1. INCREASING COMMUNITY-BASED ACCESS TO FAMILY PLANNING Innovative Models, Successes, and Challenges
Moderator: Victoria Graham
Reconvening Bangkok: 2007 – 2010
Progress and Lessons in Scaling-Up FP-MNCH
Best Practices in AME
March 2010

2. Rationale for Renewed Focus on Community-level FP Provision
Additional & alternative providers and points of service are critical for progress
Addresses health worker shortage and long distances/wait time at overburdened facilities
Evidence shows community provision increases FP uptake
Essential to reach urban and rural population with community-based programming
There is revitalized attention from MOHs, donors, and service delivery organizations for service provision starting with community level providers. The underserved are still underserved. Participants will be familiar with their own countries CPR, TFP, and unmet need – maternal and infant mortality rates. While there are a few success stories (Indonesia, Bangladesh) many countries are still struggling to address women and couples need for FP and birth spacing.
To accelerate progress, access must be at the heart of development work. Five years left to meet MDG goals. Time is running out fast.
The need for family planning is often greatest in rural areas where access to clinic-based services is limited. Next speaker, Jeff Spieler, will talk more about task-sharing but to orient, we are talking about using appropriately trained ‘paraprofessionals’ to counsel and provide FP which are traditionally provided by clinic-based providers. Increasing the number and type of providers in the local community increases access and uptake to the underserved (primarily rural but peri-urban also).

3. Four Key Strategies for Community Access
Community health worker provision of FP services including injectables
Outreach or mobile clinics/teams to provide FP including LAPMs
Increased access to FP services at clinics and outposts
Pharmacy/drug shop sales and provision of FP methods including injectables
[Consider deleting this slide since we aren’t talking about the others. Could be mentioned in talking points.]
There are several approaches to increasing access to FP at the community level.
Today we will focus on the first two strategies: community health workers & mobile teams.

4. Presentation Outline Jeff Spieler (USAID/USA)
Community Health Workers Provide DMPA
Hedayetullah Mushfiq (MSH/Afghanistan)
Scaling-Up the Use of DMPA at the Community Level
Bimala G.C. (Family Health Program II/Nepal)
Increase Access/Utilization of FP Services through CHWs
Hamouda Hanafi (Pathfinder Int’l/Yemen)
Mobile Health Teams as Outreach Solutions to Improve Access to Care for Underserved Populations
TBD (USAID/Nepal)
Family Planning Social Marketing
Welcome. Introduce topic and structure of session. [Suggest using this as your presentation outline slide due to time.]
This panel will highlight success and challenges from recent advancements with community-based provision of FP, with a special focus on injectables.
I’ll open this session with a few points on the rationale and benefits.
Then, we’ll have:
An overview of 2009 global technical guidance on the safety and effectiveness of providing injectables via community health workers (Jeff Spieler).
A country summary from MHS-Afghanistan regarding community-based FP/DMPA distribution (Hedayetullah Mushfiq).
An example from Nepal of taking a successful community-based provision of FP to scale (G.C. Bimala), and
A review of using mobile health teams for integrated health services in underserved areas of Yemen (Hamouda Hanafi)
All 3 country experiences will provide an illustration of the key strategy used as well as notable challenges and successes. Recommendations for those who are interested in introducing such strategies will also be highlighted.
Conclude with time for Q & A

5. Community Health Workers
Provide DMPA
Jeff Spieler
Senior Advisor for Science and Technology
Office of Population and Reproductive Health
Bureau for Global Health
USAID

6. Technical Consultation, Expanding Access to Injectable Contraception, June 2009
Convened by WHO, USAID, and FHI in Geneva; 30 experts from 8 countries and 18 organizations
Objectives:
Systematically review scientific evidence and program experience on the provision of injectables by CHWs.
Reach conclusions on evidence to inform future policies and programmes and identify research needs.
Document conclusions, including policy and program implications and disseminate widely.
Why focus on injectable contraceptives?
It is a popular method. 35 million women worldwide use injectable contraception.
High unmet need for family planning and injectables persists.
Notes on Methodology:
Research: More than 550 documents, papers and reports found in searches and through stakeholder interviews
16 projects from nine countries were identified as having documented evidence on key questions.
Key Questions related to: (1) Competency of CHWs - Screening clients successfully, Providing DMPA injections safely, Counseling on side effects appropriately; (2) Acceptability of clients and providers, and (3) Uptake and continuation rates
The nine countries included: Bangladesh (six projects), Guatemala and Uganda (two projects each), Afghanistan, Bolivia, Ethiopia, Haiti, Madagascar, Peru.
Independent review using U.S. Preventive Services Task Force rating system on quality of evidence
Background papers were prepared on: Client screening, Injection safety, Counseling on side effects, Client perspective and provider perspective, Update of services and continuation of use

