REPRODUCTIVE HEALTH SUB-PROGRAMME

Project Document between

The Government of Lebanon
and
UNFPA

1. Goal, Purposes and Outputs

The Country Programme for Lebanon under the second UNFPA cycle (2002-2006) is comprised of two sub-programmes that were developed in line with UNFPA thematic areas, namely Reproductive Health (RH), and Population and Development Strategies (PDS). The RH sub-programme provides a comprehensive and unifying approach framework based on the Country Population Assessment exercise (CPA) that succeeded in identifying needs and gaps, and thus determining priorities and strategies for improving RH particularly in underserved areas. These priorities and strategies also build on the lessons learned of the previous RH sub-programme.

Through the newly developed RH framework, four interrelated RH projects were formulated and will aim at complementing each other for the achievement of the outputs and thus will contribute to the realization of the goals and purposes.

1.1 Programme goal
The RH goal under this programme cycle (ie 2002-2006) aims at contributing to improving quality of life of the Lebanese people through (a) improved reproductive health status; (b) reduced gaps in socio-economic sectors; (c) balance between population dynamics and socio-economic development. It is worth noting that the country programme particularly the RH sub-programme will focus its interventions and activities in under-served areas where the majority of the ICPD and ICPD+5 indicators are still to be realized. A number of relevant indicators were identified for assessing he success of the goal by the end of the cycle. Those indicators area the following: Decreased Maternal Mortality Ratio (MMR); Decreased Infant Mortality Rates (IMR); Reduced Total Fertility Rate (TFR); Increased Human Development Index (HDI); Increased Gender Development Index (GDI); Increased adult Literacy among Females; Reduced HIV prevalence 15-24 years; Decreased poverty incidence.

1.2 Reproductive Health sub-programme purpose
The purpose of the RH sub-programme under this programme cycle (ie 2002-2006)is to have contributed to improved utilization of quality reproductive health services and information by women, men, and youth. A number of indicators were determined and agreed upon that would be essential for measuring the purpose. These indicators are the following: Increased Contraceptive Prevalence Rate (CPR); Reduced Unmet needs; Improved Contraceptive Mix; Increased percentage of births attended by trained health providers; Decreased obstetric and unsafe apportion complications; Increased utility of STIs /AIDS services; Increased user satisfaction from RH services; Increased RH services delivery visits by Men, Women and youth.

1.3 Reproductive Health Sub-programme outputs
The purpose of the RH sub-programme will be realized through the activities of the four complementary RH projects. The four projects are the following:

By the end of these four projects, quality, affordable and accessible RH services and information that area aimed primarily at underserved areas and specific groups will be fully integrated within a Reproductive Health package. The following are the two outputs that will be realized through the four above-mentioned projects and that will contribute to the realization of the stated purpose of the Reproductive Health sub-programme:

It is worth noting that this project is LEB/02/P03 (Integration of quality RH services into PHC in target areas) will be fully responsible for the realization of the first output with specific input of project LEB/02/P02 (IEC in support of RH at the community level) namely in the area of counseling, and integration of IEC with service provision. ON the other hand, three of the four projects (ie Ministry of Social Affairs, Ministry of Education, and Ministry of Youth and Sports) will be concerned mainly with the second output related to increased availability of information and enhanced awareness of the youth on reproductive and sexual health issues.

2. Linkages between Outputs and Activities

The activities under the RH sub-programme have been designed to complement each other and to deliver the outputs which will, in turn, contribute to the RH-sub-programme purpose of: "to have contributed to increased utilization of quality RH services and information by men, women and youth". Hence the two RH sub-programme outputs defined in the earlier section will be delivered on basis of interrelated activities as follows:

A series of objectively verifiable indicators (OVI) have been identified and selected in the RH logframe that are necessary for measuring progress and evaluating the success of the interventions, and for contributing to the realization of the purpose and country programme goal. In the absence of data and benchmarks, a series of situation analysis will be undertaken at the inception of the programme with the aim of making available baseline data.

There are also linkages that exist between the RH and the PDS sub-programme purpose and outputs namely that the RH strategy stems form the population policy document and hence the operationalization of the RH strategy is expected to contribute to the implementation of the population policy. In addition data collection, nationwide surveys or situation analysis in target areas, as well as data analysis concern both the PDS and RH. Furthermore, the advocacy components and related activities under the PDS sub-programme cater for not only PDS related outputs but also in support of RH and rights.

