The analysis of the qualitative results suggests that the initiative contributed to strengthening different health system building blocks in both countries. Most importantly, community members overwhelmingly reported benefits of the program on the health of mothers and children as well as positive socio-economic impacts. For instance, such impacts were decreased home expenditure on children's nutrition and care or pregnancy prevention through informed voluntary contraception, which allowed women to study or work. Notably, the program appeared to have contributed to lifting a negative veil of misconceptions and fears surrounding contraception.
In my opinion, the big change is the fact that, unlike in the past, our parents gave birth to up to fifteen children. This posed a great problem in caring for their children, especially during the period of recurring wars in our country. Today, thanks to this program brought by Save, everyone already knows how to do family planning and take care of their children properly. There are no more cases of malnutrition. – Male community member, DRC
Policies and Guidance
According to many participants from both countries, the initiative played a role in advocating for and positioning PAC on the national agenda along with FP. As a result, various policy documents integrated FP and PAC over the years (see Box 1).
Box 1. Examples of programmatic influences on policy changes
Task-sharing of manual vacuum aspiration to midlevel providers (nurses and midwives) and allowing manual vacuum aspiration in primary healthcare facilities;
Task-sharing of long-acting and reversible contraceptive services to midlevel providers and allowing the availability of implants and intrauterine devices in primary healthcare facilities;
Advocating for the abolishment of informal “couples counseling” obligations, where using contraception required the husband written or in-person permission;
Expanding health management information system tools of the Ministry of Health to disaggregate data by new or returning user, contraceptive method, evacuation method, and age;
Advocating for more favorable policies for adolescents to access sexual and reproductive health services.
In DRC, participants, from male champions (“men of light”) to decision-makers underscored the importance of the Law No. 18/035 of 13 December 2018, which they perceived as a game-changer as it allowed every individual of reproductive age, and therefore adolescents, “after informed consent to benefit from a contraceptive method”. Furthermore, the will of the woman or girl takes precedence over her husband/partner’s opinion. As a staff member of Save the Children put it, the program “has awakened the Congolese Government to the needs of women to let them decide.”
We had received many threats for having given methods to certain women because here, at home, it's the man who decides. But thanks to the partner [Save the Children], the new law now stipulates that it's the woman who has to decide about her health. – Health facility manager, DRC.
Participants reported that this would not have been possible without Save the Children and partner organizations as they had strategically engaged with and advocated to the MoH and provincial authorities in addition to training relevant staff members on FP, PAC, and SRH more generally. In both countries, such capacity building likely impacted policies and practices (Box 1), and training materials developed in the context of the project were used as guidelines by the government.
In both countries, Save the Children appeared to be actively engaged in coordination mechanisms with the government and other actors. For example, participants from the MoH reported how Save the Children staff, through the initiative, had been active and systematically engaged in coordination mechanisms at the provincial and health zone levels, including co-chairing working groups on FP. Staff participated in monthly coordination meetings and were reported to be quick in responding to needs related to FP and PAC services, such as addressing contraceptive stockouts or facilitating supportive supervision, even in facilities that were not part of the initiative.
Notwithstanding the similar contributions to strengthening coordination in both countries, the MoH participant in Somalia offered insights on ways to make such meetings not only technical but also political—an advocacy platform for political buy-in.
It seems the coordination is only specific to the technical level personnel and the program needs political commitment in some parts. So, I would recommend including political figures from the parliament and ministerial level to have increased commitment. The religious leaders' meetings are held in Qardho and Garowe, where many people don’t have access to. So I would recommend to make this meeting a regional or district level giving access to more people and getting new ideas. MoH participant, Somalia
In both countries, Save the Children, in partnership with the MoH, established in Somalia and supported the establishment in DRC of a training center to become a hub for capacity building in clinical care. Stakeholders perceived it to be a highly strategic investment. Backed by FP and PAC champions, who played the role of master trainers, and adequate training materials, including anatomical models and competency-based curricula, these structures contributed to the capacity development of project staff as well as personnel from other health structures backed by the government or different health partners. Save the Children and the MoH also supported the champions to extend training and supportive supervision work beyond Save the Children to “make sure that the project is sustainable because of the capacity building of staff at every level,” as reported by a Save the Children participant. For example, in DRC, this inclusive strategy had benefited outreach facilities within the Virunga General Hospital coverage area and the northern areas of the province. There, geography and insecurity had hampered access and regular program provision.
