October 2012

REPOSITIONING FAMILY PLANNING IN MALI

A Baseline

This publication was prepared by Modibo Maiga, Bintou Deme Diallo, Elizabeth McDavid, and Sabine Attama Dissirama (consultant) of Futures Group.

Photo credit (cover): Romel Jacinto Suggested citation: Maiga, M, Deme Diallo, B., McDavid, E. and Attama Dissirama, S. 2012. Repositioning Family Planning in Mali: 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 Mali: A Baseline

OCTOBER 2012
This publication was prepared by Modibo Maiga, Bintou Deme Diallo, Elizabeth McDavid, and Sabine Attama Dissirama (consultant) of Futures Group.

CONTENTS
Acknowledgments ..................................................................................................................iv Abbreviations ........................................................................................................................... v Introduction .............................................................................................................................. 1 Background: Mali .................................................................................................................... 3 Malis Health System................................................................................................................................ 3 Maternal and Child Health ........................................................................................................................ 3 Community-based Distribution of Contraceptives.................................................................................... 4 Framework for Assessing the Repositioning FP Initiative....................................................... 5 Methodology ............................................................................................................................................. 5 Study Limitations ...................................................................................................................................... 7 Application Findings ................................................................................................................ 8 SO: Increased Stewardship of and Strengthened Enabling Environment for Effective, Equitable, and Sustainable FP Programming .............................................................................................................. 8 Intermediate Result 1: Resources for Family Planning Increased, Allocated, and Spent More Effectively and Equitably.................................................................................................................... 9 Intermediate Result 2: Increased Multisectoral Coordination in the Design, Implementation, and Financing of Family Planning 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, Program Improvement, and Management................................................. 17 Intermediate Result 5: Individual or Institutional Capacity to Assume Leadership and/or Support the FP Agenda Strengthened in the Public Sector, Civil Society, and Private Sector .................................. 18 Recommendations for Repositioning FP in Mali .................................................................. 21 Annex 1. Persons Interviewed............................................................................................... 22 Annex 2. Repositioning Family Planning Results and Indicators for Mali .......................... 23 References and Additional Resources................................................................................. 34

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 Futures Group: Maj-Britt Dohlie for her instrumental management support, practical suggestions, and technical expertise (especially 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 studyfrom 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 for her insights, and Lori Merritt for her careful editing of the report. In Mali, we are especially indebted to and thank Dr. Binta Keita, Head of the Division of Reproductive Health at the Ministry of Health. In addition, we thank Dr. Famory Fofana, Futures Groups country representative, and his staff membersMariam Zouboye, Mamadou Mangara, Timoth Dao, Abdoulaye Ganda, Aicha Fadiga, and Ahmadou Coulibalyfor use of their facilities, assistance with other logistics, and participation in meetings.

iv

ABBREVIATIONS
AMPPF AMPRODE/SAHEL ASDAP ATN BCC CA CAREF CBD CERPOD CHW CPN CPS CSCOM CSCRP CSLP CSO DNP DNS DNSI DPM DRS DSR EDSM FBO FP FPE GHI GP HPP HDI ICPD IPPF IR KAP KfW Association Malienne pour la Protection et la Promotion de la Famille Association Malienne pour la Protection et le Dveloppement de lEnvironnement au Sahel Association de Soutien au Dveloppement des Activits de Population Assistance Technique Nationale National Technical Assistance (USAID bilateral health project) behavior change communication cooperating agency Centre dAppui et de Recherche la Formation community-based distribution Centre dEtudes et de Recherche sur la Population pour le Dveloppement community health worker prenatal care Cellule de la Planification et de la Statistique Planning and Statistics Unit Centre de Sant Communautaire Community Health Center Cadre Stratgique pour la Croissance et la Rduction de la Pauvret Strategic Framework for Growth and Poverty Reduction Cadre Stratgique de Lutte contre la Pauvret Strategic Framework for Poverty Reduction civil society organization Direction Nationale de la Population National Directorate of Population Direction Nationale de la Sant National Directorate of Health Direction Nationale de la Statistique et de lInformatique National Directorate of Statistics and Information Direction Pharmacie et Mdicaments Directorate of Pharmacy and Drugs Direction Rgionale de la Sant Regional Directorate of Health Division Sant de la Reproduction Division of Reproductive Health Enqute Dmographique et de Sant Demographic and Health Survey (Mali) faith-based organization family planning Family Planning Program Effort Global Health Initiative (USAID) Groupe Pivot Health Policy Project Human Development Index International Conference on Population and Development International Planned Parenthood Federation intermediate result knowledge, attitudes, and practices Kreditanstalt fr Wiederaufbau
v

Repositioning Family Planning in Mali: A Baseline

MDGs MS NGO PDDSS PDSSC PKC PNP PPM PRODESS PSI PTF RAPID REMAPOD RH RIPOD SEC SO TAC USAID UNFPA WHO

Millennium Development Goals Ministre de la Sant Ministry of Health nongovernmental organization Plan Dcennal de Dveloppement Sanitaire et Social Ten-year Plan for the Development of the Social Sector Programme de Dveloppement Social et Sanitaire des Cercles District Plan for Social and Health Development Projet Keneya Ciwara (USAID bilateral health project) Politiques, Normes, et Procdures Policies, Norms, and Procedures Pharmacie Populaire du Mali Pharmacy Popular of Mali Programme de Dveloppement Sanitaire et Social (Five-Year) Plan for Health and Social Development Population Services International Technical and Financial Partners Ressources pour lAnalyse de la Population et de son Impact sur le Dveloppement Rseau des Parlementaires Maliens pour la Population et le Dveloppement reproductive health Rseau Islam Population et Dveloppement Soins Essentiels dans la Communaut Essential Community Care (strategy) strategic objective Tableau dAcquisition de Contraceptifs Contraceptive Procurement List United States Agency for International Development United Nations Population Fund 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 (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 family planning 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 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, 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 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 32 35 28 27 29 24 22 16

Percent of Women

29

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. 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
1

Repositioning Family Planning in Mali: A Baseline

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. 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. 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 on civil society involvement in family planning in Mbour, Senegal, 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 Health Policy Project (HPP) adapted and pilot tested the framework in Togo and Niger.2 In 2012, the Futures Group applied the framework to assess Malis 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).
2

BACKGROUND: MALI
Mali is a landlocked country in West Africa. Most of its 478,839 sq. mile land mass is in the Sahara Desert. Malis population has tripled in size since independence in 1960 (Guengant, 2011). Its current population of 15.4 million people is growing at 3.1 percent annually. The potential for continued rapid population growth already exists, since nearly half (48%) of Malis people are under age 15 (PRB, 2011). Also, Malis fertility rate is among the highest in the world. If the current population growth rate continues, Malis population will increase to 36 million people in 2035 (USAID | Health Policy Initiative, Task Order 1, 2009). Mali ranks among the worlds poorest countries, with a gross national income per capita of US$600 per year (World Bank, 2011). Approximately half of the population lives on less than US$1 a day. Mali remains near the bottom of the United Nations Human Development Index, at 175 out of 187 countries (UNDP, 2011). Ninety percent of Malis people live in the southern third of the country. More than half of all Malians live in three provincesSikasso (18.1%), Koulikoro (16.7%), and Segou (16.1%)and one-quarter live in the capital city and surrounding district (Mali Institut National de la Statistique, 2009). The most sparsely populated areas are in the vast northern provinces (Gao, Kidal, and Tombouctou). Population growth and distribution as well as geography challenge the countrys development plans in the areas of food security, economic growth, and the MDGs.

Malis Health System

According to USAID/Malis Global Health Initiative (GHI) Strategy 2010, the Mali governments health budget was US$145 million in 2010. Donors contributed an additional US$96 million. The U.S. Government allocated close to US$40 million in FY2009; this amount was expected to increase to US$60 million in FY2010.
Box 1. Health Providers per Person, 2010 Doctors Nurses Midwives 1:8,646 1:1,947 1:11,413

Despite these investments, Malis health infrastructure is Strategy, 2010 insufficient to meet the needs of its growing population. According to the USAID/Mali GHI Strategy 2010, the country has only 11 tertiary care centers (hospitals), 59 secondary care centers, and 873 primary health centers. In addition, Mali has insufficient numbers of health workers (see Box 1). The staff coverage rate in facilities is only 72 percent. Furthermore, existing staff are unevenly distributed, with poor and remote districts in particular suffering from staff shortages.

Source : USAID/Mali GHI

Maternal and Child Health

Despite recent improvements, Malis health indicators remain poor. One in 10 infants die before their first birthday, and more than one in six children die before their fifth birthday (UNICEF, 2011). Maternal mortality is also high; a womans lifetime chance of dying in childbirth is one in 28 (WHO, 2012). Factors that contribute to the high maternal mortality ratio (540 deaths per 100,000 birthsWHO, 2012) are the insufficient access to health services in general and low use of reproductive health (RH) services in particular. The situation is aggravated by harmful traditional behaviors and practices, such as early, close, and late pregnancies; clandestine abortions; and insufficient obstetric care. Only half (49%) of all births are delivered by skilled attendants (MS/CPSI/DNSL, 2006). Postpartum hemorrhage is the leading cause of maternal mortality (Khan and colleagues, 2006).

Repositioning Family Planning in Mali: A Baseline

Other factors affecting maternal and child health are malnutrition, malaria, and other endemic tropical diseases (USAID, 2010). Inadequate clean water and sanitary facilities also contribute to disease. One in three (36%) Malians do not have access to clean drinking water, and three in five (59%) do not have adequate sanitation facilities, according to estimates for 2010 (WHO/UNICEF, 2012a and 2012b). Malis total fertility rate, estimated to be 6.5 children per woman in 2010, has hardly changed in 30 years; the fertility rate in 1980 was estimated to be 6.6 children per woman (Guengant, 2011). Contraceptive use remains low. According to the 2006 Mali Demographic and Health Survey (EDSM), 6.4 percent of married women were using modern methods and an additional 1.4 percent were using traditional methods (CPS/DNSI and Macro International, 2007). Despite the low contraceptive prevalence rate, a considerable number of Malian women have a strong desire to plan and space their pregnancies. Of those married women surveyed in the 2006 EDSM, 21 percent said they did not want another child and 10 percent said they would like to wait at least two years before having another child. These women were not using any method of family planning and thus are considered to have an unmet need for family planning. Thus, nearly one-third (31%) of married women would like to limit or space births but are not using family planning (CPS/DNSI and Macro International, 2007).

