This episode—our last for this season—will feature guests from Madagascar and Uganda who will share stories about strengthening partnerships and advocacy for family planning. Their insights can help us as we look to shape supportive systems and ensure that family planning programs can reach all who need them.
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From Knowledge SUCCESS and the World Health Organization’s IBP Network, this is Season 2 of Inside the FP Story—a podcast with family planning professionals, for family planning professionals.
The international family planning field has generated a lot of data, a lot of reports, and a lot of lessons learned. But we don’t often have the opportunity to get behind that information, to hear directly from the people who implemented a program, or who did the analysis, and so we reinvent the wheel or miss the mark because we don’t know what could be really critical in a particular context. Inside the FP Story is that opportunity.
Each season, we’ll hear directly from program implementers and decision makers from around the world on issues that matter to family planning programs. Through these honest conversations, we learn how we can improve our family planning programs as we work together to build a better future for all.
I’m Sarah Harlan, the Partnerships Team Lead for the Knowledge SUCCESS project. I’m pleased to welcome our narrator, Sakshi Sharma.
Narrator In Season 2 of Inside the FP Story, Knowledge SUCCESS has been collaborating with the IBP Network to explore issues around implementing family planning programs. During this six episode season, you are hearing from the authors of a series of implementation stories—published by the IBP Network and Knowledge SUCCESS. These stories offer practical examples—and specific guidance for others—on implementing high-impact practices in family planning and using the latest tools and guidance from the World Health Organization, or WHO.
So far this season, we’ve discussed programs that have mobilized and reached communities with family planning information and services. We have heard about strategies to ensure that diverse groups of adolescents and youth have access to family planning and reproductive health.
In our previous episode, we began exploring scaling up programs that improve the larger health system. This episode—our last for this season—will feature guests from Madagascar and Uganda who will share stories about strengthening partnerships and advocacy for family planning. Their insights can help us as we look to shape supportive systems and ensure that family planning programs can reach all who need them.
We will begin today’s episode in Uganda—specifically, the Sebei Cluster in mid-Eastern Uganda, which has relatively low contraceptive uptake compared with the rest of Uganda. IntraHealth International collaborated with multiple partners across Uganda to create a collaborative among implementing partners in the region. They worked together to build health workers’ capacity to deliver unbiased and integrated health care and increase voluntary access to a full range of contraceptive methods among rural and underserved communities.
We spoke to Sam Cherop, formerly of IntraHealth International, to hear more about this program.
Sam Cherop My name is Sam Cherop. I currently work with Amref Health Africa. I work as a regional coordinator. And formerly, I used to work with the IntraHealth as a Cluster Technical Manager for Sebei cluster where this story was documented.
What we implemented was basically partnerships and collaboration with the implementing partners that were supporting family planning related activities within the cluster. We came in from the angle of the activities that were cross-cutting, the four implementing partners that took part together with the local governments, and our focus was mainly to improve access to voluntary family planning services by women and men of reproductive age group.
Narrator The collaborative initially began when RHITES-E, the IntraHealth International project Sam was working for, decided to hold a coordination meeting with partners working in the cluster districts. Such meetings had not been previously held among implementing partners in the region. In addition to RHITES-E, the meeting included representatives from key local nongovernmental organizations. During the meeting, participants discovered that they faced similar challenges when implementing family planning programs. None of them had enough funding. They faced regular contraceptive stockouts. They noticed insufficient skills among health workers. And they all realized the need to involve communities more in their family planning programs, and to sensitize these communities more around the need for voluntary family planning.
To respond to these challenges, the RHITES-E team proposed ongoing partner collaboration. This way, they could pool their resources and cover more geographic areas. They could also increase involvement of local governments, which could help sustain family planning programming in the cluster.
It turns out they were right. Pooling their resources and skills had a great impact.
Sam Cherop The impact that we can now see was a dramatic increase in the number of people that eventually accessed family planning related services, given the fact that previously the numbers were very low. And then when we did this collaboration, we came up with a number of strategies and interventions that we put out there across the three districts. And by the time we're submitting this story, we had dramatic increase in numbers of people taking FP.
Narrator The collaborative worked together to address cultural barriers and to help create an enabling environment that would support family planning programming throughout the entire cluster.
In order to make sure that the collaborative stayed accountable to their goals, IntraHealth Uganda took the lead and made sure all the organizations came together—despite different donors and interests—to work towards their overall objective in supporting the districts and the Ministry of Health to meet the family planning needs of women in the cluster.