Participants overwhelmingly reported how the capacity development workshops had adopted a state-of-the-art competency-based training approach using anatomical models and checklists and underscored the usefulness of post-training supportive supervision visits made jointly by Save the Children and government staff. As a result, providers reported improved competencies as well as increased confidence, as shared by participants in Somalia:
The training gave us the confidence to do our job. The training lifted our reputation thanks to the good job we do for our patients because our work reflects the good training we received. – Provider, Somalia
Participants with programming roles stressed the important contribution of Save the Children’s model for supply chain management, one that is characterized by reactivity and reliability—“With Save, we see action. There are other partners who wanted to do the same activity, but we did not feel their approach as with Save the Children”, as reported by the Health Zone Central Bureau in DRC. Training workshops on supply chain management with reporting and other logistic management tools benefited both project staff as well as personnel from the MoH, underscoring again the potential legacy of the project to the health system.
The central warehouse in Garowe run by the ministry just told us of the impact the supply management system had on their reporting, recording, and requesting for supplies as well as monitoring the stocks. In 2017, we sent one of our staff to Bari to train government staff and now we are planning to send him to Mudug to train their supply chain officers and provide them with tools. – Save the Children staff, Somalia
Critically, the supply management approach resulted in no stockout down to outreach areas, as reported by community volunteers in Kitshanga. In fact, Save the Children was recognized to have contributed to the delivery of supplies and products all the way toward the “last mile”, i.e., to help these reach health facilities. However, contraceptive security was reported to remain fragile in both Somalia and DRC due to the inadequate in-country availability of supplies, the time lag to obtain supplies from national and international supplies, and the dependency on donors to procure supplies.
Through the initiative, FP and PAC services and contraceptives were free of charge to users at the point of care, which removed a significant barrier to utilization. Participants mentioned that the MoH has been slow in committing a budget for the purchase of contraceptives. However, participants widely warned against the risks posed to the uptake of contraceptives, including by young people, once Save the Children withdraws its support to the program. For participants, the MoH is far from being ready to take over the project in terms of removing fees for services and contraceptives, which may negatively impact service utilization by adolescents and young people.
If the partner withdraws when the government is not yet in a position to provide contraceptives to the population, this will be a barrier to young people! Imagine a young person arrives at the service to be given a prescription; she may not go and fill it if she cannot afford it. – Adolescent Health National Program staff, DRC
In DRC, some participants reported how community health insurance schemes seemed to be working in stable areas where development programs were feasible, such as in the neighborhood of the Virunga General Hospital. Such insurance schemes could reduce the financial barriers that affect the population’s access to FP and PAC services. However, it was reported that for now, they covered mainly sickness conditions and childbirth but not contraception as this was considered as health promotion.
In both countries, participants reported the multiple channels used by the project to reach the community and raise awareness about the importance of FP and PAC. The information and positive messaging likely had an impact beyond the project coverage zones.
For example, in DRC, communication channels included radio messaging (see Box 2), men of light, satisfied women, and community volunteers. Peer educators and community volunteers received support from the initiative but managed independently and would continue to do so after the end of the project.
Box 2. Messaging on the radio in the Democratic Republic of Congo
The initiative’s messages on family planning and postabortion care may have reached more than 10 million listeners, according to the director of the Pole Institute Radio (pole: compassion in Swahili), a non-profit organization dedicated to peacebuilding through inter-cultural understanding. According to the Institute, Pole covers 90% of the territory in North Kivu, 60% in South Kivu, 40% in Lituri, 25% in Uganda, 15% in Rwanda. Listeners were reported to appreciate the “Save the Children Song” as they regularly asked the radio to play it.
Building on the initial approach, which broadcasted the song in a linear one-way direction toward the listeners, more interactive options could be explored in the future, including:
Communicating a unique phone number or weblink at the end of the radio message, so that listeners could provide feedback. The Pole Institute has algorithms to analyze the quantitative and qualitative impact of auditors’ feedback;
Adopting discussion spaces, such as Forum for popular expression or Listeners’ club, where different members of the community can interact with a clinical expert;
Audio series at the end of which auditors could call and leave comments and questions that would be directly addressed by an expert.