Community-based Distribution of Contraceptives

Mali was one of the first countries in Francophone West Africa to introduce a CBD program of contraceptives. The first efforts at CBD were implemented during 1990 to 1999, with pilot projects in two regions (Koulikoro and Sikasso). The two projects trained and deployed community agents, who distributed condoms and spermicides in rural areas. In 1994, the pilot projects introduced oral contraceptives and extended the CBD program to more regions. The pilot projects were successful: contraceptive prevalence increased to 33 percent in some zones and 40 percent in other areas, especially where NGOs implemented the strategy (Leonard, no date). In 2003, the National Directorate of Health (DNS) and its partners, notably the NGO umbrella group Groupe Pivot, relaunched the CBD program. The program recruited male and female community agents to raise public awareness about the importance of vaccinations, proper nutrition, and other health issues, and to provide contraceptives, malaria treatment, and drugs to combat tropical diseases (ivermectine, albendazole, and azythromicine). In 2009, the DNS and its partners developed a new strategy for CBD, called Essential Care in the Community, which was initiated in 2011. Despite these efforts, contraceptive prevalence remains low in Mali. Use of modern contraceptive methods has increased gradually, from 1.3 percent of married women in 1987 (CPS/DNSI, 1987). (CPS/DNSI, 1987) to 6.9 percent in 2006 (CPS/DNSI, 2006). Overall contraceptive use (including traditional methods) has risen from 4.7 percent of married women in 1987 to 8.2 percent in 2006. During the past decade, unmet need for family planning has increased from 26 percent of married women in 1995/96 to 35 percent in 2006 (CPS/DNSI, 1987; CPS, 1995/96; CPS/DNSI and Macro International, 2007).

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
Under the USAID-funded MEASURE Evaluation Project, the Futures Group field tested the M&E Framework in Tanzania in 2011. Building on this work, HPP reviewed the framework components, indicator sheets, and interview guides developed for Tanzania and subsequently adapted them for use in
5

Repositioning Family Planning in Mali: A Baseline

West Africa and translated them into French. HPP then tested the framework in Togo and Niger. Each assessment was carried out by two people working in-country for two weeks. To collect the information, the assessment team met with key informants and, in some cases, small groups.
Streamlining of the methodology

With funding from the William and Flora Hewlett Foundation, Futures Group is applying the M&E Framework in six additional Francophone West Africa countries (Benin, Burkina Faso, Guinea, Mali, Mauritania, and Senegal). To streamline the work, Futures Group modified the existing methodology. Application in these countries includes the following:
1. Reviewing documents to ensure that the key documents are available in French; 2. Contacting the national focal persons who had been nominated at two previous international

meetings 3 from government, donors, and civil society with the purpose of repositioning FP; framework indicators;

3. Convening a one-day working meeting of key stakeholders to collect information about the 4. Conducting interviews with key informants to confirm or clarify specific points; 5. Drafting the indicator table and asking stakeholders to review it and send comments; and 6. Revising the indicator table and drafting the complete report.

Futures Group proposed this revised methodology to make the information-gathering process more participatory and organic, with the give-and-take discussions and clarifications that the indicators might elicit. Bringing people together to discuss each indicator promoted policy dialogue among government officials and key stakeholders and enabled participants to enrich each others knowledge. This exchange of information would not have happened through individual interviews. Most important, the process promoted ownership of the study findings. Also, the revised methodology was more cost-effective and efficient, since the assessment could be done by one person working in-country for 1012 days instead of the previous approach, which took two people and 15 or more days. To plan for the six applications in Francophone West Africa, a four-person team met in Bamako, Mali for a one-week planning and information-sharing session. At the January 2012 meeting, team members discussed the M&E Framework, clarified details for applying the new methodology, and reviewed the questionnaire. The team tested the new methodology by convening a one-day workshop with Malian stakeholders to collect information on the frameworks indicators. They also set plans for conducting applications in the remaining five countries. HPP staff in Mali greatly facilitated the study teams work. The HPPs Technical Advisor for FP/RH joined the team, and HPP/Mali staff provided logistics and administrative support and helped select invitees to the one-day workshop. In addition, the Futures Group Mali office hosted the teams meetings and the workshop for stakeholders.
Application of the framework in Mali

For the Mali application, the Futures Group team first reviewed policies, strategies, program materials, and other information related to the framework indicators in that country. The team also selected three key resource documents (translated into French) for the workshop:
1. Framework for Monitoring and Evaluating Efforts to Reposition Family Planning document
Government and donor focal persons were identified and nominated at the Ouagadougou FP conference in February 2011. The CSO focal persons were identified at the September 2011 Mbour, Senegal conference for civil society organizations.
3

Framework for Assessing the Repositioning FP Initiative 2. Explanation of Indicators 3. Semi-structured Interview Guide

The team then identified 12 key actors in repositioning family planning in Mali and invited them to the workshop. The team developed a detailed workshop agenda, sent the three resource documents to the invitees, and made hard copies for the meeting. The team also prepared two PowerPoint presentations one on the challenges and opportunities for FP programs in Francophone West Africa and one on the key elements of the M&E Framework. The presentations and resource documents also will be used for workshops in the remaining five countries. In Mali, the team conducted a workshop with nine key stakeholders, including three of the four repositioning FP focal persons and others who could provide information for the indicators. During the workshop, the team gave the two PowerPoint presentations and discussed them with participants. The participants then worked in small groups to provide information for each intermediate result and indicator. The participants also identified other resource people to contact for additional or complementary information. Next, the team interviewed many of the recommended resource people to obtain specific information. The workshop and interviews helped confirm and clarify the findings of the document review and provided some further information on the implementation status of various plans. In many of the interviews, the informant called in a colleague for more information, which enriched the responses. In total, the team gathered information from 25 key informants, with the majority representing cooperating agencies (CAs) and CSOs (see Table 1 and Annex 1).
Table 1. Mali Key Informants, by Affiliation and Sex
Sex
Men Women Total

Government Officials
5 2 7

Donors
1 2 3

CAs/CSOs
10 5 15

Total
16 9 25

Following the interviews, the team prepared a draft of the Indicator Framework table (see Annex 2), and HPP/Mali sent it to the workshop participants for their feedback. Two people provided additional input. The team then drafted this report to summarize the findings.
Ethical considerations

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

Study Limitations
The study team was unable to talk with all of the key actors identified, since some were not available for the meeting or interviews.

APPLICATION FINDINGS
This section presents the findings from the application of the M&E Framework in Mali. 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 Division of Reproductive Health (DSR) of the DNS is the government-led entity that oversees and manages the FP program in Mali. The Netherlands Cooperation and the Spanish/Tunisian Cooperation provide full-time technical experts to the DSR. The DSR also manages the FP Multisectoral Working Group. In general, the DSR actively fulfills its role as the manager of the national FP program. However, because it is a division, not a directorate, the DSR lacks the authority and decisionmaking powers needed to ensure optimum coordination. For instance, there is no coordinated plan for annual FP campaigns, since each partner agency has its own plan that follows the directives of its home organization or office. Coordination of activities at all levels (national, regional, district, and community) needs to be stronger to reduce duplication, avoid gaps, and ensure that all partners use the same approach and tools. Currently, some partners bring in their own information-collection system for use at the district level, without accounting for the existing national system. Also, the methodology for calculating couple years of contraceptive protection needs to be uniform across the country and all partners. Another government entity is the National Commission for the RH Products Security Plan, which prepares the contraceptive procurement tables and keeps close track of donations and purchases. This commission was created in 2002 and is housed in the Ministry of Health (MS). Recently, the government has created two new multisectoral committees: (1) an RH theme group to focus on repositioning family planning after the February 2011conference in Ouagadougou; and (2) the Civil Society Coalition for Repositioning Family Planning, created after the September 2011 Mbour, Senegal conference. The DSR will need to facilitate coordination of these committees to ensure synergy and avoid competition or confusion.
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 Mali: Family Planning Program Effort (FPE) Score and Contraceptive Security Index. 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. Malis FPE score has risen markedly in recent yearsfrom 11.3 in 1982 to 61.4 in 2009indicating major progress in family planning, especially in the areas of policies and plans to strengthen the FP program (Ross and Smith, 2010). Since the highest score is 100, Malis FPE score also indicates considerable room for improvement. Another index suggests an inadequacy in contraceptive supplies. The Contraceptive Security Index uses a rating system that assigns points to 17 indicators related to the supply chain, finance, the health and social
8

Application Findings

environment, access to FP, and use of FP. The 2009 Contraceptive Security Index for Mali was 44.2 (out of a possible score of 100), indicating a relatively low level of contraceptive security (USAID/DELIVER, 2009). FP partners and the Ministry of Health in Mali do not seem to be aware of either of these instruments.
Indicator 3: Evidence of FP policies implemented and resources allocated and subsequently used in relation to the same FP policies

In Mali, FP services are offered, in principle, in all health structures across the country by the government health agents at all levels and community health agents through the CBD strategy. However, much work remains to ensure that nationwide coverage becomes a reality. Several partners support the implementation of health services, including family planning. The FP Multisectoral Working Group has organized the month-long FP campaign every year since 2005. Examples of policies and plans implemented include (1) the creation of a budget line item in 2009 for the purchase of contraceptives; (2) the ministerial notice in 2008 identifying approved methods and products and setting lower prices for contraceptives; (3) and the 1991 circular letter from the MS that authorized the social marketing of contraceptives. In addition, the Policies and Norms for RH Services provide guidance for how RH policies should be implemented. The annual reports of local and international NGOs and implementing agencies provide the evidence that those policies actually are being implemented. Resources for family planning in Mali are diverse and substantial, including financial resources for contraceptive purchases and technical assistance (in the form of seconded staff to the DSR) and through various bilateral and multilateral projects. They also include construction and material resources, collaboration on training activities, studies, behavior change activities, and policy and strategy development. Since the Ouagadougou conference, there have been additional commitments by partners to support repositioning FP activities. Between 2009 and 2011, Mali has witnessed a 66 percent increase in funds for contraceptive commodities.

