP focal persons designated during the 2011 conferences, government officials, representatives of international and national nongovernmental organizations (NGOs) and other partners, and donor representatives. The Futures Group team then prepared a detailed agenda for the working meeting, developed two PowerPoint presentations, and made hard copies of the background documents for use during the meeting. Both the presentations and documents also will be used for the working meetings for the remaining countries. The meeting, held in Conakry, included a presentation of an update on challenges and opportunities in family planning in the Francophone West Africa region, an orientation to the M&E Framework, group work to inform participants about the IRs and indicators, group work on the indicators, and reporting on each of the indicators. The indicator table was filled out as the meeting progressed. Some people who either were unavailable or had not been invited to the meeting were identified as having information to contribute. The Futures Group team made separate arrangements to interview them prior to leaving Conakry. The meeting concluded with several recommendations for the government and its technical and financial partners to strengthen their RFP efforts in Guinea.

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). 3 Benin, Burkina Faso, Guinea, Mali, Mauritania, and Senegal.

Framework for Assessing the Repositioning FP Initiative

Table 1 provides a breakdown of the contacts by affiliation and sex, including participants at the meeting and those subsequently interviewed (see Annex 1).
Table 1. Affiliation and Sex of Contacts in Guinea
Sex
Men Women Total

Government Officials
3 5 8

Donors
3 1 4

CAs/CSOs
9 2 11

Total
15 8 23

Following the meeting, Futures Group team drafted a complete indicator table and sent it to the participants for their feedback. The team then incorporated the additional input into the table and drafted this report on the Guinea application (see Annex 2 for the final indicator table).
Ethical Considerations

The protocol and data collection instruments for both components of this study were submitted to the Futures Group Research Ethics Committee and were 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 meeting or interviews. Good data were extremely hard to come by. Despite these limitations, this study provides an important baseline for repositioning family planning in Guinea.

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 Directorate of Family Health and Nutrition (DNSFN) is the governmental entity responsible for managing the countrys FP program. It was elevated from an RH Division to a Directorate in 2011 as a direct result of the refocused attention on repositioning FP (RFP) in Guinea. It has three divisions: mother and child health/family planning (SMI/PF), adolescents and youth health, and mens and womens health. The mandate of the DNSFN is to design and implement all elements of policies and programs related to family health (FH); coordinate all FH activities (programs, NGOs, etc.); mobilize and supervise the management of all resources needed for implementing training and research related to family health; promote and coordinate all research and training programs in family health; strengthen the management and information system for family health, along with the Bureau of Strategy and Development; promote the management of family health and ensure collaboration with other structures and partners; supervise and evaluate all FH activities, projects, and programs; and liaise with NGOs and other partners working on family health. The DNSFN leads at least three FP-related multisectoral committees: the RH Products Security Committee, which oversees and manages the Contraceptive Security Plan; the Family Planning Committee, which includes RFP; and the committee that oversees and directs the Accelerated Campaign to Reduce Maternal Mortality in Africa.
Indicator 2: Evidence of documented improvement in the enabling environment for family planning, using a validated instrument

Data from two validated instruments are available to assess the enabling environment for family planning in Guinea. The Family Planning Program Effort Scores were developed as an international measure to gauge key areas of each countrys FP program. The scores are based on the average scores submitted by 1015 local experts on 30 indicators that cover a countrys family planning program related to policies, services, evaluation, and access to FP methods. Guineas score has stagnated and even gone down a little in recent yearsfrom 48.2 in 1999, to 45.3 in 2004, to 46.2 in 2009indicating a need for more effort, especially in the areas of policies and plans to strengthen the FP program (Ross and Smith, 2010). As the highest score is 100, the scores also indicate considerable room for improvement in Guinea. The Contraceptive Security Index uses a rating system that assigns points to 17 indicators related to the supply chain, finance, the health and social environment, access to FP, and use of FP. The scores for Guinea were 44.2 in 2003 and 48.3 in 2009, out of a possible 100 points (USAID | DELIVER, 2003, 2009). While the improvement is a welcome sign, the scores indicate a relatively low level of contraceptive security. Much more can be done to ensure that adequate contraceptive supplies are widely available.

Assessment Findings Indicator 3: Evidence of FP policies implemented and resources allocated and subsequently used in relation to the same FP policies

The government of Guinea is showing evidence of commitment to family planning. The 2011 conferences, workshops, and high-level meetings on RFP have had an effect on national leaders. In 2011, the National Assembly doubled the health budgetfrom 3 percent to 6 percent of the national budget. The National Assembly also allocated 54 billion Guinean francs (GF) (approximately US$7.7 million 4) for safe motherhoodparticularly to fulfill the promise made by President Alpha Cond when elected in 2010 that all women would be able to obtain free caesarean sections. It is still early to determine whether these funds will actually be disbursed and used for the purposes intended and whether and how much of that funding will be used for family planning. Still, these are promising signs. Guinea, assisted by its partners in RFP, is implementing FP programs as best it can, given the many challenges it faces. The 2010 and 2011 annual reports of the DNSFN and partners show that they are implementing such policies (MSHP/DNSFN, 2011, 2012).

Intermediate Result 1: Resources for Family Planning Increased, Allocated, and Spent More Effectively and Equitably
The M&E Framework has the following four indicators related to resources for family planning: 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 by activity) IR1.4: New and/or increased resources committed to family planning in the last two years In Guinea, good data are hard to find. It is difficult to obtain information on the resources mobilized and used for health. MSHP and UNFPA informants were unable to provide information on FP budgets and/or contraceptive procurements. Accordingly, the information in this section should be considered partial. The proportion of the national budget allocated to health programs has been very small in recent years. In 2010, the government allocated 3 percent to health programs. Of this amount, 75 percent was allocated to salaries and 25 percent to equipment, medicines, and vaccinations. In 2011, the Honorable Hadjia Rabiatou Serah Diallo, a champion of female health in the National Assembly, led the charge to increase the health budget to 6 percent of the national budget. While there still is a long way to go to reach the Abuja pledge of 15 percent, the funds were very much needed and appreciated. The MSHP and stakeholders will need to monitor the implementation of this commitment to make sure the funds are effectively allocated and disbursed for health. The government established a line item for RH products in 2011, but no contraceptives have been purchased yet under this line item, according to government informants. Guinea has had a Contraceptive Security Plan since 2004, and the plan recently has been updated for the 20112012 period. UNFPA, USAID, and WHO provide support for training, provision of equipment and materials, contraceptives, and supervision in the field.

