Lessons Learned ComNet co-ordinated by the German Foundation for World Population (DSW) Contents 1. Introduction ............................................. page 2 2 2. Quality of Care in Bangladesh .................. page 3 3. AR&SH in Cambodia, the Lao PDR, Sri Lanka and Viet Nam ........................... page 4 4. Community Based Services in Nepal and Pakistan ................................ page 10 Introduction The EC/UNFPA Initiative for Reproductive Health in Asia (RHI) covers seven countries in South and South East Asia. It targets populations with very diverse reproductive health (RH) needs and, therefore, uses a wealth of different approaches. Altogether, the RHI consists of 42 projects, with more than 90 stakeholders. In addition, networks set up by individual projects enlist the collaboration of at least 100 community-based organi- sations (CBOs). For each country programme, a “country focus” was selected, taking into account the country’s most urgent RH needs, the comparative advantage of civil society organisations and the recommendations of UNFPA, which were endorsed by the local advisory group, where existing. As a result three different country focus areas were defined. In Bangladesh, the five projects aim to improve the quality of RH care, in particular that of clinic-based RH services. The programmes in Cambodia, the Lao People’s Democratic Republic (PDR), Sri Lanka and Viet Nam all focus on providing reproductive and sexual health (R&SH) information and services to young people and adolescents. The projects in Nepal and Pakistan concentrate on strengthening community based RH information and services. This report summaries a selection of some of the lessons learned, best practices and success stories resulting from the experience of over three years of implementation of the RHI in the seven countries. Publisher The EC/UNFPA Initiative for Reproductive Health in Asia (RHI) Editor ComNet co-ordinated by the German Foundation for World Population (DSW) Photo credits EC/UNFPA funded RHI Nepal, cover; Mak Rémissa/DSW, back Design Itta Howie, Bristol, UK 2. Quality of Care (QoC) in Bangladesh The RHI Bangladesh chose to focus its intervention on the delivery of a comprehensive package of RH services in urban under-served-areas, with 3 a special emphasis on quality of care (QoC) and clinical contraception. The projects are designed to effectively complement and contribute to the implementation of the Health and Population Programme of the Government of Bangladesh (GoB), for which this is an area of major concern. The RHI in Bangladesh has addressed QoC in a holistic manner, targeting QoC within the clinical and non-clinical context of RH services, as well as within the context of overall management of the respective projects, building organisational capacity at the same time. To ensure consistency, both in the overall approach and in the identification of clinical and non-clinical aspects within all projects, a QoC group was formed, composed of participating NGOs. Main Lessons learned: • Quality of Care increases client satisfaction • To achieve Quality of Care, choices need to be made between the adaptation and new development of protocols and guidelines • The process of improving Quality of Care is usually lengthy and should be uninterrupted • Quality of Care increases client attendance Quality of Care increases client satisfaction: In Bangladesh, providers have a reputation for not treating clients well. For example, poor com- munity members were hesitant to visit clean and well decorated clinics, assuming that the services were not meant for them or would be too expensive. The RHI programme tried to change this by introducing RH service protocols and by training the service providers on how to behave towards and communicate with clients. Clients were then asked about the conduct of service providers during exit interviews, which showed an increase in client satisfaction. At the same time, clients were educated in the type of care they should expect. To achieve Quality of Care, choices need to be made between the adaptation and new development of protocols and guidelines: The avail- ability of standard protocols and guidelines for clinical services, which were developed by the GoB in collaboration with NGOs saved time and resources. In addition, the adaptation thereof also contributed to an inter- nally coherent and homogenous approach to family planning and RH services in Bangladesh. 4 The process of improving Quality of Care is usually lengthy and should be uninterrupted: Improving QoC is a labour-intensive process that requires time, effort and motivation. This holds particularly true for behavioural change, which is necessary if a better understanding of the client situation is to be achieved. Service providers need encouragement to see the value in using RH service protocols and giving time to com- municate with clients. Close monitoring and supervision is required, as well as regular refresher training to sustain quality and to compensate for the dropout of service providers. Quality of Care increases client attendance: Investing in QoC pays off in the end. The improved management of clinics, service delivery procedures, behaviour of service staff towards clients, as well as more cleanliness, have led to a substantial increase in clients (between 19% and 48% within one year). For example, one of the RHI project hospitals expanded their facilities from ten beds to 35 beds and also introduced blood bank services, while offering daily RH services, including family planning. As a result, the number of total services rendered increased from 23,861 in 2000 to 35,527 in 2001. 