Assessment of the CBD and YC
Projects of the Kenya/German
Reproductive Health Programme
Carolyne Njue
Consultant Researcher
Ian Askew
Population Council
September 2006
Table of Contents
Table of Contents ........................................................................................................................ i
Acronyms ...................................................................................................................................ii
Acknowledgements ...................................................................................................................iii
Chapter 1: Introduction .............................................................................................................. 1
1.1 Background ...................................................................................................................... 1
1.2 Objectives of the Assessment .......................................................................................... 1
1.3 Assessment Approach ...................................................................................................... 2
Chapter 2: Description of CBD and YC programmes ............................................................... 2
2.1 History.............................................................................................................................. 2
2.2 Current structure, size and functioning ............................................................................ 3
The CBD/YC Organizational framework .......................................................................... 4
2.3 Programme performance and agent productivity in the current 13 districts .................... 5
a) CBD programme ............................................................................................................ 5
b) YC programme .............................................................................................................. 9
2.4 Perceptions of the CBD programme .............................................................................. 11
a) Achievements............................................................................................................... 11
b) Problems identified ...................................................................................................... 11
Suggested solutions .......................................................................................................... 14
Chapter 3: Future directions for the CBD and YC programmes ............................................. 16
3.1 Recommendations for future strategic directions .......................................................... 16
3.2 Recommendations for revising GTZ’s community based programmes ........................ 17
3.3 Recommendations for operations research to re-orientate and re-organize communitybased RH programmes ......................................................................................................... 18
Appendices ................................................................................................................................ iv
List of people interviewed .................................................................................................... iv
Terms of reference of the consultant ..................................................................................... v
Work plan / time frame ........................................................................................................ vi
i
Acronyms
BCC
CBD
CBO
CBRHS
CPR
CORPs
CYP
DHMT
DED
DHMT
DMOH
DPHN
DDPHN
DRH
DMS
DMRIO
FHI
FP
FHOK
GoK
GTZ
GDC
HBC
ICTS
IEC
IGA
KEPH
KESPA
MIS
MOH
MYWO
NCPD
NGO
NHSSP II
PHMT
PMO
PMU
PMOH
PMTCT
PLO
PLWHA
RH
SDP
SHF
SSP
SWAp
TOR
YC
Behaviour change communication
Community based distributor
Community based organizations
Community Based Reproductive Health Services
Contraceptive Prevalence Rate
Community Owned Resource Persons
couple years of protection
District health management team
German Development Service
District Health Management Team
District Medical Officer of Health
District Public Health Nurse
Deputy District Public Health Nurse
Division of reproductive health
Director of Medical Services
District Medical Records and Information Officer
Family health International
Family planning
Family health options Kenya
Government of Kenya
German Technical Cooperation
German Development Cooperation
Home Based Care
Information, Communication and Technologies
Information, education, communication
Income generating activity
Kenya essential care package for health
Kenya service provision assessment survey
Management of information systems
Ministry of health
Maendeleo ya Wanawake organisation
National Council of Population and Development
Non-governmental organization
National Health Sector Strategic Plan II
Provincial health management team
Provincial Medical Officer
Project Management Unit
Provincial Medical Officer of Health
Prevention of mother to child transmission
Provincial Liaison Officer
People Living with HIV/AIDS
Reproductive health
Service Delivery Point
SANIPLAN / HEALTH FOCUS
Sector Strategy paper
Sector-Wide Approach
Terms of reference
Youth Counsellor
ii
Acknowledgements
We wish to thank the GTZ Kisumu staff for their hospitality and for assisting to set up the interviews.
We would also like to thank Phoebe and Rebecca for their invaluable assistance during fieldwork.
Special thanks also go to all those who gave up their valuable time to be interviewed or to participate
in group discussions.
iii
Chapter 1: Introduction
1.1 Background
Contraceptive prevalence (all methods) for currently married Kenyan women rose from 17% in 1984
to 27% in 1989 and to 39% in 1998, but has stagnated at 39% in 2003. The stall has been reflected in
a reversal in the rapid fertility decline that Kenya had been experiencing, and is most evident among
the least educated and younger women1. There has also been a shift in the method mix over time,
with a decline in the proportion of women using the pill, IUD, sterilization and traditional methods and
a dramatic increase in use of injectables. At the same time, the level of unmet need for family
planning2 has remained unchanged among currently married women at about 24% since 1998. There
seems to be little connection between overall changes in contraceptive use and perceived risk of
HIV/AIDS.
The support of GTZ to the Ministry of Health (MoH), Kenya began in 1986. In 1991 the project began
to support the Ministry in establishing a community-based system of contraceptive distribution using
volunteers. The strategy was based on training large numbers of lay community members recruited in
the catchment areas of a service delivery point (SDP) of the MoH. The majority of the volunteers were
trained in the western region, specifically Nyanza and Western provinces. This is the original and still
primary region for GTZ support, where high population densities combined with low contraceptive
prevalence rates (CPRs) create conditions threatening social and environmental stability. The main
goal was, therefore, the reduction of high fertility and increase in contraceptive prevalence in the
target districts.
However, a recent study by the MOH/GTZ of its CBD project3 shows a clear and consistent decline in
the numbers of contraceptives and condoms distributed through the project, a high drop out rate of
CBD agents and their engagement with other programmes, and possibly a reduction in their
productivity. There is now serious concern by the German partners that the project objectives might
not be met, and may be inappropriate for the immediate future given this changing environment. At
the same time, the Kenya Essential Package for Health (KEPH) is being formulated, which places a
strong emphasis on community activities and Community Owned Resource Persons (CORPS), and
so the achievements and challenges of the MOH/GTZ CBD strategy need to be documented to
provide guidance as this strategy is implemented. GTZ commissioned this assessment so as to be
able to achieve the following objectives.
1.2 Objectives of the Assessment
a) Review the community-based distributors (CBDs) and youth counsellors (YCs) supported
strategies and activities in terms of appropriateness, effectiveness and efficiency, and
sustainability.
b) Develop recommendations for urgent organisational and strategic questions regarding the
objective of the component, indicators, the work plan and the institutional set-up.
c) Prepare the way forward for operational research and strategic decisions regarding the role of
CBD in the Kenyan RH programme and the German support to this programme in line with
SWAp and CB-KEPH context and other ongoing changes.
1
Central Bureau of Statistics (CBS) [Kenya]. 1984. Kenya Contraceptive Prevalence Survey 1984. First Report.
Ministry of Planning and National Development. Contraceptive Prevalence Survey Programme; Central Bureau of
Statistics (CBS) [Kenya] Ministry of Health (MOH) [Kenya], and ORC Macro. 2004. Kenya Demographic and Health
Survey 2003. Calverton, Maryland: CBS, MOH, and ORC Macro. 38 p.
2
Women who would like to postpone their next pregnancy but are not using contraception, and women whose last
pregnancy was mistimed, are considered to have unmet need for family planning for spacing purposes. Women who
want no more children and are not using contraception, as well as women whose last pregnancy was unwanted, are
defined as having unmet need for family planning to limit fertility.
3
Status of CBD-activities, Annual report 2004, MoH/GTZ Reproductive Health Programme, Kisumu
1
1.3 Assessment Approach
The assessment included four components:
-
An extensive review of reports, annual strategic plans, relevant tools, manuals etc. made
available by the GTZ Kisumu office
-
An analysis of the programme HIS from 1990 to the 1st quarter of 2006;
-
Visits to all 13 districts in which the programme is implemented where interviews were held with
the following key informants:




-
Project Management Unit (PMU): GTZ/Kisumu staff, Project Liaison Officers (PLOs);
District Health Management Team (DHMT): District Public Health Nurse (DPHN) and
CBD/YC district focal point persons
Randomly selected CBD supervisors and key staff from SDP level
Representatives of selected organizations with FP CBD programs/experience;
Focus group discussions with CBD agents, former agents and YCs.
