INCREASING COMMUNITYBASED ACCESS TO FAMILY
PLANNING
Innovative Models, Successes, and
Challenges
Moderator: Victoria Graham
Reconvening Bangkok: 2007 – 2010
Progress and Lessons in Scaling-Up FP-MNCH
Best Practices in AME
March 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 Increasing Community
Access to FP
• 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 CHWs
Hamouda Hanafi (Pathfinder Int’l/Yemen)
Mobile Health Teams as Outreach Solutions to Improve Access to
Care for Underserved Populations
Sitaram Devkota (USAID/Nepal)
Family Planning Social Marketing
Community Health Workers
Provide DMPA
Jeff Spieler
Senior Advisor for Science and Technology
Office of Population and Reproductive Health
Bureau 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 Afghanistan
Hedayetullah Mushfiq, Program Manager, Tech-Serv Project
Management Sciences for Health - Afghanistan
Strategies and Approaches
Train volunteer CHWs to provide access to DMPA
for all Afghan women regardless of where they live
Community support
• Involve Shura-e-Sehie
(Community Health
Councils)
• Family Health Action
Groups
Access to female CHWs
• Skilled CHWs
• DMPA counseling
• Technical competence in
providing DMPA
• Community maps
Birth spacing promotion
• Culturally appropriate
• Correct misconceptions
Contraceptive choice
• DMPA first injection
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 20042009 regarding DMPA, OCs, and condoms and supplied them
with all three methods
• Increased CPR from 26% in 2006 to 42% in 2009 in 13 USAIDsupported 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
200000
180000
160000
140000
120000
21Non-USAID
Provinces
100000
80000
60000
13 USAIDSupported
Provinces
40000
The Whole
Country
20000
0
2005
2006
2007
2008
2009
(two quarters)
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/Utilization
of FP Services
in Rural Nepal through CHWs
G.C. Bimala
Performance Improvement Program Officer
Family Health Program II - Nepal
Strategies and Approaches
Increase Access/Utilization of FP Services in Rural Nepal
through CHWs
• 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
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 CommunityBased Outreach Solution to Improve
Access to Care for Underserved
Populations
Hamouda Hanafi, Director
Basic Health Services Project
Pathfinder 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 Bank
Challenges:
• 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 Devkota
USAID/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)
500,000
450,000
445,801
400,000
350,000
300,000
284,075
250,000
252,778
200,000
127,570
150,000
93,206
100,000
50,000
313,560
2,263
30,222
47,170
0
1978
1983
1986
1994
1998
2005/
2006
2006/
2007
2007/
2008
2008/
2009
Questions and Comments
Thank You!