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: 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 committed to family planning in the last two years It is extremely difficult to get accurate data on all FP expenditures in Mali, as in other West African countries. Often programs are integrated, with accounting taking place for family planning in combination with safe motherhood or CBD (including management of childhood illnesses), rather than for family planning alone, or within the overall context of district health services, for example. In addition, it is often difficult to find data for resources spent versus resources allocated for family planning. Contraceptive purchases are one of the major FP line items where it is often possible to find good data. The Directorate of Pharmacy and Drugs (DPM) in the Ministry of Health in Mali provided the information for all of the tables shown in this section.

Repositioning Family Planning in Mali: A Baseline

In 2009, the Malian government made the decision to contribute to the purchase of contraceptives each year, at a level to meet between 10 and 15 percent of the contraceptive needs nationwide. However, this was not put into effect in 2009. Beginning in 2010, a line of credit for 500 million CFA (approximately US$1 million) per year was established to allow for contraceptive commodities. The line of credit was not used in 2010. In 2011, the government spent 109 million CFA (US$218,000) on the line of credit. The 2011 budget currently is being implemented. In 2012, the government thus far has allowed 129 million CFA (US$258,000) through this line of credit. The decision and action on the part of the government shows that it took a strategic decision and moved to implement that decision over just a few years. In addition, each year of its implementation has shown incremental increases in the government funding of FP commodities. It would be useful for interested CSOs and other partners to track funding allocations to this line of credit and ensure that it is used in full every year.
Malis technical and financial partners have taken on the biggest burden of the FP program. Based on data provided by the DPM, resources for contraceptive commodities increased by 66 percent from 2009 to 2011 (see Table 2). Table 2. Contraceptive Commodity Purchases (US$, based on an exchange rate of 500 CFA per US$1)
Partner Year
2009 2010 Public Sector MS UNFPA USAID Total 381,369 497,592 299,785 1,178,746 372,924 312,608 880,015 1,565,547 Private Sector KfW USAID Total 1,545,014 33,497 1,578,511 1,864,477 21,421 1,885,898 2,125,424 31,699 2,157,123 5,534,915 86,617 5,621,532 480,415 420,203 1,102,697 2,003,315 1,234,708 1,230,403 2,282,497 4,747,608 2011 Total

Sector

Year
2009 2010 National 2011 Total

Public Private Total

1,178,746 1,578,511 2,757,257

1,565,547 1,885,898 3,451,445

2,003,315 2,157,123 4,160,438

4,747,608 5,621,532 10,369,140 Source: MS/DPM.

According to the MS, contraceptive purchases are projected to increase during 2012 and 2013, based on commitments from the major partners. The commitments for 2012 are about 60 percent higher than 2011, while those for 2013 are slightly lower than the 2012 level (see Table 3).

10

Application Findings

Table 3. Projected Contraceptive Purchases for 2012 and 2013, by Partner (US$)
Product
MS USAID 2012 UNFPA KfW Total MS USAID 2013 UNFPA KfW Total MS USAID 20122013 UNFPA KfW Total 198,000 515,732 2,393,524 2,101,480 5,208,736 198,000 320,546 2,182,515 2,024,192 4,725,253 396,000 836,278 4,578,221 4,125,672 9,936,171

Freight
61,380 61,887 650,882 651,460 1,425,609 61,380 38,465 605,179 627,499 1,332,523 62,760 246,120 1,256,061 1,278,959 2,843,900

Total
259,380 577,619 3,044,406 2,752,940 6,634,345 259,380 359,011 2,787,694 2,651,691 6,057,776 458,760 1,082,398 5,834,282 5,404,631 12,780,071

In 2011, the United Nations Population Fund (UNFPA) also provided four trucks, 56 office computers, nine laptops, one video projector, and 32 printers. It also provided 39 million CFA for renovation of the central warehouse for medicines. The Netherlands Cooperation and an anonymous donor provided funds to Population Services International (PSI) for the promotion of long-term methods. The funds are difficult to detail because the activities are integrated. USAIDs total contributed FP resources over the last three years show an increase each year (Sangare, 2012): 2009: Budget FP/RH US$6,480,067, includes contraceptive purchases made through USAID | DELIVER 2010: Budget FP/RH US$7,435,000, includes contraceptive purchases made through USAID | DELIVER 2011: Budget FP/RH US$8,565,000, includes contraceptive purchases made through USAID | DELIVER

11

Repositioning Family Planning in Mali: A Baseline

One other major indicator that demonstrates government commitment to health is whether it has met the goals set at the Abuja conference. Abuja set a target of 15 percent of the national budget to be allocated to health. In 2010, Mali committed 11.8 percent of its national budget to health (USAID/Mali GHI Strategy, 2010). However, it is difficult to check whether the ministry actually has received this funding and spent it on health. This situation suggests that civil society watchdog groups have an opportunity to monitor health budgets and expenses. Association Malienne pour la Protection et la Promotion de la Famille (AMPPF)/International Planned Parenthood Federation (IPPF) has also provided US$102,500 for FP programs. Mali has experimented with at least two new financing mechanisms. Since 2005, PSI has managed a social franchising program with 60 private clinics in Bamako. Also, the DSR supports a contracting program with local NGOs for providing long-term FP methods. Both examples are promising cases of new financing mechanisms for family planning, but they have not been evaluated from a financial point of view, and so in some respects remain theoretical.

Mali certainly is not lacking in resources for family planning. The challenge is organization and coordination so there is no redundancy or gaps.
Key donor informant

For 2009, 2010, and 2011, see IR1.1 above. However, it should be noted that the Government of Mali did not contribute any funds for contraceptives in 2009 or 2010, even though it had the line of credit. In addition, the World Bank has proposed starting a US$30 million urban FP program next year, and the French Muskoka funds planned for urban family planning in Mali, to begin in 2013, amount to 30 million Euros over five years, in addition to funds it has provided to UN agencies. WHO has provided US$70,000 to support family planning in Mali. The William and Flora Hewlett Foundation has provided US$200,000 to IntraHealth and US$300,000 to Futures Group for assistance with family planning to several countries in the region, including Mali. The Netherlands has provided US$4 million. The Netherlands also funds a project called Pays Bas OMD5, which is providing US$22 million for five years for maternal and infant health and RH and FP programs contributing to achieving Millennium Development Goal 5.

Intermediate Result 2: Increased Multisectoral Coordination in the Design, Implementation, and Financing of Family Planning 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 policies and programs. In general, the Futures Group team found numerous examples of multisectoral coordination. These examples will be reported under the various sub-IRs.
IR2.1: Evidence of family planning programs incorporated into national strategic and development plans

The Government of Mali has incorporated FP programs into its national strategic framework documents and plans. The two generations of the Strategic Framework for Growth and Poverty Reduction (CSCRP) (20072011 and 20122017), the principal strategy document for the countrywith which all sectoral strategies must alignhas references to improving access to primary healthcare, including family planning. The framework discusses the need for fertility reduction and the importance of improving access to services, including FP services. The Ten-Year Plan for Health and Social Development (PDDSS) (19982008) mentioned family planning only cautiously in its 1998 version. The new PDDSS is currently in development, so the 1998 version has been extended. The MS is actively involved in

12

Application Findings

preparing the new version, so it is likely that family planning will have a more prominent place in the strategy. The Five-Year Plan for Health and Social Development (PRODESS) follows from the PDDSS and refers directly to activities of Repositioning FP, including actions will be taken to improve data collection and strengthen repositioning family planning to increase the level of contraceptive use and to reduce unmet needs. The next generation of the PRODESS is also in development at this time, and the MS is involved in its development. Of note is that the PRODESS in development will likely have a section on gender, including indicators, so FP activists are optimistic that repositioning family planning will be one of the major anchors of this strategic document. There is a need to convince leaders in the community, associations, and religious groups, as well as political leaders and leaders in other ministries (Education; Promotion of Women, Children, and Family; Social Development; Economy; and Finance), to be more involved in and favorable to FP activities.
IR2.2: Evidence of governments engaging multiple sectors in family planning activities

The MS/DNS is responsible for the development, coordination, and monitoring of FP policies. Implementation of all health activities, including FP activities, devolves to the Regional Health Directorates (DRS) that support the operational level. Various actors participate in FP service provision in particular, NGOs and associations, private organizations, and faith-based organizations (FBOs). The yearly FP campaigns are the most visible and high profile of the activities that the MS implements through the DSR. The Multisectoral FP Group (see IR2.3, below) spends weeks, and sometimes months, planning these month-long multisectoral campaigns. In 2002, the National Commission for Monitoring the Contraceptive Security Plan was formed to implement and monitor the plan. In 2011, the name of the plan was changed from the Contraceptive Security Plan to the RH Products Security Plan; the commissions name was then also changed to the National Commission for Monitoring the RH Products Security Plan to reflect the change in the plans name. This commission meets regularly (the intention was to meet quarterly, but the group actually meets twice a year). It is quite active in updating the plan, sharing new commitments, and reporting on commodity shipments received. Following the 2011 Ouagadougou conference, the MS created an RH Thematic Group. Its action plan is the Repositioning FP action plan developed in Ouagadougou and refined at the Mbour, Senegal conference. Another group, the Coalition of CSOs for Repositioning FP, was created in 2011 at the Mbour conference and is developing its terms of reference and organization in 2012. The 2011 FP conferences and other international activities generated a great deal of commitment and excitement regarding family planning and led to the creation of two new multisectoral groups. Stakeholders should determine whether these groups become viable and active on the Mali FP scene and what value they add. The Government of Mali will need to think about creating synergy among these groups if they do become viable, perhaps strengthening one coordination mechanism rather than creating new groups or networks that might exist only for the ad-hoc needs of a partner or a small group. MS leadership in multisectoral coordination needs to be strengthened to allow it to assume fully its coordination role and let civil society play its role in developing innovations.

