This document provides an independent evaluation of Parts A and B of the Egypt Population Project (EPP). It finds that the EPP achieved several objectives including breaking down social barriers to family planning, improving service provision, increasing contraceptive prevalence and vaccinations. It analyzes the effectiveness of project components like social change agents and microloans. Challenges included sustainability after phasing out funds. Lessons learned included the importance of partnerships and decentralized management. Further interventions were still needed in some communities.

1. Khaled El-Sayed Hassan, Ph.D. Independent Evaluation of Part “A” and Part “B” of the Egypt Population Project

2. Objectives The main purpose of this evaluation is to review the efficiency and effectiveness of subprojects implementation and measuring its outputs and effects

3. Methodology Employed - The qualitative approach is applied in collecting the main information for evaluation. - Other supplementary quantitative data and information are derived from the project and subprojects documents and reports.

4. Information Collection Tools Two main instruments are designed : * Structured Questionnaires to gather information from: professional service providers (physicians and nurses). Subprojects directors, SCAs, community leaders, and NGOs board members. Representatives of MOHP and SFD at the subprojects locations. Representatives of MOHP and SFD at the central level. * Focus group discussions to collect the required information from beneficiaries of the subprojects.

5. Sampling Subprojects in phases I, II, and III of the EPP were the main frame for the sample withdrawal . A total of 36 subprojects are carried out in the three phases of EPP, and implemented in 7 governorates. A random sample of 11 subprojects (representing about one-third of all subprojects) was selected. This sample is highly representative for the 7 governorates and the first three phases of the project under evaluation.

6. Main Achievements of EPP Breaking the social and traditional barriers that were preventing women from going to family planning clinics. Improving the level of services provision. Increasing the level of CPR. Increasing the level of maternal vaccinations and child immunizations. Providing cheaper commodities and services in the subprojects clinics, compared with other sources. Raising the awareness of local community of the concepts and issues of FP/RH.

7. Main Achievements of EPP 6. Introducing new services that were not available before, such as counseling services. 7. Training of services providers, and the equipment upgraded gave them the trust and help in accurate examination and diagnosis. 8. The improvement in client/provider interaction has an impact in creating a kind of understanding and mutual trust among them. 9. In addition to other economic, and social impacts.

8. Principal Components of the PAP 1. SCAs Component: - The network of SCAs proved to be one of the most effective components of the EPP. They have good skills in communication with the target women, in establishing good relationships, and opening channels for dialogue with them. Behaviors and attitudes changed in the subproject areas are mainly attributable to the efforts of SCAs. - The SCAs have executed more than 3.5 million home visits, organized 1.7 thousand health education seminars, helped 9.3 thousand families to get micro credits, and attracted 5.6 thousands illiterate women to be enrolled at illiteracy eradication classes.

9. Principal Components of the PAP 2. Small Loans Component: Majority of local leaders and beneficiaries met in the field perceive the small loans component as the best component, for the following reasonable reasons: It represents a direct personal benefit for beneficiaries. It is the only component capable to achieving sustainability for the majority of the implemented subprojects. It contributes to raising the standard of living of families, and consequently decreases the desire for more children.

10. Principal Components of the PAP 3. CBC Component: Most of beneficiaries highlighted the role of CBC activities in increasing the awareness of family planning methods and some of reproductive health components. More than half of the ladies interviewed showed a good knowledge of different types of family planning methods, the possible side effect of some methods, and the usage procedure. They also expressed good knowledge of some of reproductive health components such as, follow-up during pregnancies, maternal and child health, and the follow-up after delivery. CBC activities played a good role in reducing the rumors about family planning methods, and increasing believes with the concept of “ Small Family = Better Life” .

11. Major Challenges 1. Phasing-out and Quality of Services: Phasing-out of subprojects’ funds is leading to decline in the quality of services compared to the subprojects lifetime. Although many of subprojects introduced sustainability plans, but the only component that received a sort of planning to be sustained, is the small loans component. As for FP/RH services, no specific sustainability plans was observed. This is also valid on the other components of the subprojects. The return of recycling the loans is not quite enough to sustain the service provision and other components as well.

12. Major Challenges 2. Sustainability of SCAs: In view of sustainability plans prepared by the NGOs, the total number of SCAs is expected be to reduced to 25% of its current size in some subprojects. Thus, loss of the results achieved, and recession in the attitudes and behaviors corrected is highly expected. Sustaining all the SCAs after the phasing-out of EPP fund is difficult. Administrative and financial dependence is recommended to be transferred to the newly established general department for NGO support, at the Population and FP Sector of MOHP. SCAs can replace the traditional body of Raedat Reefiat .

13. Major Challenges 3. Turn over and performance: The rapid turn over of services providers had a negative impact on the performance of EPP. This is not restricted on service providers only. This is also valid on the high-level administration, subprojects mangers, and health and population directors at the governorates level as well.

14. Lessons Learned 1. Partnership is A Major Driving Force of Success: Effective partnership established between NGOs and MOHP can be considered as the major driving force behind the success in achievement of the goals and objectives of EPP. Governmental plans developed with representation of NGOs, and other civil society institutions are more realistic than those developed with a sole governmental vision. Assistance provided by the SFD in this regard represents an influential transition in the scope of work of the fund.

15. Lessons Learned 2. Subprojects as A Model of Decentralized Management: EPP can be considered as a pioneer in adopting a decentralized management approach. Efforts of the SCAs, management of the small loans and adult education activities are directed locally by the implementing NGO. Previous service delivery activities and awareness campaigns used to be managed centrally. These decentralized dimensions of management are all done within the general framework of the EPP strategy and work plan. But the supervisory team of each of the subprojects had a wide margin of freedom in decision taking, in accordance with the surrounding environment and circumstances.

16. Lessons Learned 3. Dynamic Adaptation with NGO Models Dynamic adaptation of the work with NGOs is observed along the different phases of the EPP : The initial model worked with in phase I was the active big NGOs working having branches in different villages. In phases II and III, work is done with small less experienced NGOs. In Phase IV, SFD, with its close cooperation with NGOs, monitored an alternative model of NGOs, which is the cluster formation of NGOs spread-out in a larger number of communities .

17. Voices From The Field 1. Further Interventions Required: Despite the obvious changes in behaviors, Upper Egypt communities still in need for more efforts to change some rigid habits and attitudes, such as: Female circumcision, early marriage, and marriage of relatives. Influence of the mothers-in-law in the decisions related to family size, Husband's rejection that his wife receives the service by a male physician, Rare practice of pre-marriage examination, Poor usage of male commodities, High frequency of unwanted pregnancies, and Revenge and its impact on the average family size.

18. Voices From The Field 2. Need to Male Agents Some voices from the field call for training a number of males to act as social change agents. They say that, there are areas with special sensitivity in Upper Egypt communities that need intervention of male agents, such as the poor usage of male commodities, and revenge.