THE ACQUIRE Project End of Project Report to USAID

This evaluation explores the ACQUIRE Project – Access, Quality, Use and Reproductive Health, which was United States Agency for International Development (USAID)'s flagship project for global leadership in family planning (FP)/reproductive health (RH) service delivery. Funded from October 2003 to September 2008, ACQUIRE was implemented and managed by EngenderHealth in partnership with the Adventist Development and Relief Agency International (ADRA), CARE, IntraHealth International, Meridian Group International Inc., and the Society for Women and AIDS in Africa (SWAA). The Project's core mandate was to provide comprehensive programming support for FP/RH facility based services with an emphasis on long-acting and permanent FP methods (LAPM): intrauterine devices (IUD), implants, female sterilisation, and vasectomy.

ACQUIRE worked primarily in 3 ways: developing models, tools, and approaches and implementing these in the field; developing, synthesising, and disseminating global knowledge; and providing technical assistance to country programmes. ACQUIRE provided global technical input and support to 22 countries to increase access to, improve the quality of, and scale up RH/FP services. According to this evaluation, over the life of the project, ACQUIRE served over 2.1 million LAPM clients, the majority of whom were IUD users - followed by female sterilisation, implants, and male sterilisation.

The Office of Population and Reproductive Health (PRH) of the Bureau for Global Health (GH), USAID conducted a participatory review of ACQUIRE in 2007 and concluded that ACQUIRE was successful and highly valued in the RH/FP community. ACQUIRE was especially commended for providing high-quality technical assistance to and advancing technical leadership through a collaborative and synergistic approach with field programmes. The major materials produced by ACQUIRE are available on a searchable knowledge resource, called a digital archive, for the RH/FP community. The archive contains more than 70 programmatic models, tools, approaches, and reports to help policy makers, programme planners, managers, and service providers.

Key accomplishments include:

I. Increased Access to Quality RH/FP Services

• The successful development and implementation of the Supply-Demand-Advocacy (SDA) programming model and implementation of its components in 10 field programmes. Initiatives typically started by examining factors that shape behaviour. To close gaps in information about and acceptability of RH/FP services, ACQUIRE designed and supported comprehensive, integrated approaches for revitalising LAPMs and postabortion care (PAC), using community engagement coupled with communications and marketing efforts. The work focused on improving the image and quality of IUD services (Ethiopia, Ghana, Guinea, Kenya, and Uganda) and on vasectomy services (Bangladesh, Ghana, and Honduras). The model has been adapted internationally beyond ACQUIRE.
• The successful development and testing of models to improve access to services including the model to address the RH needs of young married adolescents, the community postabortion care model (COMMPAC), and the FP-HIV integration model.
  • ACQUIRE implemented a two-year pilot in two districts in Nepal which established a peer education network to disseminate information to married couples, support local health facilities to provide youth friendly-services, and foster an enabling environment within the community. A project evaluation showed great success: The median age at marriage rose from 14 to 16 years (a statistically significant increase), while median age at gauna (when a married girl moves into her husband's home following menarche, for consummation of the marriage) rose from 15 to 16. The percentage of married adolescents visiting government health facilities for services also increased, from 36% in 2005 to 42% in 2007. ACQUIRE then replicated the model in Bangladesh.
  • ACQUIRE implemented an existing community model designed to raise awareness about and to mobilise the community for the prevention and treatment of incomplete abortion. In the Nakuru District in Kenya, the COMMPAC project led communities to develop health emergency transport plans and PAC payment schemes and successfully advocate with the local government for funds to build roads, construct bridges, and build new dispensaries to improve women's access to public-sector services. Providers were trained, and private donors and community contributions provided necessary equipment. Contraceptive use increased during the project period in 22 health facilities adjacent to the COMMPAC communities: from 8,500 to 13,800 new users and from 2,000 to 4,300 continuing users. USAID/Kenya is promoting COMMPAC as a model for other provinces.
  • ACQUIRE developed a holistic FP-antiretroviral therapy (ART) integration approach that involved developing a package of tools (programme framework, training curriculum, provider job aids, and client brochure), and piloting and evaluating the process of integration in two countries. The approach was first piloted in Ghana and then replicated in eastern Uganda within The AIDS Support Organization (TASO). Directly following sustained FP introduction in Uganda, the number of ART clients accessing FP showed a sizable increase, from almost zero to 30 clients per month, holding constant for the pilot period. TASO adopted the integration approach and began to roll it out to all of its centers throughout Uganda as part of its five-year strategic plan.
• The successful replication of evidence-based practices: the performance needs assessment (PNA) tool; the Client Oriented Provider Efficient (COPE) model; the Men as Partners (MAP) approach; and participatory learning and action (PLA) methodologies. For instance, MAP was integrated into ACQUIRE's efforts to improve the acceptability, awareness, and use of vasectomy services (Bangladesh and Ghana) and was an important element of community interventions designed to improve access to PAC (Kenya), the IUD (Guinea and Kenya), and RH services for married youth (Bangladesh and Nepal). The MAP approach was also the strategic underpinning of a range of activities designed to address male gender norms in HIV prevention, care, and support activities through the Male Norms Initiative. This programme engaged men in 3 countries (Namibia, Tanzania, and Ethiopia) in HIV and AIDS prevention, care, and treatment. ACQUIRE developed a needs assessment package to identify gaps and opportunities in male engagement programming, a curriculum for engaging men in HIV and AIDS in a group education process, a curriculum for involving communities in male engagement, and a curriculum for facilitating greater use and support of HIV and AIDS services by men for themselves and their partners. More than 30 organisations in Ethiopia, Mozambique, Namibia, and Tanzania have incorporated strategies from these tools into their programmes.
• The successful replication of community-based approaches for PAC and FP for HIV positives between countries.
• The development and support of a programme to prevent and treat obstetric fistula in 18 sites and 10 countries that resulted in the training of 29 surgeons and over 2,000 fistula repairs completed.

