Reducing Maternal and Child Mortality through Strengthening Primary Health Care in SA (RMCH) Contraception & Fertility Planning Support Dr NA Skeyile 29 January 2015

Outline of the presentation 1.Background – The Mandate 2.What we did (with the districts) 3.How did we do it 4.What did we achieve – CFP Dashboard 5.What did we learn 6.What still needs to be done 7.How will we get there 8.RMCH in 2015

Rationale for DFID RMCH support: three strategic gaps Past inability to translate national policy into action (Knowledge to Action) Poor management of public health sector services (Leadership) Inadequate primary health care (PHC) (service delivery) Compromising delivery of effective MNCWH services (access, coverage, quality and utilization)

The Mandate  Crisis: < than 1 million women who fall pregnant annually, 8% are girls under the age of 18 years & these account for 36% of maternal deaths. (source: NCCEMD –The National Committee for the Confidential Enquires into Maternal Deaths)  The new National Family Planning Campaign launch – (February 2014) – the theme “Dual Protection” for consistent use of a condom together with another form of contraception  Sub-dermal implant introduced

RMCH CFP - technical assistance Focus: 25 Priority Districts Objectives: 1.to strengthen & accelerate the implementation of CFP policy and guidelines at district and facility level 2. to strengthen and maximise the use of available resources, avoid duplication of efforts and encourage sustainability How: align to the KZN 5 Point Contraceptive Strategic Plan  Improve HCP training and Mentoring  Promote Integration of Contraceptive Services with other Services  Improve Record Keeping, review implementation status and reporting  Improving demand creation – Contraceptive awareness and access  Post training – mentoring / monitoring & responding to upcoming grey areas  Strengthening FP counselling

Situational analyses and prioritization conducted

Bottlenecks identified  Weak Integration of services  Commodities  Capacity building  Monitoring & response  Quality assurance (to improve the quality of family planning services – identified CFP related problems; analysed the causes of the problems; prioritised and developed solutions; implemented corrective measures and reviewed to respond).

Barriers to FP uptake  method‐related concerns  belief that methods interfere with the body’s normal processes  concerns about the safety, efficacy and side effects of modern methods

TA approach Leadership:  the active engagement of MNCWH coordinator + DCSTs + SRH manager at provincial, district and sub-national levels to increase programme ownership and involvement planning Capacity building:  support FP trainings to improve competency and skills  Post training – mentoring / monitoring & responding to grey areas Data use:  Improve record keeping, monitoring and review implementation status in order to determine improvement and identify barriers to better outcome and develop appropriate interventions

TA approach Demand creation activities – to improve awareness and access → (Grantees & Forums already existing & having a voice in the communities; WBOTs) Coordination: Collaboration and coordination – facility readiness assessment, post training follow-up and support supervision, advocacy within the district and province between programmes

Facility Readiness for FP services Four key indicators of quality CFP provision that we used to assess the readiness of health facilities:  Presence of at least one midwife in the facility  Adequate number of the CFP methods supplied  The basic amenities of infrastructure  The basic equipment for provision of most methods

STRATEGY – TRAINING  Identify training needs  Establish rationale for training (What informs training? – data and root cause analysis)  Training pre-requisites – Who has been trained? (how long ago) – Where are they working? – Where is the training going to take place? – What is the follow up plan? – Who is going to do the follow up? – What tool will be used for follow up? – How do we get the report?

Training Strategy – Sustaining CFP at a district level Provincial Master Trainer Capacitates the districts by training District trainers District Master trainer and Champion for CFP Mentors the sub-districts and does the monitoring, review and responds to gaps in the district Each sub-district has a Champion trained in CFP Form Roving Teams

Meeting the Unmet Need Link FP to other services  prenatal care  post-partum care/breastfeeding  Immunization  child health services

Achievements Contraception and Family Planning  Support and participation in CFP training workshops – 100% facilities are offering CFP and have at least 1 P/N trained in CFP  Dissemination of CFP policies and guidelines and WBOTs education material  Trained WBOTs team leaders in use of CFP education material

Legacy  Improved utilization and analysis of data to plan interventions  The culture of post training follow up and mentorship  CFP tools FP facility readiness tool TOR for established Roving teams Implementation status tracking tool Post training follow up tool SOPs for MOUs; CHCs and PHC Family planning flipchart for WBOTs; SOPs  “Let’s Talk” song by Yvonne Chaka Chaka

I (integration of services & commodities) ComponentChallenge/Bottleneck Current intervention strategy Lesson Learned Commodities Frequent stock-outs of CFP methods leading to clients receiving a method based on availability Frequent facility-level stock-outs have negative effect on the service and hinder efforts to scale-up implementation at district level of care Weak integration of CFP into other relevant departmental activities (DBE; Department of Social Welfare etc) Weak collaboration between DBE & DOH (from national through to the district level) on issues of introduction of SRH interventions into schools Strengthening the ISHP programme by introducing multi stakeholders meetings RMCH support to the districts to strengthen Networks of care forums (multi-sectoral stakeholders involvement) to link with schools (School based support teams) Failure to actively partner in the planning and implementation of SRH interventions results in disjointed programming and missed opportunities for introduction of CFP in schools which can exacerbate Teenage pregnancy in schools. In addition an “opt-in” policy for SRH services in schools leads to long consultative processes which the service in schools

II (capacity building) ComponentChallenge/Bottleneck Current intervention strategy Lesson Learned Capacity Building Inadequate district- level personnel dedicated to reproductive health (RH) Establishment of Roving teams Promote capacity-building strategies that include on-the job training, mentorship, and supervision Inadequate number of facility-level health care providers trained in SRH Roll out of HCP training in CFP Establish an in-service training database and evaluate training outcomes Pre- and in-service training has limited impact if health facilities are understaffed and workers overburdened

III (Monitoring & response/ Community involvement) ComponentChallenge/Bottleneck Current intervention strategy Lesson Learned Monitoring & Response Weakness in data management HCP will not prioritize data management unless they recognize its usefulness to programming). Data management must be a Core component of all in-service trainings for health care providers Community awareness and male involvement Poor demand for CFP services by the community Developing Community- Based SOPs Increased community sensitization on CFP through WBOTs and strengthening of referral mechanisms has helped to overcome cultural barriers that prevent access to CFP

Recommendations  Integrated MNCH services with better budget line  Consider community based distribution of FP services (WBOTs TL)  Forecast of years contraceptive requirement done  Male involvement  Youth-friendly services revisited  FP providers’ knowledge and skills up-to-date – (on-the-job- training with continuous mentoring)  Well-functioning district procurement and distribution of commodities and supplies should be in place  National Family Planning Implementation Plan that filters down to the facility level

For keeping me healthy and making my life worth living for!