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Which Family Planning Methods can Community Health Workers Provide? Policy Data from 25 Countries

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This poster was presented by Kristen Devlin at the International Conference on Family Planning (ICFP) in Kigali, Rwanda in November 2018.

Since 2012, the Advancing Partners & Communities (APC) project has supported community health programs globally, with a focus on family planning. APC develops practical tools and approaches to help global and national level stakeholders identify knowledge and programming gaps to harmonize and scale community health programs. For decades, community health workers (CHWs) have been critical to reaching last-mile communities with family planning (FP) interventions. Information on the types of FP methods CHWs can provide, is often fragmented across country policies and strategies. To fill this gap, APC launched the Community Health Systems Catalog in 2014 as a one-stop 'shop' for key information on FP and community health policies and programs across 25 countries. This catalog identifies guidance on: 1) The number and type of CHW cadres that can provide FP interventions by country, 2) Which FP interventions CHWs can provide, 3) Gaps in FP policy guidance.
This resource on community-based FP policies advances global knowledge and can be used to: Compary community-based FP interventions, inform dialog on FP task-sharing and -shifting, identify policy areas where clearer more comprehensive guidance is needed.

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Which Family Planning Methods can Community Health Workers Provide? Policy Data from 25 Countries

  1. 1. The CHS Catalog Includes FP Data from 25 Countries Afghanistan, Bangladesh, Benin, Democratic Republic of the Congo, Ethiopia, Ghana, Haiti, India, Kenya, Liberia, Madagascar, Malawi, Mali, Mozambique, Nepal, Nigeria, Pakistan, Philippines, Rwanda, Senegal, Sierra Leone, South Sudan, Tanzania, Uganda, and Zambia KEY FINDINGS How many CHW cadres could provide at least one FP intervention? There was guidance for 60 CHW cadres, averaging 2–3 per country, with a range of skills, roles, scopes of work, and program inputs that support them. Fifty-four of 60 CHW cadres (90%) could provide at least one FP intervention, and the remaining six cadres did not provide any FP interventions. All 25 countries had FP guidance available for at least one CHW cadre. Policies for individual CHW cadres varied in availability, quality, and content. Which FP interventions could CHWs provide? The graph below shows the number of countries that allowed at least one CHW cadre to provide or counsel on each FP method. The majority of countries had clear guidance on most FP products. All countries allowed CHWs to provide OCPs and condoms, and many countries approved CHWs to administer injectables. A number of countries permitted higher-level CHW cadres, such as community midwives, to insert implants and/or IUDs. None could perform vasectomies or tubal ligations, though many CHWs could refer clients to higher-level facilities for these services. Only some countries had explicit instruction for CHWs to provide education or counseling on fertility awareness methods. What were the gaps in FP guidance? Over half of countries had absent or unclear information about whether CHWs could distribute ECPs, as shown in grey in the map below. Many policies did not include fertility awareness methods in CHW training curricula or job descriptions but CHWs were not explicitly forbidden to educate on them. Sierra Leone, however, had a newly updated CHW curriculum that did not mention CycleBeads, so it was presumed this method was not within their scope. KNOWLEDGE CONTRIBUTION While community-based approaches to improving FP access are far from new, guidance for CHWs had never been aggregated and synthesized within and across countries before APC’s Catalog. This resource on community-based FP policies advances global knowledge and can be used to: Compare community-based FP interventions permitted across countries and CHW cadres within each country. As national stakeholders design new policies and strategies to scale up and strengthen FP programs, they often seek examples and information from other countries to support their planning and decision-making processes. Inform dialogue on FP task-sharing and -shifting. Exploring the policy data to identify which CHW cadres can provide which FP services, and how different levels of CHWs work together to reach last-mile communities, can provide information on an array of service delivery models designed to reach underserved women with critical FP services. Identify policy areas where clearer, more comprehensive guidance is needed. For example, this analysis showed that policies should more clearly articulate guidance for ECP provision and education on fertility awareness methods by CHWs. This information will help guide investments and decisions by donors, policymakers, and program designers. BACKGROUND & MAIN QUESTIONS For decades, community health workers (CHWs) have been critical to reaching last-mile communities with family planning (FP) interventions. They have been instrumental in increasing access to and voluntary uptake of contraceptives particularly among poor, underserved women. In recent years, a growing evidence base has shown that with adequate training, supplies, and support, CHWs can safely and effectively provide a range of contraceptive methods, resulting in an expanded role for CHWs in FP provision. Information on the types of FP methods CHWs can provide, however, is often fragmented across country policies and strategies. Community-level provision is sometimes absent from FP guidelines, revealing a global knowledge and policy gap in the community-based family planning policy landscape. To fill this gap, APC launched the Community Health Systems Catalog in 2014 as a one-stop ‘shop’ for key information on FP and community health policies and programs across 25 countries deemed priority by USAID’s Office of Population and Reproductive Health. APC developed the catalog to identify guidance on: 1. The number and type of CHW cadres that can provide FP interventions, by country. 2. Which FP interventions CHWs can provide. 3. Gaps in FP policy guidance. APPROACH APC updated the CHS Catalog in 2016–2017 using a 121-question survey that included questions about the number and type of CHW cadres in each country and the FP interventions they could provide, according to policy: • Administration or provision of the following FP products and procedures: condoms, oral contraceptive pills (OCPs), injectable contraceptives, emergency contraceptive pills (ECPs), implants, intrauterine devices (IUDs), and permanent methods. • Information, education, and/or counseling on the aforementioned methods and non-product FP methods: the Standard Days Method, CycleBeads, lactational amenorrhea method, and ‘other fertility awareness methods,’ such as the two-day and rhythm methods. Country experts and APC staff reviewed community health policies, strategies, curricula, and other documents to complete the questionnaire through an electronic platform. Country authorities vetted policies when possible. APC staff performed data quality checks and analyzed data by tabulating and aggregating FP interventions by CHW cadre and country. Since 2012, the Advancing Partners & Communities (APC) project has supported community health programs globally, with a focus on family planning. APC develops practical tools and approaches to help global and national-level stakeholders identify knowledge and programming gaps to harmonize and scale community health programs. Kristen Devlin | Kimberly Farnham Egan | Tanvi Pandit-Rajani JSI Research & Training Institute, Inc., 1616 Fort Myer Drive, 16th floor, Arlington, VA, USA Which family planning methods can community health workers provide? Policy data from 25 countries Across these 9 countries, 17 cadres could provide ECPs, and 2 countries did not allow any CHWs to provide them. The 14 other countries did not capture information on ECPs in recent and available community health policies. 13 12 13 11 1 4 21 10 25 25 25 20 5 21 4 22 3 2 9 14 15 Info on Standard Days Method CycleBeadsInfo on Lactational Amenorrhea Method Other Fertility Awareness Methods (TwoDay, Rhythm, etc.) Condoms Oral Contraceptive Pills Injectables Implants IUDsEmergency Contraceptive Pills Permanent Methods Yes, policies allow at least one CHW cadre to provide No, policies do not allow or include Information unavailable or unclear Policy Guidance for CHW Provision of Emergency Contraceptive Pills Number of Countries with Policy Guidance for Family Planning Methods ACKNOWLEDGEMENTS: Advancing Partners & Communities (APC) is a cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A-12-00047, beginning October 1, 2012. APC is implemented by JSI Research & Training Institute, Inc., in collaboration with FHI 360. We acknowledge the contributions of the participating health workers and Ministry of Health staff. The views expressed do not necessarily reflect the views of USAID or the United States Government.

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