Sponsored by: U.S. Agency for International Development (USAID), World Health Organization (WHO), Action for West Africa Region Project - Reproductive Health (AWARE-RH), Advance Africa, the POLICY Project

Repositioning Family Planning in West Africa

Repositionnement de la Planification Familiale en Afrique de l’Ouest

Community-based Programmes: a

Strategy for Improving Access

and Quality

Ian Askew

FRONTIERS in Reproductive HealthPopulation Council

What Have We Learned From 20 Years of CBD in West

Africa?

CBD Can Generate Interest in Child Spacing and FP Use

Index of attitudes towards FP in rural Senegal

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10

Relais ASC town

Pre-intervention Post-intervention

• CBD agents and key individuals stimulate community and couple discussions

• Building social acceptance allows couples to practice without stigma

• Most successful with same sex interactions

CBD Can Increase Use of FP

• Immediate increase as agents legitimise FP and increase access

• More methods provided increases overall CPR

• Increase in use may take time due to building new social norms

• CBD can augment clinic-based quality improvements

CPR after introducing CBD in Mali

1%

11%

21%

10%

0%

5%

10%

15%

20%

25%

30%

35%

No agent One year Two years

Condoms and referral Pill added

What Types of “CBD” Have Been Tried?

• Public and Private Sector:– Government programmes– NGO, church-based, employment-based

• Agent status:– Part-time – voluntary or allowance– Full-time – salaried employees– Male, female– Home visits, depot/post

No single model – each developed to fit the situation

Performance of CBD Programs Can Vary by ModelMean annual CYP provided per distributor

2

4

11

11

47

55

19

32

34

44

74

95

205

250

0 50 100 150 200 250 300

GRMA Ghana

MOH Zanzibar

MOH Kenya

MOH Tanzania

UMATI Tanzania

CHAK Kenya

MYWO Kenya

FLPS Kenya

PPAG Ghana

NCCS Kenya

FPAK Kenya

SDA Tanzania

NCCFP Kenya

ZNFPC Zimbabwe

salaried agents

agents with allowance

voluntary agents

Cost-effectiveness Can Vary by Type of Program

Mean cost per CYP

$7.41

$9.40

$7.03

$8.18

$8.76

$13.36

$14.97

$7.15

$7.38

$13.21

0 2 4 6 8 10 12 14 16

FPAK Kenya

NCCFP Kenya

SDA Tanzania

NCCS Kenya

UMATI Tanzania

CHAK Kenya

MOH Kenya

ZNFPC Zimbabwe

MYWO Kenya

FLPS Kenya

US$

Salaried agents

Agents paid allowance

Voluntary agents

Why Is CBDa Repositioning Strategy for FP?

• Fertility preferences still high• Interest in using FP to space or limit births

still low• Changing these social norms requires

education and discussion at individual, family and community level

• Clinic-based services cannot easily stimulate or facilitate such social interactions

Why Is CBDa Repositioning Strategy for FP?

• Providing contraceptives through clinics limits their physical, financial and social access

• Clinics cannot effectively reach men with FP messages and condoms

• CBD facilitates continuation of use

• CBD can offer FP integrated within a range of basic health information and services (malaria, ORT, iron tablets, STI information, etc.)

Challenges – Can CBD Provide More FP Services?

• Currently offering information, condoms, pills, spermicides, NFP, and referral for clinical methods

• But:– Can injectables be offered?– Can emergency contraception be offered?– Can IUCD be offered?– Dual protection messages can be

communicated – but to what effect?

Challenges – HIV, Safe Motherhood and Child Survival Services?

• Feasibility of providing basic HIV/STI information proven, but:– Can verbal risk screening and referral be

added?– Can STI treatment for males be added?– Can CBD link with VCT, ART and home-based

care?

• Information about pregnancy and child nutrition?

• Birth planning and support for assisted deliveries?

Major Challenge– Ensuring Sustainability

Transition from pilot project to routine programme critical – but how?

Diversification of programme role and income sources (NGOs: Ghana; Zimbabwe)

Planned phasing: (MOH: Ghana)– Pilot model, then experiment to test effectiveness

(Navrongo)

– Sustain, and demonstrate replication (Nkwanta)

– Gradual nationwide expansion (CHPS) Revitalise existing government community

programmes (Senegal)

Critical Elements in Sustaining Community-based Programmes

• Commitment to a large-scale, routine CBD programme– Belief in cost-effectiveness of strategy– Willingness to engage community-level cadre as

standard staffing component

• Pilot test model first to identify how it works• Plan for going to scale from the beginning:

– Immediately sustain successful pilot model in project sites (and expand to district level)

– Document successful configuration and pilot its replication in limited additional districts

– Develop systems to enable expansion nationwide

Programmatic Recommendations

• National leadership….with district ownership• Reinvigorate (and reconfigure) existing community-

level cadres rather than develop new cadre• Do not use volunteers in isolation from an employed

cadre• Offer a range of related and integrated services• Include possibility of cost- and profit-sharing for

commodities• Move from project-funding to line-item budgeting as

soon as possible