Chapter 2: Description of CBD and YC programmes
2.1 History
Kenya has a long history of using CBD as an integral part of its family planning programme. It adopted
the CBD strategy in the early 1980s, providing community based services through a variety of
institutional arrangements. The Family Planning Association of Kenya (FPAK) was the first
organisation to establish a CBD programme in 1982 and was followed in 1983 by Chogoria Hospital
and the Maendeleo ya Wanawake Organisation (MYWO). Throughout the 1980s and early 1990s, a
number of different organisations, including NGOs, CBOs, FBOs, the MOH and some municipal
authorities, developed CBD programmes with technical and financial support from a range of donor
and international technical assistance agencies. The programmes varied in the strategies they
applied, their geographical coverage, the number of agents involved, the catchment areas served by
the CBD agents, the links with clinics, their requirements for a medical examination for new pill clients,
the range of services provided by agents, and in the status, remuneration, recruitment and
supervision of agents. Two Population Council publications chart the progress of CBD in Kenya
through the nineties decade, the main period of growth of the movement, and document the main
areas of concern4.
The MoH/GTZ Reproductive Health Project remains the largest single CBD programme in Kenya.
Since 1990, it has promoted the CBD programme through MoH structures, initially through a pilot
project in Lamu district, Coast province. The major thrust of the program has been towards the
establishment of large-scale system of community-based distribution of contraceptives. This strategy
was based on training large numbers of lay community members in the catchment area of SDPs.
Implementation focused on the development of structures and skills to support the Division of Family
Health (now the Division of Reproductive Health) to support CBD agents in improving access to IEC
on FP, including a limited range of services (pills and condoms). The programme expanded steadily in
terms of the numbers of CBD agents and in the number of client contacts / CYPs achieved, reflecting
the incorporation of several new districts in eastern and western Kenya into the programme. By year
2000, a total of 20 districts were being supported; 4 districts in eastern province, and 16 districts in the
three western provinces5. The 16 districts have gradually reduced to the current 13 districts in
Western and Nyanza provinces6.
4
Mundy, J. and I. Askew (1994). Current experiences with CBD of family planning in Kenya”, ORTA Africa Project II,
Nairobi, The Population Council. Chege, J. and I. Askew (1997). An assessment of community-based family planning
programmes in Kenya, ORTA Africa Project II, Nairobi, Population Council.
5
Western region comprises Nyanza, Western and Rift Valley provinces.
6
Projects in Mt Elgon, Uashin Gishu and Trans Nzoia closed down. The 13 remaining districts include Vihiga,
Kakamega, Butere Mumias, Siaya, Lugari, Bungoma, Migori, Bondo, Rachuonyo, Suba, Kuria, Homabay and
Nyamira.
2
It is important to understand the context of donor funding in the 1990s. USAID was investing heavily in
CBD through its own cooperating agencies and local NGOs. However, when it withdrew much of its
direct support for CBD in 1996-97, the period of rapid growth was effectively over. The MoH/GTZ
collaboration also supported very little new training, while individual programmes either disappeared
abruptly (e.g., CHAK, KMYW) or were severely reduced in scale (e.g., FPAK, MYWO). Supervisors
were retrenched and the monthly allowance of Ksh.400/- removed in June 2000, leading to a further
discontinuation of CBDs. Fee-for-service was introduced in 1998 by some CBD programmes in
Kenya. However, MOH/GTZ only conducted feasibility studies on fee for service (willingness & ability
to pay for FP services) and the findings were never implemented.
CBDs had by this time made a substantial contribution to the family planning efforts in Kenya, and are
thought to have been associated with the rapid decline in fertility observed in Kenya over that period,
but programmers were beginning to perceive limitations with the approaches. In 2001, the focus of the
MOH/GTZ CBD activities in Nyanza and Western province were extended to address adolescent and
youth sexual and reproductive health (SRH) needs, through a peer education approach that involved
the training of youth counsellors (YC). Though linked through some common structures within the
GTZ/MoH programme, this is actually a separate approach from the existing CBD activities. Unlike the
CBDs, whose focus centres around education around family planning and distribution of and referral
for contraceptives, the role of the youth counsellors is a broader attempt to address the sexual and
reproductive health needs of young people holistically. The programme was developed initially
through collaboration with FHI in conducting a study on promoting dual protection through the condom
using youth counsellors. It targets youth in the age range 15 to 24 years and is implemented through
MOH facilities with existing community groups. Having the youth as the target group required
additional skills, through social mobilization, training and follow-up. The MoH partners in the
implementing districts also benefited by undergoing training in curriculum and IEC materials
development. Since its inception, YC projects have been established in 11 districts same as those of
the CBD programme in Nyanza and Western provinces.
In 2002, the inclusion of a strategy directing project support to the PHMTs, through the
operationalisation of the provincial Projects Liaison Office (PLO), was expected to ensure increased
effectiveness and efficiency in project implementation by the DHMTs, and ultimately the SDP and
community levels, but this objective is far from being realized. Implementation of the PLO strategy
evolved differently in Western, Nyanza and Eastern provinces. However, there were other broad
issues that affected the entire western region that also needed to be addressed, including diminishing
interest in the project by CBD agents and tighter budgets for the CBDs. Issues of sustainability were
thrust to the fore.
The MoH/GTZ subcontracted management of the CBD and YC programmes to SANIPLAN/HEALTH
FOCUS in 2005, a private consultancy firm based in Germany. Since 2000, the objectives and
approach of the CBD project were modified from a traditional FP commodity distributor approach to a
redefined service package that addressed reproductive health more broadly, highlighting issues of
HIV/AIDS, reproductive and sexual rights, women’s and youth empowerment and gender equality.
The aim was to refresh, repackage and motivate the programme through the following activities:
1) Access to CBD services improved – CBD replacement, recruitment, and an improved referral
system;
2) Quality improved through updates/refresher training for supervision, motivation, and data
management;
3) Increased demand for services through community mobilisation and social marketing.
2.2 Current structure, size and functioning
The current structure and scope of the programme is fully described in a 2004 Status Report prepared
by the Project Management Unit (PMU) 7 and so will not be described in detail here. In brief, GTZ
works in close collaboration with the MoH and other stakeholders at several levels. At the national
level, the Steering Committee fulfils advisory and coordination roles, while GTZ provides technical
support to the MoH at all levels of the CBD and YC programmes implementation. The MoH is also
7
Status Report of the MoH/GTZ Youth Counsellor Programme 2004 Project Management Unit (PMU), Kisumu,
MoH/GTZ Reproductive Health Programme.
3
responsible for implementation of new policies and guidelines through the Provincial Health
Management Teams (PHMT) and the District Health Management Teams (DHMT). At each province
and district, the PHMT and DHMT are responsible for the development of the provincial and district
annual work plan, based on the national policies and local priorities of health concerns.
The PHMTs have established Reproductive Health Teams, which work within the district teams. The
PMU in Kisumu manages the CBD and YC programmes through coordinating between MoH and GTZ
(through the Programme Liaison Officer (PLO), providing technical assistance, financial
disbursements, training, IEC materials, and supervision. In 2003, the PMU handed over to the PHMTs
responsibility for disbursement of programme funds to their districts. This shift of project support and
focus aimed at enabling the MOH to achieve responsibility and ownership of the programmes.
The CBD/YC Organizational framework
Moh Hqs.
DMS
Prov.
PMO
Current funding channels
RH team
NGOs
District
DMOH
MOH/GTZ
PLO
RH
team
NGOs
PMU
Previous funding channels
RH team
NGOs
District focal person
(DPHN/DDPHN/DMRIO etc.,)
CBD
Facility
i/c
Community
*From the Kisumu reports
CBD supervisors
RH team
NGOs
YC
YC supervisors
Steering committee,
advisory and
coordination role
Coordination, technical
assistance, monitor,
financial disbursement,
provision of training,
materials, IEC and
support supervision
Implementation level
(plan, oversee the
execution of CBD
activities, keep track of
CBD supervisors
performance and
expenditure details)
SDP level (CBD
agent’s motivation,
support and
supervision)
Trainers
RH team
CBD groups,
CBD agents, &
clients
NGOs
YC
groups, YCs, &
YC clients
RH team
RH team
NGOs
NGOs
Sensitize/lobby support
for and distribute
contraceptives, refer
clients, maintain activity
records, report activities
to supervisors
*Peer counseling (YCs)
Bottom-up approach
The District Health Management Teams (DHMT) are responsible for development of appropriate
supervision tools (such as checklists), supporting activities at facility level, resolving any conflicts
involving CDB agents, community and the facilities, lobbying for other support for CBD agents, and
ensuring contraceptive security. Within the DHMTs, these tasks often lie with the District Public Health
Nurses (DPHNs) who plan for, propose and organise regular updates for both CBD supervisors and
CBD agents and submit proposals to the PMU, keep track of the performance of supervisors and
keep record of the programme’s expenditures.
