Serving the underserved_A mid Term Review Report

1
Serving the underserved:
Expanding reproductive health choices through
improved access and equity in Kenya and Tanzania
Marie Stopes International Australia
Mid Term Review
Australia Africa Community Engagement Scheme
February 2014

2
Contents
Acknowledgements............................................................................................................... 3
1. Executive summary........................................................................................................ 4
2. Project overview............................................................................................................. 8
3. Mid-term review methodology ...................................................................................... 12
4. Findings ....................................................................................................................... 14
4.1 Progress against objectives and outcomes................................................................ 14
OBJECTIVE 1.............................................................................................................. 15
OBJECTIVE 2.............................................................................................................. 38
OBJECTIVE 3.............................................................................................................. 41
4.2 Project Performance Findings.................................................................................... 43
(a) Relevance............................................................................................................. 44
(b) Effectiveness ........................................................................................................ 47
(c) Equity.................................................................................................................... 49
(d) Efficiency .............................................................................................................. 50
(e) Value for money.................................................................................................... 52
(f) Sustainability......................................................................................................... 57
(g) Monitoring and Evaluation Systems...................................................................... 59
4.3 Stories of Significance ............................................................................................... 60
5. Recommendations and Strategies ............................................................................... 65
6. Conclusion................................................................................................................... 67
Annexes.............................................................................................................................. 68
i. Acronyms.............................................................................................................. 68
ii. Detailed MTR methodology................................................................................... 69
iii. MTR fieldwork schedule........................................................................................ 76
iv. Results chart......................................................................................................... 78
v. List of evidence sources...................................................................................... 114
vi. Additional stories of significance ......................................................................... 119
vii. MTR team feedback on the MTR process........................................................... 128

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Acknowledgements
This mid-term review (MTR) was funded and supported by the Australian Government
through the Australia Africa Community Engagement Scheme (AACES) program.
Representatives of the Australian Department of Foreign Affairs and Trade (DFAT) in Kenya,
Tanzania and Australia have been instrumental MTR participants and their input and support
is greatly appreciated.
The global Marie Stopes International (MSI) partnership has contributed significantly to this
MTR. Of special note is the active involvement of personnel from Marie Stopes International
Australia (MSIA), Marie Stopes Kenya (MSK), Marie Stopes Tanzania (MST) and MSI’s
global headquarters in London whose time, expertise and resources have been invaluable.
The provision of programmatic and technical expertise and data from MSIA, MSK, MST and
all other MSI employees is gratefully acknowledged.
The participation of individuals and organisations external to the global MSI partnership has
been critical to this MTR. Their involvement, which includes the provision of programmatic
and technical expertise and data, is sincerely appreciated and respected. Project
stakeholders include clients, community members, Government officers, private healthcare
providers and partner organisation representatives in Kenya, Tanzania and Australia.
There are numerous people who deserve an individual mention, due to their involvement
and assistance which has been of particular importance in undertaking fieldwork and the
subsequent analysis. Special thanks are extended to Edward Kubai, Vitalis Akora, Roy
Okoth, Mengi Ntinginya, Emmanuel Phillipo, Lilian Charles, Cristin Gordon-Maclean, Maya
Goldstein and Batya Atlas for their invaluable input to this MTR. In addition, the efforts of the
recruited fieldwork team members were highly commendable and instrumental to the MTR
process. Special thanks are also extended to: Sam Ogare, Diana Muthoni Ndungu, James
Munene, Jeremiah Ochieng, Alice Abuyah and Mercy Otieno in Kenya; and Nuru
Abrahamani, Hussein Masenga, Neema Chande, Gertrude Paul, Lucas Touina Mtei, Moreen
Mlaki Julius, Joan Nimrod and Alfred Mwanjali in Tanzania.
This MTR report has been prepared by MSIA and interPART & Associates.
Photographic credits: Kerry Thomas unless otherwise noted. Contributors include Maya
Goldstein, Edward Kubai, Stephanie Maseki and James Mhina.

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1. Executive summary
Overview
Serving the underserved: Expanding reproductive health choices through improved access
and equity in Kenya and Tanzania is a maternal health project being implemented through
the Australia Africa Community Engagement Scheme (AACES). The implementing
organisation is Marie Stopes International Australia (MSIA), in partnership with Marie Stopes
Kenya (MSK) and Marie Stopes Tanzania (MST). MSIA is one of ten Australian NGOs
implementing AACES projects over five years, from 2011-2016.
The overall goal of the MSI1
AACES project is to contribute to increased access to and
uptake of equity sensitive sexual and reproductive health (SRH) services by marginalised
populations in Kenya and Tanzania. Target groups include women and men of reproductive
age in disadvantaged and geographically isolated communities, youth and people living with
disabilities. The project area is the coastal regions of Kenya and Tanzania.
The project design is structured to deliver outcomes against the following three AACES
objectives, with the first comprising the major investment focus:
Objective 1: Marginalised people have sustainable access to the services they require.
Objective 2: Australian Government policies and programs in Africa are strengthened,
particularly in their ability to target and serve the needs of marginalised people.
Objective 3: The Australian public are more informed about development issues in Africa.
The MSI AACES Mid Term Review (MTR) was designed and implemented with a focus on
gathering qualitative information to supplement existing quantitative data, and to build
capacity of MSI teams in mixed method, participatory approaches. Lead by an independent
consultant, fieldwork was undertaken using local teams, following processes set out in an
independently peer-review protocol. National Summit workshops2
were a feature of the
approach and instrumental in verifying results and the development of recommendations.
Findings were gathered against key evaluation questions and criteria as set out in the MSI
AACES Monitoring and Evaluation (M&E) Frameworks and the MTR Protocol. Three main
sets of findings are presented in this report:
 Progress against MSI AACES objectives and outcomes, and elaboration of insights that
influence project progress and on-going development.
 Project performance in relation to relevance, effectiveness, equity, efficiency, value for
money, sustainability, M&E systems.
 Stories of significance, as highlighted through the MTR process.
1
Although MSIA is the contractor holder, throughout this document the project will be referred to as MSI’s
AACES project, to encompass all MSI partners involved and implementing this work (MST, MSK, MSIA and MSI
in the UK).
2
One day multi-stakeholder, participatory review, validation and co-development workshops.

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Overall result statements
Against Objective 1, the MTR has confirmed that the MSI AACES project is delivering
significant benefits to underserved women, men, young people and people with disabilities in
Kenya and Tanzania. The project is delivering impressive increases in awareness,
knowledge and demand for SRH and family planning services amongst marginalised groups,
as demonstrated by a significant increase in uptake of services.
The MSI AACES project has also successfully facilitated increased capacity of service
providers to deliver equity sensitive and sustainable services. Readiness, willingness and
ability of service providers to deliver equity sensitive and sustainable services will be
improved with further follow-up and support. Overall, MSK and MST are making strong
progress against stated AACES objectives and outcomes, and contributing to the overall
AACES goal that marginalised people have sustainable access to the services they require.
Against Objective 2, the MTR has revealed that the MSI AACES project is acknowledged
by DFAT and AACES partner organisations for being proactive and professional in
progressing and strengthening DFAT policy and programs in Africa. In sharing experiences,
MSI AACES has earned substantial respect for quality, relevant content and processes. MSI
AACES activities are contributing to evidence-based appreciation for the role that SRH and
family planning can play in advancing development goals. This is supported by use of MSI’s
global reporting framework and Impact 2 calculator. All targets have been met or exceeded.
Against Objective 3, MSI and CARE Australia have successfully worked in partnership to
develop and implement the ‘Bare’ initiative, an innovative approach to informing Australians
about development issues in Africa and the AACES program. ‘Go Bare’ targeted young
Australian women who have not traditionally engaged with development issues. Shifting from
a ‘marketing’ to a ‘public relations’ approach in 2013 was particularly cost effective, meeting
or exceeded most targets with a reduced a budget.
Progress against targets3
It is estimated that services provided through the MSI AACES project will avert
approximately4
:
 127,500 unintended pregnancies;
 17,400 unsafe abortions;
 303 maternal deaths.
3
MSIA set family planning targets for AACES in 2012. The target of 95,304 is for ‘Number of persons accessing
a family planning method’ from June 2012- June 2014
4
The estimated impact of providing FP services has been measured using the MSI Impact 2 calculator. Data
provided in this table is based on the estimated impact of FP services over the lifetime of the service
Results for the MSI AACES Project: July 2011- December 2013
101,694 marginalised people have accessed SRH and family planning services (against a target of 95,304):
 41,745 in Kenya
 59,949 in Tanzania
This includes:
 82,465 women and 1,961 men who accessed family planning services, a 41% increase from Y1 to Y2
 Approximately 37,700 youth accessing SRH and family planning services.
 217 people with disabilities (PWDs), with steady increases over time

