Findings from Desk Review & Proposed Framework Rouzeh Eghtessadi (MPH)

1. Regional Framework for Sexual and Reproductive Health (SRH) Best Practice Documentation and Sharing in the SADC Region Findings from Desk Review & Proposed Framework Rouzeh Eghtessadi (MPH) Southern Africa HIV and AIDS Information Dissemination Service (SAfAIDS) Email: rouzeh@gmail.com

2. Thrust of Assignment Consultancy expected to produce: • A Report (combining data collated in the desk review report and data from the administered questionnaires) on Practices, Progress on implementation, Guidelines and Protocols on sexual reproductive health in the SADC Region; and • Regional Guidelines (including specific criteria) for Identifying, Documenting and Exchanging (sharing) experiences and Best Practices on Sexual and Reproductive Health, to be adopted by Member States

3. Consider…. • While analysis of Member State responses is ongoing, available data from desk review is ample evidence to systematically inform direction of SRH Best Practice Documentation and Sharing within a SADC framework • Methodology would ideally needed to enable in-country visits to do on-site data collection and observation • Timeframe - rapid methods, though thorough and comprehensive , were conducted within stringently short period of time • However has created a strategic springboard and body of evidence - for consolidation and further research

4. Background (1) • Multiple commitments to SRH universal access and SRHR (International – ICPD; Continental – MPoA; and regional – SADC Gender & Development Protocol) • Despite omission of SRH from the MDGs, recent evidence highlights universal access to SRH as keystone to meeting MDGs and a key investment in sustainable development • SADC Sexual and Reproductive Health Strategy (2006-2015) objective 4 speaks to best practice agenda: “To enhance sharing of information, experiences and best practices among Member States”

5. Background (2) • SADC Secretariat resolved to develop Regional Guidelines for Documentation and Exchange of Best Practices in SRH in the SADC Region, to: • Serve as a tool for consensus building among Member States (MS) on what constitutes a ‘best practice’ within SRH practice • Catalyse repositioning if SRH practices in the region • Guide MS in identification, systematic documentation and strategic dissemination and uptake (adaptation and replication) of SRH best practices (BPs) • Define criteria for SRH BPs that will ensure harmonised approach to BP documentation by Member States • Facilitate mitigation interventions around SRH in the region

6. Background (3) • In recognition of the rich repository of experiences in the SADC region - relevance of BPs to SRH • Commitments translated into national policies, laws, guidelines, strategic plans, roadmaps and protocols • These guide practices and service delivery in SRH at national, provincial/district and community levels • Lessons learnt, sharing of ‘working’ practices in SRH core areas leads to adoption of improved, cost-effective, effective and sustainable practices and approaches • Improved quality of SR health among women, men and adolescents • MDG targets met, beyond just 4,5 and 6 – informing policy decision-making (financial, human capacity etc)

7. Defining… • 9 Core SRH areas:family planning, STIs (HIV), safe motherhood, sexual violence, reproductive cancers, abortion, infertility, adolescent and youth SRH (AYSRH), interpersonal counseling, comm and health education • Best Practices: no universal definition “…. a technique or methodology that, through experience and research, has proven reliably to lead to a desired result. In the context of health programmes and services, a practical definition of a “Best Practice” is “knowledge about what works in specific situations and contexts, without using inordinate resources to achieve the desired results, and which can be used to develop and implement solutions adapted to similar health problems in other situations and contexts” • A best practice can be anything that ‘works’ to produce results without using immoderate resources, either in full or in part, and that can be functional in providing lessons learned • UNFPA, WHO, UNESCO, Global Health Council, UN interagency committee on women & gender equality

8. Processes …towards generating information for regional SRH framework for BPs • Dual Methodology: • Regional Desk Review (27th August – 9th Sept 2010) on practices, progress made by Member States, guidelines and protocols and related documents (roadmaps, strategic plans etc) • Administered questionnaires to Member States (analysis in progress) • Data sources: SADC Secretariat, 14 Member States, UN agencies and partners, online databases and resources • Themes : • Practices, guiding documents related to, and progress made the 9 core SRH areas • Status of BPs