In doing this work, they found strength in numbers, and were able to address challenges as a collaborative group.
Sam Cherop We were operating in a very complex terrain that had various prevailing challenges and needs from communities that would actually not be addressed by one implementing partner. And also, that we could find strength, in a collaborative that we could use that kind of strength to address the various challenges.
Narrator This program helped the modern contraceptive prevalence rate increase from 13 percent to 16. And overall, there were significant increases in the number of women using long acting reversible contraceptives.
We asked Sam to share what elements of the program led to this impact.
Sam Cherop The element of constant coordination meetings, because in those coordination meetings, the element that I would embed in almost as two in one was the element of data review in those coordination meetings. That eventually worked magic for us. We would always have meetings—biweekly, monthly, and quarterly meetings. In these meetings, we were constantly reviewing our data to focus on areas where we think are not doing so well, to further refine our strategies, our interventions, what was different that we could modify?
Narrator We asked Sam one thing he wishes he’d known before starting the program.
Sam Cherop Looking at the element of sustainability on first sight, we realized that we have issues with the continuous work, especially that is being done and funded by donors. So the one thing that we really hope that if we had done before, it would have been productive, was an earlier engagement of local governments, for them to commit resources towards family planning related activities.
Narrator Engaging local governments earlier was a key lesson learned. In addition, Sam shared program challenges they faced at every level—and how they overcame them.
Sam Cherop So let me begin with the district and say we had two to three major challenges at the district level where we had inadequate funding in the Department of Health. We didn't have lots of budgets or the local governments had not committed a lot of monies in supporting family planning related activities.
And then the second challenge is even when we brought in the element of commitment of resources from local governments, especially resources generated from local revenues, the government officials were reluctant to really make commitments towards this kind of allocation of funding. And then the third challenge was around competing priorities. Beyond family planning, there were a number of other activities surrounding HIV, surrounding vaccination out there, that were all being done concurrently.
And then on issues around non-commitment—we kept on engaging through dialogues, through the performance reviews, to demonstrate to them the element of importance of committing resources.
That's why they were able to give us that money that they give us. And with the element of competing priorities at district level, we had to go back to restrategize and ask the district teams to have what we call weekly DHT meetings, district health team meetings, for us to discuss activities of the week so that we could distribute the available persons, according to the activities that were prevailing in a given district in that particular week.
Narrator At the facility level, Sam identified three major challenges—the need for more training among healthcare workers, frequent stockouts of family planning supplies, and inadequate use of data from health facilities.
Sam Cherop So with issues of skills, we commenced a number of trainings, especially using approved manuals, those of WHO and Ministry of Health manuals here in Uganda. We followed this up with mentorships where we had mentor and mentee designated at district level brought together via various platforms for quick engagement with each other to just continue improving on the skills that they have gotten.
And then we had an element of learning sessions, which were instituted on monthly, and then on quarterly.
With issues of stockouts around reproductive health commodities, we majorly did two main activities—that’s redistribution of commodities among facilities that had surplus, but also emphasized more on building capacity of health workers in placing orders, correct quantifications, delivered in time, to actually fit into the increasing demand, which were generating from community.
On issues around data use, we formed data quality committees which would scrutinize data before submission, on monthly and quarterly basis.
Narrator At the community level, the coalition faced two main challenges: They faced issues of resistance to family planning, due to the influence of cultural norms and values. But they also had geographical issues—some communities were far away from the health facilities and could not access them.
Sam Cherop How we handle the element of resistance—we continued engaging them on various advocacy programs, especially using the approach of community group engagement. We were able to do radio talk shows, do posters, do dramas, and then do community drives to have them further enlightened and during such processes, we were clearing up issues around myths and misconceptions of family planning. And then on issues of long distance, we decided to conduct outreaches, family planning related integrated outreaches to communities, which were really far away from the health facilities.
Narrator As a coalition, they were able to analyze data and quickly respond to the challenges they saw at each level—district, facility, and community. We asked Sam what he thought others could learn from their experience.
Sam Cherop One of them is around collaboration and that will tell us that collaboration with the implementing partners and other stakeholders can really be enhanced in a way, if done clearly, it could turn out to be very efficient and in such a way that members can always leverage on each other's activities, funding, as we further discuss donor interests, and then divide responsibilities, which will enhance trust. And in a way, this would also be avoiding duplication of activities while making sure that the resources that we have are put into use. The other is also that further the collaboration provides a conducive environment for stakeholders to nurture relationships as we continue sharing experiences and improving voluntary family planning uptake by service users.