3. Linkages between RH Sub-programme and Component Project (Integration of quality RH services into PHC in target areas)

The implementation of this project (ie LEB/02/P03) with the Ministry of Public Health is concerned mainly with the first output and builds on a number of issues as follows:

The integration of Reproductive Health into Primary Health Care is being currently practiced and operationalized at the levels of logistics, premises, equipment, personnel and health information system. The current project's personnel are the same people overseeing the Primary Health Care network at the national level. In fact the current thinking at the MOPH is to down number the health outlets served by the project to around 150 (from 430). Under this second programme cycle and within the context of this new project, those centers are meant to be full-fledged Primary Health Care centers offering the whole RH package while ensuring high and optimal quality.

Currently, the PHC outlets provide only selected gynecological cases, FP and some antenatal care, resulting in a fragmented/incomplete integrated RH package (or incomplete). Incremental and integrated RH care should include: a) Proper counseling for premarital couples, youth, women in late fertility life stage, b) choice of modern family planning methods; c) early detection of reproductive system cancer; d) early detection of STIs/HIV; e) post-partum care; f)) prenatal and antenatal care; and g) gynecological treatment. Therefore, this project will aim at designing and introducing an RH package in the selected 150 PHC in target areas.

The selection of the 150 health care centers in the proposed programme will consist of centers belonging to the Ministry of Public Health, Ministry of Social Affairs, and NGOs. The selection of these centers that shall receive "integrated and incremental services" will be made on basis of agreed upon criteria and pre-requisite particularly in terms of necessary staffing available at the center. Additional criteria will include patients load, catchment area, presence of minimum infrastructure, etc. In addition to the 150 centers in target areas, 10 centers will be selected and will be supported and upgraded to constitute the "Centers of Excellence" that will aim at providing a comprehensive RH package, services addressed to the youth, laboratory services (ie Papa smear and other, etc..) as well as selected referral services. Criteria will be established for selecting these centers on basis of availability of human resources, geographic distribution, patients load, minimum infrastructure, etc…

The health provider team in each of the 150 centers as well as the centers of excellence should consist a minimum of a physician, a nurse/midwife and a social assistant/health educator. Health provider team should be aware about the job description and his/her mission in the community. This team should be exposed to a variety of training to upgrade their skills in new technologies and quality of care and to update their information and knowledge in RH concepts. The training management plan will be prepared by the Ministry of Public Health, the Ministry of Social Affairs with input from UNFPA as well as staff of selected centers. The training courses curricula should include among others the following areas:

a) Interpersonal communication skills (such as counseling principles, technique and skills);
b) Gender sensitization and gender mainstreaming in RH services that will include Gender-based Violence (GBV) and HIV/AIDS throughout the gender approach/analysis based on human/reproductive rights framework
c) Contraceptive technology;
d) Infection prevention;
e) Ante-natal/post-partum care
f) Early detection of reproductive tract/genital cancer
g) Early detection of STIs;
h) Reproductive tract infection;
i) Puberty and menopausal care;
j) Infertility prevention;
k) Health education and information dissemination; and
l) Monitoring and assessment.

The comprehensive and integrated RH package must include as well a) increase in modern family planning free and informed choices including proper counseling, b) women empowerment and male participation, c) elimination of all forms of discrimination and violence against women, adolescents and girl child, and d) provision of counseling for young people.

The high maternal mortality rate (MMR) of 104 per 100,000 could be due to many factors such as absence of a comprehensive antenatal care, lack of provider's skills to detect high-risk pregnancy, absence of referral system, gender sensitive issues as inequity and discrimination through life cycle among others. These factors could be addressed by operationalizing the standard clinical operating protocols and service delivery procedures (including post-partum care protocols) and by promoting early initiation of breastfeeding in the first hour after delivery. There is need to urge providers to emphasize post-partum care during antenatal care for early detection of risk factors. The proper care will avoid maternal and infant problems that will lead to a reduction in infant and maternal mortality rates. One of the project's interventions is to support and upgrade two maternity wards in under-served areas (ie North and South Lebanon) with the aim of improving Emergency Obstetric Care and safe delivery essential for reducing maternal mortality.

