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pbf&fp - Cameroon case study


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Bitouga, Berk, Diego Rios, Aparna & Afounde

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pbf&fp - Cameroon case study

  1. 1. ARE FAMILY PLANNING SERVICES «HIGH QUALITY » IF FEW ADOLESCENTS SEEK CARE ? A case study: Cameroon Bitouga Bernard Berk Ozler Diego Rios Zertuche Aparna Jain Afounde Jeannette Improving quality of care measurement of family planning in Performance-Based Financing system,  September 14-15  2017, Antwerp
  2. 2. Family Planning and adolescents reproductive health in Cameroon Barriers to access to contraception among adolescents Innovative experiences in promoting, accessing and using FP services by adolescents in Cameroon Adolescents clinics PBF program
  3. 3. General population: 21 917 602 10-24 years old: 34% 10-19 years old : 24% Source : Recensement Général de la Population  et de l’Habitat 2010
  4. 4. Direction de la Santé Familiale  MINSANTE CAMEROUN Total Fertility rate (15-49Y) : 4,9 General Fertility rate (15-49Y) : 209‰ Early pregnancies prevalance  (MICS, 2014): 25,6%* East: 53,1 Littoral:18 South: 44,6 Douala: 6,8 Center: 38,6 Yaoundé: 11,6 * National level Adolescents fertility rate  (MICS, 2014) : 119 ‰ * East: 206 South:183 Center: 177 Littoral: 72 Douala: 55 Yaoundé54 Adolescents fertility rate  (MICS, 2014) : 119 ‰ * East: 206 South:183 Center: 177 Littoral: 72 Douala: 55 Yaoundé54
  5. 5. Direction de la Santé Familiale  MINSANTE CAMEROUN * without MAMA  concidered as a traditional method Adolescents fertility rate  (MICS, 2014) : 119 ‰ *Use of Birth Control Methods among adolescents   All methods : 16,1% (DHS, 2011) Modern: 12,2% (DHS, 2011) Traditional : 3,9% (DHS, 2011) 24,2% (MICS, 2014) 16,4% (MICS, 2014)* 7,8% (MICS, 2014) Use of Long Acting Reversible Contraceptives Methods ( LARCs) among adolescents  IUD : 0,1% (DHS, 2011) Injectables: 1,1% (DHS, 2011) Implants : 0,2 % (DHS, 2011) 0,0 % (MICS, 2014) 0,9% (MICS, 2014) 1,1% (MICS, 2014) All methods (15-49Y) : 23% (EDS, 2011)  34% (MICS, 2014) modern methods (15-49Y):14% (EDS, 2011)  16% (MICS, 2014)*
  6. 6. Direction de la Santé Familiale  MINSANTE CAMEROUN * MICS 2014   For limiting % For Spacing  % Total % 15-49 Y 7,3 10,7 18 15-19 Y 0,3 15,7 16 Situation  42% of women of reproductive age are between 15-24 years old  1/3 of young people (between 15-24 years) are married  Among the 2/3 of young non-married, almost half are sexually active Unmit needs *
  7. 7. Direction de la Santé Familiale  MINSANTE CAMEROUN
  8. 8. Direction de la Santé Familiale MINSANTE CAMEROUN Contraceptive method Price (CFA) Price US $ Observations Oral pills 125 0,22 Three cycles of pills DMPA I/M Injection 255 0,45 An injection, this price includes consumables Insertion of an implant 2140 3,79 This price includes consumables Insertion of an IUD 1000 1,77 This price includes consumables Men's Condoms 50 0,09 Ten condoms Women's Condoms 100 0,18 Ten condoms Removing an Implant 1000 1,77 In case of expulsion and reinsertion, only the insertion is invoiced to the client Removal of an IUD 500 0,89
  9. 9. Direction de la Santé Familiale MINSANTE CAMEROUN Health care providers in Cameroon (2017): 38,122 % of trained health care providers in FP: 6.4% (2,344) Number of health care facilities: 5,086 % of health care facilities with at least 1 trained FP provider: 30.4% (3,373) RegionsRegions Total number ofTotal number of health carehealth care providers (public etproviders (public et private)private) % of health care% of health care providers trained inproviders trained in FPFP Adamawa 1198 23,2% west 1268 15,1% East 1443 12,8% North-west 1606 11,3% Far-North 3728 9,5% South-west 3679 7,4% North 3847 4,4% Littoral 6938 4,2% South 5119 3,9% Center 9296 3,4% Total 38122 6,4% Source: Department of Family Health, Cameroon (2017)
  10. 10. Direction de la Santé Familiale MINSANTE CAMEROUN Source: CENAME 2017 / Departement of Family Health contraceptives quantification 2017
  11. 11. Direction de la Santé Familiale MINSANTE CAMEROUN 1. Ensure the mobilization of the budget line for the purchase of contraceptive products 2. Establish a subsidy mechanism for FP services for the most vulnerable targets including youth and adolescents and women with disabilities 3. Strengthening multisectoral commitment to FP 4. Disseminate the framework documents of the SR / FP available to Cameroon and implement the priority interventions selected 5. Institutionalize the use of certain methods in the Community approach, in particular pills and injectable contraceptives 6. Conduct advocacy to increase the budgetary allocation for the SR by 5% as well as the share allocated to FP 7. Mobilize donors including private sector and civil society to finance FP 8. Ensure that contraceptives are secure so that there is zero stock-out of contraceptive products 9. Provide the full range of contraceptives by ensuring the quality of services including FP counseling training and supervision of health workers 10. Ensure the accountability of government and funding partners for FP