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Key MSI AACES achievements include:
a) The impact on marginalised groups in expanding access to SRH and family planning
services that target their needs. There has been a steady increase in numbers, coverage
and types of marginalised people who have benefited from MSI AACES activities and
services. The reported positive changes in the lives of individuals and families include
socio-economic and health benefits and enhanced ability to contribute to local societies.
b) The partnerships that have been nurtured with government and private sector providers
and pursued with community-based organisations (CBOs), disabled persons
organisations (DPOs) and NGOs. These are enabling substantial increases in
awareness and service provision; greatly expanding reach and accessibility; as well as
strengthening the relevance, effectiveness and sustainability of the project.
c) Understanding about equity and inclusion as these relate to developing meaningful,
realistic strategies that can deliver tangible benefits for different marginalised groups is
not only generating benefits for the AACES program but also for wider MSI, government
and development sector stakeholders.
d) The learning and development that has emerged from the project, and its active
utilisation to improve services, inform policy efforts and guide on-going investment. This
has been supported by strong foundational information, benchmarks, standardised data
systems, and reflective practice activities at AACES project and program levels.
e) Increasing recognition of the role and contribution of SRH and family planning as
a powerful development strategy by stakeholders across the AACES program. There is
greater appreciation that SRH and family planning can leverage achievements in other
sectors (and vice versa) and as such support cross-sectoral collaboration.
f) Value for money outcomes that have been elicited through the MSI AACES design;
from piloting and refining project strategies; and through MSI’s capacity to quantify key
elements using global, standardised tools. These approaches have offered opportunities
to attach value statements MSI’s AACES project.
Effectiveness of strategies
Approaches that work
 Provision of high quality SRH and family planning clinical training and services that imbue
trust, client and provider satisfaction, and provide the foundation for other MSI AACES
activities.
 Audience specific strategies (e.g. visually disabled Disability Advisor, Youth Peer Educators,
Edutainment, PhotoVoice5
, disability and youth specific IEC materials).
 Supporting the private sector through social franchising in Kenya.
 Collaboration between AACES NGOs.
 Public relations approach to awareness raising activities with the Australian public.
Approaches that require attention
 Some outreach strategies are not yet delivering expected results (e.g. the reach and
regularity of outreach teams places limits on service access and capacity building).
 Need for additional follow-up and consolidation of training provided to service providers and
community mobilisers
 Some M&E approaches are not serving the project as well as it could (e.g. some M&E
Framework targets and methods are not as appropriate or feasible as initially envisaged).
5
PhotoVoice is a visual monitoring tool, where participant groups are trained in photography, encouraged to take
a photo of an issue of importance for them and write a story to capture this. The PhotoVoice group then identifies
themes and often displays their photos and stories to raise public awareness and generate discussion.

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Key lessons
a) Inclusion and equity. The needs of marginalised groups are significant and the
contexts are complex; it takes time to build understanding and skills to promote sensitive
SRH and family planning information and services.
b) Relationships have a critical role in galvanising positive SRH and family planning
uptake. There is an understanding that this occurs across all levels of the AACES
program. Mutual credibility and trust are key factors. Strategies and resources utilised
should be acknowledged and accounted for in performance management and M&E.
c) Acknowledging complexity whilst retaining focus. MTR findings elaborate the
complexity of the program context including socio-cultural, economic and political
dynamics that influence the uptake of positive SRH and family planning practices with
marginalised target populations. Effective management of these while staying focused
on core tasks is a high order strategic function.
d) Participation. Cultivating the active engagement of key stakeholders, including target
beneficiaries, provides opportunities to enhance the relevance, effectiveness and
ownership of initiatives. This takes time, effort and particular skills.
e) Capacity building requires various integrated strategies if progress and achievements
are to be sustained, and has planning, development and M&E implications.
f) Monitoring and evaluation. In working with a range of strategies, the project is
providing a model against which to assess and compare performance. This has
implications for M&E frameworks and ways to capture outcomes, including qualitative
change.
Key recommendations
The following recommendations have been endorsed by MTR Summit6
participants and
research teams. More detailed strategies to address these are provided in the report.
Recommendations
1. Continue to strengthen networking and engagement with other sectors,
organisations, community and religious authorities to enhance access to SRH and
family planning services by marginalised groups.
2. Continue to develop innovative ways to engage marginalised groups (women, men,
youth and people with disabilities) across the SRH and family planning continuum.
3. Continue to refine and adjust outreach models to best meet the needs of
communities and marginalised groups.
4. Continue to enhance the capacity of project staff, service providers and
stakeholders to provide equity sensitive services to marginalised groups.
5. Continue efforts to provide IEC and BCC that is contextually appropriate to the
needs of marginalised groups.
6. Enhance M&E systems to better identify qualitative outcomes and strategies to
improve project performance.
7. Consider additional strategies by which achievements can be sustained, and on-
going SRH and family planning activities and services can be developed.
8. Continue to progress partnerships and experience sharing with AACES NGOs,
DFAT and national Governments to build support for SRH/family planning services.
9. Utilise experience of a public relations approach to raise awareness among the
Australian public in development of future activities.
6
Summit workshops were held in Tanzania and Kenya as part of the MTR process. They brought together
stakeholders from MST,MSK, MSIA, local partners and government officials to discuss key findings of the MTR
and agree on significant stories.

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2. Project overview
2.1 Overview of the AACES project
The Australia Africa Community Engagement Scheme (AACES) is one of the largest
Australian Government programs of funding for Australian non-government organisations
(NGOs) in Africa7
. The program focuses on community-based interventions across the
sectors of water and sanitation, food security, and maternal and child health (MCH). AACES
is being implemented in 11 African countries8
over five years (2011-2016), through 10
Australian NGOs9
and their local partners.
As one of the implementing Australian NGOs in the AACES program, Marie Stopes
International Australia (MSIA) is partnering with Marie Stopes Kenya (MSK) and Marie
Stopes Tanzania (MST) for the delivery of the project: Serving the underserved: Expanding
reproductive health choices through improved access and equity in Kenya and Tanzania.
As set out in the approved project design document10
, the overall goal of the MSI11
AACES
project is to contribute to increased access to and uptake of equity sensitive sexual and
reproductive health (SRH) services by marginalised populations in Kenya and Tanzania.
AACES has three objectives, of which Objective 1 is the major investment focus:
Objective 1: Marginalised people have sustainable access to the services they require.
Objective 2: Australian Government policies and programs in Africa are strengthened,
particularly in their ability to target and serve the needs of marginalised people.
Objective 3: The Australian public are more informed about development issues in Africa.
The AACES program focuses on partnership, community empowerment, learning, innovation
and value for money.
2.2 Overview of sexual and reproductive health and family planning in Kenya
and Tanzania
Kenya and Tanzania face significant challenges in terms of SRH and family planning.
Maternal mortality in both countries is high; in Tanzania, it is estimated that one woman dies
7
Please note that the AACES program commenced in 2011 under the auspice of the Australian Agency for
International Development (AusAID). As of October 2013, AACES has continued under the administration of the
Department of Foreign Affairs and Trade (DFAT). In this report, the term DFAT is primarily used and
encompasses both periods.
8
Ethiopia, Ghana, Kenya, Malawi, Mozambique, South Africa, Tanzania, Uganda, Zambia and Zimbabwe.
9
ActionAID, AFAP, Anglican Overseas Aid (which works in a consortium with the Nossal Institute and Australian
Volunteers International), CARE Australia, Caritas, Marie Stopes International Australia, Oxfam Australia, Plan
Australia, Water Aid, World Vision and Australian Overseas Aid.
10
‘Serving the Underserved: Expanding reproductive health choices through improved access and equity in
Tanzania and Kenya’ May2011.
11
As noted above, although MSIA is the contractor holder, throughout this document the project will be referred
to as MSI’s AACES project, to encompass all MSI partners involved and implementing this work (MST, MSK,
MSIA and MSI in the UK).

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for every 117 live births12
. The contraceptive prevalence rate is low across both countries,
standing at 46% in Kenya and 34% in Tanzania13
.
These challenges are even greater in coastal regions. The Kenyan coastal area is ranked as
one of the lowest in the country in relation to key reproductive health indicators including
fertility rates, teenage pregnancy, unmet needs for family planning and women’s
development14
. Ensuring access to quality and affordable SRH and family planning services
is essential to improving these indicators.
2.3 Overview of Marie Stopes Kenya and Marie Stopes Tanzania
MSK is a local NGO affiliated to MSI. Founded in 1985, MSK’s core business is the provision
of integrated SRH and family planning for women, men and young people of reproductive
age. MSK service provision is mainly through three channels: static clinics; social franchises
and mobile clinical outreach. With funding from a number of different donors, MSK operates
26 static clinics, 280 social franchisees and 15 outreach teams. Twenty social franchisees
and two outreach teams are funded by the AACES program. Through these channels, MSK
offers high quality and affordable short term, long term and permanent methods of family
planning to women, men and young people.
MST was established in 1989 as a locally registered NGO. As Tanzania’s largest specialised
SRH and family planning organisation, MST is renowned for providing a wide range of high
quality, affordable and client-centred SRH services and information for women, men and
young people. MST has approximately 21% of the contraceptive market share in Tanzania,
largely through long-acting reversible contraceptives and permanent methods delivered in
hard-to-reach rural and urban slum areas. MST provides services through static clinics,
mobile clinical outreach and auto-rickshaws (bajaji). Currently, MST has a network of 11
static clinics, 24 outreach teams and 14 bajaji that operate in more than 100 out of 169
districts across the country.
2.4 Overview of the MSI AACES project in Kenya and Tanzania
In addressing the project goal, the focus of the AACES project is on expanded SRH and
family planning outreach services that target hard-to-reach populations alongside innovative
approaches to demand creation.
In seeking to reach and serve marginalised populations, particular groups have been
identified on the basis of their:
 Age – young people are a focus;
 Gender – largely focussed upon women, with some targeted interventions for men;
 Disability status;
 Geography – attention to areas where there are insufficient, absent or poor-quality
services.
12
State of the World Population, UNFPA 2012
13
State of the World Population, UNFPA 2012
14
Serving the Underserved: Expanding reproductive choice through improved access and equity in Kenya and
Tanzania, May 2011