II. Improved Performance of Service Delivery Providers

• The development of the Fundamentals of Care resource (FoC) package that assists programme planners, managers, supervisors, and providers in implementing and evaluating facility-based services according to these fundamentals (informed choice, medical safety, and ongoing quality improvement).
• Applied the FoC in 10 countries - mostly through the use of the performance needs assessments (PNA), implemented in 11 country programmes (Bangladesh, Benin, Bolivia, Ethiopia, Ghana, Guinea, Mali, Nigeria, Kenya, Rwanda, and Uganda). ACQUIRE developed assessment tools for the PNA that centred on analysing the fundamentals of care at the facility level. ACQUIRE conducted a review of the PNA experience in these countries and identified common programming issues.
• Trained over 70,000 persons in 18 countries, mainly in FP clinical skills and counseling. In addition, ACQUIRE developed a resource package that provides an overall approach to programming for training, as well as information, methods, and tools for designing, developing, planning, implementing, and evaluating training. And ACQUIRE conducted 3 standardisation workshops to raise the profile of the IUD and to improve trainers' and providers' knowledge, skills and practice. Approximately 100 clinicians, trainers, and programme leaders attended from 19 countries of East and West Africa.
  
• Developed a resource package for trainers, programme managers, and supervisors of RH/FP programmes that provides an overall approach to programming for training, as well as information, methods, and tools for designing, developing, planning, implementing, and evaluating training.
  
• Developed and implemented a curriculum for facilitative supervision that focuses on the role of supervisors in ensuring the fundamentals of care (FOC). Utilising participatory learning techniques, the curriculum enables supervisors to acquire knowledge and skills in the facilitative approach to supervision so that they can monitor the quality of services using the FOC - providing feedback, motivating staff, using data for decision-making, and communicating constructively. ACQUIRE used the curriculum in Bolivia, Bangladesh, and Uganda.

III. Strengthened Environment for RH/FP Service Delivery

ACQUIRE's work under this result falls under two interlinked categories: policy and advocacy, and knowledge-to-practice. ACQUIRE's policy work focused on making the case for FP and for investing in LAPMs to generate needed commitment from managers and political leaders at the national and programmatic levels. Examples of key ACQUIRE interventions are the development and use of FP/RH advocacy tools and materials, updating service guidelines and advocating for supportive policies using the latest medical evidence. ACQUIRE's knowledge-to-practice work stressed the ongoing need for dissemination of up-to-date and accurate information, tools, and evidence-based best practices to programme leaders and managers, FP/RH providers and supervisors (especially providers and supervisors of clinical services). Key interventions in this category were participating in global efforts to disseminate the latest knowledge of IUDs; providing medical/clinical leadership, especially in regard to LAPMs, within the RH/FP community; participating in global initiatives to foster use of best practices; conducting and participating in information dissemination and knowledge-sharing events; and producing and disseminating of a wide variety of publications.