3.Adolescent Reproductive and Sexual Health in Cambodia, the Lao PDR, Sri Lanka and Viet Nam Providing reproductive and sexual health (R&SH) information and serv- ices to young people and adolescents was selected as a focus in order to complement government initiatives, which mostly targeted married couples. In the Lao PDR and Sri Lanka, a particular emphasis was put upon raising awareness and advocating for the necessity of addressing the reproductive health (RH) needs of adolescents. Recent research indicates, that adolescent knowledge of R&SH issues is minimal. In addition, there is sufficient evidence to suggest that ado- lescents are increasingly engaging in unprotected pre-marital sex, result- ing in unwanted pregnancies with a high incidence of abortions and an increase in the STD/HIV prevalence. Furthermore, adolescents and young people account for as much as one third of the total population of the countries studied, representing a substantial target group of which the RH needs are insufficiently or not at all addressed. Main Lessons learned: • Adolescent Reproductive and Sexual Health Services need to be 5 complementary and integrated • Adolescent Reproductive and Sexual Health Services are more successful when they are designed in a ‘youth-friendly’ manner • Integration into other activities makes RH more attractive to young people • IEC campaigns with mass media involvement play an important role in spreading information on Adolescent Reproductive and Sexual Health and backing up the use of (A)RH services • Adolescent Reproductive and Sexual Health programmes cannot take place without the involvement of gatekeepers • Different target groups require different, tailor-made approaches • Peer education is a powerful tool under certain conditions • Youth should be involved from the start in strategy design and project formulation • Advocacy is required as a groundbreaker for Adolescent Reproductive and Sexual Health information and services Adolescent Reproductive and Sexual Health Services need to be com- plementary and integrated: There is a need for linkages between providers of RH information on the one hand, and those offering services on the other. A dysfunctional referral network between the two may discourage young people from seeking further services. For example, experience in Viet Nam showed that referring young people to public hospitals, where they were not received well, discouraged them from returning. An alter- native may be for the existing RH centres to provide a wider scope of services. The project in Sri Lanka, found that one of the keys to successful work with young people is to supplement counselling with other RH services through establishing linkages with medical personnel for referral. This system is supported by volunteers who create awareness at community level on AR&SH needs. The Youth Centre in Lao PDR is an illustration of this lesson, successfully combining both RH information and services. Adolescent Reproductive and Sexual Health Services are more success- ful when they are designed in a ‘youth-friendly’ manner: All projects in the four countries have revealed a strong need and demand for RH infor- 6 mation and services designed specifically for young people. One of the most important elements here is to ensure the confidentiality of the clients in order to gain and retain credibility amongst the target group. Some RHI project clinics in Viet Nam, have established an anonymous regis- tering system to ensure client privacy. If clients do not want to disclose their real names, they can choose a fruit as their name instead. The projects in Cambodia experienced that youths were willing to seek services in a clinic, providing the atmosphere was favourable and the opening times and location were convenient. In Hanoi, for example, the fact that a clinic was located in the middle of a crowded market place where market women sit waiting for customers was a barrier to young women seeking services, as they were uneasy about being watched entering the clinic. Training the service providers in skills needed to deal with ado- lescents was undertaken in all countries, and has proven to be instrumental in building trust between beneficiaries and service providers. In Viet Nam, young people expressed their wish to have a centre dedicated entirely to them, rather than shared with others. This, however, makes it difficult for the centres to achieve financial sustainability, as adolescents are seldom able to pay for services. Establishing different hours of operation for the two target groups appears to be a solution. Integration into other activities will make RH more attractive to young people: By combining RH service provision and/or RH counselling