Exchange rate of 7,000 GF = US$1.

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Repositioning Family Planning in Guinea: A Baseline

During 20042010, USAID contributed US$14.9 million to the Guinea FP/RH sector, WHO has contributed US$31,000, and AGBEF has received US$2,351,359 (MSHP/DNSFN, 2011, Analyse Situationnelle). The team was unable to obtain information on UNFPA contributions. As has been the case for several years, USAID and UNFPA exclusively procure all contraceptives for the MSHP, but the distribution network still suffers from weaknesses that result in frequent stockouts. In 2011, consultants discovered that approximately 1 million condoms in the Central Pharmacy of Guinea were about to expire. Most were distributed rapidly, but, as a result, USAID decided not to order any condoms in 2012. USAIDs 2012 contraceptive order included 253,440 cycles of pills, 4,000 IUDs, and 100,000 Depo-Provera injections. AGBEF has its own clinics and receives funding directly from IPPF, as well as some funding from other donors. From 2009 to 2012, AGBEF reported having received funds from IPPF for FP programming and commodities (see Table 2).
Table 2. IPPF Funds Allocated to AGBEF
Year
2009 2010 2011 2012 Total

FP Programs (in US$ thousands)

520 393 479 286 1,678

FP Commodities (in US$ thousands)

85 68 59 53 265 Source: AGBEF.

Through the Agence Franaise de Developpement, the French government is planning to provide Guinea with 5 million Euros (US$6.1 million) for five years, beginning in 2012. The plan for this program has been developed and highlights support of the reduction of maternal and infant mortality to address MDGs 4 and 5. Funds also are allocated for FP activities. Private clinics are recognized as an important part of the health system, but nothing about them is quantified. However, key informants said that contraceptives are sold in almost all private clinics. Equipment for health centers is not attributed to a specific program (such as family planning or maternal and child health (MCH)). USAID (through its partners) and UNFPA support health centers in improving the quality of services. UNFPA has provided technical assistance for contraceptive security in 27 health buildings and has renovated four health centers, as well as a surgery theater, in the maternity center at Bok. Table 3 shows the distribution of public health personnel by region and profession in 2006 for a population of about 10 million people. Note that nearly two-thirds (66%) of the countrys midwives work in Conakry.

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Assessment Findings

Table 3. Distribution of Guinean Public Health Professionals, by Region, 2006

Profession
Doctors Midwives Health Aides Health Technicians Dentists Dental Technicians X-ray Technicians Biologists Lab Technicians Public Health Technicians Pharmacists Pharmacy Assistants Total

MEP
69 2 8 23 1 3 0 15 0

Ckry
371 265 467 491 8 8 5 18 63

Bok
70 14 74 229 0 0 0 0 9

Faranah
52 19 73 273 1 0 0 4 16

Kank
67 13 66 517 1 1 0 5 7

Kindia
118 36 86 383 2 1 1 15 28

Lab
66 10 50 281 2 1 0 3 8

Mamou
43 12 38 215 1 1 1 6 19

NZr
84 30 147 473 1 1 0 12 17

Total
940 401 1,009 2,885 17 16 7 78 167

Women
380 401 497 1,600 4 2 3 55 80

0 5 5 149

11 4 4 1,759

4 0 0 414

0 3 3 452

11 1 1 702

17 5 5 713

1 1 1 437

6 2 2 357

17 1 1 803

67 177 22 5,786

34 68 10 3,189

Source: MSHP. 2010. Plan Strategique de Survie de lEnfant (Draft) 20092015.

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 Futures Group 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

The Poverty Reduction Strategies (DRSP 20072011 and DRSP 20132017) do not mention the 1996 population policy, but they do include family planning as one of the main strategies. The PNDS and Gender Policy also both include family planning.

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Repositioning Family Planning in Guinea: A Baseline

The 1996 Population Policy should be a reference for other sectoral policies. However, it only timidly includes a mention of family planning. Other sectoral policies and strategies (education, food security, nutrition) do not mention it at all, even though the problems they seek to address are population-related. These sectoral policies not only fail to take into account either family planning or the population policy, but demographic projections were not used to set objectives. Although not part of the Box 2: Key National policy, family planning has been included in curricula for the Sectoral Policies and Plans secondary schools since 2011.
Poverty Reduction Strategies, 20072011 and 20132017

Gender Policy Sectoral Education Program, 20082015 National Strategy for Food Security, 2003 National Policy for Food and Nutrition, 20052015, 2005 Housing Plan of Action, 2007 (drafted, not approved) National Family Policy, 2009

The Family Code of 1996 was not adopted, although some NGO informants say it will be introduced again. In addition, the Family Policy of 2009 has a strong FP section and even calls for the Family Code to be adopted.
IR2.2: Evidence of governments engaging multiple sectors in FP activities

Civil society organizations are regularly involved in preparing strategies, action plans, and evaluations and are included as members in the multisectoral committees that exist for reproductive health and RH products security. Religious groups are involved only for one-off activities, but this may be a promising sector for involvement. The Muskoka plan for Guinea will focus on implementing activities to strengthen the health system, including governance and coordination, beginning in 2012 (MSHP/DNSFN, 2012, Initiative Franaise).

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

The following structures have been established but are in need of strengthening and consolidation: The DNSFN has a mandate to coordinate family planning and has a committee of 15 members, which includes partners, civil society, and other ministry representatives. The steering committee for the RH Products Security Plan meets two or three times per year; they last met in January 2012. An RFP group has been established but has never met. The Road Map for the Fight against Maternal Mortality established a multisectoral committee, but it is not functioning, according to informants. There is a multisectoral Commission on Population. The team could not find additional information about this group. These groups were established to prepare various action plans and then appear to have become inactive. It would be beneficial to combine some of them into a more active group with specific tasks and timelines.