7. Conclusions Overall conclusions and policy implications:
With training, CHWs can screen, initiate DMPA, counsel, and provide reinjections with equal competence
CHW provision of DMPA expands choice and access for underserved and increases uptake
Sufficient evidence exists for national policies to support introduction, continuation, and scale-up
Programmatic guidance:
Monitoring CHW competency in screening is needed
Supervision of providers enhances skills and confidence
Auto-disable syringes should be used
WHO guidance should be followed regarding eligibility
Other conclusions:
Continuation rates are as high as clinical provision
Most clients were satisfied with CHW provision; trained CHWs are comfortable providing DMPA
Additional programmatic guidance is available on supply and waste management, commodities; training, supervision, and monitoring; sustainability of community-based programs; non-clinical delivery systems (pharmacies, drug shops, social marketing); and policy issues.
For details, refer to the WHO technical brief or the article in the March 2010 issue of the journal “Contraception”.

8. Broader Implications
A key strategy to address health worker shortages:
“Task sharing” refers to allowing appropriately trained health workers with less formal medical training to deliver the same services as those with more training, where appropriate.
CHW provision of DMPA is one example of task sharing that has potential to relieve overburdened health systems and positively impact development, family planning utilization and women’s lives.
CHWs currently provide DMPA in more than 12 countries.
Policies and operational guidelines should reflect that trained CHWs can initiate use of DMPA and provide reinjections.

9. Scaling-Up the Use of DMPA at the Community Level in Afghanistan
Hedayetullah Mushfiq, Program Manager, Tech-Serv Project
Management Sciences for Health - Afghanistan

10. Strategies and Approaches
Train volunteer CHWs to provide access to DMPA
for all Afghan women regardless of where they live
Community support
Involve Shura-e-Sehie (Community Health Councils)
Family Health Action Groups
Birth spacing promotion
Culturally appropriate
Correct misconceptions
Access to female CHWs
Skilled CHWs
DMPA counseling
Technical competence in providing DMPA
Community maps
Contraceptive choice
DMPA first injection

11. Challenges and Successes
Prior to 2009, CHWs could only give 2nd and subsequent doses of DMPA and could not give the first dose
Only 8% of Community Health Supervisors are female, yet more than half of CHWs are women
Even after CHWs were allowed to give the first injection, many NGOs were reluctant to implement this policy
Successes
Trained 21,226 volunteer CHWs in all 34 provinces during regarding DMPA, OCs, and condoms and supplied them with all three methods
Increased CPR from 26% in 2006 to 42% in 2009 in 13 USAID-supported provinces
Developed a new national policy in 2009 that permitted CHWs to provide the first dose of DMPA, using a screening checklist

13. Recommendations/Advice
Conduct more frequent post- training follow up, monitoring and supervisory visits to health posts (where CHWs are based)
Strengthen coordination among HSSP, MoPH, Tech-Serve, NGOs and other stakeholders
Correct misconceptions about FP (especially DMPA) at the community level
Conduct advocacy meetings at national, provincial, district and community levels regarding DMPA
Orient Shura-e Sehi to mobilize communities regarding support for improved access to FP including DMPA
Train CHWs in the 21 non-USAID supported provinces to give the first dose of DMPA

14. Increase Access/Utilization of FP Services in Rural Nepal through CHWs
G.C. Bimala
Performance Improvement Program Officer
Family Health Program II - Nepal

15. Strategies and Approaches
Increase Access/Utilization of FP Services in Rural Nepal through CHWs
CHW: accessible, available, understand social-cultural context
Involvement of District office - DIP
Clinical site Preparation
CTS for Trainer
Training of CHW
FP Services
Counseling
Condom
Pills
DMPA
Referral
Contraceptive availability

16. Challenges and Success
Getting adequate caseload for clinical training
Not enough clinical trainers at district level
Conducting post training FU; monitoring and supervision (district supervisors not competent)
Linkages with community service delivery interventions
Successes
Decentralized clinical training; Trained 2,218
Expanded to 26 districts, 9 more already on going planned
Current user increased – pills (30%), DMPA (9.4) after training
Most (72%) providers felt improvement in counseling
Improved availability of condoms, pills, DMPA - 99% (06/07)

17. Contraceptive Use Before and After Training

18. Recommendations and Advice
Scale up training to CHWs to increase access of services, especially in remote areas
Consider number of trainees per batch according to client flow.
Improve linkages with community (e.g. Mothers Group) and out-reach activities (EPI, PHC-ORC) for service delivery
Strengthen post-training FU/support through district team
Ensure continuous supply of FP commodities to CHWs.