with activities that are appealing to young people, the services and project activities become better known and attract a larger segment of the target group. The youth centres in Viet Nam offer entertainment activities, which help to reduce the clients’ embarrassment and shyness when coming for services. Instead, they can “drop-in” to the bookshop and “on-the-way” seek counselling and services. This approach is applied in other projects too. In Cambodia, e.g., karaoke facilities and libraries make the centres an attractive place for young people to meet. The youth centre in Vientiane in the Lao PDR has more than 200 regular visitors attending activities, such as musical performances, language lessons, break dancing, etc. – in addition to participating in the RH training and peer education programmes. One of the lessons learned in Viet Nam is that it is important to provide information and counselling on a wide variety of topics that affect young people. The issue of trafficking of women and children was integrated into the discussions on reproductive rights during the training of peer counsellors. Peer educators are also trained to provide advice on personal relationships. This was also the experience in Lao PDR where the youth worker counsellors are regularly consulted on a range of issues, including 7 difficulties in the family, early sexual relationships and drug abuse. The peer education programme has focused on RH information, drug abuse and road safety issues as these were all identified by youth as being key issues affecting their lives. An interactive radio show in Cambodia, titled “Especially for You Young People” offers advice on various aspects of being young. An agony aunt and an “older brother” answer young peoples’ questions in a live call-in show, providing a good medium to reach the target group. IEC campaigns with mass media involvement play an important role in spreading information on Adolescent Reproductive and Sexual Health and backing up the use of (A)RH services: To complement individual counselling, the RH projects have found the use of mass IEC materials beneficial to reaching large numbers of young people. A regular radio soap drama “Lotus on a Muddy Lake” combines everyday topics with advice and information on general health topics and R&SH. It is well-known and popular throughout Cambodia and has reached many young people, as well as older age groups. In Viet Nam, promotional activities have been implemented via a variety of media, including newspapers, television and the distribution of information leaflets. The most appropriate and most cost effective mass IEC methods are identified by carrying out surveys of clients seeking individual services and information as a result of the campaigns. In Lao PDR, two RHI projects have sought to address the specific RH needs of ethnic minority youth. IEC materials have been especially devel- oped or modified for use with non-literate adolescents in the northern provinces of Luang Namtha and Oudomxay. Many projects have stressed the positive synergy resulting from the sharing of IEC materials with RHI and non-RHI projects. In the Lao PDR, the sharing of IEC materials and the participation of non-RHI Government partners in key training courses has helped raise the profile of ARH within the national RH programme. Key materials have also been repro- duced by the Ministry of Education for use as teaching aids to support the national curricula on population/RH and sexual health education. Adolescent Reproductive and Sexual Health programmes cannot take place without the involvement of gatekeepers: The active consultation and involvement of gatekeepers, such as teachers, parents, relatives, in-laws, and community leaders has been a key to success in all of the RHI projects. This is especially necessary due to the particular sensitivity of the subject of AR&SH. In Sri Lanka, the experience with elders and leaders with regard to AR&SH was surprisingly positive; fears of creating controversy 8 were found to be baseless. R&SH counselling for adolescents is new to Sri Lanka, which is why the project implementers approached the gate- keepers with great caution. After a positive environment for R&SH coun- selling had been created, the projects found that a great number of youths seeking R&SH services and information had been encouraged to do so by their parents and relatives. An innovative approach was taken in involving gatekeepers in Battambang, Kratie and Prey Veng in Cambodia, where the RHI project in these areas managed to obtain the support and the active involvement of Buddhist monks. As the monks are highly respected within the community, their consent for the project and their part in advocating messages related to youth and R&SH have greatly contributed to the project’s success in reaching young people. In a different project in Cambodia, the support of Cambodia’s growing garment sector was obtained, enabling the project to provide R&SH services and information in the factories. After a long period of negotiation and advocacy with the Garment Manufacturers’ Association of Cambodia (GMAC), a shift was observed from initial sus- picion and hostility on the part of the factory