10
The project goal and objectives are being achieved through a combination of: service
provision through outreach and social franchising; demand generation and education;
capacity development (for MSI, Government and other healthcare providers); and policy
influence (DFAT and the Kenyan and Tanzanian Governments).
In Kenya, the AACES project operates in the urban sites of Mombasa and Malindi as well as
extending service delivery to Lamu, Kilifi, Tana River, Taveta Taita and Kwale counties.
AACES activities in Tanzania are coordinated from MST’s head office in Dar es Salam,
extending service reach to Tanga and Pwani. A second MST outreach team focusses mainly
on the Mtwara region15
. Dar es Salaam was selected for AACES because it has high unmet
need for family planning and a high population density, making the city a good location to
develop, test and launch innovative initiatives to reach marginalised groups.
Implementation of the AACES project occurs through service delivery by MSK and MST in
partnership with Government (e.g. from health facilities to policy levels), private-for-profit
service providers and distributors, and NGOs and community-based organisations (CBOs).
Figure 1: MSI AACES operating areas in Kenya
15
During the first two years of the AACES project, the MST outreach team in Mtwara also delivered services into
the Lindi region. The Mtwara outreach team has consolidated its activities to focus upon the Mtwara region alone.
Lamu
Malindi
Kilifi
Mombasa
Tana River
Taveta
Kwale

11
Figure 2: MSI AACES operating areas in Tanzania
Tanga
Dar es Salaam
Pwani
Mtwara

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3. Mid-term review methodology
Overview
The MSI AACES MTR was undertaken as part of an agreed AACES program process. The
MTR design, implementation and reporting process occurred over eight months, from July
2013 to February 2014. The key fieldwork was undertaken in Kenya and Tanzania during a
three week period in November and December 2013. This MTR report has been cleared by
MSI’s independent ethics review committee, and the national Independent review boards in
Kenya (KEMRI) and Tanzania (NIMR).
The MTR design was based on the: M&E framework from the Project Design; country-level
M&E frameworks; and consultations between DFAT, MSI in the UK, MSIA, MSK and MST.
The MTR was led by an independent consultant working in close collaboration with the MSIA
AACES Project Manager and M&E teams in MSK and MST. The MSIA Strategic
Development Advisor and MSI UK Research Program Advisor (East and South Africa) have
also provided guidance and support16
.
The purpose of the MTR was to assess how MSI’s AACES project is tracking against its
objectives as well as to identify areas for improvement and potential strategies to address
these.
Figure 3: Overview of the MTR process
16
Notes of consultations held between these investigators are available on request.
Doc & lit review
(Australia & Africa)
Drafting
review
protocol
Inception
meetings
Review
protocol
& planning
activities
Team
training
Finalise
report
DFAT
follow-up
with
AACES
Dissemin
-ation
Draft
report
Circulate
draft
report
MSIA /
MSI UK /
MSK /
MST
feedback
Draft
findings
& trip
report
MSI
review
Dissemin
-ation
Information
analysis &
interpretation
including:
 Quantitative
 Qualitative
 Process
In-country
sense-making
Summit
workshops
Australia-based
analysis
In-depth
interviews
Focus group
discussions
Stories of
significant change
& case Studies
Timeline:
July Aug Sept Oct Nov (Fieldwork) Dec Jan Feb Feb-Mar
2013 2014
Site visits
STEPS
1 2 3 4 5 6
Review Information & Analysis & Draft Draft Finalise
initiation data gathering interpretation findings report report

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Approach
With reference to the project’s M&E frameworks, the MTR approach and this report have
been informed by ‘performance story reporting’ methodology17
. This allowed for the
gathering of qualitative information (including lived experience of marginalised target
populations) and quantitative data/metrics (related to the targets set out in the AACES M&E
frameworks). Attention was given to capturing insights and deepening understanding whilst
also accounting for progress against project objectives and outcomes. As such, a mixed
method approach18
was employed, with a focus on careful sampling within the parameters of
available time and budget. Twenty four focus group discussions (14 in Kenya and 10 in
Tanzania) and 48 in-depth interviews (24 in Kenya, 19 in Tanzania, and five in Australia)
were conducted across three project counties in Kenya and four project districts in Tanzania.
Analysis
Findings from across the sources were cross-referenced and primarily analysed using
triangulation19
and thematic analysis20
. These techniques are recognised to enhance the
rigour and validity of results and recommendations. Quantitative results have been
calculated in accordance with MSI tools and methodologies for quantifying impact.
Analysis was also undertaken by review teams comprised of independent consultants
working in coordination with project personnel. A further filter and level of transparency was
provided by those who participated in the Summit workshops, as they critiqued and refined
the key results and draft recommendations.
Capacity building
Of particular relevance, the MTR approach integrated and combined participatory, action-
learning and capacity building methodology. This included engaging representative samples
of beneficiaries and project participants (such as service users and healthcare providers) as
well as other key stakeholders (such as Government employees) to generate and/or review
MTR data, information and stories of significance. A feature of the MTR methodology was
the team sense-making sessions and Summit workshops, which were held in Kenya and
Tanzania at the end of the fieldwork data collection.
For a more detailed description of the MTR methodology, please refer to Annex ii.
17
Performance Story Reporting is derived from the Australian Government’s Building Better Data Project (2007-
2008); it draws on work by Mayne J, 2004, ‘Reporting on outcomes: setting performance expectations and telling
performance stories’, Canadian Journal of Program Evaluation, vol19,no.1.pp.31-60; Dart J & Mayne J, 2005,
‘Performance Story’, in S Mathison (Ed), Encyclopedia of evaluation, CA: Sage, pp.307-8; & Thomas K et al,
various Australian Govt Performance Story Reporting evaluation studies, 2007-2012, interPART & Assoc.
18
For further information on mixed methods research, please refer to: USAID, 2013, Technical Note ‘Conducting
Mixed-Method Evaluations’; Bamberger M, Rao V & Woolcock M, 2010, ‘Using Mixed Methods in Monitoring and
Evaluation. Experiences from International Development’, World Bank Policy Research Working Paper 5245;
Patton M Q, 2008, Utilization Focused Evaluation, CA: Sage; and Tashakkori A, & Teddlie C, 2010, Handbook of
mixed methods in social and behavioral research (2nd Edition), Thousand Oaks, CA: Sage.
19
For further information on triangulation, please refer to: Patton M Q, 2008, Utilization Focused Evaluation, CA:
Sage; Bamberger et al, ibid; Thomas, ibid.
20
For further information on thematic analysis, please refer to: Guest, G 2012, Applied Thematic Analysis.
Thousand Oaks, CA: Sage

14
4. Findings
The findings arising from the MTR process are presented in three main sections.
 4.1 Progress against objectives and outcomes, which provides key results data for
each of the project’s three objectives; narrative summaries in relation to awareness,
demand, capacity and access to services as experienced by marginalised people and
target groups; and other information relevant to stated objectives and outcomes.
 4.2 Project performance findings, which offer a synthesis of key project performance
achievements and challenges according to seven thematic areas, including a discussion
on value for money.
 4.3 Stories of significance, which present key stories of lived experience and
significant change. Each story has been chosen by Summit workshop participants and
those leading the MTR for particular reasons, which are listed alongside the stories.
4.1 Progress against objectives and outcomes
This section presents programmatic findings for each of the three AACES objectives and
corresponding outcomes as set out in the MSI AACES M&E framework. Key MSI AACES
results are presented, with details provided in the evidence-based Results Chart in Annex iv.
Following the results are narrative findings that provide disaggregated information and
insights on the specific marginalised groups targeted by the MSI AACES project.
Figure 4: MSK AACES outreach in Tiwi, Kenya.

15
 The MSI AACES project is delivering impressive increases in awareness and
knowledge of SRH and family planning services amongst marginalised groups, as
demonstrated by uptake of services.
 Qualitative evidence confirms that MSI is widely considered (by community people,
clients, service providers and government authorities) to be a trusted source of
SRH and family planning information. This is crucial in galvanising service demand
and uptake.
 Criteria against which to reasonably measure increases in awareness and
knowledge could benefit from refinement.
OBJECTIVE 1: Marginalised people have sustainable access to the services
they require
OUTCOME 1.1 There is an increase in awareness and knowledge of SRH and family
planning services by marginalised groups
Results statement for Outcome 1.121
MSI AACES approaches
 Understanding initial levels of awareness and knowledge of SRH and family planning in
project communities, particularly for marginalised groups, and monitoring changes over
time. This has been achieved through research activities e.g. the Disability Feasibility
study in Tanzania and baseline research in Kenya and Tanzania; regular monitoring
through case studies, PhotoVoice, and feedback from community health workers
(CHWs)/community-based mobilisers (CBMs), youth peer educators (YPEs) and service
providers; and the MTR.
 Working with existing structures to raise awareness about SRH and family planning,
including working with local community leaders, service providers, youth groups,
CHWs/CBMs and disabled persons’ organisations (DPOs).
 Developing new ways to inform and raise awareness of SRH and family planning among
marginalised groups. Innovative undertakings have included the development of a youth
peer education network in Kenya, the recruitment of a Disability Coordinator in Kenya
and the introduction of a youth-focused outreach model in Tanzania.
Key outputs
 MSK has reached approximately 266,450 young people through youth-focused
awareness raising activities conducted by YPEs and youth groups. YPEs can
communicate directly with their peers and raise topics which are often considered taboo.
YPEs are provided with health education training aids to give them confidence and
support to offer SRH and family planning information to their peers.
 MST has launched an innovative, youth-oriented two day outreach model which focuses
upon awareness raising and demand generation for young people (i.e. through a social
activity or sport) on day one, followed by youth-friendly service provision on day two.
21
A results statement is a summary of what the MTR team leaders can confidently say has been achieved by the
project thus far. This statement is informed by detailed evidence as listed in the Results Chart (Annex iv).

