INCREASING COMMUNITY-BASED ACCESS TO FAMILY

PLANNING

Innovative Models, Successes, and Challenges

Moderator: Victoria Graham

Reconvening Bangkok: 2007 – 2010Progress and Lessons in Scaling-Up FP-MNCH

Best Practices in AMEMarch 2010

Rationale for Renewed Focus on Community-level FP Provision

• Additional & alternative providers and points of service are critical for progress

• Addresses health worker shortage and long distances/wait time at overburdened facilities

• Evidence shows community provision increases FP uptake

• Essential to reach urban and rural population with community-based programming

Four Key Strategies for Community Access

• Community health worker provision of FP services including injectables

• Outreach or mobile clinics/teams to provide FP including LAPMs

• Increased access to FP services at clinics and outposts

• Pharmacy/drug shop sales and provision of FP methods including injectables

Presentation Outline

Jeff Spieler (USAID/USA)Community Health Workers Provide DMPA

Hedayetullah Mushfiq (MSH/Afghanistan) Scaling-Up the Use of DMPA at the Community Level

Bimala G.C. (Family Health Program II/Nepal)Increase Access/Utilization of FP Services through

CHWsHamouda Hanafi (Pathfinder Int’l/Yemen)

Mobile Health Teams as Outreach Solutions to Improve Access to Care for Underserved Populations

TBD (USAID/Nepal)Family Planning Social Marketing

Community Health Workers Provide DMPA

Jeff SpielerSenior Advisor for Science and Technology

Office of Population and Reproductive HealthBureau for Global Health

USAID

Technical Consultation, Expanding Access to Injectable Contraception, June 2009

Convened by WHO, USAID, and FHI in Geneva; 30 experts from 8 countries and 18 organizations

Objectives:– Systematically review scientific evidence and

program experience on the provision of injectables by CHWs.

– Reach conclusions on evidence to inform future policies and programmes and identify research needs.

– Document conclusions, including policy and program implications and disseminate widely.

Conclusions

Overall conclusions and policy implications:• With training, CHWs can screen, initiate DMPA, counsel,

and provide reinjections with equal competence • CHW provision of DMPA expands choice and access for

underserved and increases uptake• Sufficient evidence exists for national policies to support

introduction, continuation, and scale-up

Programmatic guidance:• Monitoring CHW competency in screening is needed• Supervision of providers enhances skills and confidence• Auto-disable syringes should be used • WHO guidance should be followed regarding eligibility

Broader Implications

A key strategy to address health worker shortages: – “Task sharing” refers to allowing appropriately trained

health workers with less formal medical training to deliver the same services as those with more training, where appropriate.

– CHW provision of DMPA is one example of task sharing that has potential to relieve overburdened health systems and positively impact development, family planning utilization and women’s lives.

– CHWs currently provide DMPA in more than 12 countries.

Policies and operational guidelines should reflect that trained CHWs can initiate use of DMPA and provide reinjections.

Scaling-Up the Use of DMPA at the Community Level in

AfghanistanHedayetullah Mushfiq, Program Manager, Tech-Serv

ProjectManagement Sciences for Health - Afghanistan

Community support• Involve Shura-e-Sehie

(Community Health Councils)

• Family Health Action Groups

Birth spacing promotion• Culturally appropriate• Correct misconceptions

Access to female CHWs• Skilled CHWs• DMPA counseling• Technical competence in

providing DMPA• Community maps

Contraceptive choice• DMPA first injection

Train volunteer CHWs to provide access to DMPA for all Afghan women regardless of where they live

Strategies and Approaches

Challenges and Successes

Challenges • Prior to 2009, CHWs could only give 2nd and subsequent doses

of DMPA and could not give the first dose• Only 8% of Community Health Supervisors are female, yet more

than half of CHWs are women• Even after CHWs were allowed to give the first injection, many

NGOs were reluctant to implement this policy Successes • Trained 21,226 volunteer CHWs in all 34 provinces during 2004-

2009 regarding DMPA, OCs, and condoms and supplied them with all three methods

• Increased CPR from 26% in 2006 to 42% in 2009 in 13 USAID-supported provinces

• Developed a new national policy in 2009 that permitted CHWs to provide the first dose of DMPA, using a screening checklist

CBD of DMPA/FP in Afghanistan

0

20000

40000

60000

80000

100000

120000

140000

160000

180000

200000

2005 2006 2007 2008 2009 (two quarters)

