1. Community Based Family Planning and HIV/ AIDS Services Project Project Team: Mexon Nyirongo – COP; Njuru Nganga – DCOP; Joyce Wachepa – FP Advisor; Flora Khomani – HIV/AIDS Advisor; Chimwemwe Msukwa – M&E Advisor; Olive Mtema – Policy Specialist; Carol Bakasa – Gender/Communication; Ricky Nyaleye – Gender/Communication

2. RATIONALE FP is the key to improvement of socio-economic wellbeing of people in developing countries. Access to FP services in rural areas is limited. Modern FP method can help avert unwanted pregnancies thereby reducing MMR and IMR in Malawi. The project works through a network of CBDAs and HSAs to provide FP and HIV & AIDS services in the hard to reach underserved areas.

3. Project Geographic Scope Karonga (11): CFPHS Kasungu (3): BASICS & CFPHS Nkhotakota (6): CFPHS Salima (9): BASICS & CFPHS Chikwawa (18): BASICS & CFPHS Mangochi (21): BASICS, CFPHS, & TBCAP Phalombe (26): BASICS & CFPHS Balaka (16): BASICS & CFPHS = Project Head Office

4. CFPHS Approaches Define and develop the supply and capacity of service providers at district, health center and community levels Create demand for FP and HIV & AIDS services through BCC, community networks and outreach Review current policies and advocate for supportive policies

5. 5 FFSDP MODEL DELIVERY OF QUALITY, INTEGRATED SERVICES for FP and Prevention & Treatment of HIV/AIDS/STIs PROVIDERS (incl. CBDAs /HSAs) RH/FP CLIENTS Proven FP capacity with performance improvement opportunities Regular formative supervision Adapted info. system Incentives Respect for clients’ rights Understanding of needs of both genders Well informed Aware of FP benefits Able to freely chose preferred FP method Understand their rights Continue use of chosen method and adhere to indications for use Sustainable use of quality, integrated FP/RH services Enabling policy and social environment MANAGEMENT& LEADERSHIP SUPPORT at Zonal & National Levels Clear policies & guidelines Adequate norms & protocols Effective strategies & approaches for different groups Planning & mgt tools Human resource mgt Financial mgt systems & tools Supply mgt system Mgt information system Quality assurance system FULLY FUNCTIONAL DISTRICTS Technical & Operational Support Trained & motivated staff Sufficient equipment, drugs, & supplies Adequate infrastructure Functional referral system Functional MIS FULLY SUPPORTIVE COMMUNITIES Positive social atmosphere (stigma reduction, reduction of GBV) Attention to underserved & high-risk groups Affordable services Informed choice COMMUNITY SUPPORT SYSTEMS Engaged traditional & elected leaders Social marketing & BCC activities Community involvement Local FBOs/NGOs motivated and engaged Community structures involved: women’s & men’s groups, youth associations Local governments involved in all activities Social Support & Local Ownership Political Support, Dialogue, & Advocacy

6. Family Planning Services 6

7. FP service Accomplishments 1003 CBDAs trained 293 Supervisors trained; 361 HSAs trained in DMPA 96 Nurses and Clinical officers trained in LTPM 15 TOTs and 205 providers trained in Standard Days Method. SDM provision started January 2010 7

8. FP Service Provision 8 CFPHS Trained Provider inserting Jadelle DMPA Practicum

9. FP Results About 90,046 DMPA doses given by HSAs Jan-Dec 09 271,799 people counseled on FP and HIV messages 9

10. Results: New and Old Clients By HSAs and CBDAs Yr 09 CBDAs made 3,007 referrals for other FP methods. Thus likely drop in new users

11. Results Continued

12. 12

13. FP service delivery Challenges Retention of CBDAs vs incentives Reporting Proper disposal of hazardous waste Drop out of service providers. 13

14. HIV TESTING AND COUNSELING SERVICES 14

15. Accomplishments 76 CBDAs trained in Door to Door provision of HTC. 15 HSAs trained in HTC 13 HSAs trained in HTC Supervision 15

16. HTC SERVICE RESULTS 83, 220 people learned their HIV status between Sept 08 and Dec 09 through door to door integrated HTC and FP services by the 76 trained CBDAs 16

17. People Counseled & Tested for HIV – by Quarter Dec 08

18. HTC Service Delivery Challenges Proper disposal of hazardous waste Availability of Test Kits 18

19. DEMAND CREATION 19

20. Activities: Increase demand for contraceptives and HIV testing Message design workshop conducted Communication strategy document developed Branded BCC campaign launched page 20

21. Listening Club activities 25 FP Listerners clubs (already existing) per district were trained. Trained 2 members from each club to lead the listening activity. Listerners clubs meeting conducted every Wednesday Discussion guides developed to assist during listening activity. page 21

22. Community drama performances A script based on the radio drama series was developed for community drama performances Three community drama troupes per district identified and trained. Troupes asked to perform regularly in their communities. page 22

23. Community Sensitization/ Open days CBDAs, HAS and HTC Counselors showcase the services they provide. As of December 2009, 13 open days were held throughout the project districts. page 23