16
 In 2013, MST partnered with Comprehensive Community Based Rehabilitation in
Tanzania (CCBRT), a national DPO and NGO. In collaboration, MST and CCBRT
conducted a study entitled, ‘Barriers and Facilitating Factors for People with Disabilities
to Access Sexual and Reproductive Health Services’. This report is raising awareness
amongst MST, CCBRT and the Tanzanian Government, and informing strategies for
engaging people with disabilities (PWDs) in SRH and family planning.
Key outcomes
 Adoption of the new, youth focused outreach model in Tanzania has seen an increase in
the proportion of young people serviced by MST in AACES project areas, increasing
from 37% (2011) to 41% (2013). Opportunities exist to further enhance this.
 On average, MSK is reaching approximately 11,050 young people per month with
information about SRH and family planning.
 The BCC strategy formative research report conducted by MST in 2012 found that 87%
of young men and women have heard about SRH services, and that 83% of young
people in AACES project areas were aware of family planning services.
 The Disability Feasibility Report, conducted by MST (2013), indicated 91% of interviewed
PWDs had heard about family planning as a result of MST AACES project activity.
 In Kenya, the number of family planning adopters22
among women, youth and PWDs has
increased 470% between 2011 and 2013 (731 at the start of the project to 4191 clients
after two and a half years). Approximately 26% of MSK AACES outreach clients and
12% of MSK AACES social franchise clients are family planning adopters.
Overall, the MTR found evidence of significantly increased awareness of SRH and family
planning amongst marginalised groups as a result of AACES. However, levels of knowledge
vary between groups. In addition to the quantitative evidence, qualitative results from focus
group discussions (FGDs) and in-depth interviews (IDIs) highlight that across all groups:
 Existing knowledge and beliefs impact on people’s acceptability of SRH and family
planning information. This is particularly true in remote locations, for those that have low
literacy and/or are otherwise unable to access information.
 Service providers, particularly those involved in AACES (including CHWs, health
facilities, outreach teams), are generally the most trusted sources of SRH and family
planning information amongst communities. Teachers were also identified as trusted
community members but have (self-identified) variable capacity to provide reliable and
sensitive SRH and family planning-related information.
 Family, friends and peers are a common source of information about SRH and family
planning for all groups. In these instances, perpetuation of myths and misconceptions
can lead to significant inaccuracies in information.
 The effectiveness of differing media platforms varies with audience and context. As the
MTR revealed, there is no one best method. Rather where multi-pronged, locally
contextualised approaches that target different audiences are utilised, effectiveness
appears greater23
. Opportunities exist to expand such efforts through experience sharing
and networking.
22
‘Adopters’ refer to FP clients who have not used a modern method of FP in the last three months. This is
considered a more effective measure of changes in contraceptive behaviour than tracking first time users.
23
The effectiveness of such approaches is supported by research (Thomas K et al), by MSK’s four-pillared
marketing strategy and is reflected in MSI and CARE strategy process in delivering AACES Objective 3.

17
Specific findings for marginalised and target groups:
Marginalised women
 Consistent across all FGDs, women are more aware of SRH and family planning
methods and services than all other groups, including men, youth, and PWDs. Some
women even report raising awareness of family planning themselves and mobilising new
family planning users, particularly their husbands/partners; this is more prevalent in
Kenya than in Tanzania, and in more urbanised areas.
 Women’s knowledge is often limited to short term methods, which are better understood
and more frequently discussed than long term methods.
 Myths and misconceptions about family planning methods and side effects are still
common amongst women. In Tanzania, there is heavy emphasis on and misinformation
around side effects such as weight gain and bleeding. Infertility and cancer are both
regularly cited family planning myths in Kenya and Tanzania.
 Awareness is shifting to modern methods over traditional methods. One FGD in
Tanzania noted that their community was reducing its reliance on traditional methods
because women ‘kept getting pregnant’.
Men
 FGDs revealed men to be less informed about SRH and family planning than women.
SRH is largely perceived as ‘women’s business’ and, as such, men tend to exclude
themselves from engaging with these services.
 Myths, misconceptions and negative perceptions also prevail amongst this group. For
example, many men believe that vasectomy will cause reduced libido and that family
planning methods make women infertile and/or promiscuous.
 Knowledge of how SRH and family planning methods work is also limited in some
communities. In many areas, particularly in Tanzania, vasectomy is equated with
castration or ‘loss of manhood’. Most men expressed reservation in using condoms
because of reduced pleasure and irritant effects.
 In some MSI AACES target communities, including Tandahimba in Tanzania, men were
very knowledgeable about SRH and family planning. For the most part, these men had
received information from their wives.
 Some women in Kenya reported that their husbands are becoming more interested in
SRH and family planning, as evidenced by the fact that more of them are accompanying
wives to health facilities and to MSK outreach activities.
 Male awareness of SRH and family planning is heavily dependent on context. For
example, men are likely to be better informed if there is progressive community
leadership or if their partner feels comfortable within their relationship to discuss SRH
and family planning.

18
Youth
 The MTR revealed that MSI’s AACES activities are an important source of reliable
information for young people, especially in contexts where accuracy through other
sources can be unreliable. Service providers report increasing knowledge amongst youth
since the inception of MSI’s AACES project, with a shifting perception that family
planning is not just for adults.
 FGDs with young people revealed that they have mediocre but growing awareness of
their SRH and family planning options, including where to access services. However,
youth experience challenges in accessing further knowledge due to cultural and social
barriers. For example, there is conflicting legislation on sex education in schools (see
‘Challenges in supporting children and youth’ below); parents are often not supportive;
teachers act like parents; and youth educational entertainment (‘edutainment’), as they
are created by adults, often do not resonate with young people.
 SRH and family planning knowledge is similar between girls and boys in Kenya, whilst in
Tanzania girls tend to be better informed than boys. Increasingly, boys and young men
say that they receive family planning information from their girlfriends.
 Other demographic groups believe that young people have the greatest access to SRH
and family planning information and services through peer networks, social media and
targeted youth programming. However, given youth uptake remains low, the extent of
access barriers and how access is being translated into service uptake is unclear.
 In Tanzania, youth cite media (e.g. radio) as particularly effective, as well as edutainment
such as MST’s outreach video. In Kenya, the YPEs have been particularly effective in
promoting awareness and knowledge.
 There is a tendency among young people to focus on side effects of family planning (e.g.
weight gain, reduced pleasure) and related misconceptions (e.g. infertility and cancer).
 Other target groups identify young mothers and children of reproductive age (as distinct
from youth) as being particularly disadvantaged in terms of access to information and
services. Through the AACES Innovations Fund, MSI and Plan are piloting strategies to
target young mothers in Kenya. Opportunities to address children’s needs could lie in
collaboration with NGOs such as Save the Children.
Men’s involvement
Approximately sixty women had to come to the Kiliman village dispensary so that a
nurse would weigh and check the health of their babies. Amongst the mothers, there
was one man and his daughter. On being asked why he was in attendance, the man
replied,
“I brought my daughter here because my wife isn’t well. Women
shouldn’t have to do everything every day. I love my wife and
daughter, and it’s my responsibility too”.
On overhearing this, another woman said:
“Yes, you should do seminars for wives and their husbands on family
planning, because men are stubborn and ignorant. Last week I got
beaten for even raising the issue of family planning. And he threatened
to divorce me.”
MTR site visit, Kiliman Dispensary, Rufiji District, Tanzania

19
People with disabilities
 FGDs revealed PWDs have the lowest knowledge of SRH and family planning compared
to other groups. They face great difficulties in accessing knowledge and services for a
range of reasons. These include physical barriers - outreach teams are often not going
‘deep enough’ into communities to reach PWDs, and many services are not physically
accessible (e.g. transport, stairs); social and cultural barriers - stigma is high and
healthcare provider attitudes towards PWDs are generally poor; financial - direct and
indirect costs of accessing SRH and family planning events and services; and
accessibility – with SRH and family planning information rarely provided in an accessible
way for people with different disabilities (e.g. visual or hearing) and literacy levels.
 Two-way isolation of this group (by themselves and their community) also affects the
ability of PWDs to access information and services. These factors are consistent with
global disability studies24
and are reflected in the Convention on the Rights of PWDs.
 Working with PWDs is a relatively new initiative for the global MSI partnership and there
is substantial learning arising through the AACES project in support of this activity. In
both Tanzania and Kenya, the engagement of disability specialists (personnel and
partner organisations) has been a crucial first step in building project and partner staff
understanding and capacity. This is beginning to yield modest but relevant results. These
include adaptation of IEC materials, addressing embedded attitudes and
misconceptions, and building skills to talk with people with different kinds of disabilities.
 Importantly, MSI AACES’s recognition of PWDs as sexually active and inclusion of DPOs
in the project is a significant step that is respected by PWDs whom the project serves. It
is also stimulating wider community reflection on attitudes towards disability.
24
For an example, please refer to WHO & World Bank (2011), The World Report on Disability. UN; Geneva.
Challenges in supporting children and youth
“Contraception education in schools is not allowed. Well actually, some sexual health
information is okay, but need to be careful. It’s because there is a contradiction
between the Ministry of Education [MoE] and the Ministry of Health and Social
Welfare [MoHSW]. The MoE do not allow sex education, but this is a silent rule. The
MoHSW mandate contradicts this. So it is better when girls and boys come to us.
I have one scenario to illustrate…..We were doing an outreach session, and we saw
two young girls on the edge, peeping from behind a tree at us. We went over and
asked them what they wanted. They said “we want family planning services, but we
can see our mothers there, and we’re afraid”. We said “be patient, we’ll find a way to
serve you”… Once the mothers were gone, we called them over and served them.
But there is another issue too… more and more young girls – they are just children
really – are having sex… and getting pregnant, but how can we give them education
when they are ‘children’ and we are only supposed to work with ‘youth’?”
Reflection by the MTR team on information from Mtwara region, Tanzania