9. Findings

10. Drawn from SADC documents; ICPD +15 report; MDG Goals Report (2010); WHO work in the Africa region biennium report (2010) and progress report RH strategy 2010 and World Health Statistics (2010); Member States MNH Roadmaps, UNFPA Country Profiles (2009) and African MNH Profiles Roadmap Assessment Report (2010); amongst over 90 other resources (international, regional and national) • Best Practice specific findings: • Definitions • Institutionalising into programming • Status of SRH BP documentation, mapping and sharing • Sample Profiles of SRH BPs: analysed for criteria building • Existing Criteria for BP documentation and dissemination (sharing)

11. Status of SRH BP Documentation, Mapping and Sharing (1) • Limited systematic documentation and sharing of SRH related best practices within the SADC region, and an absence of standardized guidelines and criteria that steer the identification, documentation and sharing of SRH best practices within a methodical fashion, by Member States • The Implementing Best Practices (IBP) Knowledge Gateway • is a global electronic communication tool, users of this platform (including those outside the IBP network) increased six-fold in 2009, to approx 175 000 user • works closely with the WHO–UNFPA Strategic Partnership Programme (SPP) to increase the use of evidence-based guidelines and tools in family planning, maternal health and STIs towards the goal of universal access

12. Status of SRH BP Documentation, Mapping and Sharing (2) • The WHO Reproductive Health Library (RHL); conducts research on strategies for implementation of evidence-based practice; with building capacity, to facilitate informed decision-making based on generated evidence base. • While the RHL repository does not explicitly coin its outputs as ‘best practices’, it presents a vital pool of information on SRH practices that are evidenced to ‘work’, and can be a strategic link for sharing of SADC Member State generated SRH best practices. • The Special Programme of Research, Development and Research Training in Human Reproduction (HRP) is the main instrument within the UN (UNDP,UNFPA, WHO, World Bank) system responsible for research in reproduction. In scaling-up antenatal care in southern Africa, linked to HIV services and violence against women programmes, the HRP is implementing an intervention (Malawi, Mozambique, and South Africa) to improve maternal and newborn health (MDGs 4 and 5) and to strengthen health systems through integration of related vertical services with ANC packages based on the WHO Antenatal Care Model

13. Sample Profiles of SRH BPs: analysed for criteria-building Where there is a will there is a way: nursing and midwifery champions in HIV/AIDS care in southern Africa In 2003 UNAIDS and the Southern African Development Community (SADC) AIDS Network of Nurses and Midwifes (SANNAM) documented a series of best practice interventions[1] as part of the UNAIDS Best Practice Collection, covering Botswana, Lesotho, Namibia, South Africa and Zambia. Commonly underscoring these practices was the recognition that education and specialist training in HIV is hugely empowering to nurses and midwives, and is often the catalyst for taking personal action; networking and adding on to what already exists makes better sense than creating new structures; communities have ideas and skills that should be respected and harnessed; and programmers should focus their efforts on transferring skills and building the capacity of the family and community, rather than doing everything themselves. Best practice criteria-related facets: integrated training, drawing on technical expertise, skills transfer for sustainability, community involvement and empowerment [1]http://data.unaids.org/publications/IRC-pub02/jc900-midwives_nursing_en.pdf

14. From Inception to Large-scale: promoting adolescent SRH[1] The Geração Biz ("busy generation") programme in Mozambique (with support from UNFPA), has been credited with contributing to improved communications and interactions among government institutions and sectors within the adolescent SRH (ASRH) domain. The programme design has prompted continuous investment in capacity-building, that expanded to integrate advocacy and management skills, which led to increase in internal policies, strategic planning, and public policy development. Its multi-sectoral approach beyond only improving health services, has engaged referrals from adolescent centres, schools, and peer educators in the community, and resulted in increase in ASRH access. Scaling up monitoring and coordinating systems within referral structures has contributed to increased motivation of service providers and peers, and enabling data generation that informs cost-effective implementation. The intention for scale-up was part of the programme design from the start, and thus accelerated implementation, and was complemented by producing tools and guidelines for cascade use in new facilities of service provision. The programme design facilitates that selected sites become modes for development new protocols of practice, and the flexible nature of design allows for adaptation as per community trends and changes in culture of needs for ASRH. Youth involvement, in particular young PLHIV, has resonated with the programme design and roll-out, and been evident in increase in youth influencing policy, providing types of SRH services/support, and community mobilization towards SRH. Specific integration of VCT for HIV, HIV care and support, has proven to serve as a strategic entry point for young men to come to youth friendly SRH facilities. Best practice criteria-related facets: strong surveillance systems, modeling for replication, flexibility, community (target ) involvement, displays multi-sectoral approach, scale-up integration [1]From Inception to Large-scale: The Geração Biz programme in Mozambique (Pathfinder, WHO, 2009) http://whqlibdoc.who.int/publications/2009/9789241598347_eng.pdf

