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Activity Data Sheet PROGRAM:  Ecuador TITLE AND NUMBER:  Increased use of sustainable family planning/maternal child health services, 518-002 PLANNED FY 2001 OBLIGATION AND ACCOUNT:  $1,247,000 (DA) PROPOSED FY 2002 OBLIGATION AND ACCOUNT:  $0 (DA) STATUS: Continuing INITIAL OBLIGATION: FY 1995   ESTIMATED COMPLETION DATE: FY 2001 Summary: This program was scheduled to phase-out at the end of FY 2000. However, a one-year extension was approved in 1999 in order to continue support to the two largest family planning non-government organizations (NGOs) in Ecuador, Association for Ecuadorian Family Well Being (APROFE) and Medical Center for Orientation and Family Planning (CEMOPLAF). FY 2000 marked the end of USAID's health activities in Ecuador after a half-century of assistance. An extension of the assistance to family planning activities was necessary to help cushion the effects of the nation's financial crisis. These circumstances threatened to erode the sustainability and cost recovery accomplishments that USAID has promoted particularly among NGO family planning clinics. Ironically, these circumstances also served as an additional catalyst to persuade USAID's partners to urgently address sustainability issues. The program beneficiaries are children ages 0-5 years and fertile-aged women. All activities aim at improving cost recoveries of family planning NGO partners and improving quality and access to family planning services were funded exclusively with Population funds. Activities that focus on improving quality and access to maternal/child services, and on increasing sustainability of health NGOs, were funded by the Child Survival earmark. Key Results: Sustainability and replication of health reform models, major concerns for USAID during the phase-out of this activity, achieved mixed success. Cost recovery levels of private and private-public clinic models continued to increase even during the economic crisis. However, the national public health sector reform efforts were disappointing, with the Government of Ecuador (GOE) only minimally adopting proven organizational, service delivery, and financing schemes. At the same time the IDB and the World Bank have both made plans to fund continuation of several USAID-initiated models, and are already funding different clinics for program-initiated actions such as the community medicine training program and installation of comprehensive information systems. In 2000 our key local NGO partner in health, the Center for the Studies of Population and Social Development (CEPAR), downsized to its core technical staff and reduced operating expenses, resulting in savings of nearly $800,000 to supplement its fund-raising capacity. This is especially significant, since CEPAR was almost entirely dependent on USAID support for more than two decades. However, their failure thus far to significantly strengthen the capacity of their Board of Directors is a weakness that will hamper future success. This offers a potential "lesson learned" for USAID programs with NGOs, as CEPAR has consistently met or exceeded performance targets. More attention must also be given to sustainability issues, and in particular to the long-term institutional strengths and weaknesses of our NGO partners. Key results in family planning activities include increased consolidation of local family planning NGOs hard hit by financial constraints in 1999-2000. These local NGOs have recovered significantly in late FY 2000 and early FY 2001 from the harsh effects of devaluation, inflation of costs of imported goods, and the GOE's earlier decision to freeze bank accounts. Additionally, they were still able to attract a growing clientele to their private, fee for service clinics. Performance and Prospects:   With completion of health program activities in FY 2000, the five-year targets were achieved. For example, from a baseline of zero in 1995, women and children (0-5 years) using improved or expanded maternal/child health services increased to over 200,000 per year by FY 2000. In line with the program focus on expanding services through the private sector, most of these beneficiaries received services in NGO or NGO/public partnership service delivery points. Evidence of the strong role played by the private sector is further reflected in the improved cost recovery of 10 health NGOs. From an average of 26% in FY 1996, six of these 10 achieved an average of 