But then, periodic meetings are important because these present moments where we pause and reflect on: Where are we? What is that we have done right? What is that that we haven't done right? If we did it right, why? If it didn't work as we had planned, why did it not? In that way, we're able to do some root cause analysis and come up with areas where we still need to focus.
We further looked at the element of focusing on community-based interventions actually plays a key role, especially in changing or challenging cultural practices and addressing myths and misconceptions on issues around rumors.
Narrator This program used principles of community group engagement—which is considered a high-impact practice in family planning—to design this program. We asked Sam more about why they used this approach, and what they learned.
Sam Cherop The community group engagement kind of worked magic for us, because it presented an opportunity for us to diversify and even dig deeper into cultural values and norms that wouldn't have otherwise come out. But through the constant of various approaches like drama, community dialogues, discussion with elders, religious leaders, we were able to get input from them directly.
Narrator We asked Sam to explain more about how they strengthened the health workforce, and increased skills and information received by health workers.
Sam Cherop So we basically picked out the various guidelines of WHO. We further picked together with that of the Ministry of Health, because the Ministry of Health actually picks most of its data from those guidelines. We triangulated them and then now used them to conduct TOT trainings at a regional level. And then we printed contextualized and compressed guidelines to these mentors. on their day to day work, whereas they’re visiting facilities, they are using this for quick reference. We also give some to the health workers where even in absence of mentors, they could use this for quick reference in case they wanted to refer to an element which wasn't very clear to them.
Narrator Another important aspect of this program was establishing trust. This was especially important when working with different organizations funded by different donors. Trust and transparency helped them establish a framework to support each other during the process.
Sam Cherop We also instituted learning sessions that were facility-based and then district based. During these learning sessions, we are reviewing the best practices that we're working across the board and those that we're working for particular indicators to further see if this was working for family planning.
Narrator This story shows us the value of ongoing partnership and collaboration. As Sam explained, this program was able to achieve more as a collaborative than any individual partner could have achieved alone.
As we just learned, strong partnerships can help us ensure a more supportive enabling environment for family planning programming. Working with these partners to advocate for improved family planning policies can make our programs reach more people with the services they need.
Our final story this season is a prime example of how national-level advocacy—with a clear understanding of the government’s budget cycle process—can lead directly to improvements in domestic financing for family planning. In Madagascar, Options Consultancy Services Ltd. advocated for and succeeded in removing taxes on donor-funded FP commodities as a means to increase national financing for family planning. The additional funding is an important step to help ensure all individuals have access to contraception.
To hear more about this program, we spoke with Dr. Onisoa Rindra Ralidera of Options Consultancy, the country lead of Hope Change in Madagascar.
Dr. Onisoa Rindra Ralidera I am Dr. Onisa Rindra Ralidera. I am the country lead of Options Consultancy Services in Madagascar for the WISH2ACTION project of UK Aid.
This story started in 2019 when we saw that it was very difficult for the state and for the Ministry of Public Health, more specifically, to allocate funds for family planning. As we know, Madagascar is among the poorest countries in the world and therefore, we depend a lot on donors. The situation in Madagascar is that more than 95% of contraceptive product needs are met by donors, with less than 5% provided by the Ministry of Public Health or by the state.
Narrator Although the Ministry of Public Health (MoPH) pays for less than 5% of contraceptive supplies—equivalent to about 235,000 US dollars—they are required to pay an estimated 94,000 US dollars in taxes each year on the donated commodities.
Dr. Onisoa Rindra Ralidera Why not use these taxes to be able to increase the allocated funds? So, we looked at the zero-rating process. So, we started to write a letter from the Minister of Public Health to the Minister of Economy and Finance to request the zero-rating of these contraceptive products in the finance bill for 2020. The Minister of Economy and Finance accepted. And the standard political process therefore is that the bill is drawn up within the ministry of Economy and Finance after they will present this at the government council level. And after its adoption at the Council of Ministers level, it goes to the parliamentarians level. So, what we did, we contacted parliamentarians directly, more specifically the health committee within the National Assembly because it is they, the parliamentarians, who hold the final decision.