15. Existing Criteria for SRH Best Practice Documentation • Documentation criteria: • SADC Framework for Developing and Sharing Best practices on HIV and AIDS (2006): effectiveness, sustainability, cost-effectiveness, relevance, innovativeness, replicability, and ethical soundness • WHO Guide for Documenting and Sharing “Best Practices” in Health Programmes (2008) • FHI/UNAIDS Best Practices: HIV/AIDS Prevention Collection (2001) • SAfAIDS BP criteria for HIV, culture and gender programmes (2008) • IPPF, UNFPA, WHO, UNAIDS, GNP+, ICW, Young Positives The Rapid Assessment Tool for Sexual and Reproductive Health and HIV Linkages (2009) offers a useful springboard to developing BP criteria and relevant tools for documenting • Family planning practices ABCDs can be considered ‘working’ criteria • Client-provider interactions (CPI) offer 6 criteria • Community-based distribution (CBD) models offer 6 criteria

16. Existing Criteria for SRH Best Practice Dissemination (sharing and exchange) • Dissemination criteria and platforms: • Advance Africa/USAID Reproductive Health Best Practice Compendium (online platform) submission form enables verification • UNAIDS Best Practices collection (online) • WHO programme to Map Best Reproductive Health Practices, sharing evidence based clinical practices through annual electronic journal and the Reproductive Health Library (RHL), as well as via worldwide workshops to ensure health-care workers access • WHO has proposed 3 major ways for health related BPs: • African Regional Best Practice Series • Africa Regional Office Website • Distribution of CD-ROMs containing BPs during WHO Regional Committee meetings, conferences, workshops to reach those with limited internet access

17. Recommendations • SRH policy and practice/service delivery - in response to challenges identified, these areas should continue to be considered at national and regional levels. And will inform decisions on areas to focus on when generating best practice documents and sharing for cross-learning • SRH Best Practice Framework – proposed structure, criteria and cycle of systematic steps to institutionalise

18. Policy and practice related (1) • Adopt comprehensive integrated SRH programmesversus vertical programmes. The diversion of resource-attention to HIV had taken away some attention from SRH; there is indications of a shift back to SRH and this repositioning needs persistent attention. Establish integration-supporting mechanisms: optimize and mobilize resources to implement SRH services reciprocally integrated with HIV programmes. Invest in skilled personnel who can provide quality integrated services including emergency obstetric care (EmOC) services, STI management and family planning in communities • Task-shifting in human resources, especially in response to maternal survival, be explored to counter lack of availability and use of quality skilled care during pregnancy, childbirth and the immediate postnatal period, and in family planning[1] . Linked to this, build on the growing debate on the use of Traditional Birth Attendants (TBAs) in rural and hard to reach communities. Thus counter current weak human resource development and management systems, and continuing brain drain of skilled personnel within and outside the SADC region. Also learn from Non-physicians clinicians (NCPs) programme. [1] Task shifting is expanding the roles of family planning providers- Allowing lower-level providers to take on some of the responsibilities of higher-level providers could improve services (FHI, 2009)

19. Policy and practice related (2) • Leverage policy to accelerate the promotion of evidence-driven SRH and programming based on operational research and the scale-up of BP documentation and sharing, and commit resources to practices proven to work effectively and sustainably • Seek systematic technical assistance, to support governments’ and national bodies’ capacity to provide leadership in determining country priorities around: funding, coordination and harmonization, and surveillance and M&E of implementation of SRH programmes • Community involvement in SRH has increased in many countries, and structures and mechanisms need to be set-up to ensure continued and scaled-up community participation, especially of vulnerable groups such as women, adolescents and youth and PLHIV