94% cost recovery in FY 2000 On the family planning front, cost recovery by two of the program's family planning NGOs, APROFE and CEMOPLAF, averaged 90%. Both organizations also built up sustainability funds of several million dollars to support their efforts once USAID's assistance ends. During FY 2000, APROFE strengthened its social marketing program and extended the Community Network of contraceptives distribution, while CEMOPLAF continued to mount an aggressive campaign to increase demand for reproductive health services. Key results planned for FY 2001 are increased cost recovery of these partners and improved quality and access to family planning services. USAID will also provide oversight to further strengthen their capabilities to manage their resources (including the sustainability funds) in the future. Significant progress was achieved toward the program goal of improving the quality and access of family planning services, particularly as indicated by couple years of protection (CYP). CYP services provided by CEMOPLAF and APROFE increased from 642,000 to 706,017 during FY 2000 and are expected to reach 750,000 CYP in FY 2001. This illustrates large increases in the supply and demand for family planning services, basic to long-term sustainability. Complementary efforts were also made to increase quality of services delivered. APROFE performed a Quality Survey in 15 cities, and used the data to design the institution's marketing strategy for reproductive health services. Similarly, CEMOPLAF conducted an assessment of each clinic to develop a strategy to improve quality of service and increase the number of users. To assure adequate use of its sustainability fund beyond USAID's phase-out, the Mission is helping CEMOPLAF to partner with U.S. financial institutions for establishing a trust fund to allow it to receive, on a monthly basis, income to cover its current 10% deficit while maintaining quality service. During FY 2000 the program focused some of its efforts on CEMOPLAF's institutional strengthening to remedy deficiencies in management and leadership of the Board of Directors. This year, USAID will continue to provide oversight and support to the Board and staff to strengthen their management capability. In FY 2001, DA funds of $1,250,000 will be used for contraceptives and technical assistance in order to increase cost recovery of APROFE and CEMOPLAF while improving quality and access to family planning services. Possible Adjustments to Plans:  The Mission received additional funding for contraceptives and technical assistance for FY 2001. This will leave CEMOPLAF and APROFE with adequate stocks of contraceptives for their programs, as well as with strengthened capabilities to prepare their future projections on consumption. A trust fund of over $3 million is planned for CEMOPLAF's sustainability fund, subject to that institution's adoption of adequate measures to assure transparency and sound fiscal management. USAID will determine the terms and conditions under which the NGO will be entitled to receive a monthly amount from the trust to cover their operating deficit. This financial mechanism should protect the sustainability fund from misuse (an important issue, with initially troubling signs from the NGO) and assure the institution's stability. During FY 2001, we will concentrate our efforts to have this NGO incorporate new members to its Assembly for more transparent management. If these steps are not executed, USAID will need to adjust its plans with respect to management of the sustainability fund. Other Donor Programs:  USAID continued to be the principal donor through 2000 in population and family planing, providing substantially greater assistance than the second leading donor, UNFPA. The latter approved a new four-year Plan for Ecuador with roughly a $2 million annual budget. In health, the World Bank is the leading donor. Its $45 million loan for health sector modernization, MODERSA, continued to be the dominant program, but will undergo major review and restructuring of its objectives during CY 2001 in response to the World Bank's growing impatience with the slowness of achieving the health sector reforms planned under this project. Major Contractors and Grantees:  Family planning activities are implemented through two local NGOs, APROFE and CEMOPLAF, and three key U.S. contractors: Johns Hopkins University (JHPIEGO and the Population Communications Services Program, JHU/PCS), and John