The DHMTs and the supervisors are the implementers of the CBD programme. The CBD supervisors
are health workers based at those rural health facilities that have been chosen as an SDP. The SDP
4
is the project focal point for planning and reporting for both the CBD agents and the YCs but they
carry out their activities anywhere in the community. According to project records, 1,400 CBD
supervisors have been trained and are responsible for motivation, support and supervision for CBD
agents in their areas of jurisdiction. When the YCs programme was introduced in 2001, the CBD
supervisors also took charge of supervising them. The CBD supervisor in turn reports to the district
CBD focal person (i.e. DPHNs, DDPHN or DMRIO).
The supervisors play a crucial role in motivating and guiding the CBDs and YCs. For example,
supervisors have encouraged their CBDs and YCs to form groups and to start various activities in
their respective communities, many of them income-generating activities (IGAs). Some groups have
even gone as far as legally registering themselves at their respective social services departments.
CBD agents are volunteers selected by the villagers to serve their RH needs in the community and as
a link with the SDPs. They mainly concentrate on distributing contraceptives (pills and condoms),
sensitising communities on their roles, and soliciting or lobbying community support for family
planning. They also provide referral services to their clients to the local health centres/dispensaries for
other FP cases and maintain activity records.
YCs focus on a broader understanding of adolescent SRH, including FP, but also sexuality and
relationship education, life skills and HIV&AIDS prevention. They carry out peer-to-peer counselling,
conduct group sessions and refer to the facility if need be. They have been involved in the distribution
and social marketing of the public sector branded SURE condom, as well as participating in youth
forums. They keep records of their activities and report to the supervisor at the facility.
2.3 Programme performance and agent productivity in the current 13 districts
a) CBD programme
The MOH/GTZ Reproductive health project has, over the past 15 years, supported the training of
approximately 13000 CBD agents for the entire Western and Eastern provinces. Approximately 8900
of them are from Nyanza and Western provinces. Additionally, 1,400 supervisors were trained in the
western region. The bulk of the CBD agents training took place during 1991-1999 period and included
an intensive two-week phased training. For supervisors, updates have been regular.
The programme performance and agent productivity as described here is limited to the current 13
districts under study, in Nyanza and Western provinces. Those districts that dropped off at any point
in time have not been included in the analysis discussed here, (for completeness and relevance).
Trends over the last 15 years, show that the number of new clients and revisits increased rapidly in
the 13 districts, peaking in the years 1997 to 2000 (figure 1), whereas the annual number of condoms
distributed reached 12 million by 1999 (figure 2). In 2005, the number of condoms distributed reached
3.2 million condoms; this translates to around 10 CYP per CBD in condoms, a praiseworthy
contribution to HIV-prevention. In 2000, the annual number of pills distributed, stood at 1.3 million and
by 2005, only 300,000 pills were distributed.
5
Figure 1: Aggregate number of new and revisit clients seen by CBD agents in the 13 districts
800000
New clients
Total Clients
revisits
700000
600000
500000
400000
300000
200000
100000
0
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Figure 2: Numbers of condoms distributed by CBD agents
Number of condoms
14,000,000
12,000,000
10,000,000
8,000,000
6,000,000
4,000,000
2,000,000
0
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Figure 3: Number of pills distributed by CBD agents
Pills distributed
1400000
1200000
1266340
1090827
1000000
1062490
800000
692851
600000
590820
400000
310895
200000
0
2000
2001
2002
Last 5 years
6
2003
2004
2005
In the last 5 years, the data clearly shows that the number of active CBD has been declining (table 1).
Of the originally trained CBDs (8,919), in 2005, only 27% (2,389) were still active and reporting. The
declining numbers of active and reporting CBD agents may have had serious implications in terms of
the volume of services provided.
Table 1: Number and proportion of active CBDs and mean outputs, by district
2001
2002
2003
2004
2005
Nyamira
1130
385
353
255
302
233
252
Kuria
396
147
164
121
107
118
106
Migori
913
549
469
353
247
177
131
H/Bay
476
168
182
208
227
190
205
Rachuonyo
828
288
161
288
152
151
52
Siaya
690
397
364
320
322
252
184
Bondo
275
177
149
119
80
81
41
Suba
501
319
292
334
322
296
197
Totals
5209
2430
2134
1998
1759
1498
1168
47%
41%
38%
34%
29%
22%
CBDs
2000
District
Original
Trained
Number and proportion of active CBDs
Kakamega
838
613
646
560
491
428
393
Lugari
308
173
162
155
141
140
123
Vihiga
882
375
378
371
349
293
257
B/Mumias
548
330
316
284
300
233
172
Bungoma
1128
486
664
486
499
410
276
Totals
3707
1977
2166
1876
1780
1135
1221
53%
58%
51%
48%
31%
33%
Clients/CBD
238
211
196
174
173
131
Pills/CBD
287
254
274
196
224
130
Condoms/CBD
2236
1605
1394
1406
1980
1344
Annual mean outputs
Table 2 shows that monthly outputs in 2005, on average each of the reporting and active CBD agent
distributed 11 pills, 112 condoms, recruited 4 new clients, made 7 revisits and 1 referral. As further
observed by the CS, this implies that one CBD on average ‘produced’ 8.8 CYP in pills, 8.96 CYP in
condoms, and 48 new clients, 84 revisits. This is low, but not extremely low.
7
Table 2: Performance of reporting and active CBDs by district in 2005
H/Bay
Rachuonyo
Siaya
Bondo
Suba
Kakamega
Lugari
Vihiga
B/Mumias
Totals
Migori
1130
396
913
476
828
690
275
501
838
308
882
548
1128
8916
No. of CBDs reporting
252
106
131
205
52
184
41
197
393
123
257
172
276
2389
Total pills distributed
26784
5453
15337
63188
2393
14580
4737
21560
52117
18063
35020
27888
23775
310895
Avge pills per CBD per mnth
9
4
10
26
4
7
10
9
11
12
14
14
7
11
Total condoms distributed
423808
151691
128729
379572
60500
290266
41723
346127
214650
197719
509638
227352
240156
3211931
Avge condoms per CBD per mnth
140
119
82
154
97
132
85
146
46
134
165
110
73
112
New Clients
10135
7266
4861
12369
1134
5384
1333
13617
14670
6466
10947
11655
7979
107816
Avge new clients per CBD per mnth
3
6
3
5
2
2
3
6
3
4
4
6
2
4
Revisits
18238
9190
8806
23185
1828
9217
2481
15666
33149
15830
25252
25145
16742
204729
Avge revisits per CBD per mnth
6
7
6
9
3
4
5
7
7
11
8
12
5
7
Referrals
856
832
1512
1557
175
2003
155
5982
1560
788
5489
1863
5001
27773
Avge referrals per CBD per mnth
0.3
0.7
1
0.6
0.3
1
0.3
3
0.3
1
2
1
2
1
8
Bungoma
Kuria
Nyamira
Originally trained CBDs
2005 CBD
Performance
b) YC programme
Since its inception the YC programme has achieved remarkable coverage very quickly. The reporting
rates and the number of active youths combined present the number of YCs actually involved in the
programme. The drop out rate between the numbers trained to those still “active” is high (figure 4). On
one hand, a decrease in reporting rates could mean that the trained YCs have stopped working, i.e. they
have dropped out due to factors like migration or lack of motivation; it could also mean that they are
“actively” working, but have decided no longer to report.