13

Assessment Findings IR2.4: Evidence of government support for private sector participation in family planning

Box 3. Guineas Major Health/RH Policy Documents Population Policy (1996) National Health Policy (2001) National Health Development Plan (PNDS) (20032012) Policy and Program for RH (PNSR), (2001); revised in 2012 (draft) Law N 010/2000 on RH National IEC Strategy (1996) Road Map for the Reduction of Maternal, Neonatal, Perinatal, and Infant Mortality (20122015) Strategic Plan for RH Product Security (20082012; 20112012) Strategic Plan for Repositioning FP (20082015) Operational Action Plan for FP (20122013) Breastfeeding Policy (2008) MCH Strategic Plan Child Survival Strategic Plan (2010) Strategic Plan for the Health and Development of Adolescents and Youth (1995) Regional and district health development plans National Reproductive Health Policy (also called Family Health and Nutrition Policy) (draft 2011)

Informants said that the MSHP supports the work of AGBEF and increasingly works with the private sector. AGBEF confirmed this; it has a few clinics throughout the country. The team could not find evidence of government support of any other private sector FP work. UNFPA does provide some funding to AGBEF and local NGOs and institutions to help implement the MSHP mandate in the field. The for-profit private sector is not integrated into the health system. The MSHP does not receive any reports, statistics, or other information from this sector. Private pharmacies do sell contraceptives. Informants reported apparent conflict of interest within the private sector, since some civil servants also run their own private clinics and pharmacies.

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 FP services and information

At least one partner said that the timing is perfect now for health policy work in Guinea. It is the golden hour. All of the laws, policies, and strategies listed in Box 3 promote better access to family planning, except the breastfeeding policy, which does not mention it.

The RH Law, passed in 2000, does not yet have operational guidelines and does not include the latest thinking on reproductive health. Many knowledgeable people think that it needs to be revised. The law states that couples and individuals have the right to decide freely all questions relative to their reproductive health with respect to the laws in effect, public order and good morals. They can decide the number of their children and of their births, and have access to information to do this and have the right to access better reproductive health. The 2001 National Health Policy permitted the development of the PNDS. The 2003 PNDS states that its highest priority is the reduction of maternal mortality, but it includes no sub-objective on family planning. FP promotion, without objectives or further explanation, is cited as one of the many programs to be implemented under RH. The MCH Strategic Plan has a specific objective on family planning, which is to reach a contraceptive prevalence rate of 15 percent for married women by 2015; this is the same as the MDG goal.

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Repositioning Family Planning in Guinea: A Baseline

The National Reproductive Health Policy, which was revised in 2011 but is not yet validated, is now called the Family Health and Nutrition Policy. It also clearly stipulates this goal and identifies family planning as one of its main priorities. The document updates the 2000 RH Policy for the next 10 years and takes into consideration the new aspects of RH. District health plans guide implementation of the national-level policies and strategies in each health district.
IR3.2: Existence of national or subnational policies or strategic plans that promote access to FP services and information for under-served populations

The MSHP has a strategy for community-based services and a CBD policy that addresses activities in rural areas, where people tend to be poorer and less educated and have less access to services than urban residents. CBD services are available in only about half the country. Local and international partners support much of this work, using community health workers (CHWs). The existing CBD policy does not permit provision of injectable contraceptives at the community level. However, Save the Children is conducting a pilot test of injectables by CHWs in the department of Mandiana this year as an objective of the RFP action plan. If the results prove conclusive, the DNSFN plans to revise the PNP to include provision of injectables by CHWs. Youth and adolescents are considered vulnerable populations. In 1995, the MSHP developed a Strategic Plan for the Health and Development of Adolescents and Youth. In addition, the 2009 Norms and Procedures for Reproductive Health included a separate volume on youth and men. This volume discusses the importance of reaching youth early with correct information about puberty onset, genital organs and their functions, reproduction, and prevention of sexually transmitted diseases. It also discusses case management of specific sexual pathologies and problems in men, including impotence, early ejaculation, and prostate and urinary problems. Regional and district health development plans are schemes to implement the national policies at the regional and district operational levels and are developed from the national guidelines and policies. Each rural community has a Rural Development Committee to coordinate the local development plan and a management committee to supervise the health center.
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

The RH Law does not have any implementing directives. MSHP officials want to revise the law to take into account new aspects of reproductive health. The PNP 20082015, which is being disseminated now, includes directives for implementing the policies in place, including FP policies. However, informants say that service providers in the districts are not likely to be aware either of the existence of the PNP or its contents. This suggests the need for a thorough dissemination of the PNP to service providers at all levels. The Strategic Plan for Repositioning Family Planning (20082015), written in 2008, exists, as does the Operational Action Plan for Family Planning (20122013). These plans need to be combined and harmonized with the plans written during 2011 at the Ouagadougou and Mbour conferences. The DNSFN then needs to implement the full plan for RFP. The National Pharmaceutical Policy includes antiretroviral drugs and contraceptives as part of the List of Essential Medicines.

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Assessment Findings IR3.4: Evidence that policy barriers to access to FP services and information have been identified and/or removed

The RH Law (2000) replaced the outdated Health Code, removing many of the old barriers to family planning. The Health Code prohibited abortion under any circumstances, whereas the RH Law allows it to save the life of the woman, and in cases of rape, incest, or fetal impairment (Center for Reproductive Rights, 2009). The updated RH Products Security Strategy removed barriers found as a result of a 2007 analysis. An interim strategic plan developed in 2010 combined essential medicines and antiretroviral drugs with contraceptives and other RH products and included a holistic condom program. The 2011 National Policy on Reproductive Health (PNSR)changed to the National Policy on Family Health in the final revisionincorporates many new and best practices not in the 2001 version. However, this document has not yet been validated.
IR3.5: Evidence of the implementation of policies that promote FP services and information

MSHP reports examined by the team, especially those from 2010 and 2011, show that policies are being implemented. However, in 2010, the Division of Reproductive Health (DSR) (designated the DNSFN in 2011) implemented only 13 of the 25 activities planned. In 2011, the DNSFN implemented 45 activities, exceeding the planned 36 activities. Most of these were implemented in collaboration with partners. In addition, family planning has been integrated into fistula care sites. AGBEF reports provide evidence of its actions in implementing the national policies that promote FP services and information in AGBEF clinics throughout the country. AGBEF representatives reported a doubling of contraceptive use among its clients between 2010 and 2011.

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
This IR assesses the extent to which policies and programs are grounded in data and information to ensure that there is a sound rationale for selecting program strategies, activities, and other elements.
IR4.1: Evidence of data or information used to support RFP efforts

Box 4 No one can take informed decisions with these data.