20. Mobile Health Teams as a Community-Based Outreach Solution to Improve Access to Care for Underserved Populations
Hamouda Hanafi, Director
Basic Health Services Project
Pathfinder International - Yemen

21. Strategies and Approaches
Growth of health facilities in Yemen without appropriate human resources & equipment.
70% of Yemen population live in rural areas that do not attract medical staff / hard to reach
Mobile teams serve understaffed health facilities
Provide integrated services, medicines, referrals
Midwives: best for supporting FP provision

22. Challenges & Successes
Results:
First encounter with MD for many women
11,000 clients/yr on average = 45 a day
Scale-up by USAID and World Bank
Challenges:
female doctors, security, medicines, maintenance, financial sustainability

23. Recommendations Cost effective solution to lack of human resources
Can support specific interventions such as FP or immunization
Schedules and approaches can be adjusted

24. Increasing Community Access to Family Planning Through Social Marketing Programs
Sitaram Devkota
USAID/Nepal

25. Strategies and Approaches
Traditional Outlets and Non traditional Outlets
Sangani Social Franchise Network
Pariwar Swasthya Sewa Network
Traveling rural field representatives
Sangini Didi Neighborhood Program
(women’s groups )
Village Marketing Program (VMP)
Ensuring Quality of Service Delivery
Traditional Outlets (Medical Shops, Pharmacies and clinics): condoms, oral pilss, injectables, CDK, Point of use water treatment, Virex , ORS
Non traditional Outlets (Barber shops, Cobblers, Pan (piper beetle )/ Bendi (cigarettes) Shops, Convenient stores, Fruit stalls, Bus ticket counters, Cyber cafes, Tea stall) : Condoms, Point of use water treatment
Sangani Social Franchise network: Sangani (3 month injectable)
“Sangini”, meaning female friend, is the brand name for Depot Medroxyprogesterone Acetate (DMPA). A network of private providers launched 1994 by Nepal CRS Company in collaboration with the Nepal Fertility Care Center. Multiple providers often work out of one outlet.
Pariwar Swasthya Sewa Network -PSSN (Family Health Service Network):
IUD
Implant
There are currently 100 providers in the SEWA network, which is operational in Rupandehi. CRS is planning to expand this model, using KfW funding, to additional districts in 2010
Traveling rural field representatives: CRS’s TRSRs are mobile sales persons that focus on hard-to-reach mountain and hilly areas making efforts on opening new outlets, restocking existing ones, and linking to commercial distribution system; and conducting on-the-spot BCC activities.
Sangini Didi Neighborhood Program (women’s groups )
CRS is increasing availability of condoms and other health products such as Nava Jeevan and Clean Delivery Kits in Jumla district through a local NGO, acting as a remote distributor
CRS trains NGO personnel in social marketing, and each has the responsibility to cover certain territories within the district
All localities in Jumla district are now stocked with CRS products, and the local NGO is linked to the commercial distribution system.
Village Marketing program: CRS is increasing availability of condoms and other health products such as Nava Jeevan and Clean Delivery Kits in Jumla district through a local NGO, acting as a remote distributor
Ensuring Quality of Service Delivery
CRS Company, in coordination with a local NGO have developed an extensive training and monitoring system for the Sangini Network
Key elements include
Introductory and contraceptive updates for providers (including US FP policies)
Review meetings with providers
On-the-job coaching
Routine monitoring of service delivery performance (including compliance with US FP policies)

26. Recommendations Work in close coordination with government
Working with traditional and non-traditional outlets increases sustained availability of health products.
The “Sangini” network model has proven itself as a successful model for expanding access to injectable contraceptives in Nepal
Strengthen traveling rural field representatives to increase access to hard to reach population
Mobilize Community-based Organizations (CBOS) through Village Marketing Program (VMP)

27. Success of Social Marketing Program Couple Years of Protection (1978-2009)
The chart shows the cumulative CYP generated by all FP methods (Condom, Pills, Depo, IUD and Implant). The sales of condoms, pills and Depo is increasing every year. However, the sales of long term FP method like IUD and implant is nominal. Social Marketing contributes more than 20% (22.4%)
To the CYP.
Strong coordination and collaboration with public sector.
Additionally, Social marketing approaches has established itself as a leading public health initiative in Nepal
CRS became synonymous with family planning and its condom brand, Dhaal, synonymous with condom
CRS’s marketing efforts have helped to lower cultural and societal taboos in openly discussing family planning
Challenges:
Difficult geographical terrains: It take several days to reach certain hill and mountain districts.
Shortage of trained human resources especially for IUD and implant services

28. Questions and Comments

29. Thank You!