In 2017, members of the IAWG Training Partnership Initiative started the crafting of the first toolkit dedicated to supporting the implementation of Objective 6 of the MISP – catalyzing participatory planning to transition from the MISP to comprehensive SRH programming. Results from pilots in DR Congo, Bangladesh, and Yemen converged to suggest that the toolkit was effective in catalyzing the production of consolidated work plans for comprehensive SRH, efficient in its methodology considering the workshop’s duration, and inclusive of key stakeholders and decisionmakers. However, any future implementation should engage community members, including those from often marginalized populations. The pilots yielded several lessons learned, such as enhancing pre-workshop data preparation, equipping all participants with adequate knowledge of the MISP, and defining common principles for collaboration, which allowed for successive improvements of the toolkit. In Yemen, logistics constraints called for a creative solution in the form of training selected participants in Sana’a who, in turn, became facilitators for the workshop in Aden.
Nature of Prioritized Activities
Each of the humanitarian situations had its own specificities, gaps, and opportunities in terms of the health system building blocks and response to the SRH needs of the population. Priority activities with crosscutting impacts on SRH services and outcomes were high on the agenda, such as ensuring a sustainable supply chain (notably for the hard-to-reach Kasai region or siege and blockade-affected Yemen), rebuilding and restoring destroyed and looted health facilities in the Kasai region, and enhancing human resources for health .
The emphasis on common themes, such as strengthening the overall provision of comprehensive SRH services, capacity development of the health workforce, community mobilization, adolescent SRH, and maternal and newborn health services is somehow unsurprising, albeit critical. Trained, motivated, and retained staff form an essential building block of the health system as they enable access to a wide range of information and services . For instance, in Yemen, new community midwives were trained since 2018 to improve coverage and replace those who retired, left to care for their families, quit their job due to prolonged periods of unpaid salaries, or died, among others . The focus in the work plan to continue supporting the development of such cadres builds of these recent efforts and identified opportunities, and was championed by representatives of the national midwifery association who participated in the workshop.
The MISP objectives focus mostly on the supply side of health services, which must complement activities that generate demand, such as community mobilization and involvement . Although adolescents and young people form a large, if not the largest, cohort across low-income and middle-income countries – including in crisis-affected communities – they often do not have access to adolescent-responsive SRH services that address their specific needs . Basic and comprehensive emergency maternal and newborn care is part of the MISP objectives. These services can be challenging to implement with adequate quality, coverage, and effective referrals that must be sustainable during the recovery and redevelopment phases .
Other priorities, such as family planning or gender-based violence, were subsumed under the overall plan to enhance a comprehensive SRH service package or specifically underscored, or both. For instance, the highlight in Cox’s Bazar’s plan to increase awareness on gender-based violence and the quality of related services reflected the high needs in this context .
Implications for Policy, Practice, and Research
The collective work plans for comprehensive SRH that participants developed at the end of the workshops are multipurpose. They could help strengthen the implementation of comprehensive SRH information and services and focus attention on key problem areas. If used to feed into an advocacy and resource-mobilization strategy, they could garner support and funding for programs that feed into the overall reproductive, maternal, newborn, child, and adolescent health program.
Initial planning for comprehensive SRH should start at the onset of the acute response, and the participatory process proposed in this toolkit should begin as soon as the MISP clinical services are available and accessible and progress towards reaching Objectives 1 to 5 and other priorities of the MISP are underway. This participatory process could also take place when agencies begin longer-term planning with new funding cycles and in preparation for humanitarian appeal processes. The integration of comprehensive SRH services into these mechanisms could contribute to avoiding service delays and ensuring their sustainability.
Operations research is needed to examine, whenever possible, the implementation of the toolkit in a real-time transition from an acute response toward recovery and health system strengthening. Researching the implementation of the toolkit in protracted situations is equally important. In both cases, the question remains whether and how a work plan with priority activities developed in a participatory manner would translate into the concrete implementation of these priorities and contribute to health system strengthening efforts.
The bigger question will be whether and how each of the settings will implement the prioritized activities in terms of advocacy, identification of sustainable resources, and eventually expanded access to quality services that the community will utilize. The toolkit preempted the possible challenge of seeing the work plans remaining without follow-up and implementation by participating stakeholders. Therefore, it included an important step: a post-workshop follow-up process that participants would conduct to ensure that plans are followed through and challenges addressed—seed funding, even if limited as it was the case in the three countries, could help with the initial operationalization of identified priorities. This review and synthesis of the workshop pilots are limited to the toolkit. However, the IAWG community needs to continue learning about the follow-up to the workshops in DR Congo, Bangladesh, and Yemen. For example, who in the three countries led their operationalization? What was the process undertaken? How useful was the process in advancing the implementation of the work plans? How did it strengthen the health system? What were the challenges, breakthroughs, and recommendations to improve the continuum from planning to implementation?
