1. Community-Based Distribution of DMPA in Malawi Margot Fahnestock Futures Group September 30, 2009

2. Presentation Outline 1.Context for CBD of DMPA in Malawi 2.From Debate to Policy Decision 3.Implementation 4.Future Directions

3. 1.Context for CBD of DMPA in Malawi

4. Malawi

5. More About Malawi Bordered by Mozambique, Tanzania and Zambia 14% urban, 86% rural population Decentralized government, with 28 districts Predominantly Christian population (approximately 80%)

6. Family Planning in Malawi Malawi has been a success story in sub-Saharan Africa Country enjoys strong policy environment for family planning; included in: –Reproductive Health Policy –Reproductive Health Strategy –Road Map for Accelerating Reduction of Maternal Mortality According to MICS, CPR has increased but fertility still high...

7. Making the Case for CBD of DMPA in Malawi By 2010, Malawi’s RH strategy aims to: –Reduce TFR to 4.9 –Increase modern CPR to 40% Fertility rates are still very high Rural access to health centers is challenging Health centers are extremely understaffed Malawi has 20-year history with CBD agents

8. "There are so many patients here to see. The number is about 75 to 100 patients per day. Sometimes people wait for hours to be attended to. Yesterday I was alone on duty without even any medical assistant to help me. Sometimes I have to do both day and night shifts in the same day! – Loveness Makeyi, 35, Nurse/Midwife, Khonjeni Clinic, Malawi Source: “Help Wanted: Confronting the healthcare worker crisis to expand access to HIV/AIDS treatment: MSF experience in southern Africa.” Medecins Sans Frontieres. 2007.

9. But Who Should Administer? Malawi is one of the only countries in Africa with a low-level, paraprofessional, MOH employee – the Health Surveillance Assistant (HSA) –Are they overloaded? Malawi’s CBD agents (CBDAs): –Many do not have high school education –Most are volunteers, with few or no incentives

10. Malawi’s Secret Ingredient: The Health Surveillance Assistant (HSA)

11. 2.From Debate to Policy Decision

12. A Long Debate In Malawi, the debate to allow lower-level health workers to administer DMPA was very controversial Medical professionals were hesitant to allow “paraprofessionals” to administer injections BUT – HSAs already administer immunizations to children under five

13. March 2008 – Ministry’s Big Policy Decision March 2008, Senior Management team of the MOH decided to allow HSAs to administer DMPA in communities Reproductive Health Unit critical to this decision: –Presented literature from other countries –Argued that CBD approach is safe –Highlighted large demand for DMPA

14. Multiple Factors May Have Contributed to the Policy Decision Late 1980s Malawi implements CBD programs Mid-1990s Several districts in Malawi begin to allow HSAs to provide DMPA 1999 – 2003 World Bank-funded CBD project using traditional birth attendants September 2007SWAp Review September – December 2007 USAID | Health Policy Initiative stakeholder assessment and focus group discussions

15. Current Policy in Malawi on CBD Provision of DMPA Current policy: –HSAs can administer DMPA at the community level (phase-in process) –Guidelines for HSA administration of DMPA approved late 2008 Policy challenges: –DMPA and pills still not deregulated –Districts required to pay 12% handling fee to Central Medical Stores for DMPA (essentially 112%) –HSAs still not allowed to provide oral contraceptives, resulting in referral issues

16. 3.Implementation

17. USAID-funded CBD Initiatives in Malawi USAID | Health Policy Initiative (HPI) –Analysis of feasibility and acceptability of CBD of DMPA –Operational policy barriers analysis to financing and procurement of contraceptives Community-based Family Planning and HIV/AIDS Services Program (CFPHS) –Mission bilateral –MSH is prime contractor –Subcontractors: PSI Futures Group –Three-year project with one year option

18. Implementation Through the MSH-led CFPHS Project Project includes HSAs and CBDAs: –CFPHS trained CBDAs in 8 project districts –One HSA has 10 CBDAs reporting –CBDA provides oral contraceptives; female and male condoms; CycleBeads; counsels on multiple methods –CBDAs refer clients requiring DMPA to the HSA Project hired and trained CBDAs from 8 districts in 2008-2009 – more than 1,000 FP trainers trained HSAs from 9 districts in 2008- 2009

19. Implementation (Cont.) Training –Select HSAs chosen to be training for DMPA provision –HSAs providing DMPA receive 5-day training session Supervision –HSA supervisors –Supervision linked to health centers –Nurses-in-charge, environmental health officers, supervise HSAs at health centers Supply –USAID | DELIVER Project assisting with reporting –HSAs resupply DMPA at health centers –Sharps containers provided

20. 4.Future Directions

21. Future Directions Phase-in period –Ends in November 2009 –FHI will evaluate HSA provision of DMPA in 9 districts Scalability of program –HSAs make scale-up more achievable –National coverage of HSAs Plans for scale-up –MOH plans to scale up after evaluation –Pilot-test CBDA provision of DMPA? Challenges for scale-up –Public sector supply of DMPA –Future of HSA cadre

22. Is the CBDA the Future of CBD of DMPA in Malawi?

23. Thank You