Figure 4: Continuity of YCs within the programme
900
779
800
700
573
564
600
173
174
207
233
170
187
200
226
253
300
282
320
400
407
452
500
100
16
21
23
0
2000
2001
2002
Trained
2003
Active
2004
2005
Reporting
Ps: the numbers of YC trained are cumulative
Figure 5 also shows an almost 10% per annum decrease in the YC reporting rate in both Nyanza and
Western provinces
Figure 5: Proportion of trained YCs that are still reporting
60%
50%
40%
Nyanza
30%
Western
20%
10%
0%
2002
2003
2004
Year
9
2005
YCs are important agents of change and resource and reasons for their dropout should be followed up.
Equally of concern is the measuring of the YC performance with CBD-performance indicators “Clients”,
“visits” and “distribution”. This is not really how YC activities should be measured, considering their wider
mandate, YC might be very active spreading information, generating knowledge or changing values.
In terms of outputs, though there has been an annual increase in the number of YCs trained, this was not
commensurate with the number of condoms distributed (figure 6).
Figure 6: Number of condoms distributed by YCs
Distribution of Condoms ('000) by reporting YCs
10000
9161
9000
8000
7000
5800
6000
4900
5000
4000
4700
3200
2800
3000
2979
1500
2000
1000
0
2001
No. of YCs trained2002
No. of condoms distributed
2003('000)
2005
Figure 7: Levels of YC activity by type over time
35000
30000
25000
20000
15000
10000
5000
0
new clients
revisits
individual counseling
2002
2003
10
2004
group counseling
2005
referrals
Figure 7 paints a mixed picture of the YCs’ performance. The numbers of new clients and revisits
fluctuate in 2002 and 2004 and reduce by over half in 2005. The numbers of individual and group
counselling sessions have increased over the years whereas the number of referrals increased in 2004
but dropped heavily in 2005.
In general, both the performance of CBD and YC programmes may have been jeopardised by the fact
that some of the district level staff in the programme appear to have been fairly inactive; it is not clear
whether low reporting levels are because of CBD agents or YCs not reporting, or whether supervisors
have not been submitting the reports onward to the PMU. At the time of this assessment, six districts
have been supported to provide refresher training for approximately 960 CBD agents at time of study
(Vihiga, Lugari, Butere/Mumias, Bungoma, Suba and Homa Bay), but according to Kisumu GTZ staff, this
is far below the desired target.
2.4 Perceptions of the CBD programme
a) Achievements
The CBD programme has been an important vehicle for addressing a myriad range of RH needs in the
community. Most respondents demonstrated a good understanding of the concept of community-based
distribution as a way of enhancing community participation in programmes to improve people’s life
situations. One DDPHN noted that CBDs are important because “they understand their people and
community better so they know them better and are able to communicate with them better”. Most
respondents also clearly understood that the programme objectives are to communicate information on
family planning, distribute pills and condoms, and direct clients to appropriate referral centres.
There was wide acknowledgement that the programme had brought contraceptives within easy reach of
many people, who no longer needed to travel long distances to obtain contraceptives. The benefits most
frequently cited were greater awareness about family planning and related health factors among women,
decreases in negative attitudes towards contraceptives, reduced induced abortion cases, and increased
likelihood of female condom use. In some sites, it was noted that the CBD programme had become a
useful tool for promoting marital contraceptive use; in Mbale, Vihiga District for instance, a participant in a
focus group session said that, “seeing married people visiting family planning clinics together has become
a very common thing today. Before this project came to this area, we never used to see such things
around”.
Many examples of linkages between the programme’s activities and those of the government and NGOs
working in the sites were given. The programme has opened training opportunities for agents and
supervisors. In Migori District for example, the CBDs have been integrated into public health activities as
community health workers, where by they are given some remuneration by the facility
and in Suba District the referral cards have been used by other groups for Integrated Management of
Childhood Illness (IMCI), home based HIV/AIDS care provision, and tuberculosis management.
The emphasis on using fertility-related measures for indicating programme performance was thought by
many to be limiting and inappropriate, especially with respect to HIV/AIDS. A wide range of factors
determines community fertility levels and relying on a single intervention to explain demographic changes
is likely to cause misleading conclusions. In addition, there was an almost universal agreement that the
recording and reporting system was inadequate to measure programme performance.
b) Problems identified
Health system and programme environment
MoH officials emphasised the issue of poor physical infrastructure within the provinces. In Siaya District,
for example, poor roads and long distances make it difficult for the timely delivery of contraceptives, which
partly explains the irregular supply of contraceptives.
The opposition faced by the CBDs from religious groups, especially the Roman Catholic Church, which
does not approve of artificial contraception, was another problem encountered during implementation of
the programme.
Gender was not accorded due consideration during the design and implementation of the programme.
There was, for example, an imbalance in the number of men and women CBD agents, and so the
11
programme worked differently for men and women in various sites. A DDPHN expressed this oversight:
“More women than men are trained, yet in the Luo community the woman has to be subjective. The
needs of men are not fully addressed by the female CBDs. It is hard for a man to disclose to a woman
reproductive health matters at a local level”. “Male involvement in family planning is necessary because
they are the decision makers when it comes to contraceptive use”.
The RH concerns of the people in the area have moved from family planning to other pressing issues like
home based care, HIV prevention, and STIs Poverty reduction and the economic status of both the service
recipients and the CBDs was not accorded sufficient consideration. Poverty emerged as a fundamental
matter with which the programme had to grapple and poverty levels have rendered volunteerism difficult. A
MoH official in Suba District succinctly wondered “How can you expect them to work for no pay yet there is a
lot of money being given out by NGOs working on HIV/AIDS in this area?”
On a more positive note, in Siaya District, a government health official reported, “men are now accepting
use of contraceptives and condoms due to economic issues”. These two examples are an indication that
the economic situation such as poverty in communities plays a significant role in spelling out whether RH
services are used and the level of community involvement to address them.
The impact of HIV/AIDS on the performance of the CBD/YC programme was not originally given the
weight it deserves, yet death or disability from HIV/AIDS appeared to be a major cause of drop outs
among CBDs. Moreover, as one supervisor pointed out, “the HIV scourge has reduced the number of
men to be reached”.
The influence of CBD activities on other related programmes was not adequately addressed at the
planning stage. It emerged that there were several RH interventions going on simultaneously in the
project sites, including family planning, safe motherhood and HIV/AIDS. This large number and range
activities may has rendered it difficult to determine whether the observed changes were as a result of the
CBD/YC programme activities or were due to the efforts of other related programmes.
Programme systems and services
The programme was initially very vibrant but has gradually become less active and is losing popularity.
Many CBD agents and MoH officials expressed some negative opinions about the project. To begin with,
the principle of volunteerism that underlies the programme is failing, as CBDs are calling for some form of
material incentives to sustain their motivation. One respondent suggested that this may be due to lack of
confidence in GTZ/Saniplan to honour some of the promises made earlier to the agents. For example,
CBD agents report that they had been told that they would be provided with travelling and lunch
allowances when attending meetings, but this was never done. On the contrary, the Kisumu project staff
report that CBDs and YCs are paid travelling and lunch allowances whenever they come for training not
monthly meetings8.
Many of the CBDs talked of being demoralized and for this reason, are less attentive to the programme
activities. Some have eventually moved to other programmes operating in their areas that offer monetary
incentives for their services. Demotivation seems to be an important cause of increasing dropout rates
and declining volume of services provided. Others reasons that cause CBD drop out were reportedly
migration, death, serious illness, inability to physically do the job, the desire of YCs to further their studies,
moving to other areas in search of employment, etc.
The age of the CBD agents and their interactions with clients has also not been given due attention.
Some of the CBDs have inadequate knowledge on FP, and especially the newer methods. “They
[referring to the CBD agent] are too old so people are unwilling to get the contraceptives from them”. As
summarized by the Suba District DPHN, “if we do not train and recruit new people it is dying [referring to
the programme]. Moreover, some of the CBDs that were selected in a public baraza simply dropped off
once their expectations failed to materialize.”