Quality Assurance of the PHC services will be the milestones in increasing the demand and acceptability and in creating client satisfaction. Delivery of quality services should be standardized by using the quality of care tools (i.e. SCOP, SDP, SMP) through upgrading the service providers' skills in management and Quality of Care, technical skills, and monitoring (utilization of monitoring and assessment tools). Therefore training can be achieved either through implementation of protocols for quality of care (in-service) or through the curricula in training institutes (pre-service) or both.

The statistical unit at the Ministry of Public Health and the management of the national RH programme are very essential at the central level for transforming the RH information into national data and indicators for decision-maker provided there is proper registration. Support will be provided through the PDS sub-programme and the Central Administration of Statistics for enhancing and strengthening the capacity of the MOPH statistical unit in data collection and dissemination, provided the statistical unit is functional and staffed.

With regard to the development of a contraceptive commodity logistic and management strategy, this component will entail the undertaking of a logistics needs assessment study, which is an essential prerequisite for the elaboration of the strategy. The strategy will be followed by a national technical meeting among various stakeholders particularly with the national authorities. Building the capacity of selected staff (ie logistic officers, district coordinators, warehouse staff, etc..) on logistic management will also be provisioned during this cycle. It was suggested that an exit strategy would be implemented whereby the Government of Lebanon through the MOPH will exert maximum effort to fully absorb this contraceptive commodity strategy from within its domestic resources by the end of the cycle (i.e. 2006). With the aim of increasing modern contraceptive choices, some new methods may be introduced however on basis of acceptability such as injectables ie Norplant. As such, a feasibility study will be conducted to assess the level of acceptance among users.

While sexual health and STI/HIV are considered parts of RH services for couples and young people in accordance with ICPD PoA and ICPD+5 recommendations, efforts should be exerted to raise the awareness and change the attitude of health providers towards provision of these services but also from gender perspective, biological and social differences, male and female attitudes and stereotypes as influential and fundamental factors in the increase of the infection among women and youth. In order to upgrade their knowledge and skills for screening of STI and for counseling, a specific training course should be developed for physicians that could consist of simple bed side screening, referral mechanisms for pap smear, counseling, gender analysis, and health education. The clinic could be the real resource for health problem detection for health surveys, and bio-medical research, since there is no statistic on prevalence of STIs. It is envisaged that the centers of excellence should be properly supported for provision of these services particularly to the youth population.

There is real need to improve service statistics on STIs in order to expand the coverage and improve reliability. In Lebanon the National AIDS Programme (NAP) is responsible for screening HIV/AIDS cases, undertaking health education programmes and national campaigns, distributing condoms for prevention, and undertaking relevant studies and surveillance targeting not special groups. The NAP needs to have active role in youth education and supply of IEC materials. The university contribution in STI/HIV programmes is very important and as such efforts must be made to involve relevant universities in research, training, community outreach, and production of materials.

The IEC interventions under the 3 IEC projects namely the one with the Ministry of Social Affairs (ie LEB/02/P02: IEC at community level) will support the RH project (ie LEB/02/P03) particularly through a number of IEC activities that aim at providing RSH information at the community level but also for adolescents including peer education and counseling activities and will also increase adolescents' awareness of responsible RSH behaviors as well as their ability to cope with peer pressures through a comprehensive life-skills package. Community awareness activities coupled with provision of services would lead to the creation of a better understanding among decision makers of adolescents' need for RSH information and would consequently reduce potential opposition.

To attain the first RH output, the following key activities will be undertaken mainly through the implementing agency (ie Ministry of Public Health) and input of the Ministry of Social Affairs (MOSA):

Lastly, it is worth noting that the all this project (ie LEB/02/P03) under the RH sub-programme as well as other projects will benefit from and support the regional UNFPA projects on HIV/AIDS prevention targeting mainly the youth population. As such, a coordination mechanism will be established to ensure complemetarity and harmonization of activities.

4. Component Project Execution and Implementation Modalities

The duration of this project will extend over a period of 49 months starting December 2002 and ending in December 2006.