24. Integration of Gender Based Violence into all activities Developed GBV modules with the help of a GBV consultant. Ensured that GBV was incorporated in the training of CBDAs and private sector providers Ensured that all materials developed for the BCC campaign were gender sensitive page 24

25. Increased accessibility to oral and injectable contraceptives Initiated family planning provision through private clinics, pharmacies and drug stores Trained 292 private sector providers in FP service provision Distributed 12 813 cycles of oral contraceptives and 99 285 vials of injectable contraceptives. page 25

26. Results: 32 525 people reached through community drama 56 034 people (26 676 male and 29 358 female) reached with family planning and HIV and AIDS services through open days. 26

27. Demand creation and increasing access: Open Day 27

28. POLICY AND ADVOCACY 28

29. Policy Landscape analysis Activities Consultative meetings Document review Disseminated findings at FP sub committee 29

30. Results 30 9 policy areas identified Policy on CBD of DMPA included in SRHR policy Oral pills de regulated Policy language on social marketing included in SRHR policy

31. CBD of DMPA Activities Several debates HPI feasibility Study 2007 Operational barriers study Madagascar study tour in June 2008 Stakeholder’s dissemination meeting July 2008 SRHR policy review Guidelines development Workshop Results MoH decision on HSAs March 2008 Consensus to pilot HSA.. DMPA initiative Policy statement on CBD of DMPA guidelines and training materials developed and approved Oct. 2008 Guidelines disseminated June 2009 31

32. 32 Integration of FP and HIV/AIDS Survey Objectives: meaning, purpose, challenges, lessons Data collected in Sept. 2009 Report submitted to MSH home office Dissemination and consensus building workshop in May 2010. Results expected to guide policy and guidelines development

33. Social Marketing Guidelines Literature review Consultations Interviewed CBDAs in two districts Lessons learnt from other countries presented to RHU and options for Malawi discussed RHU prefers to pilot in urban or semi urban using a private sector organisation Government’s policy of free health services Working with PSI to pilot 33

34. Advocacy with Faith Based Organizations Consultative meetings with Muslim clerics on FP and HIV/AIDS services and Islam Conducted high level advocacy conference in August 2009 Resolutions a guide to Muslims on FP and HIV/AIDS issues; and future programmes FP and HIV/AIDS presentations at women’s gatherings 34

35. Advocacy with regulatory bodies Pharmacy, Medicines and Poisons Board of Malawi Medical Council of Malawi Nurses and Midwives Council of Malawi 35

36. Policy Challenges Conflict between policy, practice and regulation. Policy on free health service affecting community based social marketing efforts and private sector involvement. HSA provision of other contraceptive methods. Ministry’s view regarding CBDA administration/provision of DMPA at the community level Sustainability and scale-up of CBD program Integration of FP and HIV/AIDS services 36

37. MONITORING AND EVALUATION 37

38. CFPHS Project falls under USAID SO 8 SO 8 has 4 Intermediate results as follows: o Increased use of improved health behaviours and services o Improvement of quality services o Increased access to services o Strengthening health sector capacity. Monitoring and Evaluation

39. 3 Indicators chosen to monitor SO8 as follows: o Percentage of under-five children sleeping under insecticide-treated bed nets o Contraceptive prevalence rate o Use of condoms during risky sex Only last two relate to the CFPHS Project

40. Monitoring and Evaluation Contribute to Goal Level indicators Total fertility rate Prevalence of HIV among 15 to 49 year olds 40

41. Critical Assumptions Facilities are adequately staffed. Political and professional support is available for CBDAs to deliver FP and HIV/AIDS services. Policies have been approved by MOH enabling CBDAs to provide injectable contraceptives. Contraceptives, STI medicines, and HIV test kits are available.

42. Monitoring and Evaluation: Main Outputs for Project Monitoring – Program Inception Detailed Implementation Plan (DIP) Performance Management and Evaluation Plan (PMEP)  Indicator definitions  Work plan  Data Quality Assessment checklist Baseline Survey »Conducted April 2008 »Report released January 2009

43. Life of Project Outputs Monthly reports Quarterly Reports Bi-annual Reports Annual Reports

44. Challenges Staff turnover high Data collection difficult by design (work in hard to reach areas) Data management

45. Looking forward Improve data management Use of modern communication systems for data reporting – Associated challenges of expenses involved Staff and Volunteer (CBDA) motivation

46. LESSONS LEARNT OVERALL 46

47. Major Lessons Learned Well trained non-medical workers can effectively provide selected FP methods. Community based services reduces workload at health facilities. SDM has created a lot of interest among the catholic community in FP; Increased training of LTPM providers has increased demand for Jadelle;

48. Major Lessons learned cont… Demand Creation activities improves service uptake Integrated community based FP and HTC services reduce stigma High level advocacy improves political will. 48

49. Capacity gaps in FP and HIV&AIDS issues exist among the Muslim community A sustainable advocacy strategy is important 49

50. Conclusion Scaling up integrated CFPHS can accelerate meeting the FP and HIV & AIDS demands of the underserved rural communities. 50