In several sites, apart from CBD work, both the CBD agents and MoH officials were entrusted with
multiple responsibilities. These include involvement in related programmes such as TB campaigns,
vaccination campaigns and home based care for PLWHA. As a result, it had become particularly difficult
8 Information on allowance payments is contradictory and should be followed up
12
for them to devote a lot of time to the CBD and YC programmes. Some CBDs no longer even recruit new
clients but wait for clients to come to them, further limiting program performance.
Another factor was the competitive environment within which they carried out their duties. Other players
have come into the field and offer the CBD agents and supervisors’ lucrative incentives and allowances.
As a result, most of them have thus shifted their commitment to these newer projects, especially on
HIV/AIDS.
The issues of method preference and cost sharing were cited as posing a threat to the programme’s
success. A majority of the people interviewed expressed the view that although the main method offered
was pills, many women preferred the injectable to oral contraceptives. Furthermore, the contraceptive
users were expected to meet part of the cost of obtaining them, yet they were able to acquire them for
free from some clinics. As remarked by the Bondo District CBD supervisor “it is hard to ask them to
charge for condoms as the community members will opt to go to the health centres where they get them
free of charge”. However, according to the Kisumu project staff, a research on fee for charge was
conducted between 1998-1999 by GTZ and showed that the community was willing to pay for these
products but there is no supporting policy for this practice. CBDs however sell the products as a way for
them to generate income (a packet of SURE condoms goes for 5-10 shillings while a packet of pills can
cost up to 50 shillings or sometimes ‘in-kind’ exchange).
The mechanism for tracking the progress of the programme was unsatisfactory, due to poor records and
weak reporting systems and little feedback. A large number of respondents thought that supervision of
the programme activities and follow-up actions were now undertaken with less seriousness than
previously, and very few CBD agents adhered to the activity register. Even when they submitted the
returns, they never got to know about subsequent actions because of poor feedback and follow up. In
some districts, it was reported that supervision was only done on a quarterly basis or at a time convenient
to the supervisor. Supervisors hardly ever convened group meetings, or if they did, it was irregularly.
Although some of the CBD MOH officials blame this on their heavy workload, thus inadequate time for the
programme, poor supervision and monitoring. This may have denied the CBD agents and YCs of the
opportunity to have appropriate updates and to perform better.
There is contradictory information with regard to refresher training, while the CBD respondents reported
that no recent trainings have taken place, the Kisumu project staff said there have been regular updates.
What has happened and what not should be followed up. Measures for indicating programme
performance also seem to be limiting (e.g. poor recording and reporting system) and in some cases,
inappropriate (e.g. the fertility-related measures, the CBD-performance indicators used in the YC
programme). These measures should be carefully looked at during the strategic planning to switch from
just recording & reporting to give more emphasis on OPR to monitor performance.
Lack of a sense of honesty on the part of the CBDs agents was yet another issue. In some sites, such as
Siaya, it was reported that CBD agents had at one time failed to remit half of the money received from
condom sales as stipulated in the regulations, which prevented them from being able to go back to the
SDPs for more condoms to distribute, and may have prevented them from getting thorough updates on
how to sell and re-supply. Moreover, this situation may have led to more dropouts. However, according to
the Kiumu project staff, there is no concrete evidence that CBDs are denied free supplies; Siaya case is
isolated. However this incidence calls for concrete evidence.
Programme management
Poor relations between the MoH and Saniplan staff / Kisumu staff is an important concern. Some District
Coordinators (the DPHNs) reported a lack of support by the Kisumu office. A particular MoH official in
Western province further accused the Regional coordinator of “constantly being harsh to the MOH
officers.” This dissatisfaction seems to be associated with the accounting procedures and management of
funds.
Some participants felt that the management structure of the CBD and YC programmes has a long chain
of command that occasionally led to delays in the delivery of services to the communities. The job
descriptions and division of labour among the PMU members are not clear. Furthermore, the capacity
required for effective and efficient delivery of the services was felt to be lacking. Although the CBDs had
been taken through some training when the programme started, most of them said that no recent training
had taken place. Some CBD agents are thus unable to meet the information and service demands of their
13
clients as underlined by this DDPHN: “the majority of the CBDs cannot explain how and who should use
some contraceptives”.
One MoH officer indicated that some GTZ staff had inadequate knowledge of RH issues. In one Nyanza
province district, a particular DPHN, for example, boldly lamented “a GTZ officer [volunteer] was imposed
on the DPHN’s office with little knowledge about contraceptive matters which made it very difficult for me
to coordinate his activities.”
In addition, many MoH staff had problems influencing the CBDs and YCs to have a favourable attitude
towards the programme.
Regular transfer of CBD supervisors or DPHNs and their replacement with staff not orientated nor trained
in CBD activities has proved a major problem in coordinating and supervising programme activities. For
example, in Kakamega, the new DPHN in charge of the CBD or YC programme knew very little about the
programme activities, she had not been orientated nor well briefed on what it was all about. Other officials
had retired or lost interest, so there are very few left to guide the CBD programme.
There were concerns that the YC programme is not yet mature enough for expansion. Respondents feel
that its scope is rather wide and the training modules are neither well structured nor participatory enough.
For example, during YC training, some DHMTs introduce topics of their choice into the timetable, which
are often not relevant to the goals and objectives of the project.
Over-reliance on GTZ for programme funding emerged as the common fear that sustainability would not
be feasible. The programme was initiated in the hope that it would register the support of community
members themselves on a purely voluntary basis, but the steady dropout rates indicate that pure
voluntarism can only be sustained for short periods of time, after which more volunteers need to be
recruited and trained. Even for those who have tried income generation activities to sustain involvement,
this has not been successful. For example, in Bondo District an in-kind land donation to the CBDs to
enable them to practice farming with a view to using the proceeds to support their program activities
ended on realizing that GTZ would not provide any finances. There seems to be an expectation that GTZ
would then intervene with financial assistance.
Many respondents indicated that there was little effort to share the lessons learned in various sites of the
programme and from related activities of other interventions.
Suggested solutions
Health system and programme environment
Closer collaboration between the CBD and YC programmes and other similar community-based projects
working in the same areas would enable them have an opportunity to learn from the experiences of each
other and implement the lessons learned.
The MoH needs to fully own the programme, including not only having full management responsibility but
also providing all necessary resources. Clearly this will need to be a gradual process of transition
between the MoH and GTZ. However, district budgets are often tight and alternative budgets either
‘programme’ or ‘vertical’ funding by NGOs is required. In addition to including the CBD and YC
programmes within the district or provincial annual budgets, some participants suggested that the CBD
programme could possibly make use of the available devolved funds opportunities, such as the
Constituency AIDS Control Fund, Community Development Trust Fund, and the Local Authority Trust
Fund.
Programme systems and services
Participants suggested the need to inculcate gender impartiality in the programme design so that both
men and women can equally benefit. The role of men in FP is critical; the programme should enrol more
male agents to reach men with both messages and condoms.
Though the programme is based on voluntarism, the provision of incentives to the CBD agents such as
unconditional replacement of old bags, provision of bicycles to facilitate transport, holding regular
meetings and allocating some money to cater for meeting allowances was suggested to curb the high
dropout rates of CBDs and youth counsellors from the project. These incentives would facilitate focus on
14
achieving the programme’s goals and objectives. The revised programme should explore various
financing alternatives as a way of resource mobilization.
The number of CBDs agents and YCs recruited and trained should be increased to cater for replacement
of dropouts and to extend the geographic coverage in some districts. In relation to this, the
replacement/recruitment process and profile of CBD agents should be revised to address the minimum
knowledge level needed and sustainability of a CBD presence.
Regular refresher training to enable CBD agents and YCs to cope with changing reproductive health
circumstances over time, such as those associated with emerging contraceptives. Training for new CBDs
and YCs joining the programmes needs to be reviewed and updated. Further training is needed in the
areas of communication, basic drug dispensing skills, hygiene and focus on life skills education for YCs.
Service provision guidelines should be disseminated to all CBD service providers and agents.