13

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

Two important multisectoral structures promote family planning. The first is the Multisectoral FP Group and its subcommittees, created in 2004 and managed by the DSR. The group meets regularly (at least every three months) and is active throughout the year, especially when planning and implementing the month-long FP campaign held every spring. The group also coordinates all of the FP work throughout the country and is a forum for partners to share research, program results, and other news. This multisectoral group includes not only NGOs and civil society organizations, but also religious leaders, parliamentarians, and the private sector (pharmacies, clinics). The second multisectoral committee, focusing on the Contraceptive Procurement List (TAC), oversees the security of RH products. A few years ago, the partners recommended that the two groups be combined, but the DNS and the DPM decided against it. In addition, see above, IR2.2, for a discussion of two new groups.
IR2.4: Evidence of government support for private sector participation in family planning

The government actively encourages the Malian private sector to participate in family planning. Both the PDDSS and the PRODESS discuss the private sector and encourage its participation in all governmental sectors. The Malian civil society is a major actor in family planning, and its activities are integrated into the national yearly FP action plans compiled by the DSR. The private sector also is included in the yearly FP campaigns. The DSR supports the financing of NGOs, including AMPPF/Netherlands Cooperation, and supports performance contracts with NGOs for health services. In addition, Marie Stopes International, a private sector provider of FP services, recently established offices and services in Mali, with the authorization of the MS. Mali is a model of civil societys active participation in the promotion of family planning. It is a country that exhibits good coordination of NGOs through Groupe Pivot (GP), a network with more than 150 NGO members, and between the NGOs and the government.

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

Mali has a range of national and subnational policy and strategy documents, plans, and guidelines to promote access to FP information and services by the population. Box 2 lists the major documents that, in their succeeding iterations, continually improve the environment for and remove barriers to access to FP services and information.

14

Application Findings

Box 2. Malis Major Health Policies Health Sector Policy (1991) RH Law (2002) Ten-year Plan for the Development of the Social Sector (PDDSS) (20012011)* Five-year Plan for Health and Social Development (PRODESS II) (20092011) (extended)* District Plan for Social and Health Development (PDSSC) Strategic Plan for Repositioning FP (2011) Strategic Plan for RH Communication Strategic Plan for Reproductive and Sexual Health of Adolescents and Youth Plan for the Security of RH Products (2011 2015) (not yet validated) Operational Plan for Procurement and Distribution of RH Products Guide for Constructive Engagement of Men in FP/RH National Action Plan for FP (20112015)
* New PDDSS and PRODESS plans in development

Both the PDDSS 20012011 and the PRODESS IIpolicy documents that currently are in effectdeal with health and social services in general, and maternal and child health in particular, in promoting highquality FP services. The PRODESS II focuses on geographic access to health services. It describes strategies to reach people who live beyond 5 kilometers from a health center, such as community outreach and mobile units offering various services. The goal is to provide these people with a minimum package of services to reduce maternal, neonatal, infant, and child mortality, but also address issues of fertility and nutrition. The Cercle levels (districts) develop their Five-Year District Plan for Social and Health Development (PDSSC) for decentralizing health services and integrating family planning into operational plans in the regions and districts and at peripheral levels. Mali currently is in the process of developingwith its partnersthe ten-year PDDSS for 20122021 and the five-year PRODESS for 20122017, both of which will place special emphasis on maternal and child health, including family planning.

The Strategic Plan for Repositioning FP demonstrates a clear commitment to strengthening CSO involvement in family planning; this was written while keeping in mind the guidelines from the 2011 Ouagadougou conference and the Mbour workshop on civil society involvement in family planning. The Mali government strongly supports partnerships among the public and private sectors. Diverse partners participate in offering FP services, especially local NGOs and associations, private entities, and community and faith-based organizations.
IR3.2: Existence of national or subnational policies or strategic plans that promote access to FP services and information for under-served populations

Like many other African countries, Mali has developed policies to help it reach the MDGs, especially with regard to poverty reduction and sustainable economic growth. The first Strategic Framework for Poverty Reduction 20022006 (CSLP), written in May 2002, did not include any mention of family planning. The next generation of CSLP (20072011) was developed based on evaluations and lessons learned from the first. Thanks to advocacy efforts by the Futures Group and the World Bank, family planning was included in the second generation CSLP.

15

Repositioning Family Planning in Mali: A Baseline

Since the 1990s, Mali and its partners, especially local NGOs, have been implementing a CBD strategy to reach under-served populations, particularly in rural areas. Nearly half of all Malians live more than 5 kilometers from a health center. The personnel in the health centers generally cannot cover their entire area by themselves. Malis CBD strategy is included in its health policies and strategies, and uses community agents who play a major role in implementing health programs in Mali.

There are no policy constraints to offering FP services to adolescents and youth in Mali. What we need to do is find ways to take adolescents service to scale and that requires innovations.

In 2008, the MS prepared a document (Document de Rflexion, Key partner in FP 2008) to contribute to analysis of the use of community agents and identify specific issues and decisions needed to ensure more thorough health coverage, especially at the community level. As an outcome of that discussion and analysis, the Mali government put in place a new CBD strategy in 2011, the Essential Community Care (SEC); this strategy is intended to guide those CBD programs implemented by partners, especially NGOs, and favors better access to high-quality services. Malis RH policy covers men, women, youth, adolescents, and other vulnerable groups, including the mentally ill. The government also has developed a strategic plan for communication in RH, with different approaches tailored to specific target groups.
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 Mali government has issued important guidelines and operational directives to accompany policies and strategies concerning family planning at different levels of the health system. For example, in 2005, the DNS/DSR finalized and validated the Policies, Norms, and Procedures (PNP) for RH, with technical assistance from UNFPA and USAID. These documents serve as operational guidelines in the provision of health services throughout the country. Other documents that guide implementation of policies and strategies include the following: The 2002 RH law, which includes implementing texts; A national FP action plan, which the DNS/DSR and its partners develop every five years to conform to the RH plan in effect, based on the PNP for FP/RH; The Road Map for the Reduction of Maternal and Neonatal Mortality, developed every 10 years and aligned with PNP for FP/RH and the current strategy; The document for involving traditional midwives in offering services (2005)this document was developed to implement the directive allowing them to provide services; The National Supervision Guide (2008), issued to accompany the FP/RH Strategic Plan; The Plan for RH Services for Youth and Adolescents, developed in 2005, in part to implement the RH policy; and The Circular Letter on Contraceptive Prices, issued in 2011 to accompany the implementation of the PNP at all levels.

16

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

There is ample evidence that policy barriers to family planning have been identified and removed in Mali. The 1990 population policy4 lifts the prohibition of providing FP services to women, so that any woman, married or not, with or without parental or spousal authorization, can have access to family planning. Before 1990, this significant barrier prevented many women from using FP services. In 1991, the MS issued a circular letter to allow any woman (of reproductive age) to have access to a contraceptive method anywhere in the country. A directive issued in 2005 authorized traditional midwives in villages to provide FP services. In addition, directives from the MS, issued in 2007 and revised in 2011, reduced the prices of contraceptive methods to the client. These two measures resulted in a considerable reduction in the price of family planning and made FP methods more accessible to women at all levels of the health system. The evaluation report of FP services (DSR/ATN, 2008) identified several barriers to FP service provision. The MS and its partners have made enormous efforts to identify and eliminate barriers to providing FP information and services. These efforts need to be continued and strengthened.
IR3.5: Evidence of the implementation of policies that promote FP services and information

Refer to SO 3 above for information regarding this indicator.

Intermediate Result 4: Evidence-based Data or Information Used to Inform Policy Dialogue, Policy Development, Planning, Resource Allocation, Budgeting, Advocacy, Program Design, Guidelines, Regulations, Program Improvement, and Management
This IR is designed to assess the extent to which policies and programs are grounded in data and information to ensure a sound rationale for selecting the program strategies, activities, and other elements.
IR4.1: Evidence of data or information used to support repositioning FP efforts

Malis MS takes advantage of the data available to support repositioning FP efforts. Information coming from the DHS; the National Directorate of Population (DNP); and other ministries (Education, Agriculture, Labor, Womens Affairs, etc.) has been incorporated into the Spectrum policy system and used to convince decisionmakers to support family planning. The MS used national data to design the RAPID presentation for Mali, which local policy champions showed to high-level decisionmakers, including the Prime Minister and the Ministers of Health, Womens Affairs, and Youth and Sports.
IR4.2: Evidence of international best practices incorporated into national health standards

The current PNP for RH date from 2006. In between PNP revisions, the MS issues Technical Notes (Notes Techniques) as PNP addenda to signal and authorize new best practices. Many of the internationally recognized best practices for family planning have been incorporated into national plans and strategies. Accordingly, the MS authorizes, encourages, and implements these best practices, which are considered part of the PNPs. They include the promotion of long-term FP methods in health centers and through mobile services; the introduction of injectables in community outreach services; male involvement; involvement of the private sector; involvement of civil society, religious leaders, and parliamentarians in supporting family planning; development of peer education for family planning; integration of family planning into the yearly Week of intense nutrition activities, in postpartum care, fistula care, and HIV prevention and care; and the introduction of social franchising.
4

Dclaration de Politique Sectorielle de Sant et de la Population du Mali (15 Dcembre 1990). 17

Repositioning Family Planning in Mali: A Baseline

The MS encourages task shifting and has included CBD with injectables both in outreach activities and for CHWs to practice once they have received the appropriate training. For example, the national action plan for repositioning family planning has a specific objective related to CBD and injectables. Evidence of these best practices being incorporated into national plans and norms is just one step. The MS needs to make sure that these practices actually are implemented on the ground in the districts and communities. Efforts to implement these proven best practices need to be strengthened.
IR4.3: Evidence of a defined and funded research agenda in family planning

The team was unable to determine whether a defined and funded research agenda for family planning exists in Mali. There is a great deal of FP research taking place in Mali, usually by local research firms under contract to larger international partners. The DSR is also involved in oversight of this research. Although the Planning and Statistics Unit (CPS) has a research plan, it does not take family planning into account in a meaningful way.
IR4.4: Evidence of in-country organizational technical capacity for the collection, analysis, and communication of FP information

There is a great deal of evidence to prove that in-country technical capacity exists to deal with FP information. For many years, Mali was the home of the Centre dtudes et de Recherche sur la Population pour le Dveloppement (CERPOD), funded by the Comit Permanent Inter-Etats de Lutte contre la Scheresse dans le Sahel. Created in 1988, CERPOD attracted and trained many demographers, statisticians, analysts, and anthropologists who were studying the Sahels population. In the early 2000s, when CERPOD was reoriented to focus on agriculture and reduced in size, many of those experts stayed in Mali and opened small research firms or integrated themselves into existing ones. Thus, several private research firms in Mali are capable of collecting, analyzing, and communicating FP information. The Malian government also has strong technical capacity. Key agencies are the National Institute of Statistics, the Planning and Statistics Section of the MS, the National Population Directorate, and the Division of RH in the MS, including the CPS. These structures contribute to the analysis of health information, the steering committees for the DHS, evaluation, study and report dissemination, and use of Spectrum for demographic projections. They also have benefitted from capacity strengthening in family planning.