Guinean NGO partner

Most health data for Guinea are outdated. The 2005 DHS remains the source of data on contraceptive prevalence, maternal mortality, and child health (see Box 1). These data will be updated, since Guinea is conducting a DHS this year (2012). Informants said that the government had conducted a census in 2011, although the team could not find any results from it. Guengant et al. (2010) report that during the development of policies, plans, and programs in the last several years, the government has been content either to use old data (e.g., the 1996 population growth rate of 3.1 percent continues to be used to estimate needs) or use rough estimates (see Box 4). Guengant and colleagues advise that any new policies and decisions be based on the national census of 2011 and the results of the 2012 DHS.

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Repositioning Family Planning in Guinea: A Baseline IR4.2: Evidence of international best practices incorporated into national health standards

Guineas PNP for RH was developed in 2009. Long-term methods, such as the IUD, Jadelle implant, and cycle beads method are included in the PNP. The MSHP is currently leading the expansion of IUD provision so that it is available nationwide. CBD, male involvement, and the notion of PEIGS (plan for ideal spacing and healthy pregnancy) also are included in the PNP. Box 5 However, task shifting and the provision of injectable contraceptives at the community level are not part of the PNP. PNPs are not applied in the Partners indicate, however, that the PNP documents have not been properly disseminated, and awareness of the PNP is low among district-level services providers (see Box 5). In 2012, the MSHP and Save the Children are introducing CBD for Depo-Provera in Mandiana district for 15 villages.
IR4.3: Evidence of a defined and funded research agenda in family planning
field. Service providers do not even know the documents exist, let alone what is in them.

Guinean NGO informant

Guinea does not have a defined or funded FP research agenda.

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

The Cellule de Recherche en Sant de la Reproduction en Guine (CERREGUI) is a Guinean NGO that does respected research in reproductive health. Founded in 1990, CERREGUI is a collaborating center of the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development, and Research Training in Human Reproduction, based in WHO/Geneva. CERREGUI conducts quantitative and qualitative research for many international donors and partner agencies. Its studies have covered adolescents, parents, health service providers, decisionmakers, and elderly people. Several national structures that conduct research exist, such as the following, but they are not functioning with sufficient capacity: National Public Health Institute Center for Training and Research in Rural Health Statistics, Studies, and Information Service of the MSHP The School of Medicine at the University of Conakry often collaborates on research activities with these organizations.

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 that entities provided with donor assistance demonstrate capacity to implement RFP activities independently

The DNSFN implements the FP program with its partners. NGOs, such as AGBEF, Association des Femmes de Guine pour la Lutte contre les Infections Sexuellement Transmissibles y Compris le Sida (ASFEGMASSI), and Association des Sages-Femmes de Guine (ASFEGUI) also have the capacity to

17

Assessment Findings

implement FP programs. All three NGOs receive funding for and have sufficient experience in implementing FP programs within their geographic and technical areas, in collaboration with the MSHP.
IR5.2: Evidence of government departments or other entities established or strengthened to support the FP agenda

See Indicator 1. In 2011, the DSR of the MSHP was elevated to the level of a Directorate (and became the DNSFN). This change was a direct result of the Ouagadougou Conference and the countrys renewed commitment to family planning.
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

Guinea lacks FP champions at all levels. There is no easily recognizable FP champion in Guinea, apart from the AGBEF. The Honorable Hadjia Rabiatou Serah Diallo, a female parliamentarian leader, is recognized as the key person in the National Assembly; she championed Guineas increase in its national health budget from 3 percent of the total national budget to 6 percent in 2012. The goal approved by African countries at the Abuja meeting is to allocate 15 percent of the national budget to health programs.
IR5.4: Number of regional/national centers or collaboratives for shared education and research in family planning

The Futures Group team did not find such centers operating in Guinea. The MSHP has planned a project to build a Training and Reference Center in Family Health, but it has not been built yet. Overall, the assessment found that many policies exist but are in need of revision, which is an ongoing process. Strategies and plans to implement the policies exist. However, they often include indicators, benchmarks, budgets, and M&E plans, so translating the policies into action is difficult. Guinea also needs current, accurate data to inform decisions, as well as improvement in its coordination and management of the FP/RH program. There is also an urgent need to identify and develop FP champions at all levels and in all sectors of the society.

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RECOMMENDATIONS FOR REPOSITIONING FP IN GUINEA

Guinea has made progress in creating a more enabling environment for family planning. Nevertheless, much remains to be done to strengthen ongoing activities related to repositioning family planning. According to respondents, the present environment offers opportunities for actions that would not have been possible just a short time ago. Several recommendations for the government and its technical and financial partners emerged from this assessment:
1. Revise the 2000 RH Law; develop implementation directives; and disseminate them to national, regional, and district levels and to the Guinean public at large via national NGOs. The Guinean RH Law is now 12 years old. It was developed after the 1994 Cairo ICPD.

A critical analysis and revisions are needed to take into account the most recent thinking about reproductive health. In addition, implementing guidelines need to be developed for the RH Law. The government must then disseminate them in various ways to ensure that women and men are aware of their reproductive rights.
2. Support the publication and dissemination of the new Family Health Policy and program, currently being validated, and revise the strategic plan for RFP. These revisions will take

into account the various recommendations that came out of the recent international conferences on family planning and enable Guinea to have one unified, consolidated plan. Although family planning is reflected in several plans in different sectors, no single FH/RH strategy and plan exists in Guinea to enhance planning and coordination in this area. The Repositioning Family Planning Action Plan could serve as a transition to a long-term strategy and plan.
3. Relaunch the FP Multisectoral Coordination Committee. Currently, several committees are

charged with various aspects of coordination and implementation of RFP strategies and plans. These need to be merged into one multisectoral committee led by the MSHP. This action will serve to harmonize partner, donor, and government interventions; encourage synergies; and avoid duplication of effort in the field. It also can serve to promote the RFP unified plan that will be put in place. The multisectoral committee should organize an FP campaign across the country for an intense week of advocacy, information sharing, sensitization of people, and provision of FP services, involving all of the actors (civil society, national and international NGOs, and other partners).
4. Identify, recruit, and develop FP champions at all levels and in all sectors. Guinea has very

few FP champions, and one way to keep family planning high on the agenda is to involve people from all walks of life, including religious leaders, who will speak out publicly. Evidence-based advocacy is important for decisionmakers, thought leaders, and key gatekeepers. Religious and traditional leaders, both at the national level and in communities, are important leaders and should be included in such advocacy.
5. Advocate to the government and political and legislative authorities to increase the

national health budget to 15 percent, as agreed to at the Abuja conference; create a line item for RH product procurement, including contraceptives; and monitor these efforts to ensure that the proper authorities allocate the money, disburse it for the intended purposes, and are held accountable. The multisectoral committee should make this task one of its primary responsibilities and work with champions at all levels to accomplish it.
6. Strengthen the health information and logistics system. While this is likely to be a long-term

effort, the health information system needs to account for the new indicators in RH, including policy-related indicators such as those used in this exercise for repositioning family planning. 19