  12. 12. Direction de la Santé Familiale MINSANTE CAMEROUN Objectives 1.Identify the barriers to the take- up of modern contraceptives in general and LARCs in particular among adolescent females in two regions of Cameroon. 2.We aim to identify barriers on both the supply and demand side, such as: Attitudes (NGO, provider, CHW, mother, partner) Worries (side effects, information, privacy) Cost, and other… Methods Study conducted in the East and SW regions during August-September 2016 Focus group discussions (4 in the SW and 4 in the East): • 8 FGDs with 15-19 year old girls Interviews (16 in the SW and 16 in the East): • 12 interviews with 15-19 year old girls • 5 interviews with NGO workers (3 SW & 2 E) • 4 interviews with community-health workers (CHWs) • 4 interviews with healthcare providers • 4 interviews with mothers of 15-19 year old girls • 4 interviews with partners of 15-19 year old girls
  13. 13. Direction de la Santé Familiale MINSANTE CAMEROUN Source: Ozler, Moumpe: Increasing the use of LARCs among adolescent females in Cameroon , 2016 “Family planning is not good for those of us that are young that have not yet put to birth” (19yo, single, no children, does not use FP) • “at school, we were told, our Biology lady always told us that those FP stuff that are not good because sometimes when you place it, there are some who don’t know how to place it, when the person places it in you, it moves; when during the years that you are asked to do with it, when it finishes when you go again to get it off, they cannot find it, they cannot find it, and it gets stuck in you and it causes you problems, that is why I was afraid.” (19yo, in relationship, 2 children, uses calendar method) Fear of side effects Incomplete knowledge, mixed with misconceptions and rumors Preferred FP method depends on: perceived effectiveness, side effects, personal preference, cost Some distrust of CHWs distributing FP methods at home
  14. 14. Direction de la Santé Familiale MINSANTE CAMEROUN Source: Ozler, Moumpe: Increasing the use of LARCs among adolescent females in Cameroon , 2016 • Cultural/political barriers: "They told us that this is a policy implemented by whites to prevent Africans from reproducing... they say it is the re-colonization and whites are now have a strategy to re- colonize Africa and they start asking us not to reproduce and so that they will occupy the empty land... Sometimes it is the health staff that speaks like [that] and precisely there is the medical delegate, who in his job description is called to carry out communications for behavior change of the providers what we call the CCC.” • Religious barriers: "it is God who gives children and God gives at his time so that, by giving a method to a woman, it goes against the will of God that is, we take an action to block God's decision. ” • Word of mouth: "We have already met in a health area where women who after inserting the IUD returned and requested the withdrawal. And the reason for this was that the "husbands"... say they feel that there is something that inconveniences them... now she will spread the news that I have got it removed because it inconveniences my guys. And that's how the others begin to scroll in the health facility to request for removal.“ (Regional coordinator NGO, man, 43Yo)
  15. 15. Direction de la Santé Familiale MINSANTE CAMEROUN Source: Ozler, Moumpe: Increasing the use of LARCs among adolescent females in Cameroon , 2016 "Io fte n he ar that the re is this m e tho d that e xists but I have ye t se e n ho w it happe ns; ho w it is pre pare d o r ho w it is do ne , but Ikno w that, e ithe r the y m ay us aware that us that e ithe r inje ctio ns o r the y place so m e thing the re in the arm , Ido n’t kno w ho w the y callit? Ido n’t kno w. That’s abo ut what Ican kno w. “ (59yo, married woman, 6 children, retired civil servant) Limited knowledge on FP & Long Acting Reversible Contraceptives methods ( LARCs)
  16. 16. Direction de la Santé Familiale MINSANTE CAMEROUN Source: Ozler, Moumpe: Increasing the use of LARCs among adolescent females in Cameroon , 2016 Lack of training in providing FP Methods Lack of training in management of side effect “I am not still clear with that idea that women are still talking about weight, so I don’t know to go about that particular aspect. Most of them complain of bleeding, their spouse complain that each time the go into their wives they come out with blood. For me I told them that it depends on individuals the way their body reacts to the drugs. Because some don’t complain, some say all is fine; some support the drugs for some time and after some time it goes off. I don’t know” ” (Midwife, 49yo, Married, 4 children).