The project LEB/02/P03 (Integration of quality RH into PHC) will be nationally implemented through the Ministry of Public Health. During the previous cycle, MOPH has shown growing capability in executing and coordinating relevant activities namely with regard to capacity building of health care providers and improving the RH information system (RHIS). The MOPH has established a network of national partners and alliances both within the public and civil society levels, and expanded this partnership in terms of capacity building, research, coordination and support in implementation. More so, MOSA has committed to securing financial support for the implementation of the project, which certainly has implication on ensuring ownership and sustainability of the quality assurance of RH within its own PHC as well as the MOSA's social development centers and NGO's dispensaries. The MOPH played a crucial and lead role in ensuring thorough monitoring of RH services at the PHC through proper registration and dissemination of data and information on the RH situation at the regional level.

The implementation will be carried out primarily through the Ministry of Public Health but with collaboration of other ministries namely the Ministry of Social Affairs. Additional partner ministries will certainly benefit from this project namely the Ministry of Education and Ministry of Youth and Sports. The implementation of MOPH will primarily focus on executing the training workshops (ie BLs 30) given the MOPH expertise and direct involvement in ensuring quality assurance. Some components of this project will be sub-contracted to academic institutions, NGOs, media institutions, national programmes, and national consultants/experts. Specifically, the following will be sub-contracted: development of contraceptive commodity strategy; undertaking of Norplant feasibility and acceptability study; development of a RHIS software; and development of maternal audit systems.

Partnership with the following entities will be established for executing various components of the project: relevant universities such as the AUB Faculty of Health Sciences (Health Education Resource Unit), the Balamand University (Faculty of Health Sciences), the Lebanese University, and others; the National AIDS Programme; NGOs concerned in RH and GBV such as the Lebanese Council to Resist Violence Against Women, YWCA, LFPA, GLIP, and others; professional and medical societies/associations, pharmaceutical companies, as well as others. In addition, the project will pursue collaboration and build further partnership with the national consultants/experts who were involved in developing quality of care tools and undertaking research studies in the previous programme cycle.

The collaboration with above entities will be made on basis on a set of criteria for selection and aiming at ensuring optimal delivery programme activities on basis of comparative advantage and existing added value for this collaboration. Their performance shall be subject to systematic monitoring and assessment to ensure compliance with quality standards in delivery of related outputs.

Collaboration with relevant multilateral and bilateral agencies (including WHO, UNICEF and others) will be strengthened to ensure that complementarity and harmonization of mutual interventions and activities.

UNFPA will be entrusted with the overall monitoring and evaluation of the project and will be responsible for executing some components of the project such as procurement of equipment and contraceptives, and selected sub-contracts, upon need. In addition, UNFPA will provide necessary support for advocacy activities that are mainly implemented under the PDS sub-programme. Finally, the UNFPA CO will, necessarily, shoulder some specific execution related to recruitment of national consultants, and build the national capacity in Results-Based Management (RBM) to optimize the use of resources and to manage results.

The UNFPA CO will also seek the provision of technical services of the Country Support Team (CST) advisors in critical stages of the project monitoring and evaluation as requested by the implementing agency. The UNFPA will recruit under this project a National Professional Project Personnel (NPPP) for a period of 18 months to assist in the overall monitoring and coordination of the Reproductive Health programme implemented by various ministries. It is expected that the NPPP will require her/him to have relevant knowledge in RH programmes including IEC, as well as managerial and monitoring skills. In addition, the services of a part time logistic/administrative support staff may be required for a period of 12 months to support the coordination of the national RH programme as well as the overall monitoring the day-to-day activities.

It was agreed that the Ministry of Public Health will strengthen its institutional setups particularly the establishment of a Reproductive Health unit - and UNFPA will support this arrangement - by reviewing jointly (ie MOPH and UNFPA) the need for provision of support of all or selected staff of the existing project personnel. It is fundamentally crucial that all Terms of Reference of the existing staff (as well as new ones) will need to be carefully revised and modified to ensure the qualifications, tasks and competencies of the project staff meet the needs of the required activities. Any recruitment of new project staff will be carried out in accordance with the provisions of UNFPA Guidelines on recruitment. It is worth noting however, that currently and due to banning for recruitment of new Government employees, the Ministry of Public Health will not be able in the short term, to absorb the project staff within its structure therefore it is practicing the so-called "modified institutionalization" in the framework of this project in the sense that the project personnel are fully covered through the government cost sharing of this project. Nevertheless and with the aim to ensure further sustainability of the RH programme, the MOPH will exert maximum efforts to establish an RH unit within the structure of the Ministry and to absorb the exiting staff by the end of this cycle as core staff in support of the RH unit.

