The distribution of emergency contraception by community health workers through THE CASCADE training implementation model Beatrice Bainomugisha, WellShare International Panel Discussion CHW symposium 22nd February 2017 Hotel Africana, Kampala , Uganda (Rwizi Hall)

Background-Current Programs WellShare is a sub-grantee to Advancing Partners and Communities (APC) project in 15 sub-counties of two districts--Iganga and Kumi (2014-2017) WellShare builds capacity of districts to implement Community Based Family Planning services through Village Health Teams (VHTs)

Cascading training model for CBFP MOH Master trainers trained 10 District health Teams who in turn trained and supervise 43 Health Facility staff who in turn trained and supervise 257 VHTs. MoH CBFP training Manual for VHTs for short term methods (pills, condoms, Depo IM, Sayana Press, ECP)

Identification of gaps in ECP provision by VHTs Conducted continuous quality improvement identified low distribution and uptake of ECP Few VHTs were distributing ECPs Most Health centers had ECPs expire in August 2015 No steady supply of ECPs at community level We work though the government health facilities to build capacity of districts to offer CBFP services. through HMIS reports from NMS citing low consumption and demand for ECPs

Evidence for the ECP gaps Conducted an ECP assessment in 4 CBFP Districts of Iganga, Arua, Kanungu and Mubende in December 2014 to January 2015 Goal: Understand dynamics of ECP distribution by VHTs to improve integration of ECPs into existing community-based FP programs Objective: To assess current knowledge, use, supply and barriers to uptake of ECPs in districts where community-based FP programs are operating VHT Survey (23) VHT Client Interviews (both Users and potential users) (80 –60 potential; 20 ever users) FGD with Health workers (32 FGD) KII with District and National level stakeholders (32 district key informants, 5 national level informants)

VHT: Familiarity & Provision of ECPs Heard of ECPs (22/23) Refer for ECPs (6/23) Counsel on ECPs (4/23) 96% VHTs ever heard of ECPs 26% VHTs had ever referred someone for ECP 17% VHTs ever counselled on ECPs 9% VHTs ever provided ECPs Thus more VHTs have heard of ECPs; much fewer have provided Provide ECPs (2/23) = 1 VHT

Summary of Key Findings Most VHTs know ECPs, only about half the potential users were aware of the method VHT provision of ECPs would increase awareness of, demand for, and greater access to ECPs Inconsistent Supply and Stock outs challenges Radio, VHTs, and health center staff recommended as information sources on ECP Respondents emphasized need to adequately train VHTs in ECP provision Bulk of ECPs are dispensed through Public Sector-Government HCs Most of the FGD/Community had little knowledge on ECP (mechanism, timing of use, advantages and disadvantages, side effects, etc) Stock outs common concern (n=22, predominantly district-level) “We get constant stock outs because we are given very few doses and by the time we get them, everyone wants a dose. So in no time, they get finished; for example, the last time of replenishment we were given about 5 doses but in two days they were all finished. In fact since September 2014, we have not received any ECPs.” Reasons for stock outs Communication errors; requisition office errors; not ordering more ECPs until existing stock already gone (n=12) Not receiving enough supplies to begin with; running out before next distribution cycle (n=10; 8 of 10 were In-charge at facility) ECPs expiring due to low demand (n=4) National Medical Store delaying or not fulfilling requests (n=3)

Response to ECP gaps: Advocacy Along with other IPs, WellShare shared assessment results, and advocated for provision of ECP to facilities and VHTs UNFPA procured and dispensed to the districts in September 2016 via UHMG/ADS Mention a series of meetings where WellShare shared results of the ECP assessment, got recommendations

Response to ECP gaps: Cascade implementation model Additional training & support to VHTs in 2016 WellShare adapted an ECP training module for DHTs, Heath Workers and VHTs (integrated with all FP) Topics: what are ECPs , types of EC (IUD, Yuzpe/COC, Levonorgestrel), mechanism, side effects, counseling, referrals Refresher training and integration of module to train new VHTs Bullet 2 -Sessions for the training module included. 1 what are ECs , who is it for, types of ECPs. How ECPs are used Dosage, Using COCs for EC (Yuzpe), How ECPs prevent pregnancy, side effects, issues surrounding Ecps (Repeated use, Abortion, infertility and use among adolescents, ECP screening and communication, counselling for ECP (case studies and counselling role plays), Follow up and referrals for clients, Key messages For refresher trainings DHTs were trained together with Health Center staff in ECP as well as refreshed on other methods For scale up Sub counties in Iganga, Health Facility staff were trained by the MTOT and DHT under the full 10 day training using the MoH manual but the ECP session replaced with the WellShare designed module.

Cascade Training continued VHT practicum key messages and provision of all FP methods including ECPs under the supervision of Health Workers Health Centers received ECPs through ADS (UHMG) and distributed to VHTs WellShare developed and pre-tested an ECP Job Aide and Fact sheet to support VHT service provision

Monitoring and Continuous Quality Improvement (CQI) HWs continuously support supervise the VHTs in the use of ECPs using an ECP direct observation checklist Counseling checklist for ECP Project Health Center Support Supervision Checklist including ECP Revised project VHT registers and data collection tools to integrate ECP We don’t look at Yuzpe and IUD for EC at Health center, they give our COCs but we don’t know for what. We don’t know about IUD for EC either. HMIS does not capture. We look more at quality of ECP provision by VHT. But where stock outs occur of ECP the Yuzpe can help.

Results 34% (189) of ECPs in Iganga and 46% (39) of ECPs in Kumi were dispensed at community level Community market share increased as expected ECP is an entry point for counseling on routine FP use, more women will be expected to transition from ECP to routine methods. .

Results continued VHTs conduct Community dialogues on FP including ECPs Increased interest in and demand for ECPs Two Radio Talk shows and 84 Radio spot messages on ECPs Radio Monitors receive daily questions on ECPs 1. The Kumi Radio Monitor says that ever since the ECP pre-recorded Radio Talk show was aired and radio spots on ECP started running, he receives questions every day on ECPs. Clients are making appointments with him to give more personal counselling and guide on how to get the ECPs

Impact Women and girls are empowered to access ECP at their convenience, in their communities ECP as an entry point to routine FP methods VHTs have the knowledge and skills to provide immediate ECP and refer survivors of rape and defilement for further SGBV services

Impact Availability of ECPs at community level is increasing Reproductive health service-seeking behavior of people in rural remote areas Access to ECPs can decrease unwanted pregnancies as well as teenage pregnancies in the two Districts Access to ECPs can reduce the number of women and girls dying as a result of abortions Increased interest in ECP among males as an entry point to involvement in Family Planning RH Health Seeking Behavior (PEP, STI, etc)

Challenges Inconsistent ECP supply to Health Facilities by NMS/ADS Lingering provider bias at HC level-whole system needs strengthening(in-service CMEs or Pre-service training, etc) Current System relies on IPs or pull from Health Centers Program Advocacy strategies quite costly Relies on presence of trained VHTs Address capacity of HWs to integrate ECP into FP sevices at facilities, and in training collegs.

Contacts Beatrice Bainomugisha Program Manager WellShare International bbainomugisha@wellshareinternataional.org 0772594937

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