20
Figure 5: Nanda, from Tandahimba district in Tanzania.
Better understanding the needs of people with disabilities
“Building awareness and understanding amongst staff and service providers begins
with exposure… to see that many of us are ‘able’ and approachable… and just need
information in different formats. But it takes time, and a mix of strategies like regular
workshops, interaction, exposure, experiential activities, joint activities, co-
development of IEC materials; and an adequate budget to support this.”
MSK Disability Officer, Kenya
“There is a misconception that mentally challenged people aren’t sexually active, and
don’t fall in love…; the assumption that a pregnant PWD was abused may not always
be the case.”
Summit workshop participant in discussing stories of significance, Kenya
Disability dynamics
“I got paralysis when I stopped breastfeeding…
a spirit entered me… and now I walk with a
stick; it’s God’s will. Because I couldn’t walk, I
didn’t go to school, and my father said “no”
anyway… I couldn’t play games or go out like
other people my age. Now I am 43… been
married a long time and have two children – a
boy and a girl. The older one doesn’t go to
school anymore because they beat him and he
is afraid he will be killed… maybe because of
me….he only went to Standard Three.
We are poor… farmers… so it is good to only
have two children. I overheard the ladies talking
about family planning at the market, so I got pills
from the dispensary but they didn’t explain in
depth… just said, ‘go around the card’. I try to
go to the Marie Stopes clinics but I can’t read
the posters... and live beyond the edge of village
so I don’t hear the announcements… so I just
go when I see them.
There isn’t really a habit of helping PWDs here but no [outright discrimination]…No,
there isn’t any disability organisation in this area…and I don’t have enough money to
join the revolving micro-loan scheme… so we just live… My dream is to get a radio…
so I can hear about things… and maybe a bicycle for the family too.”
Nanda, Tandahimba district, Tanzania

21
they require
OUTCOME 1.2 There is an increase in demand for services by marginalised groups
 Generating demand through BCC. By evaluating existing BCC materials and
approaches, MSK and MST have refined their communications to target marginalised
groups, including young people and PWDs. This is an on-going process.
 Working with existing structures and expanding collaborator networks to generate
demand for SRH and family planning i.e. local community leaders, service providers,
youth groups, community groups, CHWs / CBMs and DPOs.
 Piloting youth-focused activities to increase demand among young people. In Kenya,
targeted youth programming includes AMUA Leo events (through social franchises),
YPEs (through knowledge and mobilisations forums), school links, youth groups and
edutainment activities (e.g. dramas and videos). In Tanzania, PhotoVoice activities have
been initiated and a two day outreach model is specifically geared towards raising
awareness and creating demand amongst youth.
 Focusing on quality of SRH and family planning information and services by MSI service
providers and social franchisees to improve client satisfaction and encourage referrals.
Key outputs
 The MST AACES outreach teams have developed a number of BCC approaches to pilot
in their regions, including local radio, working with CBMs and IEC materials. Prior to this,
demand generation consisted primarily of loud speaker announcements, distribution of
information posters and notifications by local health providers.
 Through engaging with DPOs, MSK has provided over 3,000 PWDs with access to SRH
information. This has led to increased demand for services and, as a result, 900 PWD
were referred for SRH and family planning services.
 MSK recruitment of CHWs resulted in a 31% increase in client numbers in 2012.
 Through AACES, MST leveraged funding from USAID for a one year pilot project that
targeted young people. As a result, 77% of SRH and family planning clients served in the
pilot areas were under 25 years old, compared with 27.3% for outreach as a whole.
 The MSI AACES project is demonstrating significant success in increasing demand
amongst marginalised groups, as evidenced by uptake of services.
 There have been proportionally steady increases in uptake of SRH and family
planning services by all marginalised groups.
 Strategies that have been most effective in stimulating demand are recruitment of
CHWs and YPEs, engagement with CBOs, and utilisation of targeted youth and
disability friendly IEC information and interactive BCC activities.
 Criteria against which to reasonably measure increased demand could benefit from
refinement.

22
Key outcomes
 According to the MST’s exit interviews and outreach performance reports, there has
been an increase in the proportion of clients from marginalised groups who are
accessing MSI services due to referrals from CBOs and DPOs, from 0.51% in 2012 to
11% in 2013.
 In Kenya, exit interviews also show an increase in the proportion of clients accessing
MSI services due to referrals from CHWs and DPOs, from 13.1% of clients in 2012 to
56.2% of clients in 201325
.
 In Tanzania 80% of AACES clients and in Kenya 67% of AACES clients report accessing
services as a result of MSI demand generation materials and activities.
There have been a range of AACES activities conducted to create demand for SRH and
family planning services amongst marginalised groups, many of which have been very
successful in improving service uptake. For example:
 CHW and YPE recruitment strategies have been particularly successful.
 Working with community leaders has also been important in galvanising demand.
 In Kenya, AMUA social franchises are providing a significant positive response to
increased demand in areas where they have been established, although AACES
outreach teams are limited in their capacity to provide continuous and timely service
across the project locations, particularly into remote locations.
 An issue raised during FGDs was the high turnover of CHWs, and the effectiveness of
IEC / BCC materials that do not reflect low-literacy or local socio-cultural contexts.
25
A complete analysis of 2013 exit interviews is still being finalised.
Community-based demand generation
“As CHWs we are involved in many programs among them Marie Stopes outreaches
and community strategy. Under the CS [Community Strategy] we target 20
households. In Marie Stopes outreaches we mobilise based on community strategy
approach. Before … people called us names like ‘watu wa Ukimwi (AIDS people).
Most of them shunned us and did not welcome any household visits from us.
However, we persistently went on with community work... With time, changes began
to be recorded among the households that took the advice of community health
workers. Nowadays, we get invitations to provide health education and awareness
raising services. Training and support from MS help us do this well.’
Community health worker, Tiwi region, Kenya
“I promote family planning education…it has helped families - husbands and wives -
to decide how many children they want to have and how long should be the age gap
between the children, it’s better for everyone. People can see how the economics
improves, since now women can have time to participate in production activities. Also
it has reduced the rate of diseases such as STD’s ... And there is less malnutrition to
children because now the parents can afford to provide basic needs to their children”
Village chairperson, Tandahimba region, Tanzania
Summit workshop participant, xx, Kenya

23
 In Tanzania, AACES outreach teams have a focus on awareness raising and demand
creation but struggle to meet demands for more frequent services. Local health facilities
are not able to provide long term and permanent methods, despite high demand.
Communities are increasingly accessing family planning commodities from their friends,
shops and kiosks where little or inaccurate advice is provided.
Marginalised women
 Despite limited availability, many women have expressed interest in long term methods
of family planning. Demand for safe abortion is also high, as evidenced by continuing
cases of unsafe abortion within the project communities2627
. Some women have also
expressed a desire for more ante-natal care (ANC), post-natal care (PNC), and
prevention of mother to child transmission of HIV (PMTCT).
 In Kenya, FGDs with marginalised women revealed that CHWs and outreach teams are
the most effective means of demand generation. This is evidenced by the strong
community connections afforded to CHWs through AACES and other initiatives, such as
invitations to speak on SRH and family planning at Barazas (community meeting), at
community dialogues and other significant events. These linkages have proved an
effective strategy in reaching women with SRH and family planning information.
 In Tanzania, CBMs and community volunteers have been successful in increasing
demand amongst women, particularly for MST outreach. Local Government Authority
doctors and dispensary nurses are also effective conduits for demand generation.
 In both Kenya and Tanzania, there are women who are very satisfied with the MSI
services they have received. Their satisfaction is evidenced by them generating demand
for SRH and family planning services within their own communities, in some cases
amongst their partners and children.
Men
 Demand is generated amongst this group from CHWs / CBMs, outreach teams, health
facilities, community volunteers and their own wives/partners. There are signs that male
demand for SRH and family planning services is increasing as a result of MSI AACES
activities. However, in AACES project locations, male engagement with SRH services
remains low.
 Interest from men is stifled by lack of engagement in general on SRH and family
planning issues due to a variety of cultural, religious and gendered factors28
.
 As noted previously, men still overwhelmingly feel that SRH and family planning is for
women only. For the majority of men, prevention of sexually transmitted infections (STIs)
and unwanted pregnancies is the main motivation for increasing demand for condoms.
 Where male leaders champion SRH and family planning practices, demand tends to be
greater. Who has provided the information is a critical consideration for generating
demand amongst men. For example, receiving information from other men has often
been cited as an important motivating factor.
26
African Population and Health Research Center (APHRC), Kenya Ministry of Health, Ipas and
Guttmacher Institute (August 2013) Incidence and Complications of Unsafe Abortion in Kenya: Key
Findings of a National Study.
27
Mboya, F., et al (2013) A situational analysis on causes of unsafe abortion and abortion stigma
within Marie Stopes Tanzania health facilities catchment area. Marie Stopes International.
28
For more information, please refer to Objective 1 Outcome 1.4 on service uptake.