owners and managers, to the project receiving requests from other factories to carry out similar activities. Different target groups require different, tailor-made approaches: Youths and adolescents are not a homogenous group. Certain project activities and messages need to be adapted to the particular needs of individual groups within this target group. In the Lao PDR, for example, a project in Luang Namtha Province addressed the lack of appropriate IEC materials for ethnic minority youth, by developing materials, which include illustrations of people wearing clothing, typical for the particular area. All countries have experienced that different age groups need different information and services. For example in Viet Nam, adolescents under the age of 17 were mainly interested in information on puberty, body changes, friendship and non-sexual relationships. Young people between the ages of 19 and 24 are more sexually active and, therefore, need practical information on the reproductive system, reproductive tract infections, and advice and counselling on safe sex and contraceptive methods. Peer education can be a powerful tool under certain conditions: The widening gap between generations has been found to hamper effective information exchange and communication on the subject of RH. There- fore, a number of projects in the four countries involved counsellors and peer educators rather than parents and teachers in reaching other adolescents. The selection of peer educators and the way they are trained can have a 9 substantial impact on the success of the project. In Viet Nam, experience has shown that female adolescents can be very effective in encouraging male adolescents to participate in discussions on R&SH. At the same time, the lack of male peer educators and counsellors, necessary to provide one-to-one counselling to their peers, is reported as a serious constraint by many projects. Projects also cite the rapid turn-over of peer educators who work on a voluntary basis as an obstacle. A Vietnamese project at Van Hien University found, that students reading Psychology and Sociology made very professional peer counsellors, as this activity is very similar to what they aim to do professionally after graduation. In Sri Lanka there was a definite need to have younger coun- sellors from the same age group which is targeted by the project. Involve youth from the start in strategy design and project formulation: By involving youth in the project design and preparation, the development of IEC materials, programme management and other activities, the projects gain credibility within the target group and stand a better chance of being relevant to the young people concerned. A particular lesson learned by an RHI project in Cambodia, was that increasing the involvement of young people with low formal educational qualifications helped to empower these youth and has contributed to the development of skills, that otherwise might not have been attained. The model of peer education developed in the Vientiane youth centre in Lao PDR builds on the knowledge and confidence gained by youth who have already participated in a basic RH training course. Training course graduates are encouraged to become peer educators, and then participate in further training where they are supported to identify and select their own topics, materials and activities for disseminating RH and other infor- mation to their peers. Advocacy as groundbreaker for AR&SH information and services: The issue of AR&SH is very new to the countries in which the RHI operates. Before the inception of the RHI in Lao PDR, the R&SH requirements of adolescents were not recognised as such by existing national programmes. Initially the RHI activities focused on raising awareness of these needs. Three years later, this has changed significantly, and there is now a wide recognition of the needs of youth for RH information and a growing acceptance of the need for services for adolescents. As a result of the awareness raising activities in Sri Lanka, the Ministry of Education has introduced a small-scale pilot scheme on teacher coun- selling. This constitutes a first step towards the institutionalisation of 10 counselling in schools. The project co-ordinator attributes the success of the project as a whole to their preceding advocacy activities at different governmental levels. In Cambodia, the government is supportive of NGOs and there are no legal or policy hindrances to working with youth. In fact, a few key individuals from the government actively support the RHI programme. Nevertheless, RHI project managers have expressed, that their work would benefit from increased sensitivity to and familiarity with AR&SH issues on the part of government agencies. 