20. Policy and practice related (3) • Meet SRH needs of men adequately, and not in ‘pockets’, by design interventions for enhanced participation in the provision of SRH and family planning information and service • Innovatively empower adolescents and youthso they can overcome vulnerabilities to SRH ill-health, by ensuring that adolescent sexual and reproductive health concerns are well integrated into other interventions such as education, skills development, gainful employment and participation in decision-making, sports and culture; and programmes addressing adolescent substance abuse • Establish functional referral systems linking SRH integrated services (primary health care with maternal, child and neonatal health services) with services addressing poverty alleviation and financial investment for women

21. Policy and practice related (4) • Speak to unsafe abortions, in line with the MPoA, by compiling and disseminating data on the magnitude and consequences of unsafe abortions, enacting and disseminating policies and laws to protect women and adolescents; and offering guidelines and appropriate training to service providers in the provision of comprehensive abortion care services • Accelerate access and availability of, and investment in, new prevention technology, especially female controlled modes such as female condoms (commodity access), and microbicides, as well as medical male circumcision, in view of STI/HIV response integration • Invest in strengthening infrastructure, at national level, to facilitate access to EmOC.

22. Policy and practice related (5) • Address harmful socio-cultural beliefs and practices valiantly, and integrate this approach in existing SRH approaches that focus on increasing male involvement, and addressing the low status of women and compromised status of adolescents, and unmarried young women.

23. Proposed Structure of SADC SRH BP Framework (Guidelines) • Introduction • Purpose • Definitions • Essential Criteria • Integration into Programming (including coordination and management systems, costing, monitoring and tracking) • Cycle of BP Documentation • Dissemination Strategies • Monitoring & Evaluation (M&E) and Reporting - Surveillance (of documentation, uptake and progress) • Resources and Tools • References

24. Proposed Criteria • Effectiveness (intervention design, community involvement, M&E) • Cost-effectiveness • Sustainability (intervention sustainability, fiscal sustainability, demand creation) • Innovativeness (how unique is it!) • Replicability • Relevance • Infrastructural competence • Integrated (technical reliability, referral mechanisms) • Ethical soundness (rights-based approach, intervention transparency) • Political backing evident

25. Cycle for Best Practice Documentation Refer to page 23 in Document

26. Proposed Dissemination Strategies (1) • Establish a SADC SRH Best Practice Online Portal,which is linked to other relevant regional, international and national portals. Hosted by the SADC Secretariat, while coordination of national portals would be done by relevant Ministry in Member States. Best practices would be placed on the online platform, upon completion and endorsement, for easy access by partners across the region and beyond. A tracking mechanism may be integrated into the platform’s interface to enable monitoring access to the BPs, offering a picture of which areas of SRH best practice are most frequently accessed, and by geographical access. This platform can link to the IBP, RH Compendium, WHO RHL, amongst other related online stages • Collaborate with technical expertise, can be sought from UN agencies, CS, private sector and other regional and national partners with experience in documenting and sharing best practices, to share the documented BPs via their meetings, conferences and workshops. Link collaboration with mobilization resources towards best practices • Host SRH Best Practice Sharing Forums, to enhance cross-sharing between MS on experiences of BP documentation - could be held back-to-back with annual SADC meetings, established within existing institutional mandates.

27. Proposed Dissemination Strategies (2) • Incorporate in SADC Member States’ SRH Annual Reports, allocate section in the SRH Annual Report mechanism of reporting as it is adopted • Integrate into Materials for Advocacy and Programme scale-up, such as newsletters, policy briefs, position papers, research briefs, programming briefs, CD ROMs and similar printed materials, either generated by SADC Secretariat, Member States national SRH information sharing materials, or existing material development programmes (CS) for advocacy/programme • policy briefs on a specific best practice to lobby donors and policy makers to mobilize relevant resources towards a working approach as verified by the documented BP • programming packages to inspire replication of working practices for frontline health workers and managers, towards scale-up of effective interventions • Infuse into Physical Sharing Platforms, such as conferences, policy roundtables, research forums and workshops, where large numbers of like-minded people are present, for discussion and to influence adoption, as well ad decision-making as relevant. Sharing at thematic meetings would enable enhanced understanding of specific area of SRH

28. Evidence-based Information……. …… power to make a difference !!