COMMUNITY-BASED DISTRIBUTION OF DMPA

STAKEHOLDERS’ MEETING HELD ON 15 JULY, 2008

CROSSROADS HOTEL, LILONGWE, MALAWI

INTRODUCTION

The meeting was organised by the Reproductive health Unit (RHU) in collaboration with USAID |Health Policy Initiative, implemented by Constella Futures. The meeting was held at the Crossroads Hotel, in Lilongwe on 15th July 2008.The theme of the meeting was “The Way Forward: Malawi’s Road to Community Based Distribution of DepotMedroxyprogesterone Acetate (DMPA)”.The meeting was divided into two parts, presentations in the morning and group work in the afternoon. Three main presentations were made which acted as basis for the group discussions and plenary.

OBJECTIVES OF THE MEETING

The objectives of the meeting were as follows:

  • To share findings of Health Policy Initiative Research onevaluating community views about community based distribution (CBD) of DMPA
  • To share lessons learnt from the Madagascar study tour on CBD of DMPA.
  • To build consensus on the paramedical provision of DMPA.

MEETING PROCEEDINGS

Opening Remarks

The meeting was officially opened by the Deputy Director of the RHU, Mrs. Fannie Kachale. In her remarks, she informed the participants that the Ministry of Health recently made a decision to change policy to allow Health Surveillance Assistants (HSAs) to start providing DMPA at the community level. The ministry’s decision was based on the fact that DMPA is the most popular method in Malawi and lessons from Uganda and Madagascar experience show that the high demand for Depo Provera can best be addressed through CBD of DMPA.Mrs.Kachale finally stressed on the importance of all stakeholders to join hands in the promotion of family planning. She also assured the participants the Ministry’s commitment and support to all efforts geared at improving the reproductive Health of the Malawi Nation.

Presentations

The first presentation was onthe current status of Family Planning in Malawi and way forward by the Director of Reproductive Health Unit, Dr. Chisale Mhango. He stressed on the importance of a Family Planning strategy to improvement of reproductive health status inMalawi. Meeting the need for family planning can result into reduction of infant and maternal mortality rates. However there is a high unmet need for FP in Malawi despite the increased usage over the past decade. Although the prevalence rate for modern contraceptives has increased from 14% in 1996 to 28% in 2004, it has flattened because of the reliance on fixed service outlets which are mostly in the urban areas.

Dr. Chisale pointed out that 85% of the Malawi Population lives in the rural areas where they can not access the fixed services. Although the demand for modern contraceptives is high there is a significant unmet need because of lack or inaccessible services in the rural, where the majority of Malawians live. High unmet need has contributed to high rates of unintended ormistimed pregnancies. If nothing is done, the number of pregnancies will continue to increase each year. However, meeting the unmet Need will result into significant rise in the FP prevalence rate which in turncontributes to reduction of Maternal and Child Mortality rates.

Dr. Chisale Mhango reminded the participants of the MOH RH targets thus decreasing Total Fertility Rate fro 6.3 to 4.9%, Increasing CPR fro 28% to 40% and CBD of contraceptives from 3% to 10%. These targets can only be achieved through strategies like CBD. In 2002 the MOH under the EHP proposed HSAs to deliver more comprehensive FP and a decision was made by the MOH senior management meeting to phase in HSA provision of DMPA. This approach would help increase access to FP for rural women as services will be taken to their door step. The approach would in turn ease workload of nurses in clinics thereby improving client care.

Participants were urged to feel free to discuss and come up with the way forward for the CBD provision of DMPA by HSAs, build consensus on the development of the phased approach strategy and plans for evaluation and also to prepare recommendations to SRH Technical Working Group on issues to consider in the development of service provision guidelines, training and supervision.

After the presentation, participants were given chance to ask questions or comment. Participants presented the following issues:

  • The strategy may not contribute to increase in CPR if there is no method mix
  • Levels of literacy are also critical
  • CPR for Madagascar is very low as compared to Malawi
  • Younger mothers are the ones causing a problem with untimed/unwanted pregnancies
  • Side effects of Depo to be considered
  • What about screening procedures
  • Why depo is most preferred method: is provider or clients’ preference?
  • Consider programme for male involvement
  • Consider screening opportunities since women do not go for routine check up
  • Consider site on the body for injection

In response, Dr. Chisale Mhango informed the participants that the reproductive health programme provides a broad range of contraceptives and IUCD is also being re-introduced but what matters is what to take to the community level.

Literacy contributes to acceptance of family planning as it is in the Northern region. However, Malawi is a small community and the CBD programme can easily reach all communities. As for the young people, the services are now youth friendly and the youth can freely access them. The preference of Depo is not due to provider Influence, it is from women themselves.

It was commented that the CPR increased between 1996 and 2004 mainly due to the following reasons: the 1992 revision of the FP guidelines and the 2000 World Bank CBD program, which helped to double the CPR.