4.Community-Based Activities in Nepal and Pakistan RHI activities and projects in Nepal and Pakistan have focused on strengthening community-based RH information and services to improve the RH status of men, women and adolescents. Both RHI country pro- grammes involve large numbers of grass root level NGOs and community- based organisations (CBOs), including mothers groups and youth clubs to increase the awareness of RH in remote and under-served rural areas and among marginalised urban populations. Building the capacity of these groups and organisations has therefore received major emphasis in the programmes’ work. Considerable efforts have been made to estab- lish a high level of community ownership in the various RHI projects in order to reach a minimum of sustainability of the project activities beyond RHI funding. Main Lessons Learned: • Community-led consensus is the corner stone of community ownership • Community ownership is a condition towards achieving programme sustainability • IEC Materials have a complementary role in creating awareness and understanding of RH • Innovative approaches are needed to attract and reach under-served target groups • Commitment and motivation can change traditional beliefs and practices • Effective Network Building leads to synergy and optimal use of 11 available resources for harmonised approaches in addressing RHI goals Community-led consensus is the corner stone of community owner- ship: Before the delivery of RH information and services commences, apprehensions about outside influences on the community’s youth and women must be addressed with the community leaders. The need to prepare the groundwork with the target community members before the start up of any non-local intervention, was particularly stressed by the RHI in Pakistan. This holds especially true, when approaching adolescents. Accordingly, the RHI in Pakistan found, that the best way to reach young people in a country, where the diffusion of RH information needs to be handled with utmost caution in view of local sensivities, is to consult with village elders and local religious leaders in order to reach a community led consensus, well ahead of the start of project activities. Community ownership is a condition towards achieving programme sustainability: The management of project activities by the community, as well as active involvement of community members, leads to stronger interest in the progress and achievements of projects. Generating support from within the community is crucial for the sustainability of the project. This is one of the fundamental conclusions drawn in Nepal, where meas- ures have been taken by the local community to ensure that the project activities will continue beyond the end of the RHI.. When one of the projects in Nepal started its community empower- ment activities in urban slum areas, it attached great importance to train- ing community leaders and health volunteers in such a way, that they would be able to independently carry out RH services without having to rely on outside sources of technical support. Furthermore, each commu- . nity was encouraged to open bank accounts and to charge nominal fees for health services and materials provided by the project. This has ensured . that a minimum of financial support will continue after the project’s end. The role of the project workers has changed during the course of the project. At its inception, they were mainly involved in mobilising the communities. However, once the Community Health Centres (CHCs) and the Community Health Service Committees (CHSCs) were in place, the project workers took on a more advisory role, providing technical assistance as and when needed. IEC Materials have a complementary role in creating awareness and understanding of RH: The use of relevant information, education and communication (IEC) materials is an essential component of a holistic 12 approach towards changing attitudes regarding RH. They serve to illus- trate ideas, deepen the understanding of and complement messages and concepts related to RH. Appropriate IEC materials can greatly facilitate the transfer of knowledge and information in many different settings including training and counselling sessions and health education classes in schools. A particular success in this field has been the Jigyasa newsletter, produced by the RHI Umbrella Project in Nepal. The newsletter, which provides information on RH, has reached adolescents from varied back- grounds. Informative articles, comics, serialised stories, brainteasers as well as a doctor’s column and contributions by adolescents are included in the newsletter, making it appealing to all readers, in particular to ado- lescents but also to other youths, parents, teachers and health workers. Before publication, each issue is tested; feedback is sought from adoles- cents, but also from parents, teachers and health workers to ensure an appropriate and culturally acceptable, yet varied and relevant content. More comics and picture-illustrated stories were included in the second and subsequent newsletter issues as per the request of low-literate/illiterate adolescents. Via the publication of contributions from adolescents, Jigyasa allows an exchange within the target group itself. The newsletter is extensively used by RHI partners, other NGOs and government organi- sations, in their training and awareness raising programmes. In order to enhance male participation in RH activities, a booklet on male involvement was produced by one of the RHI partners, while another partner produced two leaflets on infertility and delivery care aimed at strengthening RH awareness raising