There is need for more regular supportive supervision, increased vigour in monitoring the programme’s
performance, and greater feedback about progress, from all stakeholders, including CBD agents. This
process should be as participatory as possible so that all stakeholders are constantly aware of the need
to regularly make adjustments to the programme in light of lessons learned, and how they need to reorientate their contribution to commensurate with such changes.
There is need for stakeholders to address contraceptive stock-outs, considering that it’s a possible cause
of the declining distribution and demotivation. Measures should also be put in place to aid CBD agents in
making client referrals. Respondents proposed inclusion of an incentive for referrals who do go to the
health facility, perhaps through subsidized fees for the services sought.
The potential for providing injectables at community level was suggested, given that it is the most popular
method. Besides, supervisors should ensure that contraceptive stocks at SDPs are adequate to satisfy
current levels of demand. Distribution of free contraceptives should be considered to enable the
programme to have a competitive advantage over other organizations providing similar services.
Other salient problems like HIV/AIDS prevention and home-based care should further be incorporated in
the programme areas. Recent refresher training has begun incorporating these aspects for CBDs.
Programme management
There should be constant dialogue between GTZ staff and MOH officials so that any conflicts/differences
that may arise between them is addressed in good time without creating adverse conditions that affect the
running of the programme. GTZ/ SANIPLAN should review concerns about the accounting procedures.
SANIPLAN should assign their own staff to monitor the RH program on a more permanent basis and to
work with the GTZ Kisumu RH persons on the CBD and YC programmes. Their presence in the country
and at the programme level will be highly beneficial to the success of the programmes.
Organizing exchanges between CBD agents and YCs and sharing of reports would enable each to learn
from the successes and failures of the other and to integrate these lessons in their respective
programmes.
Linkages between the Nairobi and Kisumu offices of GTZ need some improvement, as staff in Kisumu
report feeling somewhat unconnected, and would like to more interaction and communication.
The Kisumu YC coordinator feels that the YC programme should be re-designed, with roles and
responsibilities more clearly defined.
As long as it functions as a stand-alone project, the PMU for the MoH/GTZ RH program needs
strengthening, perhaps through additional personnel. Emphasis should also be placed on clear job
descriptions and division of labour among PMU members to enhance internal management. Technical
assistance should be primarily advisory in terms of guidelines and tools development, with occasional
monitoring of performance. A person familiar with the local context and with RH issues would be best
placed to train and work with the youth at the grassroots level while SANIPLAN’s staff could concentrate
on improving the overall quality of the programme activities, tools and manuals.
A revised monitoring and evaluation system should, besides being participatory in nature, be more
vigorous, promote and enable sharing of information, and include qualitative data collection approaches
15
to monitor quality and acceptability of the programme. The M&E system relies primarily on records kept
by CBDs on the numbers of contraceptives disbursed and the number of people served, and as such say
little about the reality of programme implementation. Occasional interviews or group discussions with
clients and CBD staff need to be held regularly to allow for regular input of their experiences.
MoH staff assigned to implement the CBD programme felt that training should go beyond nurses to
include other health professionals, as nurses’ workload is huge and sometimes have limited time to
provide to the programme. The inclusion of professionals such as gynaecologists was also suggested
(e.g. to deal with the increasing infertility concerns) as their advice and expertise would enable a more
comprehensive delivery of the programme services.
There should be greater engagement of community members in related activities such as fund raising
and development of performance indicators, to ensure that the programme is sustained and reflects the
wishes of the communities.
Chapter 3: Future directions for the CBD and YC programmes
3.1 Recommendations for future strategic directions
1. Determine an appropriate role for a community-based reproductive health programme that
conforms to the MOH’s emerging Reproductive Health Policy, Sector Wide Approach, and
Community Based Kenya Essential Package for Health. Neither the CBD or YC programme
appear to be addressing their original objectives, or reaching their full potential in terms of
productivity. Given the MOH’s strong policy commitment to CORPS and community structures within
Kenya’s NHSSP and HSR process, however, GTZ’s CBD and YC programmes provide the MOH with
an excellent framework within which to pilot-test appropriate and sustainable implementation
strategies for providing the CB-KEPH. We recommend that GTZ work with the MOH to re-design and
integrate both programmes into a new implementation structure that responds to the requirements of
the CB-KEPH. If resources permit, more than one model could be developed and piloted to compare
feasibility, effectiveness and relative resource and management requirements.
2. Develop a strong M&E/operations research component to enable the revised programme(s) to
be systematically documented and evaluated, so that it can serve as a model for replication if
proven successful. Poor reporting, recordkeeping, monitoring and use of data for programme
management emerged as key weaknesses in this assessment. Regardless of the format that the
community-based programme takes in the future, a strong capacity to document and learn about its
functioning and impact is critical. Moreover, staff and managers at all levels need to be trained and
motivated to be able to use such information for planning and management.
3. Reduce the number of districts in which the programme operates to enable GTZ and the MOH
to focus effectively on the programme’s new role. One concern was that the coverage area was
too wide especially for YC programme while for CBD, many of the districts where GTZ has been
working have secured support from various development partners for community level RH activities.
GTZ and the MOH should identify a small number (3-5) of districts in Nyanza and Western Provinces
in which it would make most sense to invest GTZ’s efforts. The choice of districts could be guided by
rating the existing districts in terms of the number of active and reporting CBDs / YCs and selecting
the most productive9, and in relation to the number of other organizations that also supporting the
MOH to implement community activities.
4. Initiate a transition phase, during which GTZ will support and build the capacity of the MOH at
provincial and district levels to develop and pilot-test one or more approaches to
implementing the CB-KEPH at the district level. A phased approach to changing the nature of
GTZ’s support to the MOH’s community-based programmes in Western and Nyanza provinces is
critical to ensure minimal disruption to both the district MOH structures and the existing users of the
programme’s services. In many of those districts where GTZ will end its support to CBD and YC
activities, it should be possible to “hand over” the active CBDs to other organizations that are already
9
The data provided above suggests that the districts in which the programme is performing most productively are: Vihiga,
Homabay, Suba, Nyamira and Lugari. The least was Bungoma and Kakamega.
16
supporting community based programmes (e.g. APHIA II, Marie Stopes, JHPIEGO, etc.). In the
smaller number of districts where GTZ will continue to support the MOH, the nature of its support
needs to gradually change through a reorientation of the partnership’s roles and responsibilities,
resource contributions, locus of decision-making, skills development, etc. A suitable period of time, of
at least six months, will be needed to allow for both GTZ and the MOH to adjust to the new
relationship. The nature and format of the new relationship needs to be jointly discussed and agreed
upon prior to its introduction to ensure a mutual understanding of each partner’s role and
expectations.
3.2 Recommendations for revising GTZ’s community based programmes
5. Drawing from draft policy guidance on the expected role of CORPS within the CB-KEPH and
forthcoming Reproductive Health Policy, and from the implementation and management
experiences described in this assessment, determine an appropriate profile for a CORPS as
an acceptable and sustainable source of RH information and services that functions within
both the health system and community. The assessment indicates that, as currently configured,
the CBDs and YCs fall between being the responsibility of the MOH and of the community. How such
CORPS can both function within the structure of the MOH and also be accountable to and
representative of their community is a perennial dilemma for community-based programmes around
the world. We recommend that GTZ commission an analysis of potential options for a communitybased programme that is both sustainable by being an integral part of the health system structure and
recurrent budget, and also ensures community needs are met through their active engagement in
managing the CORPS. Issues such as the recruitment process and supervisory criteria should ensure
accountability to the community; links with existing community based organizations and groups can
enhance motivation and support; and CORPS should have appropriate socio-demographic
characteristics (age, sex, education, etc.) to be credible and effective for serving the intended
beneficiaries.