In Somalia, Save the Children staff reported the difficulty in implementing family planning programs due to conservative traditions and practices – “even some other NGOs failed.” The successful buy-in came from the involvement during the pilot phase of women from the community who championed the cause and paved the way for the next stage of the project. Equally important was the engagement of religious scholars, elders, and community leaders who advocated for FP during community mobilization campaigns and meetings with the MoH. Father-to-father, mother-to-mother, and young people-to-young people sessions were reportedly also critical in raising awareness. However, for many, more could be done, especially reaching young people, men, and those living in remote rural settings.
Health Information System
In both countries, participants with program management functions reported the importance given by Save the Children to the use of data to inform decision-making and action, such as facility-based charts as a reflection tool during supportive supervision visits and discussions with providers or the review of routine data with the MoH and community stakeholders. Participants also highlighted the novelty of age-disaggregated data for adolescents and young people, which Save the Children introduced in 2017.
For example, in Somalia and DRC, providers who are the first line data collectors and users reported as follows:
Before, reports were stored in a facility, and, if needed, they have to be dug from a pile of papers. Now all the data is contained in the wall charts depicting the whole year. This has simplified the reporting process…It is very different from other programs. Family planning has age category to identify mothers younger than 18 years of age since those are the higher risk group. It is also different in that every provider sees how many mothers he/she did serve. - Provider, Somalia
However, they mentioned the fragmentation and potential data collection burden induced by the different reporting needs of various NGO-supported projects and donor requirements.
Participants in both countries were of the view that thanks to the project, FP and PAC services were of quality in addition to being free of charge at the point of care. In DRC, participants highlighted that the FP and PAC services reinforced women’s choice to decide on their own. The gratuity of services was instrumental in service uptake, including the adoption of long-acting contraceptives among new users. Interestingly, the perspectives of men reflected the transformation brought by the program in terms of access, availability, and removal of service fees supported by the program. The high quality of services and particularly the availability of postabortion care in the project facilities benefited the health system.
Before, there were people from rural areas who used to die due to loss of blood but now they are brought to the centers, which are open at all times. Birthspacing was something that we needed because if the children are not spaced, the mother suffers from malnutrition. - Male community participant, Somalia
Additionally, providers and master trainers outside the project trained on FP and PAC through the project contributed to expanding the coverage of these services within the health system beyond the facilities supported by Save the Children. As a result, there was an increased number of reference centers for FP and PAC thanks to the initiative, as reported by the MoH from Somalia.
Female peer educators in DRC were enthusiastic about the emphasis on adolescents and young people and their roles in facilitating access to information and services to this segment of the community. However, they mentioned angrily instances where providers or pharmacists were not respecting the confidentiality and privacy of adolescent clients by informing their family or parents.
I also think it's punishable by law: a good doctor or nurse is not allowed to disclose clients' medical information…So, I think that when you educate us, you must also do the same for nurses because apparently there are a few who have no medical ethics. – Young female community participant, DRC
Save the Children staff in both countries acknowledged the need to strengthen adolescent and young people-centered services not only within but also beyond the FP and PAC project. Other recommendations from participants are described in Box 3. Building on the participants’ perspectives, Fig. 1 summarizes the way FP and PAC program interventions were perceived to have contributed to strengthening health systems.
Box 3. Recommendations from participants to improve FP and PAC health services and contributions to health system strengthening
Participants from both countries seemed to agree on the need to:
Ensure the continuity and expansion of free FP and PAC services by advocating against the donor’s withdrawal;
Strengthen the integration of FP and PAC into primary healthcare services;
Continue to ensure the continuous availability of supplies;
Further train, support, and retain healthcare staff on FP and PAC;
Continue focusing on adolescent-inclusive services and increasing competencies of all staff dealing with the topic;
Keep engaging and mobilizing the community, with a focus on men, adolescents, and hard-to-reach communities;
Advocate to health ministries and like-minded partners to join efforts on FP and PAC programming and support enabling policy changes.
Figure 1. Strengthening health systems in humanitarian settings: a contribution model from family planning and postabortion interventions in the Democratic Republic of Congo and Somalia