on these two important RH topics. In Pakistan, the pictorial IEC material developed by the Reproductive Health Alliance (RHA) under the RHI, has been adopted by the Ministry of Population Welfare (MoPW) for use in its Family Welfare Centres – an important example of the groundbreaking work of the RHI. In conclusion, appropriate IEC materials that are culturally and socially sensitive will enhance the quality of information exchange and the receptiveness of the target audience towards RH messages. Innovative approaches are needed to attract and reach under-served target groups: In Pakistan, one of the RHI partners has used a general healthcare oriented strategy as an entry point for building goodwill and discussing RH issues. Field workers reach out to families and, once a relationship of trust is established, all aspects of RH are covered. As a result, the four community-based distribution (CBD) projects have man- aged to win the confidence of community members, and the linkages developed during this period between the community and field workers 13 have become so strong that women have now started discussing and seeking assistance and guidance on issues other than health. In addition, unmarried community girls (who would not normally be allowed to leave their homes to work) have been empowered and are now delivering RH services and information through the door-to-door CBD system, strength- ening their self-confidence in the process. A large NGO in Nepal has established under the RHI, 15 youth infor- mation centres in five districts, which cater especially to the needs of their main target audience: young people between 12 and 24 years of age. The centres provide a stable and conducive atmosphere and a meeting point for adolescents and youths from different backgrounds, as well as for the 216 peer groups formed under the RHI. These groups are either all male, all female or mixed groups comprised of young people. To attract the interest of young people various approaches are used to raise aware- ness of RH issues. IEC and reading materials on health and development issues are readily available in the centres, but also games, video shows, group discussions and individual and group counselling sessions are used to faciliate communication and information sharing on ARH. Mobile video shows and street drama have also proven to be very popular and effective in transmitting RH messages to under-served rural population groups in Nepal including adolescents and youths. These video shows and street drama performances usually attract crowds from a diverse back- ground – male and female, children and adults, literate and illiterate. They use the local language and take into account local cultural and social norms, whilst getting across key messages on health and development. Direct interaction between the drama players and the public is actively encouraged and enables the actors to immediately respond to issues not well understood. Similarly, opportunities for questions and discussions immediately after the video shows ensure that additional clarification is provided as and when required. Teachers and school children have had the opportunity to gain access to RH information and services through various RHI interventions. The visit of a 12-year old school boy to an RHI-run clinic prompted a counsellor to bring the need for RH education to the attention of the school’s principal. Intensive training of teachers led, at the request of the principal, to the provision of RH education classes at the school. Commitment and motivation can change traditional beliefs and prac- tices: In Nepal and Pakistan many communities continue to respect strict socio-cultural and religious traditions – existing beliefs may forbid 14 family planning while knowledge on RH conditions is limited and not openly discussed. Nevertheless, motivation to improve RH within the community is increasing and, thanks to the commitment of organisations and community members alike, the mobilisation of community resources for RH activities and dissemination of RH information has been increas- ingly successful. The case of a pregnant woman in Nepal highlights this accomplish- ment. Counselling on family planning and RH at an RHI clinic made her realise that the quality of her life, as well as the lives of others, could be improved if she had access to family planning methods. Through her awakened interest in the work of the clinic, she became motivated to become a family planning and RH volunteer. Despite initial opposition from her husband and family, her motivation and commitment to the cause paid off with astounding results. Her role as volunteer became a paid job, enabling her to generate income for her family and send her children to school. She furthermore managed to overcome the obstacles of a society where men and mothers-in-law dominate as decision-makers. Thanks to her efforts, her husband now uses condoms and she has man- aged to distribute more than 6,000 condoms within her community. In Pakistan, one of the projects in DG Khan province has achieved impressive results with its CBD team, that it is viewed as a model CBD programme. Responding to initial community resistance to