Site on the body for injection matters depending on provider’s gender; this meeting should agree on the recommended injection site for Malawi.

Malawi’s Road to Community-Based Distribution of Injectable Contraceptives

Dr. Maureen Chirwa gave the second presentation of the morning, called “Malawi’s Road to Community-Based Distribution of Injectable Contraceptives.” Dr. Chirwa worked with the USAID | Health Policy Initiative (HPI) in the fall of 2007 to conduct a study that examined attitudes about and policy barriers to implementing a community-based distribution program for injectable contraceptives. The study also aimed at expanding understanding of current preferences and opinions of providers and users of family planning on CBD of DMPA.Focus was primarily on using Health Surveillance Assistants (HSAs) to provide DMPA in the community. A wide range of stakeholders were interviewed such as MOH, regulatory councils, development partners, NGOs, FP users, men and women of the reproductive age group and community leaders.The districts that were included were Karonga, Kasungu, Nkhotakota, Mangochi, Phalombe and Chikwawa.

The study team conducted interviews with key stakeholders at the national and district level – including providers – and conducted focus group discussions with men and women at the community level. The findings strongly support a community-based approach to distributing DMPA. Women demand and prefer DMPA because of the convenience of receiving an injection every three months; avoiding traveling the long distance to the nearest health facility; being aware of DMPA through family and friends; and the fact that women do not have to alert their husbands to their use of family planning. Health policymakers will benefit from having DMPA available at the community level.

The findings also revealed high level of awareness of FP among women and 87% of those interviewed had used DMPA at some point. This showed that ICs were already a popular method among women in the community. However access at community level was a problem for 95% reported that they had no access to DMPA at this level. Lack of access was contributed to the following challenges faced by both health workers and clients:

  • DMPA were only provided at health centres, district hospitals or BLM clinics.
  • Nearest facilities are very far and difficult to reach
  • Long waiting time coupled with absence of providers at some service points leading do discontinuity
  • Routine stock outs of Depo Provera
  • Religious barriers at some facilities

The majority of the women preferred village clinics to health centres as a point of access. Mobile/outreach clinics were a preference among users where village clinics are not available.However, they had no interest in Home Visits as a point of access for DMPA.

Although the FP users preferred outreach clinics, FP providers did not support the idea because of the following reasons:

  • Fragmented system of outreach services
  • Unreliable schedules and services due to transport problems (45%) and Nursing staff shortage (23%).

When Health providers were asked their views on using HSAs for provision of DMPA, the majority (91%) supported the idea. This was also supported by community groups as they felt this could reduce transport costs, increase method choice at community leveland could motivate husbands to take part in FP counseling and more women would use FP. However the following critical issues need to be considered in preparation for CBD of DMPA:

a)Preparation of HSAs for service expansion which would include:

  • FP in-service training for DMPA
  • Supervision: regulation and policies governing HSAs
  • Selection and retention as it was noted that HSAs lacked a clear career path

b)CBD Systems:

  • Develop management systems – HR, referral, logistics and procurement

The priority issues to be considered would therefore be:

  • Development of standard guidelines
  • Train HSAs
  • Ensure provision of HSAs
  • Determine frequency and location of outreach services to ensure access to services
  • Secure supplies for expansion coverage
  • Develop plan for national scale-up

Dr. Chirwa pointed out that Malawi has a long history of CBD services, strong NGO- MOH partnerships in Health services and sustainable scalable Health Service Agent (HAS) model and these are an advantage for smooth CBD of ICs strategy.

After the presentation a few questions and comments were raised as follows:

  • Who is responsible for HSAs activities? DEHO/Nursing section/ clinical section? In response, an explanation was given that issues of regulation were a problem because neither Medical nor Nurses Council would regulate them. The employer MOH is the one responsible for the HSAs.
  • Career path:HSAs can be an entry point to other health science trainings like nursing, and clinical courses to those with MSCE qualification
  • CHAM institutions: Participants were assured that Catholics are the only CHAM members not in support of FP but they are softening up; as some institutions are now allowing MOH some space/ room for provision of FP services at their institutions.
  • Dissemination: Participants felt that there is need to disseminate the findings at community level and consider updating FP providers on this new development; and there is need to review the current guidelines to remove those that restrict HSAs from provision of DMPA.
  • Training: Only six days may be added to the 10-weektraining for HSAs to include ICs. However DMPA can later be incorporated in the 10 week training. Participants were informed that 5,961 HSAs were recruited in 2007 and are being trained
  • Why HSAs, not CBDAs: Participants were informed that Ministry of Health accepted to use HSAs not CBDAs: therefore the project will focus on HSAs as of now.

