1. 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)

2. 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 ( )
WellShare builds capacity of districts to implement Community Based Family Planning services through Village Health Teams (VHTs)

3. 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)

4. 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

5. 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)

6. 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

7. 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)

8. 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

9. 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.

10. 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

11. 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.

12. 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. .

13. 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

14. 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

15. 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)

16. 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.

17. Contacts
Beatrice Bainomugisha Program Manager WellShare International

18. Thank You