How to manage complex multi country programmes

Options’ Women’s Integrated Sexual Health programme (WISH), funded by UK Aid, is improving access to quality sexual and reproductive health care services across Africa and Asia by strengthening national stewardship.

Options conducted an internal review of the programme, based on consultations with our seven implementing teams in Bangladesh, Pakistan, Malawi, Madagascar, Zambia, Uganda, and Tanzania, to gain insights into what worked well and what could be improved. This revealed useful insights on how to adapt programmes in a timely manner when the context changes, provide impactful technical assistance (TA), and successfully generate and incorporate lessons learned.

These findings can help guide others implementing similar multi country programmes that aim to strengthen government stewardship of sexual reproductive health and family planning services (SRH/FP).

Adaptive programming is key to overcoming the rigidity of traditional approaches, especially during a major crisis

Traditional approaches to development programming with fixed targets and outcomes do not fit complex problems, or multi-country programmes whose pathway to achieve results differs in each context and evolves constantly. Adaptive programming improves responses to complex problems by identifying which solutions bring change.

To help overcome the rigidity of traditional development programming, we designed a Pathways of Change (PoC) adaptive management tool for the WISH programme. It sets four Pathways of Change to strengthen government stewardship of sexual, reproductive health and family planning (SRH/FP): financing, quality improvement, policy and planning, and accountability.

Figure 1: Quality Improvement (QI) for family planning Pathway of Change: illustrative example.

Source: Bandali, S et al, Pathways of change for achieving sustainability results: A tool to facilitate adaptive programming, Global Public Health, 2021 Jan 6

COVID-19 highlighted the importance of adaptive programming in mitigating the impact of the pandemic on sexual and reproductive health services, while maintaining accountability for results to the donor within the context of a payment by results contract.

WISH country teams used the PoC tool to identify actions that would help strengthen health systems resilience. For example, some countries helped develop a tool to assess health facility readiness to resume the provision of SRH/FP services during the pandemic. In other countries, the PoC helped identify ways to work with the media to highlight how the pandemic was negatively affecting SRH/FP service access, and FP commodity stock outs in particular. As a result, SRH/FP service provision was resumed more quickly and better prepared Ministries of Health for future health emergencies.

Complex programmes require continuous and joined-up hand holding

TA plays an important role in strengthening the enabling environment for SRH/FP services, and for the right conditions for their demand and supply. That’s why Options put in place a two-tiered TA system for the WISH programme.

At global and regional levels, experts provided technical assistance to country teams, who in turn used their TA skills to bring about policy and systems level changes for SRH/FP. TA was aligned with the four Pathways of Change. For example, we paired an international health financing expert with a health financing expert in country, and an international quality improvement expert with an in-country quality improvement expert. The experts provided regular handholding support, including for work-planning, agreeing annual indicators, and supporting the delivery of high-quality quarterly milestones.

Creating an enabling environment for SRH/FP requires diverse skills and intensive TA provision in health systems expertise that is tailored to country technical staff needs. This includes strong relationship-building and influencing skills with government counterparts, and an ability to generate evidence to advocate for change, and develop high-quality products and tools, such as for budget monitoring and tracking.

However, our review also demonstrated that especially in the early stages of complex programmes, there is a risk that a pathway of change-based TA structure can lead to a siloed approach that does not sufficiently exploit synergies across the pathways. Our team in Tanzania therefore shifted to working in a joined-up manner in two regions of the country, ensuring efforts within the respective financing, quality improvement, policy and planning, and accountability work steams were mutually reinforcing. In the future, another way to mitigate this risk is by agreeing on achieving a country level story of change, such as a legislative reform for safe abortion, and for the pathways and TA to align around and support this agreed result.

Creating different spaces for learning is important as it helps respond to complex contexts.

A core management objective in our programme was to close the learning loop by facilitating a culture of continuous learning and sharing lessons (including across country programmes) in real time, and to adapt and course correct efforts in country accordingly. To do this, the teams listened to what was happening on the ground and gave voice to country offices by capturing and disseminating learnings that were not necessarily captured by the logframe. Options also set up several fora to support cross country learning, including a technical working group (TWG), newsletter, participated in an annual learning event, and documented and disseminated lessons for national and global audiences.

For example, under the policy and planning work stream in Malawi, the team worked with a parliamentarian to table a discussion on Termination of Pregnancy reform in the parliament. However, when it became apparent it wouldn’t win enough support, the country team changed track to work with the media to raise awareness and increase public demand for legislative reform. Going forward, we will give more attention to supporting country teams to reflect on and document how results were achieved, and to provide more support to the timely dissemination of learnings.

All the learnings from the internal review have helped our teams to plan for future phases of the programme. As an organisation, some important reflections to improve future programming are: to engage early with local teams and stakeholders; to adapt programmes in a timely manner when the context changes or an approach is not working; provide thematic and joined-up TA; agree on a country story of change and align TA towards driving that change; and invest in adequate resources to capture and disseminate learnings through multiple channels, including social media.

Stories of change: Find out about WISH’s focus on developing an enabling environment has contributed to better SRH and family planning outcomes in Bangladesh, Pakistan and Zambia, where the programme’s work has recently been completed, focussing on the themes of intersectionality, resilience and working in partnership.

This blog was written by Priti Dave, Independent Consultant at Options.