Narrator Zero-rated goods are products that are exempt from value-added taxation. The program team contacted the chairman of the health commission, and explained the benefits of a bill removing taxes from these supplies. They included information on investment for family planning.
The chairman was convinced.
Dr. Onisoa Rindra Ralidera The chairman of the health commission was a man who was already our ally when the law governing reproductive health and family planning was adopted in 2017. This is a law that has survived a century-old law that still banned the use of family planning in Madagascar. So, it was really a step forward, a big step and he agreed to support us. He reassured us that he himself would personally influence his fellow parliamentarians to pass this law.
So, we worked a team on the advocacy letter as part of the normal process, and we made a plea within the National Assembly for it to be accepted and adopted immediately. It was passed unanimously.
So the impact is that tax exemption is effective in Madagascar. Therefore, all contraceptive products are zero-rated and therefore it is easier to have access to all these contraceptive products. The other impact is getting a lot more funds for contraceptives.
Narrator To identify the funding gap and determine how much of an impact this zero-rated plan would have, they used Madagascar’s costed implementation plan for family planning, which was developed by a national family planning committee. Partnership is crucial for any type of advocacy activities—since they were focusing on national-level advocacy, they cast a wide net when it came to partnerships, and reached out to all government institutions concerned with reproductive health and family planning. However, when it came to actually passing the bill, they targeted key decision makers—in this case, parliamentarians.
Dr. Onisoa Rindra Ralidera At the beginning we worked, and we are still working, with the national family planning committee in Madagascar to develop the official letter requesting the abolition of these taxes. So that is the normal process, but on the other hand we have understood that we needed advocacy to key decision makers who are parliamentarians. So, we began to establish, to develop a brochure that includes the summary of the benefits as return on investments of family planning, the evidence, the commitments that Madagascar made. It was a 4-page brochure, so we put everything. We identified the key decision maker, so we chose the chair of the health commission because of his commission deals with health issues in Madagascar. And since he's a real influencer among parliamentarians, he's a good messenger. We gave him all the information to be able to support. So, we decided to advocate within the ministry of public health to support us. With the president of the health commission, we made the plea together to also convince this president of the health commission and afterwards, him in person, he influenced the other parliamentarians to adopt during the plenary situation.
Narrator We asked Dr. Onisoa what she considers the most successful component of the intervention.
Dr. Onisoa Rindra Ralidera The component of success? In this intervention, having designed the brochure was really a success. We used this brochure among all the possible implementers. The other thing was knowing the normal government process and then knowing the key decision makers helped our success.
Narrator Dr. Onisoa shared additional insights—including one thing she would have liked to have known before implementing this intervention.
Dr. Onisoa Rindra Ralidera After looking back, we found that it was not enough. It was a success first, but we also had to ask for the use of funds that were formerly allocated for donor taxes to be used for family planning. We had to do this at the same time. It was possible, but we didn't really think about it at first.
Narrator Removing the taxes was one thing. It was another issue to ensure that those funds were used for family planning. And issues that arose during the COVID-19 pandemic only made this problem worse—as more issues were competing for funding.
Dr. Onisoa Rindra Ralidera So that's why we really had to ask by law to increase this budget. We had to do it in the law because if it is in by law it is more difficult to take it afterwards. So that was it, but with the accountability mechanism we made a plea to recall Madagascar's commitment to also remind decision makers of the the zero-rating of products, and to remind them to increase the budget. And we started to advocate at the parliamentary level again—in other committees, such as the finance committee, the population committee, parliamentary funds etc. They agreed to become allies to increase the budget.
Narrator While the program is still advocating to ensure that the funding is allocated properly to family planning programs, they are happy to have developed strong partnerships and alliances with decision makers.
We asked if she has any advice for others implementing similar programs.
Dr. Onisoa Rindra Ralidera In terms of advice for others, it's better to work with an approach that is not routine, but an innovative and inspiring approach. You must always remain open-minded. For example, we have this national family planning committee which brings together all the stakeholders, and really this is an opportunity. We must also see who are the other stakeholders that we must contact. We must integrate people with disabilities. We must integrate young people and adolescents, their associations. We must also go to the level of parliamentarians because among parliamentarians, as parliamentarians they are also people— doctors, financiers, communicators, etc.
You also must be flexible. Speaking with political and legislative types, you may work even at night or early in the morning. And other than that, a great piece of advice is that before you do anything, you have to first master what you want to talk about. You might encounter unexpected questions, so you must really master the program, master the data, master the information that you want to share with decision-makers. That's a big one.
