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