24
Youth
 Since the inception of AACES, young people are increasingly demanding SRH and
family planning information and services. FGDs with young people reveal that they are
motivated by an increasing awareness of the effects of unwanted pregnancies on
education and life goals.
 FGDs with MST service providers note that there has been an increase in demand
amongst young people as evidenced through an increase in the number of youth
presenting for services. MST’s two day outreach model has been successful to some
extent in generating demand amongst young people. However, providers observe more
youth loitering on the periphery during MST outreach, which they attribute to youth being
put off by adult participation.
 Youth engagement can be limited by confidentiality issues. As an example, one provider
recounted a discussion with a young person, who said “we want family planning but our
mothers are with you”.
 ‘Edutainment’ has been successful but has often been limited by context, exposure and
follow-up. PhotoVoice has been a useful activity to raise awareness about adolescent
SRH and create demand and advocacy amongst youth in Mtwara. PhotoVoice has the
potential to be more effectively utilised to leverage wider benefits.
 Schools have limited capacity to create demand due to lack of support from parents and
communities.
 Despite exposure, youth still appear to be less active than other groups in translating
SRH knowledge into service uptake. There has been some success in utilising
intergenerational education and demand creation to improve uptake of services. To
illustrate, one woman in Kenya talked about educating, supporting and taking her 11
daughters to obtain family planning so they don’t have as many children as she did.
 There is also demand among children, as evidenced by rates of primary school
pregnancies. However, this demographic group is currently not a target for the MSI
AACES program.
Sharing experiences
“I have a neighbour whose wife always conceived six months after every pregnancy.
The man looked so stressed and disturbed but whenever I talked to him about family
planning, he refused to listen. He was so green about family planning services. I
almost gave up after several attempts but found another way of going around it. This I
did by linking him to a group of women that used to meet to discuss about many
issues afflicting family life. With experience sharing as a strategy, his wife became
empowered and free to talk about family planning to him. Slowly the man became
receptive and supported the wife in practicing family planning methods.
Like with other families, health indicators in terms of nutrition and general health has
been on improvement path, while families with smaller number of children have
become role models to others. People see this and it is a good motivator.”
Community Health Worker, Tiwi region, Kenya

25
PhotoVoice: Stella
Stella, aged 20, met MST staff during
PhotoVoice supervision and is now a member of
the group. Three months pregnant and with a
six month old baby, Stella was desperate and
disappointed. Becoming involved with
PhotoVoice has helped Stella to learn more
about SRH and she plans to use a long term
method of family planning after the birth of her
second child.
PhotoVoice provides young people with an
opportunity to take a photo and tell a story about
some aspect of SRH and family planning that
resonates for them and has messages for other
youth. These are peer reviewed and those
selected are produced as posters. PhotoVoice
has potential to nurture wider benefits for those
involved, to mobilise other youth and engage
the wider community, and as a planning,
monitoring and evaluation tool.
Figure 6: Stella and her child, Lindi, Tanzania.
 PWDs feel they are generally left out of demand generation activities, and that negative
healthcare provider attitudes towards the sexual health of PWDs hinders demand
creation.
 PWDs noted that MSK and MST outreach are good SRH and family planning avenues
for PWDs, but that they require additional support to access to information and services.
 IEC materials are not always accessible or appropriate to the specific needs and abilities
of PWD. MSK is currently developing IEC materials that better meet the needs of PWDs.
 Providers, including MSK and MST, have expressed a need for support in engaging
effectively with PWDs. MST’s job aid in working with PWDs will help to increase capacity
for creating demand amongst this group by MST staff.

26
 The MSI AACES project has successfully facilitated increased capacity of service
providers to deliver equity sensitive and sustainable services.
 Evidence confirms high levels of satisfaction with MSI AACES training.
 MSI AACES engagement with stakeholders to promote equity sensitive and
sustainable SRH and family planning services is well-regarded, and is stimulating
positive change.
 Impressive increases have occurred in provider skills and the reach of services.
 Readiness, willingness and ability of service providers to deliver equity sensitive
and sustainable services will be improved with further follow-up and support.
 Criteria against which to reasonably measure increases in capacity will benefit from
refinement.
they require
OUTCOME 1.3 There is an increase in capacity and focus of service providers to
deliver equity sensitive and sustainable services
 Increasing confidence and understanding of SRH and family planning among service
providers, in particular government staff, private providers, social franchisees, and
community workers (CHW / CBMs) through formal trainings, meetings and informal
discussions.
 Developing technical skills of service providers and community workers. This includes
outreach visits, technical supervision and on the job training in service provision (family
planning services, cervical cancer screening, and HIV testing).
 Providing training and sensitisation in inclusive service delivery, particularly for MSI staff,
social franchisees and government health workers. This is evolving as MSI learning and
experience informs training, particularly regarding disability.
 Influencing government policy towards appropriate service provision for marginalised
groups (i.e. youth and PWDs).
Key outputs
 In Kenya, the baseline study revealed that only four Government of Kenya staff and four
MSK staff had been trained on equity sensitive service provision. MSK has worked to
strengthen the capacity of service providers and increase their readiness and ability to
provide inclusive SRH services. This included training 30 public and private healthcare
workers from six districts (Kwale, Msambweni, Kilifi, Lamu, Malindi and Kaloleni) on
youth friendly service provision. MSK has also provided equity sensitive SRH and family
planning training to 20 social franchisees. These providers report an improved
confidence in service provision and increased numbers of clients accessing services.
 MSK has hired David Gitau as a part-time Disability Coordinator. He is MSI’s first ever
disability-specific appointment, and brings unique first-hand experience to the project as
a person with a visual impairment. (See further details below).

27
 Integration of activities is deepening and becoming more creative. For example, in Kenya
the YPEs conducted ‘youth and disability’ initiatives on International Day of Disability in
2013. Such innovation scales up effectiveness and efficiency.
 In Tanzania, MST has provided on-the-job training to 134 public health service providers
during site visits, seconded 22 local government nurses to the outreach team for a period
of one month each and worked with 11 Local Government Authority doctors who
provided surgical services (tubal ligation) on outreach.
 MST’s partnership with CCBRT has been instrumental in nurturing mutual capacity
building, as representatives elaborate in the box below titled ‘Ripple effect impacts’.
Key outcomes
 There has been an increase in MSK’s capacity to provide disability friendly and client
focused services.
 According to the 2012 exit interviews, 99.8% of marginalised groups who
received MSK services said that they would recommend the services to a friend.
 MSK service providers and social franchisees achieved an average of 74% in
external Quality Technical Assistance (QTA) scores since project inception.
 There has been an increase in MST’s capacity to provide disability friendly and client
focused services.
 According to the 2013 exit interviews, over 95% of marginalised groups who
received MST outreach services said that they would recommend the services to
a friend.
 MST service providers achieved an average of 85% in QTA scores and 95% in
external quality scores since project inception.
 The Tanzanian Government is recognising the importance of providing youth friendly
SRH services. Responding to a request from the MoHSW, MST and the NGO
EngenderHealth have developed a ‘Job Aid for Family planning and Youth Friendly
Services’. This will be developed into an On the Job training program in 2014.
 Building on the success of MST’s outreach program, the Tanzania MoHSW has
incorporated outreach delivery of services into the updated National Family Planning
Costed Implementation Plan, recognising the crucial contribution it will make to helping
Tanzania to meet the ambitious target of 60% contraceptive prevalence rate by 2015.
MST will continue to liaise with MoHSW in assessing the cost-effectiveness of different
outreach models.
Overall, the knowledge and skills of service providers within AACES has improved
substantially since project inception. This is especially so amongst Government providers at
local levels who are accompanying MSK and MST outreach teams and through on the job
training with health facility staff. For example:
 District and County Health Officers in Kenya remarked: ‘The most significant change has
been our awareness about family planning, especially long term methods, which we
have got by MSK working closely with our health facilities... And as a member of the
county stakeholders forum, they have shared experience and forms to support our
annual planning…”
 In Tanzania, a Regional Reproductive Health Officer identified three ways in which
capacity has improved: “We have better coordination now that the Marie Stopes office is
located next door… we have more involvement in regional and district level planning…

28
annual plans and strategies, as well as operational schedules for sensitisation and
services; you have special forms so we get additional data which is very helpful; and
Marie Stopes people used to go by themselves but now they take the district midwife or
clinical officers which helps build skills…”
 In Kenya, District Public Health Nurse commented that “The community is changing so
much especially with youth, and while the leaders and Imams still hold the values, the
gap with youth is growing. Youth abortion is rising, and while we are dealing with the
family level, we haven’t yet [tackled] things at the community level. Marie Stopes has
been the main link for us to access youth friendly information and service support… we
have got strategies to increase youth engagement and referrals”.
 There is however a widely expressed need amongst all cadres for more training. While
technical capacity is generally high - especially within MSK and MST - ability to engage
with some marginalised groups is still emerging, particularly PWDs. Ability to engage
youth has increased most through the MSI AACES project to date.
 As noted by a District Public Health Nurse in Kenya, “Disability is a challenging area…
we don’t have so many PWDs but it’s not easy for them to get here, and in all honesty,
the knowledge and attitudes of health staff is poor. But with trends in disability expected
to rise through acquired injuries like traffic accidents, cancer and lifestyle diseases, we
need to know how to provide services to PWDs. This is a priority capacity building need
we want from Marie Stopes.”
 Other factors (including some beyond service provider control) can limit capacity to
deliver services; these include client accessibility, infrastructure, and availability of
commodities.
Specific findings for target groups:
MSK and MST teams
 FGDs at the community level and FGDs/IDIs with Government health workers showed
that MST and MSK outreach teams are highly trained and well received in communities
in terms of quality. On the job training has increased confidence and capacity.
 Outreach models could benefit from review and refinement. In Kenya, shorter outreach
schedules do not factor travel time adequately, with outreach sessions subsequently
starting later and running shorter than anticipated. Community (client) feedback identified
this as a particular issue, and MSK providers are now piloting longer outreach schedules
that may also provide for enhanced health facility staff training and support.
 In Tanzania, community (client) and provider (Government) informants all confirmed that
the current outreach schedule could be improved. Returning every three months was
suggested for continuity of services.
 MSK’s AACES broad mix of field staff and roles, for example utilising YPEs and working
with youth mobilisers, enables effective multi-pronged engagement of target
marginalised groups. Lessons could be shared with MST for greater reach.
 MSK and MST clinicians are ready and willing to provide services to PWDS but feel they
need support to develop skills and confidence to do so sensitively. General knowledge
and information about disability as well as specific skills needed to provide services to
PWDs (consent, clinical) has been identified as a topic of capacity building need in both
countries.
 Other capacity constraints include unexpected high demand, resulting in stock outs while
on outreach. This is common also to health facilities (see below relevant section).