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

Many Malian entities that have received donor assistance can now independently mobilize resources and implement repositioning FP programs. Organizations that have an especially high level of capacity are Groupe Pivot, the Malian IPPF Affiliate (AMPPF), Association de Soutien au Dveloppement des Activits de Population (ASDAP), the Association Malienne pour la Protection et le Dveloppement de lEnvironnement au Sahel (AMPRODE/SAHEL), and Jigi. In addition, Rseau Islam Population et Dveloppement (RIPOD) has been able to mobilize resources and implement FP activities with religious leaders.

18

Application Findings IR5.2: Evidence of government departments or other entities established or strengthened to support the FP agenda

Mali has created and/or strengthened many departments and other entities to support family planning, as discussed in other sections of this report. Examples of these departments and other entities include the following:
DNS/DSR (created in 2001) and its services; DSR is responsible for conceiving and developing policies regarding FP services, as well as coordinating and monitoring all activities;
A religious leader who is a new FP champion showed courage in his community when, after receiving training from HPP, he became the first to accompany his two wives at the local health center to receive an FP method. I started (FP) with my own family because I am convinced of the benefits of FP, said lImam Dembl (Kita/Tambaga), when asked why he brought his wives to the health center.
HPP/Success Story, September 2011

The Multisectoral Coordination Group for FP, which was created in 2004; RH Thematic Group, created in 2011; Centers for Youth, created by the Ministry for Youth and Sports; The coalition of CSOs in support of family planning, created in 2011; A central directorate for health services and social services in the army;

Community Health Centers (CSCOMs), created in the early 1990s after the National Health Policy was announced; CSCOMs regularly provide training to strengthen their staff and operations; Direction de la Pharmacie et Mdicaments de Mali (DPM), created in 2000, which defines and manages the medical supply system in Mali; Pharmacy Popular of Mali (PPM), created in 1993 as a public establishment with industrial and commercial attributes, is charged with the distribution of medicines, among other responsibilities; Networks for religious leaders; Various media representatives, who also have benefitted from training and showed significant advances in favor of family planning in their reporting; NGOs and national associations, religious leaders network, media outlets; and The Youth Group supported by AMPPF; this is another example of a structure put in place to support and promote family planning. All of these groups also have benefitted from training. Implementation of FP activities has devolved to the DSRs, which ensure the implementation of family planning and all other health activities in the eight regions of Mali.
IR5.3: Evidence of targeted public and private sector officials, FBOs, or community leaders publicly demonstrating new or increased commitment to family planning

In Mali, as in many West African countries, there are few FP champions at decisionmaking levels. However, Mali does have some vocal and committed champions of family planning. The Prime Minister, Minister of Health, and some parliamentarians have been making public declarations in favor of family planning for several years, especially since 2005. These declarations have been documented in the Accra
19

Repositioning Family Planning in Mali: A Baseline

conference on Repositioning FP and HPI and HPP project reports. Many religious leaders (Muslim and Christian, male and female) have delivered sermons in public places and in their mosques and churches, and these have been well documented. Since 1999, Adama N. Diarra, mayor of the commune of Kourouma, Sikasso, and a former cabinet minister, has been an FP champion, as has the Honorable Fanta Mantchini Diallo, an engaged parliamentarian who leads the Parliamentary group on RH. The training of religious leaders as champions in Mali has been a principal focus of Futures Group under HPI and HPP. Religious leaders sermons and preaching in mosques, churches, and other public places demonstrates their clear commitment to advancing family planning. Box 6 provides an example of support for family planning, in which Imam Dembl in Kita turned his commitment into action. CSO commitment to family planning began in 1972 with the creation of AMPPF, which is a member of the International Planned Parenthood Federation. CSO involvement has continued over the years, with more CSOs and NGOs taking up the FP mantle and implementing activities throughout the country. Recently, after the civil society conference in Mbour, Senegal, the MS again showed a great willingness to work with the CSOs. The DSR revisited the Ouagadougou action plan (developed after the 2011 conference) and integrated CSO contributions.
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 sum, Mali is in a very good position to take advantage of the substantial resources provided by partners. It has strong policies in place, even though some may be in need of revision. The country also has a roster of championsmostly at the national level, but also in some districts. It has a multisectoral coordination mechanism that performs quite well, despite not being anchored at a very high level in the MS. Additionally, it has highly sophisticated, experienced partnersespecially national partnersthat can and do implement programs on their own.

20

RECOMMENDATIONS FOR REPOSITIONING FP IN MALI

Mali has made considerable progress in creating a more enabling environment for family planning and could be said to be among the leaders in West Africa in this regard. Nevertheless, much still remains to be done to strengthen ongoing activities to reposition FP. 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. Raise the level of institutional placement of the DSR. The DSR needs to have the decisionmaking authority, staff, and other resources to ensure that family planning is a priority for the MS and Mali. The best way to do achieve this is to make the Division of RH into a Directorate of RH within the MS. 2. Increase the resources from the national budget. Mali still has not reached the Abuja target of allocating 15 percent of its national budget to health. The government and partners need to continue advocacy efforts and monitoring of the budget to ensure that commitments are made and delivered, and that contraceptives and supplies are ordered on time to avoid stockouts. In fact, an increased budget for family planning would accelerate Malis progress toward attaining some of the MDGs and also would respond to the Ouagadougou Declaration in favor of repositioning in Francophone West Africa. 3. Strengthen coordination of Repositioning FP. The coordination arm of the DSR needs to be strengthened. The MS and its partners now have several committees and working groups focused on family planning. The challenge is to maximize synergy among these groups and not duplicate efforts. In addition, partners need to participate actively in coordination efforts to follow one plan for FP activities, including a single plan for the yearly FP campaigns. In addition, coordination among FP actors needs to occur not only at the national level, but also at regional, district, and local levels, so that partner plans and activities are fully in line with the MS plans at those levels and all participants use the same information and data collection system. 4. Increase the number of champions and strengthen 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. Mali already has some champions in Parliament, among religious leaders, in the civil society, and in other domains, mostly at the national level. Identifying, creating, and strengthening champions at the national, but also regional and local levels, including in communities, would help to support task shifting of FP services to lower levels of the health system. 5. Strengthen task shifting. Stronger task shifting will allow a wider range of contraceptive methods to be offered at lower levels in the health system and in communities. Recruitment, training, and supervision of CHWs will be critical in extending quality services to rural areas and must include a clear delegation of responsibilities to community workers so they are equipped to provide injectable contraceptives. Mali should profit from the next Revision of Norms and Protocols to strengthen CBD, especially for injectables, and strengthen implementation of the constructive male engagement strategy.

21

ANNEX 1. PERSONS INTERVIEWED

Name
Binta Keita Keita Oumou Keita Doucour Arkia Diallo Mamoutou Diabat Daouda Makan Tour Simpara Fatalmoudou Tour Sidiki Kokaina Felicien Hounye Boureima Maiga Moussa MBo Tour Dieneba Tour Ibrahim Diakit Adama Tounkara Mahamadou Traor Mamadou Traor Famory Fofana Zouboye Mariam Diaw Timoth Dao Nancy Lowenthal Madina Sangare Adama N Diarra Mayor Cheick Oumar Tour Sidiki Kon Souleymane Dolo Tour Aminata Dagnoko

Affiliation
DNS/DSR DNS/DSR USAID/ATN AMPROD-SAHEL DPM ASDAP DSR Coopration Neerl PSI/Mali AMPPF AMPPF AMPPF AMPPF Ministre de la Sant Ministre de la Sant Futures Group/HPP Futures Group/HPP Futures Group/HPP USAID/Mali USAID/Mali Kourouma, Sikasso Intrahealth/Mali IntraHealth/Mali GP/SP PKCII

Title
Chef DSR Charge PF/Genre Conseillre SR/PF Coordinator/PF Point focal/Activits SR Point Focal Conseiller Technique Assistant Technique Suivi/Evaluation Director. N. Programs DAF Suivi/Evaluation Logist/Approv Sec-General

Country Director Prog. Coordinator, M&E ChargVIH/Palu Health Team Leader Sr. RH Advisor

Directeur Pays Coordinator Hewlett Executive Director Conseillre SR/PF

22

ANNEX 2. REPOSITIONING FAMILY PLANNING RESULTS AND INDICATORS FOR MALI

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 family planning programming SO.1: Instances of a government-led council, coalition, or entity that oversees and actively manages the family planning program SO.2: Evidence of documented improvement in the enabling environment for family planning using a validated instrument SO.3: Evidence of FP policies implemented, resources allocated, and subsequently used in relation to the same FP policies DSR/DNS and FP Multisectoral Working Group Ordonnance N01-020/P-RM du 20 mars 2001 creating and defining the DNS Minutes of FP Multisectoral Working Group meetings and plans The enabling environment has improved steadily since 1982. The Family Planning Program Effort Score rose from 11.3 in 1982 to 61.4 in 2009 on a scale of 100 points. The Contraceptive Security Index was 44.2 in 2009 also on a scale of 100. Family Planning Program Effort Score (2004 and 2009) (Ross and Smith, 2010) Contraceptive Security Index (PRB 2009)

FP services are offered in principle in all health structures and by government health agents and community health agents. However, nationwide coverage could be improved. Supportive policies are in place, and funds are allocated for FP.