Recommendations for Repositioning FP in GUINEA 7. Integrate the health information system with the logistics system to avoid stockouts and keep

abreast of needs wherever they exist. In addition, the Guinean Central Pharmacy requires technical assistance to enable it to fulfill its mission.
8. Support operations research initiatives, such as involving men in family planning. Any and all

initiatives to support the development of a national RH or FP research agenda are needed because recent data are critically lacking in Guinea. Not having good data makes it hard to make informed decisions, especially policy decisions that have long-term implications. This assessment shows that Guinea has made many efforts to reposition family planning since the Ouagadougou Call to Action in February 2011. The assessment can serve as a benchmark to highlight gaps in expanding access to family planning, including through community-based programming, and identify areas where challenges remain and more attention and resources are needed.

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ANNEX 1: PERSONS INTERVIEWED

Name
Talibi Kouyate Fode Camara Dr. Robert Tambolou Jean Kossaga Kourouma Dr. Mamadou Aliou Diallo Matthias Koly Kaivogui Dr. Perenamou Traore Dr. Madina Rachid Dr. Maimouna Diallo Dr. Mamady Kourouma Moustapha Diallo Robert Hanchett Fofana Diallo Fatoumata Kadiatou Thierno Diallo Dr. Saliou Diau Daillo Dr. Appolinaire Delamou Massila Dione Dr. Nagnouma Sanoh Dr. Fatoumata Diakhaby Dr. Aissatou Diallo Dr. Alpha Ahmadou Diallo Dr. Marouf Balde Dr. Samed Faza Diallo

Title
Treasurer of the Board Chief Accountant Executive Director Communications Officer Director of Programs Administrative and Finance Director AGBEF Chief Medical Officer Head of the RH Division Head of FP Service National Director of Family Health and Nutrition Country Representative Chief Technical Officer Head of FP Journalist Focal person FP Focal person FP FP Officer Focal person, contraceptive security plan Head of MCH/PF DNSFN Office of Strategy and Development (BSD) Public Health Specialist Civil administrator

Affiliation
AGBEF AGBEF AGBEF AGBEF AGBEF AGBEF Camayenne Clinic MSHP MSHP MSHP EngenderHealth USAID EngenderHealth

WHO UNFPA ASFEGMASSI MSHP MSHP MSHP MSHP USAID MSHP

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ANNEX 2: REPOSITIONING FAMILY PLANNING RESULTS AND INDICATORS FOR GUINEA

Repositioning Family Planning Results and Indicators for Mali
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 government-led council, coalition, or entity that oversees and actively manages the FP program DNSFN has the following mandate: Design and implement all elements of policies and programs related to FH Coordinate all FH activities (programs, NGOs, etc.) Mobilize and supervise the management of all resources needed for implementing training and research related to FH Promote and coordinate all research and training programs in FH Strengthen the management and information system for FH with the Bureau of Strategy and Development Promote the management of FH and ensure the collaboration with other structures and partners Supervise and evaluate all FH activities, projects, and programs; and Liaise with NGOs and other partners working on FH DNSFN has three divisions: Maternal and Child Health/Family Planning Adolescents and Youth Mens and Womens Health Family Planning Effort Scores: 1999: 48.2 2004: 45.3 2009: 46.2 Contraceptive Security Index: 2003: 44.2 2009: 48.3 Terms of reference of DNSFN in the revised 2012 Family Health strategy Key Informants

SO.2: Evidence of documented improvement in the enabling environment for FP, using a validated instrument

Ross and Smith, 2010 USAID | DELIVER PROJECT, 2003, 2009

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Repositioning Family Planning in Guinea: A Baseline

Indicators SO.3: Evidence of FP policies implemented and resources allocated and subsequently used in relation to the same FP policies

Information National leaders have allocated 6% of the national budget to health. The MSHP, assisted by local and international partners, is implementing policies. USAID, UNFPA, and the IPPF have donated contraceptive commodities and provided other support to FP programs.

Indicator Source

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Annex 2: Repositioning Family Planning Results and Indicators for Guinea

Indicators

Information

Indicator Source

IR 1: Resources for family planning increased, allocated, and spent more effectively and equitably IR1.1: Total resources spent on FP (by source and by activity/program area) A line item for RH products was established in 2011, but no contraceptives have yet been bought under this line item. In 2011, the Government of Guinea announced it would support safe motherhood programs with 54 billion GF (approximately US$7.7 million). AGBEF 2012: from IPPF only: funding for FP programs: US$286,000; FP commodities: US$53,000 USAID 2012: 253,440 pill cycles 4,000 IUDs 100,000 Depo-Provera injections Muskoka Initiative: Agence Franaise de Developpement: 5 million Euros for 5 years, beginning in 2012 Private clinics are an important part of the health system, but nothing about them is quantified. Contraceptives are sold in almost all private clinics. Guinea has had a plan for securing RH products since 2004. USAID and UNFPA exclusively procure all contraceptives for the public sector, but the distribution network still suffers from weaknesses that result in frequent stockouts. The proportion of the national budget going to health is very small: in 2010, it was 3%, of which 75% went for salaries and 25% for equipment, medicines, and vaccinations. In 2011, Parliament raised the proportion to 6% after advocacy by an FP champion. UNFPA, USAID, and WHO provide support for training, provision of equipment and materials, contraceptives, and supervision in the field. After President Conds election, he allocated 54 billion GF for the reduction of maternal mortality, especially obstetrical care, to cover his promise of free cesarean sections for women. MSHP/DNSFN. 2012. Feuille de Route Pour Acclrer la Rduction de la Mortalit Maternelle, Nonatale et Infanto-Juvnile, 20122016 MSHP/DNSFN. 2011. Analyse situationnelle de la planification familiale en Guine Key Informants Operational Action Plan for FP 2012 2013

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Repositioning Family Planning in Guinea: A Baseline

Indicators IR1.2: Number of new financing mechanisms for FP identified and tested IR1.3: Total resources allocated to FP (by source and activity) IR1.4: New and/or increased resources committed to FP in the last two years

Information Not found.