One example is the development and implementation of an LAPM advocacy package including Reality v Family Planning Forecasting Tool: User's Guide, which examines the relationship of contraceptive prevalence to contraceptive users, adopters, and commodities to help develop realistic goals for national, district, and facility-level programming; used tool to assist ministries of health to examine contraceptive use in Bangladesh, Ethiopia, and Uganda. Reality v is a planning and management tool that enables officials to project contraceptive use in their districts, helps them to set realistic improvement goals, and makes it easier to identify the resources needed to achieve them. In Uganda, for example, "a district official reported that as a result of Reality v, he was able to cite specifically what supplies he needed (and why) and for the first time succeeded in getting an increased allotment of FP funds from the national government in Kampala. Inspired, the same official proceeded to train others in his district to use Reality v."

Lessons learned:

1. Act with a sense of urgency because the need is only going to get greater - This lesson was generated from the work ACQUIRE did with the USAID FP repositioning task force to examine USAID-supported FP efforts in 5 African countries. The case studies concluded that most of the success was due to continuous investment in the programme basics of ensuring commodity and supplies, engaging clients and communities, and investing in service systems.
2. Even service programmes must have advocacy components - There is a need to make the case for FP and for investing in LAPMs to generate needed commitment from managers and political leaders at sub-national and lower levels. (It is for this reason that the Reality v tool was designed to help managers at any level (national, district, site) examine past trends, make realistic projections based on informed needs and local data, and understand the contribution their district or site has to the larger FP effort, and what it takes to move forward.)
3. Communicate effectively, broadly, and often to level the playing field for underutilised methods - "ACQUIRE implemented a range of innovative, evidence-based technical assistance activities to help increase accurate knowledge and expand IUD availability, quality, access and use in ten countries in Africa, Asia and Latin America: Bangladesh, Ethiopia, Ghana, Guinea, Honduras, Kenya, Mali, Nigeria, Senegal and Uganda. The activities consisted of supply-side, demand-side and/or advocacy interventions. The most successful of these was in the Kisii District in Kenya. The major lesson that we learned was that programs must attack the lack of accurate knowledge and understanding about these methods using multiple channels to reach potential clients, providers, community and religious leaders to convey and reinforce similar messages over time."
4. Engage communities to achieve change at many levels - Communities are critical partners in supporting RH/FP services, especially when normative change is desired. ACQUIRE linked clinics to communities, developing a tool called the continuum for active community engagement (ACE) that helps those involved with serving clients to look at those clients as community members and to analyze how much community members are empowered through the process of engaging them in their RH care.
5. Support providers to focus on client needs, particularly when integrating FP into other RH services - ACQUIRE undertook a series of interventions in Ghana and Uganda designed to meet the FP needs of persons living with HIV. The major lesson from this work was that some level of integration is possible in even minimal settings, but it requires a focus on capacity-building. One of the most important interventions is to help health care workers to examine their own values and to comfortably address sensitive issues related to sexuality and stigma.
6. Keep a focus on the basic underpinnings of sound service delivery, namely informed choice, clinical safety, and a process for quality assurance and management. These "Fundamentals of Care" are foundational and require continuous and sustained attention. ACQUIRE developed the FoC Resource Package to make it easier to reference and integrate the Fundamentals into RH/FP service programmes.
7. Programme holistically by addressing supply, demand, and advocacy components in the design of RH/FP service programmes - ACQUIRE's holistic Program Model for FP/RH service delivery positions the client-provider interaction at its centre. "This interaction is crucial, especially for LAPMs, as they must be delivered at a clinical service site by a skilled and well-supported service provider to a knowledgeable and empowered client. The Model’s four cross-cutting programmatic imperatives - to: 1) focus on the fundamentals of care; 2) use locally relevant data for sound and realistic decision-making; 3) promote gender equity; and, 4) ensure widespread stakeholder participation and ownership - are also particularly important in the provision of quality LAPM services at the individual level and/or for the effective design and implementation of LAPM programs."