29
 In Tanzania, partnership with an organisation supporting PWDs (CCBRT) has been
instrumental in developing baseline understanding and has yielded similar educational
and networking support for AACES project personnel.
 There is scope for a more targeted and sensitive approach for youth, men and PWD (as
expressed by all groups) and greater connections with DPOs and youth organisations
(as expressed by MSK and NGO service providers). A considered combination of
mainstreaming and target population specific strategies (twin tracks) may yield enhanced
equity outcomes (e.g. IEC materials for specific impairments).
Figure 7: David Gitau, part-time Disability Coordinator at MSK.
Community health workers (Kenya)
 CHWs reported positive feedback on their SRH training from MSK, noting increased
ability to improve community access to relevant knowledge and services. However
CHWs consistently express a desire for more training, including working with PWDs.
While they may not be able to provide services, CHWs say that ‘having a better
understanding of different methods and side effects means we can counter myths and
incorrect ideas…people would respect us more... we can mobilise better.’ They do
however have good overall knowledge of SRH and family planning and they are
available when needed (e.g. referring to other services and providing condoms).
 District and county personnel confirm the critical role that CHWs play, especially in
identifying/mobilising ‘hidden people’. They prioritise strengthening CHW recruitment,
training, retention, support, and monitoring processes that use participatory approaches.
 The effectiveness of capacity building with CHWs is limited by high attrition rates, and
variable incentive arrangements which also impact on mobilisation and referrals.
 TBAs and traditional healers were also identified by community and health personnel as
trusted community resource people in some locations in both Kenya and Tanzania that
could be considered for engagement.
Disability development
In Kenya, the part-time MSK Disability Coordinator,
David Gitau (left) provides support to the AACES
project.
“I joined in March 2012 and it was a brand new
experience for MSK! My job is all about building
capacity - to sensitise MSK service providers, link MSK
with disability NGOs, and access and/or assist in
developing disability-friendly materials. Building mutual
relationships between DPOs and MSK… and two-way
understanding and trust…has been a particularly
important role.”

30
Community-based mobilisers (Tanzania)
 CBMs are trained and supported by MST and generally have been successful in
mobilising community demand for SRH and family planning services. This is less so
among PWD however. For example, regional and district reproductive health officers
cited that having CBMs inform communities one week before an outreach, followed by
announcements one day before arrival enhanced numbers on clinical service days.
However, they acknowledged mobilisation mostly happened within the village vicinity.
 There is a lack of clarity within the community about the role of CBMs and community
volunteers. Some communities utilise health mobilisers, while others rely on social
mobilisers, especially for youth and PWDs. This reflects the different sector mandates
and responsibilities for these populations. Within AACES, there is one CBM per AACES
district; the CBMs work with local administrations to identify two volunteers in community
(one youth, male and female), to assist with mobilisation for outreach activities.
Generally the AACES mobilisers are considered to have good overall knowledge of SRH
and family planning and are available to provide information when needed.
Health facilities and dispensary staff
 Clinical training of health facility workers has been well received, but they too seek more
training. In both Kenya and Tanzania, capacity to deliver services is limited by breadth of
work, with often just one or two providers per health facility responsible for broad
spectrum curative and preventative primary healthcare. Clients confirm long waiting
periods. As a provider in Tanzania notes, ‘Sometimes SRH and family planning
commodities run out of stock (e.g. injectables) and clients must either choose a different
method or leave without one.’ Clinicians admit there is limited space for SRH and family
planning services, and would like MST support to better integrate SRH into their
services.
 In Tanzania, government providers report issues around SRH and family planning
commodity stock-outs, particularly for injectables and implants. However the MoHSW
noted that there may be misunderstanding around this, as all maternal and child health
commodities (including family planning) are free on request. It is unclear what is driving
this knowledge mismatch.
 Capacity to provide long acting and permanent methods is still very limited, especially in
Tanzania29
, and while technical capacity is high as a result of training, confidence is
lacking among many providers. For example, one provider noted that the health facility
was disposing of implants that have expired because no provider feels confident to use
them. Providers say they want on-going supervised practice.
 Capacity for intra-uterine device and implant removal is also low amongst this group.
 MSK and MST training on youth friendly service provision and family planning
procedures have improved Local Government Authority ability to provide these services.
However clinicians and staff admit they do not have the practical skills to attend to
PWDs, and they would like training on this. PWD feel health facility attitudes are not
friendly, nor constructed to favour PWD. Providers note there are no/poor statistics on
PWD within communities, highlighting the difficulty in accessing these people in the first
instance. A senior county health officer in Kwale, Kenya observed that he had ‘worked
for 28 years with MoH and had never seen a person with a physical disability come for
SRH and family planning’. This is now slowly changing due to MSI and DPO activities.
29
Only one doctor at district hospital level can provide long acting and permanent methods.

31
Social franchises
 In Kenya, social franchisees consistently report increased client numbers as a result of
MSK’s AACES partnership inputs. Training, equipment, commodities, road shows and
the new AMUA branding have been very well received as reported by franchisees and
AACES reports: ‘The partnership with MSK has brought massive changes to my clinic…
the training, and access to equipment means I can provide a wider range of services and
with good quality…the branding and AMUA-Leo activities attracted lots of interest, and
has led to an increase in clients…and all of this in less than one year!’ (Malindi).
 The capacity of some franchisees to provide a wider, integrated range of services,
including long term family planning procedures, has also enhanced client numbers (as
verified by before and after client data, and staff monitoring and support visits). Cervical
cancer screening is now sought by franchisees as an addition to the SRH portfolio.
However, franchisees and their staff constantly expressed a need for further on-site
training/support in order to feel confident to conduct some procedures (e.g. intra-uterine
devices), which despite training are not being performed by some personnel.
 Further assistance is also requested to be able to effectively engage with PWD, and to a
lesser extent, youth. The role of CHWs is critical in raising community awareness and
mobilising visits to social franchise clinics, as are links with community leaders.
 Enhanced quality is perceived as important by franchisees, and materials to promote
understanding and informed consent across client groups is a further requirement.
 Continuity of commodity supplies can be of concern where social franchises access
these through government suppliers. Record keeping appears burdensome and at times
incomplete. Business planning strategies will contribute towards promoting sustainability.
Figure 8 and 9: An AMUA social franchise in Kilifi, Kenya (left); Social franchisees (left three)
meeting with MSK’s Social Franchise Coordinator (right) and MTR consultant (centre).
Social franchise AMUA clinics (Kenya)
New branding is proving extremely popular and effective, supported by launch events
that draw community interest and attention. The Kilifi social franchise Clinic (above)
shows how the new exteriors stand-out in the community context. Maurice,
owner/clinical officer of the Imani social franchise Amua Clinic (right, shaking hands
with the MSK Social Franchise Coordinator) was both exuberant and considered in
conveying the benefits of being an MSK/AACES social franchise:
“Women may come with a sick child or husband and we use the opportunity to
discuss other services including MCH and SRH and family planning…the IEC
materials and training from Marie Stopes, means people can take it away and make
more informed choice… and we have the skills to provide good quality service.”

32
Regional and National Government
 MST has established good relationships with government partners at administrative
levels. There is increasing consultation and coordination, helped by co-location within a
government facility in one region (Mtwara). Activities to increase service capacity and
integration are in place, particularly through joint supervision, ‘training of trainers’ and
developing national guidelines for outreach. MST’s AACES project is a member on the
adolescent SRH committee, influencing the development of a National Youth BCC study.
 The National Coordinator for family planning in Tanzania noted, “We appreciate the
standards that Marie Stopes brings. Through the working groups we can ‘Tanzanise’ the
guidelines… and just today, MST with Australian Aid donated a vehicle, which we shall
immediately take on a joint training and supervision visit to district health facilities.”
 “The outreach work that MST is doing is great… and with the AACES model, there is an
opportunity for comparative analysis of the models… we want to know about the costs
and capacity to scale them up…. As well as learning about adolescent entry points for
family planning…” were contributions noted by the National Adolescent RH Coordinator,
in Tanzania.
 MST’s and MSK’s focus on disability through AACES is influencing the Governments of
both countries. For example in Tanzania, MoHSW and other departments responsible for
social affairs have expressed strong interest in learning from MST’s Disability Feasibility
Study conducted with CCBRT. In Kenya, the Government is interested in MSK’s AACES
reports on services provided to PWD, as this is something they currently do not track.
Ripple effect impacts
As a result of a joint disability baseline study between MST and national disability
organisation CCBRT, there has been significant mutual increase in knowledge and
capacity about SRH and disability through both the process and results.
“Participating in the MST AACES study was an opportunity to learn more about family
planning for PWD and their experiences… it brought new knowledge to my mind. We,
CCBRT, promote disability inclusion and coming to Marie Stopes is a step further in
our struggle for inclusion… this was a brilliant initiative.” Frederick, Advocacy
Program Manager.
“Going out with the disabled guys to do the disability study was really my first
experience in being with a PWD. I learnt a lot about disability and how to be with
them… I’m more confident now, and we gained a lot of information for the project. It
was a good experience.” Emmanuel, MST Research Officer
CCBRT are now considering to establish an SRH and family planning service as part
of their program, while MST may seek their assistance in facilitating disability service
provider training. Opportunities exist for similar networking, cooperation and capacity
building arrangements with other organisations to enhance and expand service
provision for marginalised groups.
MTR IDI discussions, Tanzania

33
Other healthcare providers
 In Tanzania, pharmacies, shops and kiosks are reported by youth and community
members as central places to obtain family planning commodities (e.g. contraceptive
pills). For confidentiality reasons, they are the preferred providers of family planning
products by youth. However, there is limited knowledge amongst these private providers
about the products, and rarely are instructions or information given to customers. As a
result, misuse of family planning is high. For example, FGDs with female youth highlight
that this group often buys one cycle of pills and shares amongst friends.
 There are opportunities here to engage with private providers in Tanzania, and also for
improved education and referral networks.

