Improving Access to Quality Family Planning Services in Nepal and Sri Lanka: Insights from a South-South Learning Exchange

"Learning through the systematic exchange of knowledge, skills and know-how of successful initiatives among countries is expected to result in effective and positive developmental outcomes in all spheres of human endeavour, including health."

This paper documents the process and lessons learned from conducting a South-South learning exchange (SSLE) in family planning (FP) using an online platform. SSLE describes the process when two countries in the global South - in this case, Nepal and Sri Lanka - engage in horizontal peer-to-peer learning. It is based on the belief that countries facing common challenges and seeking to achieve common goals can make faster progress through shared learning and experiences.

The conversation between the two countries was initiated in January 2020, using a 5-step methodology developed by the World Health Organization (WHO) under the FP Accelerator project (2019-2022) to engage SSLE stakeholders, guide the process, and ensure implementation of the knowledge gained. The 5 steps are: (i) define the need for and purpose of the learning exchange, (ii) plan the SSLE, (iii) facilitate the learning exchange, (iv) support implementation of the action plan, and (v) follow up after the learning exchange.

Following multiple virtual and in-person exchanges with and between countries, which are described in the article, Nepal and Sri Lanka moved on the fourth step and started implementation of the learnings in December 2021. For example, following the virtual exchange of knowledge/information and the practical "how-to", the Sri Lanka team designed a roadmap for transforming the paper based Logistics Management Information System (LMIS) into an electronic format so as to provide timely reports on FP commodity availability and use. They went on to complete the piloting of e-LMIS and scale it up to the district level. Also, following the SSLE, Nepal developed an advocacy tool for postpartum family planning (PPFP), which elaborates on missed opportunities and benefits from PPFP, and conducted policy dialogue with policymakers and programme managers in two of the provinces using the tool. Based on the learning, the Nepal team is expanding facility- and community-based PPFP initiatives.

An evaluation of the SSLE process was carried out by an independent consultant from Sri Lanka. It had an important learning component and aimed to ensure a high degree of engagement and consultation and interaction with stakeholders throughout. To date, it has found, for example:

• Some positive feedback: The majority of respondents (from a postmeeting survey) expressed that the standardised process for learning exchange helped in generating new ideas and in creating new networks/interpersonal peer and professional relationships between countries. The in-built accountability, monitoring system with after-action review, and focus on outcomes kept stakeholders motivated.
• Some challenges/suggestions: Some participants felt that the virtual modality was a barrier when it came to learning about the practical aspects of the eLMIS, as they could not be demonstrated adequately; a hands-on experience could have made it clearer. Others commented that photo stories/videos would have been beneficial and complementary to the online sessions. Still others complained that the time allocated was not adequate for the question-and-answer sessions during the exchange meetings.

Monitoring and evaluation is continuing, with a final evaluation of the outcomes/impact of the exchange expected in December 2022.

Lessons learned during each of the 5 steps of the SSLE process include:

1. Learning objectives set by the countries in the SSLE must be clear and specific, arrived at after much thought and consultation, and in line with country plans and needs.
2. Involving the government and stakeholders from the beginning of the process is crucial for creating an enabling environment for implementing the learned knowledge. For example, in Nepal, provincial managers' participation in the SSLE ensured ownership of the process both at the highest levels of the Ministry of Health, as well as at provincial levels, to enable implementation of integration of PPFP in maternal, neonatal, and child health (MNCH) services.
3. The SSLE process constantly evolves; hence, flexibility and adaptability are a must. For example, though study tours and face-to-face meetings were planned as mode of SSLE, due to the COVID-19 pandemic, the modality of exchange moved to virtual meetings.
4. Reciprocal learning is an effective way to conduct SSLE. Instead of a mentor and mentee approach, both countries were on an equal footing as seekers and providers of knowledge. Thus, they were respectful of each other and supportive of the other's goals.
5. SSLE can be conducted using virtual platform. The virtual modality had its advantages in terms of increased participation and disadvantages in terms of the quality of the experience.
6. SSLE is a time-consuming process for both countries.
7. An inbuilt monitoring system is critical. Monthly reports, meetings, postmeeting participant questionnaires, and after-action review are useful tools to keep the stakeholders motivated and committed.
8. WHO is well placed to support and facilitate SSLE. Having a strong facilitator is necessary to keep the discussion on track and to meet the aim of learning exchange, especially during virtual learning exchanges.

The researchers suggest that these lessons should be systematically documented and disseminated. "Knowledge-management platforms and tools both internal and external to WHO need to be strengthened and used to capture and disseminate SSLE practices via public-facing platforms, including the WHO website, the HRP [the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction] YouTube channel and the implementing best practices (IBP) initiative."

In conclusion: "The SSLE has made a positive contribution to improving the knowledge and capacity of national and subnational FP programme managers on technical and programmatic issues and contributed to strengthening the health systems of both countries to better elaborate, implement and deliver quality FP programmes."