6. Carefully consider the most appropriate range of reproductive health services that a CORPS
to offer, given issues of service needs and preferences, service charges, competence to
deliver, stigma and sensitivity, appropriateness of non-clinical delivery, integration of
services, etc. Promotion of the importance of family planning could and should remain at the core of
the CORPS responsibilities, given the alarming stagnation in contraceptive prevalence in both
provinces. However, expectations concerning the quantities of pills and condoms that could
potentially be provided through CORPS need to be realistic given the drastic shift in method
preference away from the pill to injectables, and the availability of free condoms and pills from other
sources. A limited range of HIV/AIDS services (e.g. prevention education, referral for VCT and
PMTCT services, support for ART compliance) could possibly be included, as could some key safe
motherhood and child survival services (e.g. promoting attendance for FANC, skilled delivery,
postpartum care, and immunization). The range of services that a CORPS can competently and
effectively provide should be determined jointly with the MOH to reflect the CB-KEHP
recommendations and existing empirical evidence. One or more configuration of services should be
pilot-tested before being standardised.
7. A strong referral and support system needs to be established with the most accessible KEPH
level 1 and 2 facilities. The way in which community members can be made aware of, and have
access to, services not available from the CORPS needs to be carefully considered, and a clear
referral and support system developed that takes into account potential accessibility, given factors
such as transportation, distance, social mobility, etc. The system needs also to be designed to
motivate as well as facilitate clients’ access to these services. Particular attention needs to be paid to
enabling CORPS and community organizations to be able advocate for and facilitate access to
emergency services when needed, in particular for pregnancy complications, postabortion care, postrape services, and newborn complications (especially during the first week).
8. Ensure regular planning and routine supportive supervision of CORPS by appropriate MOH
staff (without GTZ involvement) to ensure motivation, commitment, accountability, and
sustainability. Supervision of community workers by facility-based MOH staff has been weak in the
existing programmes, but is felt by all to be a crucial component that needs strengthening for any
successful community-based programme. The sustained involvement of GTZ has now become
detrimental to the programme’s sustainability because the MOH does not regard it as their
17
responsibility10. The precise structure for such a planning and supervisory system and procedures
(timing, nature of supervisory contacts, etc) can be developed drawing from the experiences of this
and other programmes, but this component must receive priority in any future programme supported
by GTZ.
9. One of the most critical issues to address, in whatever format a future programme takes, is
motivation and performance incentives for the CORPS. The drop-out rates for CBDs and YCs 9as
described above, in the programmes are acceptable and to be expected for programmes of this
longevity, but they still present a problem for programme planning, management, budgeting and
costs, as well as disrupting and reducing service availability within the communities. Evidence from
other CBD programmes, including those in Kenya, e.g. Pathfinder, Family Health Options (formerly
FPAK), CDC and Mariestopes show that some form of material remuneration for activities undertaken
and services rendered, increases productivity and sustains commitment to functioning as a CORPS;
pure voluntarism, as is the current situation does not motivate for sustained periods of time or for high
levels of productivity across a range of services. We recommend that as part of the programme
reorientation process during the transition period, GTZ should commission an economic modelling
exercise to provide evidence to the MOH of the relative costs and anticipated productivity of
alternative scenarios, by varying levels of CORPS remuneration, recruitment and training rates for
replacing drop-outs, levels of supervision required, etc.
10. Indicators for monitoring and for performance / productivity appraisal should be developed to
appropriately reflect the expected activities and outputs of the CORPS individually, and for the
programme as a whole. Respondents expressed concern that the programme retained a focus on
contraceptive supply indicators, when the CBD and YC activities are broader than simply delivering
pills and condoms. This point demonstrates the need to ensure that any future programme uses
indicators that directly describe the CORPS activities and productivity as well as reflect the range of
services and information they provide. Moreover, the incompleteness of the service statistics
gathered during this assessment illustrate the inefficient and ineffective data recording and reporting
systems currently in place, and the importance of ensuring that any community-based programme
needs to have an appropriate management information system in place. If community based
programmes are going to be integrated within the public health system, as is required in the KEPH
structure, then the data collected and systems for recording and reporting must also conform with and
contribute to the existing Health Management Information System.
3.3 Recommendations for operations research to re-orientate and re-organize communitybased RH programmes
Despite the CBD and YC programmes’ long duration, there is still much that is unknown about how a
reorganized and restructured programme could and should function, especially given the expectations of
the NHHSP, CB-KEPH, and forthcoming Reproductive Health Policy. Some suggestions have been given
within the programmatic recommendations above; priorities that emerged from this assessment are as
follows (not in any particular order):

Injectables are now the most popular contraceptive method in Kenya. Studies in Uganda and other
countries have demonstrated that CBDs, without medical qualifications, can safely and effectively
provide injectables. Enabling CORPS in Kenya to provide injectable contraceptives could greatly
increase access to this highly popular method, with likely increases in contraceptive prevalence and
probably reduced unwanted fertility. Such an approach is highly controversial, however, given
concerns over safety and possible abuse, and so we recommend that the feasibility and effect of
training and supporting CORPS to provide injectables be pilot-tested on a small-scale to provide
evidence on which a decision to introduce the approach or not can be based.

Recommendations 6 and 7 suggested a limited range of RH, HIV/AIDS, and safe motherhood/child
survival services and referrals that evidence from other programmes indicates can be provided
through CORPS. Assuming that the MOH can develop the appropriate systems to deliver these
services at the community level, there needs to be a potential demand or need for these services to
10
The following quote by a GTZ staff (Kisumu), illustrates this point: “Most of the district teams talk of ‘GTZ’. No matter how
many times the issue of integrated plans was repeated by GTZ staff, even from the Head RH, most of the DHMTs still
submitted ‘GTZ’ RH plans.”
18
justify investment over time in developing and sustaining such services 11. We recommend that a study
be undertaken of client perspectives on which specific services would and would not be acceptable
and desirable from a CORPS, including their suggestions on possible referral mechanisms, especially
for emergency services. This study should also include an ‘ability and willingness to pay’ component
to inform the MOH of options available for charging for services provided by CORPS.

Few CBD programmes, including this one, monitor the quality of care provided, in part because they
operate outside the controlled environment of the clinic and so present problems of measurement.
There is ample evidence that clients’ (and potential clients’) perceptions of what constitutes a quality
service differ markedly from that of ‘experts’. The implications of these differences for designing an
acceptable service provision programme are extremely important, and so we recommend that the
client perspectives study include not only definitions of quality from clients and potential clients, but
also attempts to measure the quality of services currently being provided.

Reproductive health still suffers from an image of being a female-only concern, despite numerous
studies undertaken in Kenya that have shown tremendous male interest and involvement in RH
issues. Gender issues arose frequently during the assessment, especially around the
appropriateness of different or same-sex interactions between CBDs and clients, depending on the
service being provided. In a similar vein, sensitivities still exist about unmarried people, and especially
adolescents and youth, having access to and using RH information and services, despite all the
evidence that restricting such access not only infringes their rights but also places their health, and
even lives, at increased risk. We recommend that the study on client perspectives also include an
assessment of how such a programme could engage men meaningfully, both for services provision
and use, and of how sexually active unmarried and young people could access services without
stigma and discrimination.

As noted in recommendation 9, motivation of CORPS and its relationship to their and the
programme’s productivity is largely unknown. Some evidence does exist that can be drawn together
to provide guidance to the MOH, but we recommend that GTZ also supports a study among its own
CBDs and YCs to find out what range of incentives would stimulate commitment and motivation, as
well as to identify what role such incentives are currently playing in relation to other personal and
contextual determinants of their performance and productivity.

Should GTZ proceed with the recommended transition to a new relationship with the MOH and
support for pilot-testing a CORPS-oriented programme that can implement the proposed CB-KEPH,
we recommend a household level survey in those districts where GTZ will continue to work. Such a
survey would enable the MOH and GTZ to retrospectively assess the impact of the existing CBD and
YC programmes at the family and individual level, as well as to undertake a baseline survey that will
enable the new programme to be prospectively evaluated.
Underlying all our recommendations, both programmatic and research, is a plea that GTZ consider
revisiting the approach that characterised the earlier phases of its community-based programme, during
which monitoring and research played a critically important role. Emphasis was placed on a strong MIS,
and baseline and evaluation studies at household level were regularly undertaken. The wealth of
information produced enabled the programme management to closely monitor progress and to adjust the
programme accordingly. In addition, the programme area became a type of ‘learning laboratory’, in which
nested studies on programme components (e.g. training, supervision, recruitment) contributed to
informing both programme management and the international community interested in community
programmes; this model also allowed a better understanding of the relationship between non-clinical
contraceptive delivery and fertility behaviour.