You also must know the standard political process and how to identify the key decision-maker. And you must find the right messenger—the person must be someone who is convinced of the program. The person must be steeped in the program and be able to defend it.
Narrator She said it’s crucial to be familiar with the government’s financial process as well, when working in advocacy.
Dr. Onisoa Rindra Ralidera You must know the budget cycle. We have now established, with the Ministry of Health, a budget monitoring process which helps us to track this better. Because now, Madagascar has just signed the commitment for Family Planning 2030 so we must follow up, so that it is honored, so that this commitment does not remain a signed commitment but a truly materialized commitment.
Narrator This program focused on advocacy at the highest levels of government in Madagascar. It was crucial for them to understand not only the current political process, but the history and the larger environment that influences family planning policy in the country. And, like Deepti Mathur mentioned in the previous episode, it is key for all stakeholders advocating for family planning to have a common goal. Having a favorable environment—including supportive policies—allows stakeholders to develop a shared vision.
We asked Dr. Onisoa to describe the key pillars of a supportive environment for family planning.
Dr. Onisoa Rindra Ralidera The pillars, for a favorable environment? We need partners, we need stakeholders—all stakeholders need to be on the technical committee. The Ministry of Health, which is in charge or supervises the program, must be the lead partner in order to have a really good political support. We need framework documents. We also need funding to implement. It is also necessary to have follow-ups and evaluations to be able to improve and to understand the situation and to improve future commitments. We also need legislative documents I mean, which really frame the implementation of these programs.
Narrator Advocacy—like that conducted by Dr. Onisoa and her team in Madagascar, can help ensure that these pillars are in place, forming an environment supportive of family planning programming.
We asked if she had any final thoughts, and she had some great advice about always pushing forward.
Dr. Onisoa Rindra Ralidera I will add that for this kind of high impact practice, it's not something frozen, but you always must evolve. So now we have zero-rated products. So what do we have to do now? We must make a plea to get a lot more funds and after, and after, etc. So we should not stop after a success, but always see what we can do to really expand and facilitate access. As the Reach to Action program, we started to consider people with disabilities, and now we are happy that no one is left out because there is a platform of people with disabilities that works a lot that has already been created in the coalition in the accountability mechanism to always challenge the commitments made by Madagascar.
Narrator As more countries are making commitments to the newly-launched FP2030 partnership, Dr. Onisoa’s advice is even more relevant than ever.
This story shows the importance of working with key decision makers to ensure domestic financing for family planning, create a supportive environment, and to keep pushing to improve family planning programs—striving to not leave anyone behind. This is also a clear example of the importance of policy advocacy to ensure that governments live up to their FP2030 commitments and to the families in need of life-saving contraceptive supplies and services.
Narrator This season, we have been honored to share stories from a range of programs around the world. We started by exploring community engagement strategies — including integration of family planning services with other health areas and settings — we then turned our attention to innovative strategies to reach diverse groups of adolescents with reproductive health information and ended with a focus on overall systems, policies and the enabling environment. While the countries, interventions, and audiences were diverse—many of the lessons learned are universal. We hope you find these stories useful, and we’d love to hear from you as you apply some of their insights in your own work.
These stories are part of a series of 15 stories selected from a global competition hosted by The IBP Network and Knowledge SUCCESS to highlight experiences implementing HIPs and WHO guidelines. If this episode left you hungry for more, we encourage you to read the other stories on the IBP Network website. And if you missed any episode this season, you can always catch up by listening to previous episodes.
Inside the FP Story is a podcast produced by the Knowledge SUCCESS project and the World Health Organization’s IBP Network. This episode was written by Sarah Harlan and Anne Ballard Sara, and edited and mixed by Elizabeth Tully. It was supported by an additional team, including Alex Omari, Aissatou Thioye, Nandita Thatte, Ados May, Carolin Ekman, and Michelle Yao.
Special thanks to our guests Sam Cherop and Dr. Onisoa Rindra Ralidera.
To download episodes and to find additional links and materials, please subscribe to Inside the FP Story on Apple Podcasts, Spotify, or Stitcher. You can also find Spanish and French transcripts at KnowledgeSuccess.org.
The opinions in this podcast do not necessarily reflect the views of USAID or the United States Government.
If you have any questions or suggestions for future episodes, feel free to reach out to us at info@knowledgesuccess.org.
Thank you for listening.