  17. 17. Direction de la Santé Familiale MINSANTE CAMEROUN • Mothers opinion differed on use of FP: 3/4 are supportive of FP and want their daughters to use FP methods. However: • 2/4 mothers had daughters in boarding school; they complain of not having influence over their daughters, including regarding PF (who take their advice from school, hospital, sisters) Source: Ozler, Moumpe: Increasing the use of LARCs among adolescent females in Cameroon , 2016 • “am not advising my children to take these methods because they are still very young, very tender and if you proposed sometime to them now you are destroying them. They will not learn their book, they will get involve in things that are satanic because they know that they cannot be pregnant… I don’t know how to discuss things like that with my children. At times I sent the children to their aunty who will try to discuss with them. I find this aspect of my life which is unable to discuss with my children on sexual and reproductive issues as a weakness. I really need help.” • “If I advice her to go and take an injection in case she becomes sterile she will be accusing me that my mother took me to be injected… it is difficult for one to advise them.” (47yo, married, 6 children, )
  18. 18. Direction de la Santé Familiale MINSANTE CAMEROUN Source: Ozler, Moumpe: Increasing the use of LARCs among adolescent females in Cameroon , 2016 Who should decide number of children & spacing? Supportive of FP • “The woman because she carries the baby and the man because he sponsors the child” (22yo) • “I propose first. And… I propose and explain to her why because you must not only say that ok I’m going… no. You must explain to her why because when you have a girl especially when she did not go far with studies her limits are… in her mind she is a little bit limited. So she has her own vision that she sees and you have yours. So as a I can say a man who knows this domain you say why this, you also explain. (...) now the final decision normally belongs to the two of us, if she will want she will take it and also if she doesn’t I cannot force her because it is … it is… but only that, as we say in Africa the final decision belongs, mostly belong to me” (man, 24yo, works as FP community facilitator)
  19. 19. Direction de la Santé Familiale MINSANTE CAMEROUN Target groups •10 - 24 years •Working hours: Wednesday afternoon and Saturday •Staff: MD, Nurses, Psychologist •Access: free HRG, HD de Figuil, Guider, Lagdo, Pitoa HR Ngaoundéré, HD Meiganga HR Maroua HD de Mokolo, Kaélé, Roua, Moutourwa, Guidiguis • Counseling on RH / FP issues. • Diagnosis and treatment of STI / STD / HIV-AIDS,Hepatitis; • Contraceptive supplies (female / male condoms, pills, injectables, spermicides, implants, IUDs); • Psychological support HR Bertoua, HD Abong Mbang Batouri
  20. 20. Direction de la Santé Familiale MINSANTE CAMEROUN 1- Adolescents friendly family planning services Ob 1 Ob 2 Ob 3 Ob 4
  21. 21. Matrix – Example 1  Up date training curricula  Training of trainers  Accreditation of Health facilities and certification of providers  M&E  Define quality control criteria  Introduce a practical session on management of side effect  Develop a mechanism of management of side effect  Do a community survey on satisfaction of FP among adolescent in the PBF program  Develop a training certification check list  Introduce the practical session in the training curricula  Organize a system of research of defaulter into the community  encourage follow-up home visits during the first 3 to 6 months in PBF contracts OB:3 OB:4 OB : 1 OB:2
  22. 22. Direction de la Santé Familiale MINSANTE CAMEROUN 2-Improve the demand of FP methods among adolescents Ob 1 Ob 2 Ob 3
  23. 23. Matrix – Example 1  Adapt awareness messages for the school environment  Train the educational community in SRA  Organize campaigns in schools on FP in collaboration with Health Facilities  Mobilizing key players in the community  Contract with NGOs for social marketing campaigns  Providing contraceptives at attractive prices  Conduct a comparative survey between health facilities where FP is free and where it isn’t  create PBF indicators on service delivery and FP prices for adolescents  Expand the responsibilities of CHWs  Mobilizing key players in the community OB:3 OB : 1 OB:2
  24. 24. Direction de la Santé Familiale MINSANTE CAMEROUN 3-Improve the couselling of FP method among adolescents Ob 1 Ob 2 Ob 3
  25. 25. Matrix – Example 1  Conducted mock counseling session between a midwife and adolescent; deleted extraneous elements  Added questions to frame choice around preferences and goals of adolescents  Guide choices toward LARCs while respecting autonomy  Counseling app should send SMS to client immediately after she finishes the session (assuming informed consent to obtain phone number)  App collects follow-up data and provides monitoring dashboard  Interactive continuous follow-up with client via SMS platform, either directly or via a downloadable ‘game’  Ideas regarding in-person community follow-up  Hire graphic designer to produce actual visuals and complete adolescent-specific cards [consultant under working group]  Focus groups to optimize design [consultant]  Pilot evaluation of various designs with adoption as outcome variable [working group] OB:3 OB : 1 OB:2
  26. 26. Make available the full range of FP products in FP services; Improve training of providers in ARH/ FP services; Increase the number of facilities offering FP services adapted to the specific needs of adolescents (youths friendly services); Creation of a social network and / or a website devoted to raising awareness among young people about ARH / FP