Indicator Source

Respondents did not differentiate between what was allocated and what was spent. They considered these to be the same. Equipment for health centers is not attributed to a program (FP, MCH, etc.). USAID (through its partners) and UNFPA support health centers to improve the quality of services. UNFPA has provided technical assistance for contraceptive security in 27 health structures and has renovated five health facilities. AGBEF reported having received the following from IPPF: 2009: Funds for FP programs: US$520,000; FP commodities: US$85,000 2010: Funds for FP programs: US$393,000; FP commodities: US$68,000 2011: Funds for FP programs: US$479,000; FP commodities: US $59,000 2012: Funds for FP programs: US$286,000; FP commodities: US$53,000 During 20042010, total financial contributions from partners to the Guinea FP/RH sector total were as follows: USAID: $14.9 million AGBEF: $2,351,359 WHO: $31,000 Data from UNFPA were not available.

Key Informants

Key Informants AGBEF

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Annex 2: Repositioning Family Planning Results and Indicators for Guinea

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 The Poverty Reduction Strategies (DRSP 20072011 and DRSP 20132017) do not mention the population policy, but they do include FP as one of the main strategies. The National Health Development Policy (PNDS) and the Gender Policy also both include FP. The Population Policy should be a reference for other sectoral policies. However, it only includes a mention of FP. Other sectoral policies and strategies (education, food security, nutrition) do not mention it at all, even though the problems they seek to address are population related. IR2.2: Evidence of governments engaging multiple sectors in FP activities Civil society organizations are regularly involved in preparing strategies, action plans, and evaluations. The National Assembly has been involved in action plans, advocacy, and resource mobilization for health and FP. In 2011, it led the charge to successfully double the national health budget to 6% of the national budget. However, the MSHP and stakeholders will have to monitor the implementation of this commitment. Religious groups are involved only for one-off activities but present a promising sector for involvement. IR2.3: Evidence of multisectoral structures that are established or strengthened to promote FP policy The DNSFN has a mandate to coordinate FP and has a committee of 15 members. The Steering Committee for the RH Products Security Plan meets 2 or 3 times per year; they last met in January 2012. A repositioning FP group has been established but has never met. The Road Map for the Fight against Maternal Mortality established a multisectoral committee, but so far it has not functioned. There is a multisectoral Commission on Population. 2011 MSHP letter establishing the committee to monitor Road Map Ministerial notice 2009/10 Key Informants Key Informants DSRP 20072011, 20132017 PNDS 2003 Key Informants 1996 Population Policy

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Repositioning Family Planning in Guinea: A Baseline

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

Information Informants said the MSHP supports the work of AGBEF and works with the private sector. AGBEF confirmed that it works with the MSHP, but the team could not find evidence of other private sector involvement other than NGOs.

Indicator Source AGBEF reports Key Informants

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 All the laws, policies, and strategies listed to the right promote better access to FP, except for the breastfeeding policy, which does not mention FP. The RH Law does not yet have operational guidelines and does not include the latest thinking on RH. Many knowledgeable people think it needs to be revised. The 2003 National Health Development Plan states that its highest priority is the reduction of maternal mortality, but it has no sub-objective about FP. FP promotion, without objectives or further explanation, is cited as one of the many programs to implement under RH. The MCH Strategic Plan has a specific objective for FP, which is to reach a CPR of 15% by 2015. District health plans implement the national-level policies and strategies in each health district. National RH Policy, revised in 2011 to be the Family Health and Nutrition policy; the document updates the 2000 RH Policy for the next 10 years, and takes into consideration the new aspects of RH Population Policy 1996 National Health Policy 2001, permitted the development of the PNDS PNDS 20032012 PNSR 2001 and revised in 2012 Law N 010/2000 on RH National IEC Strategy 1996, needs to be revised Road Map 20122015, 2011 RH Product Security Plan Strategic Plan for Repositioning FP in Guinea 20082015 Breastfeeding Policy of 2008 (no FP mentioned!) MCH Strategic Plan, 2010 National Reproductive Health Policy (also called Family Health policy) draft 2011

27

Annex 2: Repositioning Family Planning Results and Indicators for Guinea

Indicators IR3.2: Existence of national or subnational policies or strategic plans that promote access to FP services and information for under-served populations

Information The MSHP has a strategy for community-based services and a CBD policy that addresses activities in rural areas where people tend to be poorer, less educated, and have less access to services than urban residents. CBD services are available in only about half the country. The strategic plan for the development and health of adolescents and youth addresses youth as being vulnerable. Regional and district health development plans are schemes to implement the national policies at the regional and district operational levels and are developed from the national guidelines and policies. The RH Law does not have any implementing directives. MSHP officials want to revise the law to take into account new aspects of RH. The PNP 20082015 is being disseminated now and includes directives for implementing the policies in place, including FP policies. The Operational Action Plan for FP needs to be revised and validated once the outcomes of the conferences of 2011 are integrated. The National Pharmaceutical Policy includes antiretroviral drugs and contraceptives as part of the List of Essential Medicines. The Strategic Plan for RFP (20082015) and the Operational Action Plan for FP need to be combined and harmonized with the plans written during 2011 at the Ouagadougou and Mbour conferences. The DNSFN then needs to implement the full plan for repositioning FP.

Indicator Source Strategic Plan for the Health and Development of Adolescents and Youth 1995 Strategy for Community-Based Services National Pharmaceutical Policy Strategic Plan for Repositioning FP in Guinea 20082015

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

PNP 2009 Minimal Package of Activities identifies FP activities at every level of the health structure RH Products Security Plan Operational Action Plan for FP 2012 2013

IR3.4: Evidence that policy barriers to access to FP services and information have been identified and/or removed

The RH Law (2000) replaced the outdated Health Code, removing many of the old barriers to FP. As a result of a 2007 analysis, the updated RH Products Security Plan removed the barriers found. An interim strategic plan combined essential medicines and antiretroviral drugs with contraceptives and other RH products and included a holistic condom program. The National Program for RH 2011 incorporated many new and best practices not found in the 2001 version.