Ingredients for Success
Several factors may have contributed to the success of this toolkit, including the framing by the WHO Health System Building Blocks, which directly focused participants on interventions that could strengthen the health system. However, it is the participatory nature of the two-pronged design process that likely made the toolkit relevant to local specificities and global needs in terms of developing capacity for comprehensive SRH planning. However, do interventions based on participatory design work in healthcare?
The multiphase participation-centered design of the toolkit was likely a critical component in producing anticipated results with efficiency. Our findings contribute to the current evidence, as illustrated by a synthesis of the effect of community-based participation in various settings . The synthesis showed that collaboration among community partners, facilitators, and organizations led to community-level action that enhanced health and wellbeing, while minimizing health disparities. In the process, it also strengthened the capacity of the community in terms of evaluation skills. Another review found that participatory design could ensure that outputs are appropriate culturally and logistically, generate professional capacity and competence in stakeholder groups, result in productive disagreements followed by useful negotiation, increase the quality of outputs and outcomes over time, increase the sustainability of project goals beyond funded time frames and during gaps in external funding, and create system changes and new, unanticipated projects and activities .
The pilots were a product of strong international and national partnerships based on valued and respected collaboration. This multi-level support and investment in the initiative likely contributed to the success in the design and implementation of the workshop toolkit. Moreover, the partners involved in this project had both overlapping and differing objectives and delivery timelines. The funding and programmatic synergies through their partnerships allowed better use of funding with consequently more seed funding for actual program implementation and building buy-in for this effort.
To adhere to different timelines and opportunities, the planning for the pre-workshop preparation and workshop implementation was felt to be limited. The time constraints could have compromised the thorough mapping of the situation in preparation of the workshop, as well as limited the members of priority communities whom the planning process could have engaged—resulting planning priorities could have been different. However, local participating stakeholders came from organizations responsible for direct service and implementation and had a sound knowledge of their settings and awareness of the needs of their community, which could have minimized the risk of producing a work plan of less relevance. Further, in humanitarian contexts, actors must be nimble and responsive to varying limitations and opportunities. The rollout of the workshops was reflective of this reality and still shown to be effective in meeting its objectives.
Future rollouts of the toolkit need to consider the high staff turnover in crisis-affected contexts and factor it into the planning process and strategy for work plan implementation. For example, participants in the workshops in DR Congo and Bangladesh who participated in the planning transitioned out of the response by the time the work plan implementation began. For this reason, it is recommended that there be a clear and consistent sharing of information and knowledge about the planned transition towards comprehensive SRH programming and to ensure work plans move forward and responsibility and accountability are shared.
The facilitators of the workshop were those who conducted structured discussions with the participants in Kinshasa and Sana’a. Therefore, social desirability could have been a potential source of bias in the qualitative inputs. Further, there were no structured discussions in Cox’s Bazaar and Aden. However, results from the qualitative interviews appeared to converge overall with those from the written end-of-workshop evaluation, which took place in all settings.
Finally, it would be naive to believe that thanks to this toolkit, the planning for comprehensive SRH will be straightforward, including the implementation of the planned activities. The relief-to-development continuum is complex and often non-linear, with Yemen and the COVID-19 pandemic providing humbling and eye-opening examples (in Figure 2, drawing from our collective experience in implementing SRH in crisis-affected settings, we propose programmatic considerations for the planning of comprehensive SRH and use of this toolkit in the COVID-19 era—such a posteriori recommendations could be useful in guiding operational and other actors, but would require further research to assess relevance). Technical solutions, including this toolkit, even those embracing participatory principles in design and implementation, will often not work unless major determinants could find roots in the settings . Such determinants encompass the respect for human rights and humanitarian access, a demonstration that the acute phase of the emergency is over, and the presence of a legitimate and functioning national governmental structure . Moving from MISP to comprehensive SRH and striving for health system strengthening are contingent on these aspects as well as funding by local and international donor governments . Foreign policy considerations, rather than only technical ones, determine the investments of donors and their longer-term support to the affected populations.