34
 The MSI AACES project has cultivated very significant increased uptake of SRH
and family planning services across all marginalised groups in targeted
communities since project inception; targets have mostly been exceeded.
 Outreach services have been particularly effective in enabling access by poor
people and those in remote areas.
 Clients report high levels of satisfaction with MSI services, and are recommending
them to others. As service provider sensitivity improves, levels of satisfaction
amongst youth and PWDs is improving.
 Whilst MSI is responding to increased demand for long term methods, other service
providers have limited capacity to provide this.
 Qualitative evidence confirms and elaborates a wide range of benefits arising from
uptake of SRH and family planning services among marginalised communities.
they require
OUTCOME 1.4 There is an increased uptake of SRH and family planning services by
marginalised groups
Results statement for outcome 1.4
 Provision of equity sensitive services through mobile outreach teams in rural and remote
communities in coastal areas of Tanzania and Kenya.
 Supporting equity sensitive service provision through 20 accredited social franchise
clinics in Kenya. This includes identifying, training, supporting, monitoring and supplying
equipment and commodities.
 Supporting equity sensitive service provision through health facilities in Kenya and
Tanzania.
Key outputs
 The MSK AACES project provided SRH and family planning services to 44,013 women
and 3,370 men from marginalised groups in 110 locations across Lamu, Kilifi, Tana
River, Taveta Taita, and Kwale counties in Kenya.
 The MST AACES project provided SRH and family planning services to 57,957 women
and 1,992 men from marginalised groups in approximately 108 of locations across
Tanga, Pwani and Mtwara regions in Tanzania.
 Overall four outreach teams established to deliver services to marginalised groups.
 New outreach models were piloted to maximise impact of service delivery.
 In Kenya, SRH service delivery through social franchises increased from 1,693 in Year 1
(through nine social franchises) to 7,638 in the first half of Year 3 (July- Dec 2013)
(through 19 social franchises).
 Service delivery to PWD has seen a significant increase from negligible number of PWD
clients before the project began to 217 clients with a disability over the project so far.
 Overall MSI’s AACES project supported 228 health facilities and hospitals across Kenya
and Tanzania to provide long term and short term methods of family planning.

35
Key outcomes
 In Kenya, 34,275 women and 863 men from marginalised groups have accessed modern
family planning services during the first two and a half years of MSI AACES; this includes
a 35% increase in women and 347% increase in men in Year 2.
 In Kenya 147 PWD have received services to date, with steady increases from 53 in
Year 1 and 2 to 41 in the first half of Year 3.
 In Tanzania 70 PWD received SRH/family planning services to date, with 40 in Year 2
and 30 in the first half of Year 3 (data not recorded in Year 1).
 In Tanzania, 48,190 women and 1,098 men in rural and remote communities accessed a
modern family planning method during the first two and a half years; this includes a 40%
increase among women in Year 2. No men were reported to utilise family planning in
Year 1.
 Approximately 37,700 youth have accessed SRH and family planning services over the
life of MSI’s AACES project. This number continues to grow: from around 5,800 during
the first half of 2012 to 8,700 for first half of 2013.
 In Kenya, the number of family planning adopters among women, youth and PWDs has
increased 470% between 2011 and 2013 (731 at the start of the project to 4191 clients
after two and a half years). Approximately 26% of MSK AACES outreach clients and
12% of MSK AACES social franchise clients are family planning adopters.
Overall there has been an increase in uptake of SRH and family planning services by
marginalised groups in communities serviced by the MSI AACES teams. Most respondents
in community FGDs acknowledge there has been a reduction in number of children within
families.
 Some comments from FGD participants in Kenya and Tanzania exemplify this, for
example: “Now there is 4-5, when there used to be 10 plus. Women would have children
‘to the last egg’” and “Women used to give birth randomly. Maybe eight children. Now
they have less. Four is the maximum, and is considered a lot”.
 Although there is substantial evidence that people recognise the benefits of SRH and
family planning, uptake varies amongst groups.
Marginalised women
 Levels of SRH and family planning knowledge and uptake are greater among women
than all other groups. Women seeking services through all channels (outreach, health
facilities and social franchises and/or other private providers) has increased. Several
districts in Tanzania show substantial increases in family planning user numbers over the
last two years, which Government service providers attribute to MST and AACES
support. As a regional reproductive health officer in Tanzania noted, ‘When Marie Stopes
comes, we get more clients…”. Availability and continuity of products can be variable
however.
 Women access long term methods mostly at MSK and MST outreach, as these are
rarely available through Kenyan public health facilities and only at district hospitals in
Tanzania.
 Injectables are still the most common method, however. Women say this is mostly due to
availability, and cost considerations. For example, in Tanzania, implant and intra-uterine
device removals have high costs at health facilities/district hospitals, and while MST

36
outreach provides free removals, visits are not frequent enough to provide for clients on
demand.
 Because there are many cultural, religious and gendered factors that promote large
families, many women are accessing family planning without their partners knowing. For
example, some FGD participants noted they travel to different districts, even to the city,
to get family planning, so their husbands won’t find out. Men are still gatekeepers to
women’s health in many circumstances.
 The benefits of SRH and family planning are well articulated amongst this group, with
many respondents talking about improved health, increased savings for education and
healthcare, improved employment opportunities and time to pursue other activities to
‘uplift their household’. For example, one couple articulated how for them ‘the cost of
repeat visits to a clinic to get a 3 monthly injectable outweighed the benefit of family
planning; they would ‘rather spend the money on food’.
 Inclusion of cervical cancer screening, which can act as a complimentary service to
increase uptake of family planning has begun, but due to low staff numbers, is not being
rolled out comprehensively.
 Incentives amongst other organisations for certain methods (a kanga for an intra-uterine
device), has resulted in MST also addressing many removals.
Men
 Men have lower levels of SRH and family planning knowledge and uptake. There has
been some increase in male input but mostly in helping women access family planning.
 FGDs revealed strong rejection of vasectomy as a viable option and / or that this is not a
subject for public discussion. As vasectomy is seen as emasculating, male uptake is
limited by a very real concern of community backlash. However, MST has observed a
slow but increasing uptake in this service. For example, in Mtwara and Tandahimba over
the past three years the regional reproductive and child health coordinator reported
‘there has been an increase from zero to six, including one high profile community leader
who is an open champion for vasectomy’.
 Condom use is variable. Many men are unwilling to use them, citing reduced pleasure as
a main reason for this. Cultural, religious and gendered preferences for large families
also affect men’s willingness to utilise, or support their wife’s use, of family planning.
 Men say they would prefer services (particularly outreach) to be provided in remoter, less
obvious spaces. To encourage male uptake, men are given priority treatment when
attending government services, but it is unclear if this has increased uptake and may
have implications for equity sensitive services. The inclusion of VCT and STI services
has however improved male utilisation and engagement of MST outreach services.
Changing attitudes
One woman says ‘my husband does not want me to use family because he says he
got me to provide children for him’. However this is changing, with the economic
constraints/benefits of family planning the main drivers for such change.
One man said “I want her to give birth because I want to know how many eggs she
has, because I’ve paid the dowry”. Despite this, men are still given preferential/priority
treatment and incentives when accompanying wife (priority access), which women
find frustrating and unfair.
Comments from MTR FGDs, Kenya

37
Youth
 Youth uptake of SRH and family planning has increased to some extent in Kenya due to
the work of the YPEs and to services offered by trained providers in special ‘youth
friendly’ spaces. The MoH initiative of youth friendly rooms set up within government
health facilities as a “one stop shop” for youth SRH has not yet been completely rolled
out. It is unclear whether this will be enough to attract young people to services, with
concerns still over the confidentiality and privacy of the initiative.
 Despite the often low levels of training private providers have, youth confirm that they
prefer to visit these providers to ensure greater privacy.
 There are also still barriers for young people’s access and uptake of services in terms of
location and cost. Some young people say they go to centres to get oral contraceptives
pills to share amongst their friends, therefore saving on travel cost.
 In Tanzania, youth are primarily accessing family planning at shops, kiosks and
pharmacies, and overwhelmingly there is a preference for short term methods.
Attendance at MST outreach by this group has increased, but the presence of their
parents at these sessions can be a barrier.
 A general air of denial amongst young people about the consequences of unprotected
sex and unplanned pregnancy is also an issue in terms of translating knowledge to
uptake. There is scope to improve this, but MST service providers note that knowledge
and uptake of family planning amongst this group has been the greatest success to date
in AACES.
 Following increased uptake of services, FGDs in Tanzania have reported far fewer
numbers of teenage pregnancies, and a subsequent reduction in school drop outs.
 Kenyan service providers note that linkages with Ministry of Youth and Sport and
Ministry of Gender and Social Development (now combined in a new Ministry) , as well
as other existing youth groups, could support improved service delivery to these groups
by tapping into existing networks. This would be especially true for young mothers, who
are generally believed to be the most marginalised. The AACES Innovations Fund is
currently addressing this.
 Uptake of services by PWDs is still low, but has improved since AACES began. In
addition to clients seeking services from MSI, the project also has a flow on effect
improving health seeking behaviour among this group more broadly. As a result of
engaging with DPOs in Kenya, over 3,000 people with disabilities have received access
to information and 900 PWD were referred for SRH and family planning services.
 PWD confirm their biggest barriers are access (physical, financial, knowledge) and
provider attitudes. More training is needed and wanted by all cadres to improve
sensitivity in supporting those living with disabilities. PWDs say they want MSK and MST
outreach to ‘go deeper’ within communities to ensure they are able to access services
(currently they feel they are too concentrated on urban centres).
 AACES teams are trying to accommodate the needs of PWDs, with one outreach team
member recounting a story when he had to carry a woman with a disability from her
home some distance to the outreach site. Disability advocates suggest that, consistent
with international best practice, approaches need to be ‘twin-tracked’, incorporating both
mainstreamed and disability-specific strategies.

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