Snow, Inc., providing technical assistance and logistics, communications and reproductive health services improvement. Health cooperative agreements still active during the past year were the Partnerships for Health Reform, BASICS (Integrated Management of Childhood Illness), and University Research Corporation's Quality Improvement Project. In FY 2001, only about $160,000 in TA will be provided through JHU/PCS and the John Snow DELIVER project to further assist in management of contraceptive procurement and organizational development. FY 2002 Performance Table Ecuador: 518-002 Performance Measures: Indicator FY97 (Actual) FY98 (Actual) FY99 (Actual) FY00 (Actual) FY00 (Plan) FY01 (Plan) FY02 (Plan) Indicator 1: Couple Years of Protection (CYP) provided by APROFE and CEMOPLAF 326,050 452,884 642,819 706017 700,000 750,000 NA Indicator 2: Women and children (0-5) using improved or expanded MCH services - children 116 293 735 123 127 NA NA Indicator 3: CARE-APOLO supported NGOs achieving specific degree of cost recovery: number of NGOs by percent -- Group A* 4 @ 68% avg 4 @ 66% avg 4 @ 84% avg 4 @ 94% avg 4 @ 80 NA NA Indicator 4: Cost recovery level: APROFE 82 84 88 90 89 90 NA Indicator 5: CARE-APOLO supported NGOs achieving specific degree of cost recovery: number of NGOs by percent -- Group B* 3 @ 39% avg 3 @ 61% avg 3 @ 76% avg 2 @ 94% avg 3 @ 50% NA NA Indicator 6: CARE-APOLO supported NGOs achieving specific degree of cost recovery: number of NGOs by percent -- Group C* 3 @ 0% avg 2 @ 25% avg 3 @ 30% avg NA 3 @ 30% NA NA Indicator 7: Cost recovery level: CEMOPLAF 67 74 76 84 78 80 NA Indicator 8: Women and children (0-5) using improved or expanded MCH services - women 107 186 370 80 73 NA NA Indicator Information: Indicator Level (S)or(IR) Unit of Measure Source Indicator Description Indicator 1: IR Estimated protection provided by family planning services for a one year period, based upon volume & type of contraceptives distributed Calculation from service statistics of APROFE and CEMOPLAF: APROFE Fax dated 10/21/99 and CEMOPLAF Fax dated 10/21/99 This indicator measures quality and access to family planning services. The public sector was not included in this indicator because USAID/Ecuador contribution to their program is small and more importantly there is no reliable data. Indicator 2: IR Number of visits (000) - by children (PER YEAR) CARE-APOLO Letter No. 21448, dated 10/29/99, QA Letter dated 11/04/99, RPM Letter dated 10/29/99, and BASICS Fax dated 10/29/99 This indicator focuses on efforts to expand access through the private sector and decentralization of services. Service improvement is achieved through: NGOs - CARE: TA or training provided, systems strengthened; MOH - IMCI/BASICS: Integrated treatment of children provided. Quality Assurance/QA: Quality improvement activity implemented, such as reduced waiting time or reduced number of surgical infections. RX use/RPM: Improved use and access to/availability of drugs-medications. Indicator 3: SO Number of NGOs recovering percentage of total budget: number of NGOs by percent -- Group A* CARE-APOLO Letter No. 21460 dated 11/05/99 The APOLO-supported NGOs cost recovery indicator is the income generated through provision of services by the NGOs, as a percentage of total operating costs (synonymous with "budget" if capital expenditures not included). Pilot projects have been grouped based on sustainability achievements. *Group A: (1) Fundacion Pablo Jaramillo in Cuenca, (2) CEMOPLAF in Otavalo, (3) CEMOPLAF in Lago Agrio, (4) ASME-CX in Santo Domingo. Group B: (1) Cristo Redentor in Santa Elena, (2) Municipality of Chordeleg, (3) Municipality of Bolivar. Group C: (1) Fundacion Salud y Desarrollo in Pedro Vicente Maldonado, (2) Funedesin in Mondana, Oriente, (3) Diocesis de Riobamba. Indicator 4: IR Percentage of total costs covered by NGO generated income: APROFE Financial Analysis Reports prepared by the USAID Controller's Office, CEMOPLAF dated January 3, 2000 and APROFE dated December 2, 1999 Cost recovery, along with institutional maturity, is crucial to long term sustainability of the family planning organization. This indicator will be verified by NGO statistics and periodic audited financial information. The target is set without taking into account the sustainability funds, so even though the NGOs do not reach 100% sustainability, they will have these funds to draw upon at the end of the current agreements with USAID/Ecuador. The formula used to