23

Repositioning Family Planning in Mali: A Baseline

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) Contraceptive Commodity Purchases Partner Year 2009 2010 Public Sector MS UNFPA USAID Total 381,369 497,592 299,785 1,178,746 372,924 312,608 880,015 1,565,547 480,415 420,203 1,102,697 2,003,315 1,234,708 1,230,403 2,282,497 4,747,608 2011 Total Spreadsheets provided by the MS/DPM All other information provided by key informants

Private Sector KfW USAID Total Sector 1,545,014 33,497 1,578,511 1,864,477 21,421 1,885,898 2,125,424 31,699 2,157,123 5,534,915 86,617 5,621,532

Year 2009 2010 National 2011 Total

Public Private Total

1,178,746 1,578,511 2,757,257

1,565,547 1,885,898 3,451,445

2,003,315 2,157,123 4,160,438

4,747,608 5,621,532 10,369,140

In 2011, UNFPA also provided four trucks, 56 office computers, 9 laptops, 1 video projector, and printers. It also provided 39, 000, 000 CFA for renovation of the central warehouse for medicines. The Netherlands Cooperation and an anonymous donor contributed funds to PSI for the promotion of long-term methods. These funds are difficult to detail because the activities are integrated. USAID 2009: Budget FP/RH $6,480,067, includes its contraceptive purchases made through DELIVER 2010: Budget FP/RH $7,435,000, includes contraceptive purchases made through DELIVER 2011: Budget FP/RH $8,565,000, includes contraceptive purchases made through DELIVER

24

Annex 2. Repositioning Family Planning Results and Indicators for Mali

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

Information

Indicator Source Key informants

Since 2005, PSI has managed a program of social franchising with 60 private clinics in Bamako. The DSRs portfolio includes a program of contracting with local NGOs for the provision of long-term FP methods. Mali has a budget line item, created in 2009, for contraceptive commodities. It covers 10 percent of the total global cost. Beginning in 2010, a line of credit for 500 million CFA (approximately US$1 million) was allowed each year. The Government of Mali did not contribute any funds in 2009 and did not use the line of credit at all in 2010. In 2011, the government spent 109 million CFA (US$218,000). In 2012, the government contributed only 129 million CFA (US$258,000) through this line of credit. See inserted table on next page for the projected contraceptive purchases by partner (20122013). Projected Contraceptive Purchases for 2012 and 2013, by Partner (US$)

Report of the 2011 TAC results Reports on the contraceptive commodity acquisitions based on the contraceptive procurement tables. Direction de la Pharmacie et du Medicament. March 2011 Rapport de Restitution de llaboration du tableau dacquisition des contraceptifs (2009, 2010, 2011).

Product
MS USAID 2012 UNFPA KfW Total MS USAID 2013 UNFPA KfW Total MS 2012 2013 USAID UNFPA KfW Total 198,000 515,732 2,393,524 2,101,480 5,208,736 198,000 320,546 2,182,515 2,024,192 4,725,253 396,000 836,278 4,578,221 4,125,672 9,936,171

Freight
61,380 61,887 650,882 651,460 1,425,609 61,380 38,465 605,179 627,499 1,332,523 62,760 246,120 1,256,061 1,278,959 2,843,900

Total
259,380 577,619 3,044,406 2,752,940 6,634,345 259,380 359,011 2,787,694 2,651,691 6,057,776 458,760 1,082,398 5,834,282 5,404,631 12,780,071

25

Repositioning Family Planning in Mali: A Baseline

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

Information

Indicator Source Key informants

For 2009, 2010, and 2011, see IR 1.1, above. However, it should be noted that the government of Mali did not contribute any funds for contraceptives in 2009 or 2010, even though it had the line of credit. In addition, the World Bank has proposed starting an urban FP program next year, for US$30 million; and the French Muskoka funds planned for Mali are 30 million Euros over five years. Also, for urban FP, beginning in 2013, in addition to funds it has provided to UN agencies, WHO has provided US$70,000 to support FP in Mali. The William and Flora Hewlett Foundation has provided US$200,000 to IntraHealth and US$300,000 to Futures Group for assistance in FP to several countries in the region, including Mali. The Netherlands has provided US$4 million and has provided US$22 million for a five-year project called Pays Bas OMD5 implementing maternal and infant health and FP/RH programs. In addition, Marie Stopes International, PSI, and others are working in Mali, but the team was unable to find out many details.

IR 2: Increased multisectoral coordination in the design, implementation, and financing of family planning policies and programs IR2.1: Evidence of family planning programs incorporated into national strategic and development plans Two of the three sets of key national strategy documents take into account FP/RH and include references to access to primary health care, including FP: they are PDDSS, CSCRP, and PRODESS. The CSCRP discusses fertility reduction and improving access to services, including FP services. The PDDSS (19982008) only briefly mentions FP; a revision is underway. PRODESS, a five-year health and social development program, refers directly to activities of repositioning FP, including actions will be taken to improve data collection and strengthen repositioning FP to increase the level of contraceptive use and to reduce unmet needs. Document review of two generations of the CSCRP ( 2007-2011 and 2012 to 2017), and two generations of the PDDSS 1998-2008 and the new one in development now. One generation of the PRODESS (the five-year health and social development program) was reviewed. A new PRODESS is also in development.

26

Annex 2. Repositioning Family Planning Results and Indicators for Mali

Indicators IR2.2: Evidence of governments engaging multiple sectors in family planning activities

Information

Indicator Source Minutes of meetings, notices of meetings, reports of annual FP campaigns Decree creating the commission, meeting reports Law N 02-049, July 2002, pharmaceutical policy Law on health orientation, June 2002 Existence of the arrte, reports, and minutes of meetings Key informants

Existence of (1) the Multisectoral FP Working Group (since 2004), which meets regularly; (2) National Commission for Monitoring the RH Products Security Plan, which meets about every six months; and (3) the Thematic Group on RH, created after the 2011 conference in Ougadougou. The MS/DNS is responsible for the development, coordination, and monitoring of FP policies. Implementation devolves to the Regional Health Directorates (DRSs) that support the operational level. Various agencies participate in FP service provision, in particular NGOs and associations, private organizations, and faith-based organizations.

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

Two important multisectoral structures exist that were created to promote FP: (1) the Multisectoral FP Group and its subcommittees, managed by the DSR (since 2004; and (2) the National Commission to Monitor the RH Products Security Plan. In addition, the RH Thematic Group and the Coalition of Civil Society Organizations for Repositioning FP were established in 2011.

Minutes of meetings, agendas and calls for meetings, reports of the annual FP campaigns. Statutes and governance documents for the Coalition and meeting notes. Key Informants Review of PDDSS, PRODESS Declaration of the National Health Policy, coordination of NGOs, collaboration with NGOs; existence of a document authorizing private sector participation. MS FP action plans, reports, meeting agendas, etc. PNP Mali

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

Policy declarations PDDSS and PRODESS affirm that the private sector needs to be involved in partnership with other service providers to improve access to FP services and information. Civil society activities are integrated into the national yearly FP action plans. The MS includes the private sector to a great extent in the organization and implementation of the FP campaigns; it also supports the financing of the NGOs (e.g. AMPPF and Netherlands Cooperation). The MS supports performance contracts with NGOs for health services, including FP services.

27

Repositioning Family Planning in Mali: A Baseline

Indicators

Information

Indicator Source

IR 3: Policies that improve equitable and affordable access to high-quality family planning 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 Mali has many national and subnational policy and strategy documents to promote access to FP information and services. Examples: The Health Sector Policy (1991) The RH Law (2002), which translates the policy into specific actions and permits all individuals or couples who desire to have access to FP The policy that takes into account the need to procure and distribute contraceptives to all levels, including the most peripheral Revised strategic plan for communication in RH The Plan for the Security of RH Products (to be validated) 20112015 PDSSC plan The integration of FP services into the operational plans of the new regions, districts, and the periphery The management of health structures in the public, parastatal, private, and faith-based sectors is taken into account to reach the whole population. This also includes social marketing, innovative strategies, factories, schools, youth centers, etc. Health Sector Policy (1991) RH Law (2002) Ten-year Plan for the Development of the Social Sector (PDDSS) (20012011)* Five-year Plan for Health and Social Development (PRODESS II) (20092011) (extended)* District Plan for Social and Health Development (PDSSC) Strategic Plan for Repositioning FP (2011) Strategic Plan for RH Communication Strategic Plan for Reproductive and Sexual Health of Adolescents and Youth Plan for the Security of RH Products (20112015) (not yet validated) Operational Plan for Procurement and Distribution of RH Products Guide for Constructive Engagement of Men in FP/RH National Action Plan for FP (20112015) * New PDDSS and PRODESS plans in development. IR3.2: Existence of national or subnational policies or strategic plans that promote access to family planning services and information for underserved populations In 2003, Mali re-launched the community-based distribution (FP strategy, which is one of the major health policies. Mali also has developed strategies to focus on youth, adolescents, and men. Some of these need to be reinvigorated. In 2011, Mali developed a policy on community-based care (SEC) to strengthen community-based distribution programs conducted by NGOs under the technical guidance of the MOH. Documents (DNS, Save the Children, UNICEF, PKC) PNP ECH-SR 2008 Policy on sexual reproductive health for youth included in PNP for RH document on SEC, the new name for CBD

28

Annex 2. Repositioning Family Planning Results and Indicators for Mali

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

Information PNP (2006-2011) provides guidelines for implementing the latest policies on FP/RH. Arrts for the application of the RH Law

Indicator Source Documents, DSR, DPM, including annual reports National action plans, PNP Letter N0870 MS-SG, June 2007, reducing the price to clients of contraceptives Rapport dvaluation de loffre des services de PF au Mali (2008) Dclaration de Politique Sectorielle de Sant et de la Population (1990)/Population et PF

Schma directeur dapprovisionnement et de distribution des mdicaments essentiels y compris les contraceptifs (July 2010) Circular Letter on Contraceptive Prices (2011) National Action Plan for FP (20112015) lays out implementation of the FP policies. Introduction of contraceptives into the procurement plan for essential medicines list (schma directeur) (1996). Decree 2011-774MS-G requiring implementation of the schema directeur (2011-774MS-G) Implication des matrones dans loffre des services PF : Fiche technique SR-matrones National FP supervision guide (2008) Lifting of the barrier to access to FP by women if their husbands or parents do not authorize verbally or in writing Note authorizing midwives to provide FP is included in the Sectoral Policy on Population and Health

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

Population and FP: verbal or written authorization from the husband for FP services was removed as a barrier. Circular letter on the free access for women of any age to access FP methods Sociocultural barriers Attitudes and competence of service providers to provide long-term methods; training, in collaboration with DSR and other partners, of service providers Prices for contraceptives were revised to reduce the cost to clients with state subsidy.