In summary, GTZ’s resources for supporting a community-based programme do not permit wide-scale
support of community-level service delivery, and other development partners are now committed to largescale strengthening of community level services in Western and Nyanza Provinces. We strongly
recommend, therefore, that GTZ consider focusing its support to the MOH to enable it to create a
‘learning laboratory’ in a limited number of districts in Western and/or Nyanza provinces (where GTZ is
currently supporting activities). In this way the MOH can develop and pilot-test a systematically designed
programme through operations research that will provide it with empirical evidence on which to
operationalise its policies for providing the CB-KEPH at the community level.
11
The rapid decline in the number of pills distributed through this programme due to increasing preference for the injectable
graphically illustrates the importance of ensuring that there is a demand for the services being provided within the
community.
19
Appendices
List of people interviewed
District
Person interviewed
Designation
WESTERN
Mr. Clement Were
PLO
VIHIGA
Ms. Agatha Kondo
*Ms. Dorothy Odondi
CBD supervisor
Ms. Jessica Otieno
*Ms. Caroline Obiero
CBD supervisor
*Mr. Jairo Songa
CBD supervisor
*Ms. Millicent Okatch
CBD supervisor
*James Oyieko
CBD supervisor
Ms. Pamela Ochieng
*Ms. Judy Rajwai
CBD supervisor
Ms. Aska Baswetti
*Ms. Lucy Ndege
CBD supervisor
Mrs. Norah Bett
DDPHN
DPHN
*Ms. Mary Owuor
CBD supervisor
Mrs. Christine Ongeche
*Mr. Daniel Okuku
CBD supervisor
Mr. Charles Senso
*Mr. James Maranga
CBD supervisor
Mr. John Odira
*Mrs. G. Ajuoga
CBD supervisor
Mr. George Wanjala
*Ms. Ruth Odongo
CBD supervisor
Mr. Amogoye Chambu
*Mr. Fredrick Wamukhoya
CBD supervisor
*Ms. Jessica Otieno
CBD supervisor
Ms. Agatha Kondo
*Ms. Dorothy Odondi
CBD supervisor
Dr. Mark Ayallo
Selina Orsi
Njeri Mukoma
DPHN
KAKAMEGA
BUTERE
MUMIAS
SIAYA
BONDO
RACHUONYO
NYAMIRA
NYANZA
HOMABAY
SUBA
KURIA
MIGORI
BUNGOMA
LUGARI
KAKAMEGA
VIHIGA
GTZ Kisumu
DDPHN
DPHN
DPHN
Others
FHOK Coordinator
(YMEP)
Former DPHN Siaya
(Migori)
Former CBD focal
person, DPHN
Kakamega
DPHN
DPHN
DDPHN
DPHN
DDPHN
DPHN
PLO
DDPHN
DPHN
DDPHN
DPHN
DMRIO
DPHN
DDPHN
DPHN
DCO
DPHN
DDPHN
DDPHN
DPHN
RHO
Technical Adviser (YC)
Regional Team Leader
*Officer also acts as the district focal point person
iv
PMTCT Project
Coordinator (Migori)
4 FGD groups (CBD
agents, retired
/former agents and
YCs participants)
Terms of reference of the consultant
Development of a way forward for component 2: CBD/YC Project of the Kenya/German Reproductive Health Programme
1. Background
The most recent results of national surveys in the Kenyan health sector reveal alarming figures particularly in view of the
socio-economic and health indicators: decreasing life expectancy, increasing infant and child mortality, increasing
percentage of population living below the poverty line and decreasing contraceptive prevalence and decreasing access to
family planning services while simultaneous increasing unmet demand for family planning (FP) services among the poor.
Monitoring data show a clear and consistent decline in the distribution of contraceptives and condoms in the project area and
subsequently decreased access to family planning services for the target population. The data indicate a high drop out rate of
the CBDs and possible reduction of their productivity. It was observed that CBDs do not only drop out of the project
component but are also used by different national and international projects and programmes in an uncoordinated and almost
competitive way. There is now serious concern by the German partners that the project objectives might not be met.
At the same time, the Kenya Essential Package for Health (KEPH) is being formulated. The KEPH places a strong emphasis
on community activities and CORPS (CB-KEPH). In that context, achievements and challenges of the CBD-strategy need to
be taken into account.
Against this background it is important to review the supported strategies and activities in terms of appropriateness,
effectiveness and efficiency, and sustainability. A previous study (November 2005) by GTZ on positioning the German
Development Cooperation (GDC) within the current sector development and reform process as well as the recent strategic
workshop in Kenya of the German partners recommended to review as strategic/conceptual as well as managerial aspects of
Component 2 of the TC project. This concerns in particular the community based Reproductive Health (RH) project
component utilizing community-based distributors (CBDs) and youth counsellors (YCs) for community-based family
planning (FP) services and HIV/AIDS prevention.
The Kenyan CBD programme being one of the oldest and largest programmes of it’s kind, the international reproductive
health community would be interested in lessons-learnt regarding various aspects of CBD, including possible negative
findings on sustainability or efficiency.
As the GTZ-supported activities are relatively well documented throughout a number of years, it could be the basis for
various operational research studies.
2. Objectives of the consultancy
- To develop recommendations for urgent organisational and strategic questions regarding the objective of the component,
indicators, the work plan and the institutional setup
- to prepare the way forward for operational research and strategic decisions regarding the role of CBD in the Kenyan RH
programme and the German support to this programme in line with SWAp and CB-KEPH context and other ongoing
changes..
3. Tasks of the consultant and expected outputs
3.1. Put together available data analysing numbers of active CBD and distribution levels by number of active CBD over the
programme implementation period.
After a visit to the project region:
3.2. Discuss with DHMTs and other stakeholders in the Districts, to what extent they see the CBD/YC activities
contributing to their objectives, and what support would be needed for the districts to be enabled to sustainably support
the supervision and refresher activities for trained CBD.
3.3. Suggest a workplan for the component for the period 07/06 to 12/07, which accommodates the research and feed-back
activities (see 3.4. to 3.6.), defines the minimum support required to keep CBD/YC activities running (without a mayor
input into new trainings) and with a view of creating a maximum of sustainability and ownership at district level.
3.4. Recommendations on the organisational setup required to implement the above workplan.
3.5. In collaboration with the Population Council, review available recent research on CBD and develop draft TOR for one
or several operational research studies which would answer the following questions
3.6. Analyse feasibility of current indicators for the component and propose indicators for the period 07/06 to 12/07, taking
into account not only output of CBD and youth counsellors, and the possible input into policy development.
v
3.7. Integrate the proposed RH policy and the SWAp community strategy to the objective and strategy of the component
The consultants shall work in close collaboration with the GDC Partners especially the GDC programme coordinator, the
Kenyan key stakeholders at national and provincial level and relevant DPs.
Population Council will collate recommendations on the work plan and final analysis and interpretation of the Data. It is
foreseen that general terms, Pop. Council will provide support for support the assessment study in terms of insuring the
quality and relevance of the document.
4. Reporting
The report should be in English language with a max. 15 pages with Annexes according to needs and should be sent to the
programme leader no later than July 25, 2006
5. Study team
- Independent national expert
- National expert assigned by MoH/DRH
6. Proposed time schedule
- 3 days preparation
- 10 days in Kenya
- 3 days report writing
In the period of June to July
Work plan / time frame
Activities
4
5
6
Literature
review
X
X
X
Development
assessment
tools
Field work
X
7
10
11
12
13
14
15
17
18
19
20
X#
X#
X#
X#
X*
*
X$
X$
X$
*
21
25
26
X
X
31
X
Transcription
of interviews
X
X
Data analyses
X
X
Report
writing
X
X
Briefing
presentation
X
Key:
X activity
X* interview and MIS
24
X# interviews
* Service statistics data
X$ interviews and focus group discussion
* Compiling service statistics data
4th – 30th July 2006
vi