MSHP/DNSP/DSR. 2007. Analyse Situationelle de la Securit des Produits des SR Key Informants Revised RH Products Security Plan 2011 2012 PNSR 2001 and 2011

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Repositioning Family Planning in Guinea: A Baseline

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

Information MSHP reports, especially from 2010 and 2011, show that policies are being implemented. However, in 2010, the DSR (now called DNSFN) implemented only 13 of the 25 activities planned. In 2011, though, it implemented 45 activities, exceeding the planned 36 activities. AGBEF reports provide evidence of its actions in implementing the national policies that promote FP services and information in AGBEF clinics throughout the country.

Indicator Source AGBEF reports MSHP reports 2010, 2011

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 RFP efforts IR4.2: Evidence of international FP best practices incorporated into national health standards Most health data are outdated. The 2005 DHS remains the main source of data on contraceptive prevalence, maternal mortality, and child health. Guinea is currently conducting a DHS (2012), so these data will be updated. Long-term methods such as the IUD, Jadelle implant, and the cycle beads method are included in the PNP. CBD, male involvement, and the notion of PEIGS (plan for ideal spacing and healthy pregnancy) are also included in the PNP. However, task shifting and the provision of injectable contraceptives at the community level are not part of the PNP. Guinea does not have a defined or funded research agenda. Key Informants Guengant et al., 2010 PNP

IR4.3: Evidence of a defined and funded research agenda in FP IR4.4: Evidence of incountry organizational technical capacity for the collection, analysis, and communication of FP information

CERREGUI is a Guinean NGO that does respected research in RH. Several national structures that do research exist, but they are not functioning with sufficient capacity : National Public Health Institute Center for Training and Research in Rural Health Statistics, Studies and Information Service of the MSHP The School of Medicine at the University of Conakry often collaborates on research.

Key Informants

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Annex 2: Repositioning Family Planning Results and Indicators for Guinea

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 that entities provided with donor assistance demonstrate capacity to implement RPF activities independently IR5.2: Evidence of government departments or other entities established or strengthened to support the FP agenda IR5.3: Evidence of targeted public and private sector officials, faith-based organizations, or community leaders publicly demonstrating new or increased commitment to FP IR5.4: Number of regional/national centers or collaboratives for shared education and research in FP The Directorate of Family Health and Nutrition (DNSFN) is the Ministry of Health entity that implements the FP program with its partners. NGOs such as AGBEF, ASFEGMASSI, and ASFEGUI also have the capacity to implement FP programs and are doing so. Activity reports for these organizations Key Informants

In July 2011, the RH Division was elevated to the level of a directorate and became the DNSFN. This change was a direct result of the Ouagadougou Conference.

National RH Policy, revised in 2011 to be the Family Health and Nutrition Policy

Guinea lacks FP champions at all levels. There is no easily recognizable FP champion in Guinea, apart from the organization AGBEF. The Honorable Hadjia Rabiatou Serah Diallo, a female parliamentarian leader, is recognized as the key person who championed Guineas increase in its Abuja commitment from 3% of the national budget for health to 6% in 2012.

Key Informants

Such centers have not been found in Guinea. There is a project for the MSHP to build a Training and Reference Center in Family Health, but it has not been built yet.

Key Informants

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REFERENCES AND ADDITIONAL RESOURCES

Assemble Nationale de la Rpublique de Guine. 2000. Loi L/2000/10/AN. Adoptant et Promulguant la Loi Portant sur la Sant de la Reproduction. Conakry: Rpublique de Guine. AWARE II. 2011. Summary of Policy Barriers in AWARE II Focus Countries and Actions to Be Taken. Unpublished. AWARE II. 2011. Analysis of Barriers to Policy Implementation in AWARE II Focus Countries. Unpublished. AWARE II. 2011. Project Baseline Survey: Summary Analytical Report. Unpublished. Center for Reproductive Rights (CRR). 2009. The Worlds Abortion Laws. New York: CRR. Retrieved July 23, 2012 from http://reproductiverights.org/sites/crr.civicactions.net/files/documents/pub_fac_abortionlaws2009_WEB.p df. Cross, H, K. Hardee, and N. Jewell. 2001. Reforming Operational Policies: A Pathway to Improving Reproductive Health Programs. POLICY Project Occasional Paper. Retrieved July 23, 2012 from http://www.policyproject.com/pubs/occasional/op-7.pdf. Direction Nationale de la Statistique (DNS)/Ministre du Plan and ORC Macro. 2006. Enqute Dmographique et de Sant Guine 2005. Conakry, Guine: DNS and ORC Macro. See http://www.measuredhs.com/countries/ Guinea for 1999 and 2005. Guengant, Jean-Pierre, Mamadou Camara, and Yarri Kamara. 2010. La dmographie au centre des trajectoires de dveloppement dans les pays de lUEMOA ainsi quen Guine, au Ghana, en Mauritanie et au Nigeria : Contribution lanalyse de la Situation en Guine. Burkina Faso: Initiatives Conseil International. Haub, Carl, and Toshiko Kaneda. 2012. World Population Data Sheet 2012. Washington, DC: Population Reference Bureau. IFDC. 2012. Nations IFDC Serves. Retrieved July 23, 2012 from http://www.ifdc.org/Nations/Guinea. Johns Hopkins University/Center for Communication/K4Health Project. n.d. Elements for Family Planning Success. Retrieved August 1, 2012 from http://www.k4health.org/toolkits/fpsuccess. Judice, N., and E. Snyder. 2012. Framework for Monitoring and Evaluating Efforts to Reposition Family Planning. Washington, DC: Futures Group. Accessed at: http://www.cpc.unc.edu/measure/publications/SR-12-63 Leonard, Lori. n.d. Comprhension des Taux de Prvalence Contraceptive Elevs dans les Zones d'intervention des ONG partenaires de Groupe-Pivot Sant/ Population. Baltimore, Maryland: Johns Hopkins University. Ministre de lEconomie, des Finances et du Plan. 2007. Document de Stratgie de Rduction de la Pauvret DSRP2 (20072010). Conakry: Secrtariat Permanent de la Stratgie de Rduction de la Pauvret.

