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

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.

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

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

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FFSDP MODEL

DELIVERY OF QUALITY, INTEGRATED SERVICESfor FP and Prevention & Treatment of HIV/AIDS/STIs

PROVIDERS(incl. CBDAs

/HSAs)

RH/FPCLIENTS

•Proven FP capacity with performance improvement opportunities•Regular formative supervision•Adapted info. system•Incentives•Respect for clients’rights•Understanding ofneeds 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 SUPPORTat Zonal & National Levels

Clear policies & guidelinesAdequate norms & protocols

Effective strategies & approaches for different

groupsPlanning & mgt toolsHuman resource mgt

Financial mgt systems & toolsSupply mgt system

Mgt information systemQuality assurance system

FULLY FUNCTIONAL

DISTRICTSTechnical &

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 servicesInformed choice

COMMUNITY SUPPORT SYSTEMSEngaged traditional &

elected leadersSocial marketing &

BCC activitiesCommunity involvement

Local FBOs/NGOsmotivated and engaged Community structures involved: women’s & men’s groups, youth

associationsLocal governments

involved in all activities

SocialSupport & Local Ownership

PoliticalSupport, Dialogue, & Advocacy

Family Planning Services

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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

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FP Service Provision

8CFPHS Trained Provider inserting Jadelle DMPA Practicum

FP Results• About 90,046 DMPA doses given by HSAs Jan-Dec

09

• 271,799 people counseled on FP and HIV messages

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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

Results Continued

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

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HIV TESTING AND COUNSELING SERVICES

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

 

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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

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People Counseled & Tested for HIV – by Quarter

Dec 08

HTC Service Delivery Challenges

• Proper disposal of hazardous waste• Availability of Test Kits

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DEMAND CREATION

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Activities:Increase demand for contraceptives and HIV testing

• Message design workshop conducted• Communication strategy document developed• Branded BCC campaign launched

page 20

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.

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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.

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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.

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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

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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.

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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.

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Demand creation and increasing access: Open Day

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POLICY AND ADVOCACY

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Policy Landscape analysis

Activities• Consultative meetings• Document review• Disseminated findings at FP sub committee

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Results

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• 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

CBD of DMPAActivities

• 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

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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

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

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Advocacy withFaith 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

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

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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

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MONITORING AND EVALUATION

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• 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 serviceso Increased access to servicesoStrengthening health sector capacity.

Monitoring and Evaluation

Monitoring and Evaluation

• 3 Indicators chosen to monitor SO8 as follows:oPercentage of under-five children sleeping

under insecticide-treated bed nets oContraceptive prevalence rateoUse of condoms during risky sex

• Only last two relate to the CFPHS Project

Monitoring and Evaluation

• Contribute to Goal Level indicators • Total fertility rate• Prevalence of HIV among 15 to 49 year olds

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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.

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

Life of Project Outputs

• Monthly reports• Quarterly Reports• Bi-annual Reports• Annual Reports

Challenges

• Staff turnover high• Data collection difficult by design (work in hard to

reach areas)• Data management

Looking forward

• Improve data management• Use of modern communication systems for data

reporting – Associated challenges of expenses involved

• Staff and Volunteer (CBDA) motivation

LESSONS LEARNTOVERALL

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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;

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.

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Capacity gaps in FP and HIV&AIDS issues exist among the Muslim community

A sustainable advocacy strategy is important

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Conclusion

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

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