21Non-USAIDProvinces

13 USAID-Supported Provinces

The WholeCountry

Recommendations/Advice

• Conduct more frequent post- training follow up, monitoring and supervisory visits to health posts (where CHWs are based)

• Strengthen coordination among HSSP, MoPH, Tech-Serve, NGOs and other stakeholders

• Correct misconceptions about FP (especially DMPA) at the community level

• Conduct advocacy meetings at national, provincial, district and community levels regarding DMPA

• Orient Shura-e Sehi to mobilize communities regarding support for improved access to FP including DMPA

• Train CHWs in the 21 non-USAID supported provinces to give the first dose of DMPA

Increase Access/Utilizationof FP Services

in Rural Nepal through CHWs

G.C. BimalaPerformance Improvement Program Officer

Family Health Program II - Nepal

Increase Access/Utilization of FP Services in Rural Nepal through CHWs

Strategies and Approaches

• Involvement of District office - DIP

•Clinical site Preparation

•CTS for Trainer•Training of CHW

• FP Services– Counseling – Condom– Pills– DMPA – Referral

• Contraceptive

availability

CHW: accessible, available, understand

social-cultural context

Challenges and Success

Challenges

– Getting adequate caseload for clinical training– Not enough clinical trainers at district level– Conducting post training FU; monitoring and supervision

(district supervisors not competent)– Linkages with community service delivery interventions

Successes

– Decentralized clinical training; Trained 2,218– Expanded to 26 districts, 9 more already on going planned– Current user increased – pills (30%), DMPA (9.4) after

training– Most (72%) providers felt improvement in counseling – Improved availability of condoms, pills, DMPA - 99% (06/07)

Contraceptive Use Before and After Training

533 464

1800

2160

0

500

1000

1500

2000

2500

Pills Depo

Fig.1: New acceptors before and after training

13511764

5770

6312

0

1000

2000

3000

4000

5000

6000

7000

Pills Depo

Fig. 2 Current users before and after training

BeforeTraining

AfterTraining

Recommendations and Advice

• Scale up training to CHWs to increase access of services, especially in remote areas

• Consider number of trainees per batch according to client flow.

• Improve linkages with community (e.g. Mothers Group) and out-reach activities (EPI, PHC-ORC) for service delivery

• Strengthen post-training FU/support through district team

• Ensure continuous supply of FP commodities to CHWs.

Mobile Health Teams as a Community-Based Outreach

Solution to Improve Access to Care for Underserved

PopulationsHamouda Hanafi, Director

Basic Health Services ProjectPathfinder International - Yemen

Strategies and Approaches

• Growth of health facilities in Yemen without appropriate human resources & equipment.

• 70% of Yemen population live in rural areas that do not attract medical staff / hard to reach

• Mobile teams serve understaffed health facilities

• Provide integrated services, medicines, referrals

• Midwives: best for supporting FP provision

Challenges & Successes

Results: • First encounter with MD for many women • 11,000 clients/yr on average = 45 a day• Scale-up by USAID and World BankChallenges: • female doctors, security, medicines,

maintenance, financial sustainability

Recommendations

• Cost effective solution to lack of human resources• Can support specific interventions such as FP or

immunization• Schedules and approaches can be adjusted

Increasing Community Access to Family Planning Through Social

Marketing Programs

Sitaram DevkotaUSAID/Nepal

Strategies and Approaches

• Traditional Outlets and Non traditional Outlets• Sangani Social Franchise Network• Pariwar Swasthya Sewa Network • Traveling rural field representatives• Sangini Didi Neighborhood Program

(women’s groups )• Village Marketing Program (VMP) • Ensuring Quality of Service Delivery

Recommendations

• Work in close coordination with government• Working with traditional and non-traditional outlets

increases sustained availability of health products.• The “Sangini” network model has proven itself as a

successful model for expanding access to injectable contraceptives in Nepal

• Strengthen traveling rural field representatives to increase access to hard to reach population

• Mobilize Community-based Organizations (CBOS) through Village Marketing Program (VMP)

Success of Social Marketing Program Couple Years of Protection (1978-2009)

445,801

313,560284,075

252,778

127,57093,206

47,17030,222

2,263

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

500,000

1978 1983 1986 1994 1998 2005/2006

2006/2007

2007/2008

2008/2009

Questions and Comments

Thank You!