Dclaration de Politique Sectorielle de Sant et de la Population (1990) Circular Letter N004/Msp_As/Cab, January1991 Evaluation of FP service provision in Mali, 2008 Training reports, PNP, PRODESS I and II, Population Policy Letter N0870 MS-SG, June 2007

29

Repositioning Family Planning in Mali: A Baseline

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

Information

Indicator Source Annual activity report of the DSR. 2011 and 2010, and annual reports of partners. Reports of the national FP campaigns. Existence since 2009 of a budgetary line item for the acquisition of contraceptives (10% of the global cost) Purchase orders for the products. Arrt N 08-019/MS-SG of January 14, 2008 Circular letter N005-MspAs/Cab of January 25, 1991

Plenty of evidence exists to show that FP policies are implemented. FP services are offered at all the health structures throughout the country, including the community. Since 2005, a nationwide, month-long FP campaign has been held annually. The government has committed itself to the purchase of contraceptives from the national budget. An Arrt ministriel exists, establishing the list of products, methods and means of contraception that are legally approved in Mali. A circular letter from the Ministry of Health approved the social marketing of contraceptives.

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 family planning efforts Mali regularly uses EDSM and population data, as well as data from various ministries (education, agriculture, labor, etc.) and Spectrum, to convince decisionmakers to support repositioning FP. The RAPID presentation has been presented to high-level decisionmakers (Prime Minister and ministers of health, womens affairs, and youth and sports) Reports of FP campaigns USAID | Health Policy Initiative, Task Order 1 and HPP semi -annual reports

30

Annex 2. Repositioning Family Planning Results and Indicators for Mali

Indicators IR4.2: Evidence of international family planning best practices incorporated into national health standards

Information

Indicator Source PNP, 20062011 Reference manuals, training curricula, and training reports of services providers Guide for constructive male engagement in RH (2008) Rapports ateliers de la socit civile et coalition des OSC en faveur de la PF (Groupe Pivot Sant Population) National Standards for Youth and Adolescent Health and its national strategic plan (DNS/DSR) Reports on SIAN, Postpartum, Fistule, VIH/SIDA (DNS/DSR, CSLS/MS, Sectoral Cellule on the fight against AIDS/MS Marie Stopes International, GP/SP) programs Documents de stratgie franchise sociale (PSI, MSI) National FP Action Plan 2011 2015

Many best practices have been incorporated into national health standards, including promotion of longterm methods in health centers and mobile services; introduction of injectables in community outreach services; male involvement; involvement of the private sector; involvement of civil society, religious leaders, and parliamentarians in supporting FP; development of peer education for FP; integration of FP into the week of intensive nutrition activities, postpartum care, fistula care, and HIV prevention and care; and the introduction of social franchising.

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

Not found

In-country structures exist that have benefitted from capacity building to strengthen the collection, analysis, and communication of FP information: CPS/MS National Institute of Statistics DNP DSR/DNS

Schma directeur du SNISS (systme national dinformation sanitaire et social) Comit EDS/CPS Sant Dissemination reports from studies and evaluations Training reports on capacity building, communication EDSM Mali I, II, III, IV Ordinance N1-020/P-RM, March 2001, creating the DNS Decree N01-219/P-RM, May 2001, setting the functioning arrangements for the DNS

These structures contribute to the analysis of health information; the steering committees for the EDSM; evaluation, study, and report dissemination; and use of Spectrum for demographic projections.

31

Repositioning Family Planning in Mali: A Baseline

Indicators

Information

Indicator Source

IR 5: Individual or institutional capacity strengthened in the public sector, civil society, and private sector to assume leadership of and/or support the family planning agenda IR5.1: Evidence of entities provided with donor assistance that demonstrate capacity to independently implement repositioning family planning activities Many Malian entities that have had donor assistance can now independently mobilize resources and implement repositioning FP programs. Key organizations are Groupe Pivot, Malian IPPF affiliate AMPPF, ASDAP, AMPRODE/SAHEL, and Jigi. Establishment of a coalition of CSOs in favor of FP. RIPOD has been able to mobilize resources and implement FP activities with religious leaders. DNS/DSR and its services RH Thematic Group Centers for Youth MJS (ministry of youth and sports/youth project) Existence of a central directorate for health services and social services in the army CSCOM DPM PPM NGOs and national associations, religious leaders network, media Ordinance N01-020/P-RM, March 2001, creating and defining the DNS Ministerial directive creating the thematic group on RH; Decree creating the centers for the promotion of youth by the Ministry of Youth and Sports Texts establishing the CSCOMs Decrees creating the central direction of social services and health services in the army. Mapping of NGO interventions that is electronic Declarations, reports, and articles Activity reports of the NGOs cited and RIPOD. Coalition of civil society organizations on FP.

IR5.2: Evidence of government departments or other entities established or strengthened to support the family planning agenda

All these groups have benefitted from training.

32

Annex 2. Repositioning Family Planning Results and Indicators for Mali

Indicators IR5.3: Evidence of targeted public and private sector officials, FBO, or community leaders publicly demonstrating new or increased commitment to FP

Information

Indicator Source Texts of the public declarations USAID | Health Policy Initiative, Task Order 1 and Health Policy Project semiannual reports I started (FP) with my own family because I am convinced of the benefits of FP, said limam Dembl (Kita/Tambaga). HPP/Success Story; September 2011 USAID | Health Policy Initiative, Task Order 1 and Health Policy Project Mali reports that document champions and policy dialogue sessions; and activity reports of the champions and religious leaders.

Public declarations in favor of FP by the Prime Minister, Minister of Health, and parliamentarians. Sermons of many religious leaders (Muslim and Christian, men and women) in public places and in their mosques and churches. Since 1999, Adama N. Diarra, mayor of the commune of Kourouma, Sikasso, has been a FP champion, as has the Honorable Fanta Mantchini Diallo, a parliamentarian.

IR5.4: Number of regional/national centers or collaboratives for shared education and research in family planning

Not found

33

REFERENCES AND ADDITIONAL RESOURCES

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. CAREF/Marie Stopes International. 2008. Etude de March sur la Sant de la Reproduction dans le District de Bamako et les Villes de Kayes et Mopti. Centre dAppui la Recherche et la Formation. 2007. Etude Qualitative sur les Effets de la Campagne Nationale en Faveur de la PF et les Obstacles la PF au Mali. Cross, Harry, Karen Hardee, and Norine Jewell. 2001. Reforme des Politiques Oprationnelles: Un Trajet pour Amliorer les Programmes de Sant Reproductive/ Reforming Operational Policies: A Pathway to Improving Reproductive Health Programs. Futures Group. POLICY Project Occasional Paper. Accessed on July 23, 2012 at: http://www.policyproject.com/pubs/occasional/op-7.pdf. Diabat, Fanta Sambou. 2009. Analyse Situationnelle pour une Rponse Effective aux Besoins non Satisfaits de la PF au Mali. Family Health International. 2004. Monitoring and Evaluating Behavior Change Communication Programs, Module 6. Durham, NC: Family Health International. Finger, Bill, Marie Lapetina, and Maryanne Pribila. 2003. Stratgies dInterventions Adaptes aux Besoins des Jeunes. Family Health International, Programme YouthNet. Forum des Parlementaires Africains et Arabes pour la Population et le Dveloppement. 2005. Guide pour la Rforme Lgislative et Rglementaire en Sant de la Reproduction: Une Initiative Parlementaire. Gribble, James, Joan Haffey, and Sara Adkins-Blanc. 1997. Amliorer la Sant en Matire de Reproduction dans les Pays en Dveloppement. Washington, DC: Population Reference Bureau. Guengant, Jean-Pierre. 2011. Comment Bnficier du Dividende Dmographique?: Analyse Pays Mali. Paris: Agence Franaise de Dveloppement. Haub, Carl, and Toshiko Kaneda. 2012. World Population Data Sheet 2012. Washington, DC: Population Reference Bureau. 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 Johns Hopkins University/Center for Communication/K4Health project. No date. Elements for Family Planning Success. Accessed on August 1, 2012 at: http://www.k4health.org/toolkits/fpsuccess. Khan, Khalid S., Daniel Wojdyla, Lale Say, A. Metin Glmezoglu,, and Paul Van Look. 2006. WHO analysis of causes of maternal death: a systematic review. The Lancet, 367, No. 9516, (April 2006): 10661074.
34