calculate the sustainability rate is total income generated divided by all expenditures. The value of the USAID donations in kind (contraceptives) was treated as part of the total USAID donation in dollars. Indicator 5: IR Number of NGOs recovering percentage of total budget: number of NGOs by percent -- Group B* CARE-APOLO Letter No. 21460 dated 11/05/99 The APOLO-supported NGOs cost recovery indicator is the income generated through provision of services by the NGOs, as a percentage of total operating costs (synonymous with "budget" if capital expenditures not included). Pilot projects have been grouped based on sustainability achievements. Group A: (1) Fundacion Pablo Jaramillo in Cuenca, (2) CEMOPLAF in Otavalo, (3) CEMOPLAF in Lago Agrio, (4) ASME-CX in Santo Domingo. *Group B: (1) Cristo Redentor in Santa Elena, (2) Municipality of Chordeleg, (3) Municipality of Bolivar. Group C: (1) Fundacion Salud y Desarrollo in Pedro Vicente Maldonado, (2) Funedesin in Mondana, Oriente, (3) Diocesis de Riobamba. Indicator 6: IR Number of NGOs recovering percentage of total budget: number of NGOs by percent -- Group C* CARE-APOLO Letter No. 21460 dated 11/05/99 The APOLO-supported NGOs cost recovery indicator is the income generated through provision of services by the NGOs, as a percentage of total operating costs (synonymous with "budget" if capital expenditures not included). Pilot projects have been grouped based on sustainability achievements. Group A: (1) Fundacion Pablo Jaramillo in Cuenca, (2) CEMOPLAF in Otavalo, (3) CEMOPLAF in Lago Agrio, (4) ASME-CX in Santo Domingo. Group B: (1) Cristo Redentor in Santa Elena, (2) Municipality of Chordeleg, (3) Municipality of Bolivar. *Group C: (1) Fundacion Salud y Desarrollo in Pedro Vicente Maldonado, (2) Funedesin in Mondana, Oriente, (3) Diocesis de Riobamba. Indicator 7: IR Percentage of total costs covered by NGO generated income: CEMOPLAF Financial Analysis Reports prepared by the USAID Controller's Office, CEMOPLAF dated January 3, 2000 and APROFE dated December 2, 1999. Cost recovery, along with institutional maturity, is crucial to long term sustainability of the family planning organization. This indicator will be verified by NGO statistics and periodic audited financial information. The target is set without taking into account the sustainability funds, so even though the NGOs do not reach 100% sustainability, they will have these funds to draw upon at the end of the current agreements with USAID/Ecuador. The formula used to calculate the sustainability rate is total income generated divided by all expenditures. The value of the USAID donations in kind (contraceptives) was treated as part of the total USAID donation in dollars. Indicator 8: IR Number of visits (000) - by women (PER YEAR) CARE-APOLO Letter No. 21448, dated 10/29/99, QA Letter dated 11/04/99, RPM Letter dated 10/29/99, and BASICS Fax dated 10/29/99 This indicator focuses on efforts to expand access through the private sector and decentralization of services. Service improvement is achieved through: NGOs - CARE: TA or training provided, systems strengthened; MOH - IMCI/BASICS: Integrated treatment of children provided. Quality Assurance/QA: Quality improvement activity implemented, such as reduced waiting time or reduced number of surgical infections. RX use/RPM: Improved use and access to/availability of drugs-medications. U.S. Financing (In thousands of dollars)   Obligations   Expenditures   Unliquidated   Through September 30, 1999    0 DA 0 DA 0 DA 4,000 CSD 4,000 CSD 0 CSD 0 ESF 0 ESF 0 ESF 0 SEED 0 SEED 0 SEED 0 FSA 0 FSA 0 FSA 0 DFA 0 DFA 0 DFA Fiscal Year 2000 0 DA 0 DA     2,000 CSD 2,000 CSD     0 ESF 0 ESF     0 SEED 0 SEED     0 FSA 0 FSA     0 DFA 0 DFA     Through September 30, 2000 0 DA 0 DA 0 DA 6,000 CSD 6,000 CSD 0 CSD 0 ESF 0 ESF 0 ESF 0 SEED 0 SEED 0 SEED 0 FSA 0 FSA 0 FSA 0 DFA 0 DFA 0 DFA Prior Year Unobligated Funds 0 DA         0 CSD         0 ESF         0 SEED         0 FSA         0 DFA         Planned Fiscal Year 2001 NOA 0 DA         6,486 CSD         0 ESF         0 SEED         0 FSA         0 DFA         Total Planned Fiscal Year 2001 0 DA         6,486 CSD         0 ESF         0 SEED         0 FSA         0 DFA               Future Obligations   Est. Total Cost   Proposed Fiscal Year 2002 NOA 0 DA 0 DA 0 DA 6,750 CSD 0 CSD 19,236 CSD 0 ESF 0 ESF 0 ESF 0 SEED 0 SEED 0 SEED 0 FSA 0 FSA 0 FSA 0 DFA 0 DFA 0 DFA

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