Claudia S. Morrissey
Linda Sanei
Publication Date
September 1, 2007

This 50-page evaluation report shares the work of an evaluation team tasked by the United States Agency for International Development (USAID) to examine the growth, influence, and results of the White Ribbon Alliance for Safe Motherhood (WRA) since its inception in 1999. The WRA is described as "a global grassroots movement for safe motherhood that builds alliances, strengthens capacity, influences policies, harnesses resources, and inspires action to save women's lives everywhere." To assess it, a 2-person team conducted the evaluation over a 7-week period from June to August 2007. Data were gathered through a variety of techniques: document mining; semi-structured, in-depth in-person and phone interviews; fielding of a questionnaire with response analysis; group observation; stakeholder question and answer sessions; and a field visit to India, one of the WRA national alliances (NAs).

Excerpts from the "Key Findings" section of the Executive Summary follow:
"...WRA has achieved impressive growth since its inception:

  • From a loose group of maternal health advocates with an idea, to a world-wide presence with formalized Mission, Vision, and Principles;
  • From a coordinator housed within a project to a fully independent not-for-profit organization;
  • From 35 to 2,025 individuals and organizations;
  • From 3 to 15 active national alliances (NAs);
  • From 0 to 26 state and provincial alliances; and
  • From 5 to 91 countries.

WRA is organizing in countries where reducing maternal deaths would significantly accelerate the achievement of a Millennium Development Goal: Reduce the maternal mortality ratio by three-quarters by 2015. Active NA countries contribute 48 percent of worldwide maternal deaths. If the NAs in Nigeria and Ethiopia were reactivated, that percent would increase to nearly 60 percent. In India and Tanzania alone, WRA activities are estimated to have reached over three million people.

...Strengths of the Global Secretariat (GS) and NAs
Universally, respondents commented on how committed the WRA leadership is to safe motherhood. Many noted that the most fundamental strength of WRA is the model itself, an organizational paradigm of inclusiveness, transparency, accountability, and shared decision making. There was resounding agreement among respondents on the impressive amount of work that has been accomplished by the WRA with few staff and limited resources in a short time span. NAs are characterized as uniquely collaborative organizations, able to bring together policymakers, providers, educators, NGOs [non-governmental organisations], activists, and community members on an equal footing. In the main, responders are impressed with the traction NA events and messaging has had with top policymakers. Several national leaders noted that WRA builds trust because it is not about selling itself as an organization but about an issue - a compelling issue - saving the lives of mothers and newborns.

Weaknesses of GS and NAs
Without exception, respondents felt that the GS is underfunded and understaffed....Some felt the GS needs to be less facilitative and more directive with the NAs....Many related that WRA monitoring and evaluation is weak, a weakness acknowledged by GS staff. NAs have also been perceived as weak at tracking progress and outcomes, especially at the local levels.


Building Coalitions
WRA has engaged multilateral and bilateral donors, government ministries, Private Voluntary Organizations, NGOs, USAID Cooperating Agencies, Global Partnerships, and Foundations, as well as film producers, journalists, and other individuals from over 90 countries. 'WRA provides a forum for people to channel their passion and energy around Safe Motherhood.'

Strengthening Capacity
Beyond individual technical assistance to emerging and established NAs, the GS has assisted NAs with organizing and hosting four Capacity Building Workshops in Zambia, Indonesia, India, and Malawi, and has produced three Field Guides. Topics covered include: key components of social mobilization and effective advocacy; how to build, structure, and govern an NA; how to undertake a strategic planning process; and how to write a proposal, prepare a newsletter, and use the media. Several NAs characterized these workshops and resources as essential guides for moving their country-level efforts forward.

Influencing Policies
WRA efforts have influenced country-level maternal health policies and financial outlays, contributed to the policy dialogue, and recruited champions for safe motherhood. For example, the Government of Burkina Faso has increased its health budget by 6 percent, and the Government of Tanzania has agreed to hire all graduating providers to address the severe health manpower shortage. The Government of India created a new cadre of birth attendants and adopted protocols and practice guidelines, developed under WRA's leadership, that expand the mandate of frontline providers to include life-saving skills.

Harnessing Resources
For a young organization, WRA has been able to attract and leverage an impressive amount of resources, such as volunteer labor, in-kind contributions, and financial support...