the setting up of the clinic, the project launched a campaign addressing the local religious leaders and community elders. Resistance was overcome by explaining and providing information on health issues. With the help of Male Motivators, community acceptance has now become so great that men (traditionally a reticent group to RH) are coming to the clinic in ever-larger numbers. The clinic in DG Khan now performs the highest number of vasectomies in the Province. Elsewhere in Nepal, 2,187 CBOs with a membership of more than 24,000 women, were empowered with RH knowledge and social mobi- lisation skills via RH training and regular meetings, facilitated by the RHI. Whilst these women attend meetings and/or are involved in RH aware- ness raising activities, their husbands support these community-based RH promotional activities, either directly or indirectly by taking over household responsibilities. Furthermore, revolving funds for emergency health care have been established by the project communities, and the easy access to funds thus achieved, has reduced delays in seeking adequate health care in case of obstretic and other emergencies. Effective Network Building leads to synergy and optimal use of avail- 15 able resources for harmonised approaches in addressing RHI goals: The establishment of two working groups, RHA and Adolescent Health Awareness Network (AHAN) is the result of an effective NGO collaboration in Pakistan. Through these two networks local NGOs collaborated in the development of pictorial IEC material on male involvement in RH and training manuals for literate adolescents, their parents and service pro- viders. The message contents included in the IEC material are based on research carried out by the partner NGOs in their target communities. The IEC material was later tested in the partner NGOs’ communities to ensure its cultural appropriateness. The material developed via this collabo- rative effort has been very well received by the communities; other NGOs working in Pakistan have requested copies for use in their communities. As a result a large audience has benefited from these appropriate IEC and training materials. The pictorial IEC material developed by the RHA has been selected by the MoPW for use in its 1,700 Family Welfare Centres, where it will be made available thus contributing to the harmonisation of approaches adopted by the various agencies active at grass root level. Similarly in Nepal, effective linkages and networking between RHI partners, other NGOs and government systems have resulted in sharing of resources and increased effectiveness and efficiency of project imple- mentation. Moreover, the Department of Health Services, Ministry of Health, has made FP and IEC commodities available for distribution by RHI partners and has pledged continued support. Furthermore, the link- ages established at various levels with government officials, including the government health structure, has resulted in a high degree of political and social commitment to sustain viable and successful interventions. Finally the 91 CBOs trained by one of the RHI projects in Pakistan function at the community level, and the information and services provided by these CBOs has been instrumental in changing community attitudes to RH issues. These CBOs have brought about attitudinal and service delivery shifts from FP to RH in their communities. Acceptance by the community has been so complete that the local communities are offering community facilities to enable the projects to improve their performance and continue activities. In 1997, the European Commission (EC) and the United Nations Population Fund (UNFPA) launched the Initiative for Reproductive Health in Asia (RHI). This EC/UNFPA Initiative provides financial support over a period of five years to reproductive and sexual health (R&SH) activities and services in Asia, in line with the recom- mendations of the International Conference on Population and Development (ICPD) held in Cairo in 1994. What makes the Initiative stand out from other projects and programmes is its main strategy to work through local civil society organisations, in partnership with international and regional non-governmental organisations. With this approach, the RHI aims not only to bring R&SH information and services within the reach of populations in South and South East Asia, that are so far not served or are under- served, but also to maximise the impact of each individual organisation and the RHI programme as a whole. This Initiative represents one of the largest programmes supported by the EC in collaboration with UNFPA in the field of population and reproductive health. The production of this “lessons learned” publi- cation is a collective effort of the RHI partners, co-ordinated by UNFPA with the assistance of the “Information and Communication Network” (ComNet), an RHI regional dimension project executed by the German Foundation for World Population (DSW). For more information on the RHI, please consult Mr. Jemai (RHI Project Manager) jemai@ unfpa.org and Ms. Goppel (RHI Technical Co-ordinator) firstname.lastname@example.org and the RHI web site www.asia-initiative.org or contact email@example.com.