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References and Additional Resources

Ministre du Plan. 2005. Programme National dActions en matire de Population 2005-2009. Conakry: Secrtariat Permanent de la CNPRH, UNFPA. Ministre de la Sant et de lHygine Publique (MSHP). 2001. Politique nationale de Sant. Conakry: Rpublique de Guine. MSHP. 2001. Politique Nationale de Sant de la Reproduction. Conakry: Rpublique de Guine. MSHP. 2003. Plan National de Dveloppement Sanitaire 2003-2012, version de juin 2003. Conakry : Rpublique de Guine. MSHP. 2010. Plan Strategique de Survie de lEnfant (Draft) 20092015. Conakry: Rpublique de Guine. MSHP/Direction Nationale de la Sant Familiale et de Nutrition (DNSFN). 2011. Analyse situationnelle de la planification familiale en Guine. Conakry: Rpublique de Guine. MSHP/DNSFN. 2011. Politique Nationale de la Sante de la Reproduction (Familiale). Conakry: Rpublique de Guine. MSHP/DNSFN. 2012. Annual Report 2011. Conakry: Rpublique de Guine. MSHP/DNSFN. 2012. Feuille de Route Pour Acclrer la Rduction de la Mortalit Maternelle, Nonatale et Infanto-Juvnile 2012-2016. Conakry: Rpublique de Guine. MSHP/DNSFN. 2012. Initiative Franaise: Appui la rduction de la mortalit maternelle et infantile en Guine. Conakry: Rpublique de Guine. MSHP/DNSP/Division Sant de la Reproduction (DSR). 2007. Analyse Situationelle de la Securit des Produits des SR. Conakry: Rpublique de Guine. MSHP/DNSP/DSR. 2008. Plan Stratgique de Repositionnement de la Planning Familial en Guine 20082015, Conakry: Rpublique de Guine. MSHP/DNSP/DSR. 2009. Normes et Procdures en Sante de la Reproduction. Four volumes : (1) Composantes Communes en SR; 2) Sante de la Femme et de lEnfant; (3) Sante des Jeunes et des Hommes; and (4) Composantes dAppui. Conakry: Rpublique de Guine. MSHP/DNSP/DSR. 2011. Plan dAction Oprationnel de Planification Familiale 20122013. Conakry: Rpublique de Guine. MSHP/DNSP/DSR. 2011. Annual Report 2010. Conakry: Rpublique de Guine. MSHP/DNSP/Division AlimentationNutrition. 2008. Politique Pour la promotion de lallaitement maternel en Guine (2009 2013). Conakry: Rpublique de Guine. MSHP/Division AlimentationNutrition. 2005. Politique Nationale de lAlimentation-Nutrition. Conakry: Rpublique de Guine. MSHP/Direction Nationale de la Pharmacie et des Laboratoires. 2008. Plan Stratgique de Scurisation des Produits de la Sant de la Reproduction en Guine 20082012. Conakry: Rpublique de Guine.

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Repositioning Family Planning in Guinea: A Baseline

MSHP/Direction Nationale de la Pharmacie et des Laboratoires. 2010. Plan Stratgique de Scurisation des Produits de la Sant de la Reproduction Intgrant la Programmation Holistique du Condom en Guine, 20112012. Conakry: Rpublique de Guine. 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. Ougadougou 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, USA: Population Reference Bureau. Population Reference Bureau (PRB). 2012. Fiches des donnes sur la Population mondiale 2012. Washington, DC: PRB. Rpublique de Guine. 1991. Dclaration de Politique de Population pour la Guine. Conakry: Commission Nationale de Population. Rpublique de Guine. 1996. Dclaration de Politique de Population, version rvise, Septembre 1996. Conakry: Rpublique de Guine. Rpublique de Guine. 2002. Stratgie de Rduction de la Pauvret en Guine. Conakry: Rpublique de Guine. Rpublique de Guine. 2005. Etude du niveau dintgration des objectifs de la politique de population dans le DSRP 2002, Conakry: Rpublique de Guine. Rpublique de Guine, Institut National de la Statistique, Ministre du Plan et de la Promotion du Secteur Priv. 2007. Enqute Lgre pour l'Evaluation de la Pauvret 2007. Conakry: Rpublique de Guine. 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, USAID | Health Policy Initiative, Task Order 1. Retrieved on 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 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 from http://www.childinfo.org/files/Child_Mortality_Report_2011.pdf. United Nations Development Program (UNDP). 2010. 2010 Report on MDG in Guinea. Retrieved August 1, 2012 from http://www.gn.undp.org/html/omd1.html.

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References and Additional Resources

UNDP. 2011. Human Development Report 2011. Retrieved July 12, 2012 from http://hdrstats.undp.org/images/explanations/GIN.pdf. 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. USAID | DELIVER Project. 2003. Contraceptive Security Index 2003: A Tool for Priority Setting and Planning. Arlington, VA: USAID | DELIVER Project. Retrieved on September 9, 2012 from http://deliver.jsi.com/dlvr_content/resources/allpubs/factsheets/CSInde_2003_Book.pdf. USAID | DELIVER Project. 2006. Contraceptive Security Index 2006: A Tool for Priority Setting and Planning. Arlington, VA: USAID | DELIVER Project. Retrieved on September 9, 2012 from http://deliver.jsi.com/dlvr_content/resources/allpubs/factsheets/CSInde_2006_Book.pdf. USAID | DELIVER Project, Task Order 1. 2009. Contraceptive Security Index 2009: A Tool for Priority Setting and Planning. Arlington, VA: USAID | DELIVER Project, Task Order 1. Retrieved July 23, 2012 from http://deliver.jsi.com/dlvr_content/resources/allpubs/factsheets/CSIndex_WallChart_WebBklet.pdf. World Bank. 2012. Data by Country. Retrieved July 19, 2012 from http://data.worldbank.org/country/guinea. World Health Organization (WHO). 2012. Trends in Maternal Mortality: 19902010. WHO, UNICEF, UNFPA and The World Bank Estimates. Geneva: WHO. Retrieved September 6, 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, NC: FHI. Retrieved August 2, 2012 from http://www.fhi360.org//NR/rdonlyres/e66buwqnetdkndytax7vlqxeknagzd6fdahemwklkxj7enfcxltd4uvkgr skee7he4mcvnh6chcteo/WHOCBAinjectablesBrief0610.pdf.

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For more information, contact: Futures Group One Thomas Circle, NW, Suite 200 Washington, DC 20005 Tel: (202) 775-9680 Fax: (202) 775-9694 Email: [email protected]