Inspiring Action
WRA has organized high-profile public events that have catalyzed action. The March to the Taj Mahal in 2002 resulted in the Government of India designating April 11 as 'National Safe Motherhood Day,' and sparked a reexamination of maternal health policies, services, and provider practice guidelines.

Contributions to USAID frameworks for maternal health
All WRA activities have contributed to USAID's strategic objective for maternal health. WRA has recently facilitated focused attention in Malawi, Tanzania, South Africa, and Zambia on USAID's maternal pathways — focused antenatal care, skilled birth attendance, prevention of postpartum hemorrhage, newborn care, and fistula prevention.

Key factors that auger well for sustainability are the commitment of WRA leaders, the degree of volunteerism at the GS and NA levels, the positive relationships with governments and donors, and the broad-based, multisectoral membership at the country level.

Monitoring and Evaluation (M&E)
This is an area that has lagged compared to other WRA efforts....Since incorporation, the GS has placed more emphasis on M&E and has developed several tracking tools. NAs have been trained in the use of the tools and have agreed to report to the GS twice yearly..."

Excerpts from the Lessons Learned section follows:

  1. "Passion, commitment, common purpose, and safe motherhood 'champions' within an organizational paradigm of total inclusiveness, transparency, accountability, and shared decision making is a dynamic model for change, expansion, and impact, which has limitless potential.
  2. Key ingredients to successful alliances are:
    • 'Organic' growth, the impetus coming from individuals and organizations committed to the issue of safe motherhood, not imposed but supported by the North;
    • Strong, committed, effective, trusted, and visionary leadership;
    • Policy champions at all levels;
    • Supportive, strong, and capable institutional and host home or secretariat;
    • Democratic, transparent processes and shared decision making;
    • Mutual respect and active participation of a broad-based, multisectoral membership;
    • Technical and advocacy expertise among membership;
    • Evolution at a pace that builds trust and cohesion;
    • Sharing of information, resources, challenges, and celebrating successes, both big and small; and
    • Sustained resources;
  3. WRA's successes have lent support for the use of social mobilization techniques as effective development tools....Strengthening the capacity of civil society to first expect and then demand health sector accountability is one of the most impressive outcomes of the WRA.
  4. Viewing NA members and organizations as experts who will be strengthened through targeted capacity-building creates the conditions for very productive partnerships....As funders require WRA to show 'results' within a short timeframe, it may be tempting to alter its commitment to civil society strengthening. But this operational approach is cost effective and more sustainable..
  5. Attending to monitoring and evaluation is vital for the future growth and financial health of the WRA....The GS has recently instituted a tracking system that should capture activities and outcomes at the national and local levels.
  6. Undertaking routine strategic planning is clarifying and reaps benefits. WRA carried out a well-planned and executed strategic planning process when deciding on which organizational structure to embrace. This exercise led to the decision to incorporate the alliance as a 501(c) (3)....The process undertaken was uniformly identified as democratic, transparent, participatory, and comprehensive.
  7. Tracking and presenting financial information in strategic ways for different necessary to confirm and communicate the robustness of the WRA to donors and supporters.
  8. USAID's vision to create 'a tidal wave' in safe motherhood was spot on. USAID's support has enabled the development of an organizational model that has the necessary ingredients to achieve even greater results. Sustaining some level of support for the core operational costs of the WRA is vital."

An excerpt from the Conclusions section follows:
"...The evaluators echo the responses of those interviewed: WRA has succeeded on all fronts. Perhaps the most salient conclusion that can be drawn from this evaluation is that mobilizing civil society in order to achieve sustainable, measurable impact - in this case, a lowering of MMR [the maternal mortality rate] - will require a very long-term, large-scale, labor-intensive effort. WRA - in only eight years with USAID funding that represents a mere one half of one percent of the Agency's over-all budget for maternal health - has achieved truly impressive outcomes in terms of mobilizing millions of stakeholders across the globe and realizing significant policy changes at national levels, certainly an auspicious beginning. Whether WRA will continue have any greater success over the long range at decreasing maternal and neonatal mortality and morbidity than other better-resourced attempts remains to be seen. The evaluators are betting that it will. As one interviewee put it, 'WRA is by far the best group that exists' for advocacy on safe motherhood. The evaluators agree and believe USAID is getting value for money."