References and Additional Resources

Leonard, Lori. No date. Comprhension des Taux de Prvalence Contraceptive Elevs dans les Zones d'Intervention des ONG partenaires de Groupe-Pivot Sant/ Population. Baltimore, MD: Johns Hopkins University. Mali Institut National de la Statistique, Bureau de Recensement. 2009. 4eme Recensement General de la Population et de lHabitat du Mali, Rsultats Provisoires. Bamako: Institut National de la Statistique, Bureau de Recensement. Ministre de la Sant (MS). 1990. Dclaration de Politique Sectorielle de Sant et de la Population. Bamako: MS. MS. 2003. Population, Dveloppement et Qualit de Vie au Mali. Bamako: MS. MS. 2011. Decree 2011-774 MS-G. Requiring Implementation of the Schma Directeur on Essential Medicines. Bamako: MS. Ministre de la Sant du Mali (MS) /Cellule de Planification et de la Statistique (CPS), Direction Nationale de la Statistique et de lInformatique (DNSI) et Macro International. 2007. Enqute Dmographique et de Sant du Mali 2006. Calverton, MD: CPS/DNSI and Macro International Inc. MS/CPS/DNSI. 1987. Enqute Dmographique et de Sant du Mali (EDSMI, P.41-42). Rpublique du Mali. MS/CPS/DNSI. 19951996. Enqute Dmographique et de Sant du Mali (EDSMII, P.62). Rpublique du Mali. MS/CPS/DNSI. 2002. Enqute Dmographique et de Sant du Mali 2001 (EDSMIII, P.59). Rpublique du Mali. MS/CPS/DNSI. 2006. Enqute Dmographique et de Sant du Mali (EDSMIV, P.64). Rpublique du Mali. MS/CPS/DNSI. No date. Comprhension des Taux de Prvalence Contraceptive Elev dans les Zones dIntervention des ONG Partenaires de Groupe-Pivot Sant Population, Rapport Final. MS/Direction Rgionale de la Sant (DNS). 2005. Politique de Sant de la Reproduction des Jeunes et Adolescents. Bamako: MS. MS/DNS. 2008. Document de Rflexion: Utilisation des Relais Communautaires au Mali. Bamako: MS. MS/DNS/Division Sant de la Reproduction (DSR). No date. Comit Multisectoriel pour la Planification Familiale. Bamako: MS. MS/DNS/DSR. 2004. Plan Stratgique de la Sant de la Reproduction (20042007). Bamako: MS. MS/DNS/DSR. 2005. Politique et Normes des Services de Sant de la Reproduction. Bamako: MS. MS/DNS/DSR. 2005. Plan dAction National pour le Repositionnement de la Planification Familiale. Bamako: MS. MS/DNS/DSR. 2006. Stratgie Nationale de Communication pour la Sant de la Reproduction (2007 2011). Bamako: MS. MS/DNS/DSR. 2008. Plan dAction National de PF du Mali 20112015. Bamako: MS.

35

Repositioning Family Planning in Mali: A Baseline

MS/DNS/DSR. 2008. Document de Rflexion: Utilisation des Relais Communautaires au Mali. MS/DNS/DSR. 2008. Rapport dEvaluation de loffre des Services de Planification Familiale au Mali. USAID/ATN. MS/DNS/DSR. 2008. Guide pour lEngagement Constructif des Hommes en SR (ECH-SR). Bamako: MS. MS/DNS/DSR. 2008. "Procdures en Sant de la Reproduction." Planification Familiale, Volume 3. MS/Direction Pharmacie et Mdicaments (DPM). 2009. Rapport de Restitution de lElaboration du Tableau dAcquisition des Contraceptifs (TAC 2009). Bamako: MS. MS/DPM. 2010. Rapport de Restitution de lElaboration du Tableau dAcquisition des Contraceptifs (TAC 2010). Bamako: MS. MS/DPM. 2011. Restitution des Travaux de latelier dElaboration des Tableaux dAcquisition des Contraceptifs (TAC 20112013), Rapport Final. Bamako: MS. MS/DSR and ATN Sante. 2008. Etude dAnalyse Situationnelle de la PF au Mali. Bamako: MS. MS/DSR and ATN. 2005. Rapport de lAtelier sur lIntgration du Genre dans les Programmes de Sant. Bamako: MS. MS/Secrtariat Excutif. 2009. Rapport de Synthse: Forum sur l'Amlioration de l'Accs aux Soins essentiel au Niveau de la Communaut. Bamako: MS. MS/Secrtariat Gnral. 2009. Programme de Dveloppement Sanitaire et Social PRODESS II-Prolong, 20092011. Bamako: MS. MS/Secrtariat Gnral. 2011. Lettre circulaire N0870 MS-SG du 29 Juin 2007 du MS/Mali. Ministre de la Sant et de lAction Sociale (Sngal) and Population Council. 1995. Analyse Situationnelle du Systme de Prestation de Services de Planification Familiale au Sngal. Rapport Final. Ministre de la Sant, Population Council, and CERPOD. 1996. "Analyse Situationnelle des Services de Planification Familiale dans les Rgions de Koulikoro et Sikasso, Mali." Rapport de Recherche, vol. VI. Bamako. Moreland. Scott, Ellen Smith, and Suneeta Sharma. 2010. World Population Prospects and Unmet Need for Family Planning. Futures Group. Retrieved from http://www.futuresgroup.com/wpcontent/uploads/2010/04/World-Population-Prospects-and-Unmet-Need-for-Family-Planning10.07.10.pdf. Ouagadougou Partnership. 2012. Family Planning: West Africa on the MoveA Call to Action). White paper to be published in August 2012. A paper that provides recommendations for advancing family planning and mobilizing political commitment and resources following the International Conference on Family Planning in Ouagadougou, February 811, 2011. Washington, DC, USA: Population Reference Bureau. POLICY Project. 2005. Perspectives sur le Besoin non Satisfait en Planification Familiale en Afrique de lOuest : le Mali. Washington, DC: Futures Group, POLICY Project.

36

References and Additional Resources

POLICY Project. 2006. Guidelines for Male Involvement in Reproductive Health in Cambodia. Washington, DC: Futures Group, POLICY Project. Population Reference Bureau (PRB). 2012. Fiches des Donnes sur la Population Mondiale 2011. Washington, DC: PRB. Republique du Mali/Presidence de la Republique. Rseau Malien pour la Population et le Dveloppement. 24 Juin 2002.Loi N02-044. Relative la Sant de la Reproduction. Republique du Mali. Rpublique du Mali. 2002. Cadre Stratgique de Lutte contre la Pauvret (CSLP, 20022006). May 2002. Rpublique du Mali. Rpublique du Mali. 2011. Cadre Stratgique pour la Croissance et la Rduction de la Pauvret (CSCRP 20122017). Plan dActions Prioritaires. Rpublique du Mali. 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 from http://www.healthpolicyinitiative.com/Publications/Documents/1110_1_FP_Effort_Index_1999_2004_20 09__FINAL_05_08_10_acc.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. Roudi, Farzaneth, and Lori Ashford. 1996. Les Hommes et le Planning Familial en Afrique. Population Reference Bureau. Sahar-Iyaon Christian Some, Bekoune. 2010. Mise en Route de la DBC. Sanogo, Diourati, and Seydou Doumbia. 2001. valuation de lOffre des Services de Planification Familiale dans les Points de Prestations de Services de Sant Fixes au Mali. Bamako: Population Council. Sangare, Mandina. 2012. Private communication to Famory Fofana on February 2, 2012. Save the Children. 2003. Partenariat pour Maximiser lAccs et la Qualit des Services de Planning Familial dans la Rgion de Sgou, Mali. 20 RFA No. M/OP/GH/HSR-04-003. Smith, Rhonda, et al. 2009. Family Planning Saves Lives, 4th edition. 2009. Washington, DC: Population Reference Bureau. Accessed on August 1, 2012 at: http://www.prb.org/~/~/link.aspx?_id=3CF9B78028274F47B22914F6B9F75381&_z=z Speidel, J. Joseph, et al. 2009. Making the Case for the U.S International Family Planning Assistance. Report. Baltimore, MD: Johns Hopkins School of Public Health. Accessed on July 18, 2012 at: http://www.jhsph.edu/sebin/u/d/MakingtheCase.pdf. 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). World Development Report 2011. Retrieved from http://hdr.undp.org/en/media/HDR_2011_EN_Table1.pdf. UNDP (Programme des Nations Unies pour le Dveloppement). 2010. Rapport National sur le Dveloppement Humain Durable. Crise Alimentaire: Enjeux et Opportunits pour le Dveloppement du
37

Repositioning Family Planning in Mali: A Baseline

Secteur Agricole. Bamako: Ministre du Dveloppement Social, Programme des Nations de la Solidarit et des Personnes ges. 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 | 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 on September 9, 2012 from http://deliver.jsi.com/dlvr_content/resources/allpubs/factsheets/CSIndex_WallChart_WebBklet.pdf USAID | Health Policy Initiative, Task Order 1. 2006. Mise en Oeuvre de la Loi sur la Sant de la Reproduction en Afrique de lOuest et du Centre, Manuel du Parlementaire. USAID | Health Policy Initiative, Task Order 1. 2009. RAPID Mali, Population, Dveloppement et Qualit de Vie. Bamako: MS. 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. 2010. Recueil des Textes Lgislatifs et Rglementaires en Sant de la Reproduction et Planification Familiale au Mali. Bamako: Rpublique du Mali. USAID/Mali. 2010. Global Health Initiative Strategy. Bamako: USAID. Accessed on August 1, 2012 at: http://www.ghi.gov/documents/organization/158920.pdf. USAID. 2011. High Impact Practices in Family Planning. 2011. Retrieved from http://www.usaid.gov/our_work/global_health/pop/publications/docs/high_impact_practices.pdf. World Bank. 2011. World Development Indicators Database. Retrieved from http://siteresources.worldbank.org/DATASTATISTICS/Resources/GNIPC.pdf . World Health Organization (WHO). 2012. Trends in Maternal Mortality: 19902010. Estimates developed by WHO, UNICEF, UNFPA and the World Bank. Geneva: WHO. Retrieved from http://whqlibdoc.who.int/publications/2012/9789241503631_eng.pdf WHO/Regional Office for Africa. 2005. Repositioning Family Planning in Reproductive Services: Framework for Accelerated Action (20052014). WHO/UNICEF. 2012a. Joint Monitoring Programme for Water Supply and Sanitation: Estimates for the use of Improved Drinking-Water Sources: Mali. Updated March 2012. Retrieved from: http://www.wssinfo.org/fileadmin/user_upload/resources/MLI_wat.pdf.

38

References and Additional Resources

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 from: http://www.fhi360.org//NR/rdonlyres/e66buwqnetdkndytax7vlqxeknagzd6fdahemwklkxj7enfcxltd4uvkgr skee7he4mcvnh6chcteo/WHOCBAinjectablesBrief0610.pdf.

39

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] www.healthpolicyproject.com