It is very important to ensure the commitment of MOPH to look into the possibility of exercising its direct financial responsibility of funds by the end of the cycle particularly for non-technical project staff as well as some administrative issues. Also, MOPH will ensure that funds appropriated for this project budget, will be timely and befittingly disbursed against approved budget lines in order to implement project activities in conformity with the projects' workplan and with adequate recording of project expenditures. It is expected that in five years time, the Ministry will have almost all RH/PHC activities on its regular annual budget.

As UNFPA requires that all projects are audited yearly, services of a Government/and or independent audit firm will be secured to provide a systematic examination of the project's accounting records and equipment. Auditors will be selected, subject to joint agreement of the Government and UNFPA. The MOPH is expected to meet all reporting and audit requirements for the project LEB/02/P03. Thus the supporting financial documents, statements, and vouchers will be furnished, as requested to UNFPA. Moreover, at the end of the each calendar year, a financial statement of the expenditure of UNFPA regular funds as well as Government contribution, certified by an independent auditor, must be prepared and submitted to MOPH and UNFPA. Both parties will make sure to comply with the recommendations of the auditor to the extent possible.

The project will coordinate its activities with other UNFPA-supported projects under the RH sub-programme with the guidance of the Council for Development and Reconstruction (CDR) and support from UNFPA. A technical RH committee will therefore be established and chaired by MOPH to oversee an optimal degree of coordination and collaboration between implementing partners (TORs to be established with all implementing agencies).

The monitoring and evaluation exercises will follow the standard UNFPA guidelines. The MOPH project (ie LEB/02/P03) will be closely monitored by the UNFPA CO. The indicators set forth in the log frame matrix will be used to assess both processes and performance of the sub-programme towards the attainment of its anticipated results. To ensure effective operationalization of the results-based management approach, the UNFPA country office would develop a monitoring and evaluation plan. A standard form for results-based reporting would be developed on an annual basis at all levels of programme management. Field monitoring visits will be undertaken with the aim of identifying technical issues for backstopping missions, identifying technical and/or operational strengths and weaknesses, deciding with the implementing agency on corrective measure. Annual project review and sub-programme review meetings will take place annually to follow up on recommendations from previous year, to review progress made in the sub-programme outputs and activities (of all RH projects) on basis of the RH log frame, and to identify and discuss any reasons for problems encountered and determine corrective actions and recommendations indicating when, by whom and where they are to be taken. The mid-term programme review (MTR) is held in the middle of the programme and examines the status of implementation of the country programme based on the established outputs and respective OVIs and may propose changes in the programme directions and duration on basis of progress, achievements, constraints and obstacles in implementation. A Final Project report is due at the end of the cycle that aims at recording all the activities undertaken by the component project and its contribution to achieving the RH sub-programme outputs by providing summation of the achievements of the component project and recommendations for the effective utilization of the component project experiences and results. The closure of the project will entail financial and operational completion of the project and will be carried out jointly with the UNFPA CO in accordance with the established UNFPA procedures which will be made available to the project in due time. The end of programme/project evaluation would be conducted at the end of the cycle and aim at assessing the extent to which the RH sub-programme/component project has achieved its outputs in light of the OVI established and develops lessons learned from this analysis in terms of contribution, performance and complementarity of each component for the achievement of the sub-programme outputs. Monitoring and evaluation would be based on quantitative and qualitative indicators linked to each of the programme goals, purposes and outputs. UNFPA will exert maximum efforts to make use of national experts for the undertaking of various monitoring and evaluation exercises. During the monitoring and evaluation tasks, participation of CST advisors as well as Headquarters programme/technical staff may envisaged.

UNFPA will make available to the project relevant guidelines and procedures regarding the status of the equipment procured by UNFPA in terms of transfer of equipment, disposal of equipment, etc..