The Madagascar Study Tour

The third presentation was made by the Deputy Director of the Reproductive Health Unit, Mrs. Fanny Kachale. This presentation was based on the lessons learned from Malawi’s study tour to Madagascar. The main objective of the study tour was to learn from Madagascar’s CBD experience and develop recommendations for Malawi. Madagascar is an island country with a population of 18 million of which 70% live in the rural and has CPR of 24 %.Madagascar’s MOH decided to initiate CBD of ICs because of the large rural population, low ratio of health centre providers, the low CPR and high unmet need for contraception; similar characteristics to Malawi.

Lessons were learnt from Madagascar in six main areas as follows:

  • Selection and training of CBDAs:

providers and trainers manual were developed

selection criteria was developed

high performing CBDAs were selected among the existing CBDAs

community and Health centres were involved in the selection

DMPA providers were trained for four days

  • Role of DMPA providers at community level

Assess client eligibility

Conduct community mobilization and awareness campaigns on benefits of FP

Refer clients requiring further management

Follow up of drop-outs

  • Supervision

CBDAs are supervised with health centre staff and NGOs

They report to medical professionals at the nearest facility

They replenish stock during monthly meetings at the nearest Health facility

Refers clients

Receives written feedback from the supervisors at all levels

  • Supply Chain Logistics

They have integrated reporting systems

Good coordination at all levels on supply chain products

  • Waste Disposal

Sharps containers and waste disposal boxes are supplied to every CBDA

When they are full they are disposed at health centres

  • Challenges

The CBDAs are volunteers but have multiple tasks similar to HSAs in Malawi except for provision of immunizations

Too many reporting forms for CBDAs

Storage of FP products (records and supplies not compartmentalized)

Logistics data is not utilized for re-supply as a result CBDAs complain of getting short supply

The Malawi delegation was impressed with the Madagascar CBD of DMPA programme and felt that Malawi can use the experience to develop its own. Having conducted the stakeholders meeting, Mrs. Kachale pointed out that what remained for Malawiwas to:

  • Develop a strategic approach for piloting distribution of DMPA and conducting an evaluation.
  • Prepare national guidelines/standards for service provision
  • Develop training package
  • Implement pilot programmed in the 8 MSH districts

The morning presentations were followed by group work. The participants were divided into three groups and each group was given a task to discuss and present during plenary. The tasks were to discuss issues to consider for:

a)Developing standard guidelines for HSAs provision of ICs.

b)Training HSAs

c)Ensuring necessary supervision of HSAs

Below are the group reports:

Group A

Issues to be addressed for developing standard guidelines.

Group A proposed the following areas to be considered for the development of the HSA service provision guidelines: Members noted that the process already started by reviewing similar existing practice to draw lessons.

What should be considered now:

  • Catchment area for each HSA
  • Reporting structure
  • Guidelines to be in line with current RH guidelines
  • Scrutinise current guidelines to allow HSAs to administer DMPA
  • Education level for HSAs
  • Upgrading HSAs into HAs and other paramedical
  • Scope of work (explicit job description)
  • Look at broader picture not just HSAs
  • HSA who has undergone basic training and acquired competency
  • Assessment for competency
  • Supervision/supervisor
  • Regulation
  • Prescribing
  • Injection site on the body
  • Ethical behavior

Time Line for Development of the Guidelines to Allow HSAs to Provide DMPA

The group members proposed that the draft frameworkof the guidelines should at least be in place by August 2008.

Who should be involved?

Critical stakeholders to be engaged in the process:

  • Regulatory bodies ( NMCM, MCM,MPBM)
  • MoH (RHU and HSAs Coordinator);
  • NGOs,
  • Representatives from medical and nursing colleges,
  • CHAM

Regulation and policies governing DMPA:

  • Reschedule injectables from prescription only medications

Necessity for injection safety:

  • Waste disposal policy
  • ensure injection safety, to use disposable syringes only
  • storage of supplies
  • Infection prevention policy
  • Stipulate injection site

Minimum schedules of outreach services:

  • Monthly
  • Utilise immunisation schedule

Location of outreach services:

  • Hard to reach areas
  • Where under five clinics are done
  • Near catholic institutions

Three specific next steps:

  • Taskforce
  • Development of guidelines
  • Circulate to stakeholders

Comments and questions to group A

  • Regulation of HSAs: the Medical Council of Malawi informed participants that its Participation is to follow events on the services provided by the HSAs and MCM (current position is that they are accepting participation and not responsibility).
  • What would HSAs be doing in between if they are conducting monthly visits for DMPA?HSAs will continue providing other services over and above the FP
  • After the development of the guidelines are they going to be integrated in the RH guidelines?

Group B: Training of HSAs

Group B discussed issues to consider on training of HSAs in the provision of DMPA as follows:

  1. Selection:
  2. Not all HSAs will be permitted to provide DMPA
  3. Short term – some
  4. Long term – all
  1. Selection criteria: consider qualities and performance records of existing HSAs as follows:

HSAs working in remote areas

hard to reach

no access to health services

HSAs in CHAM facilities

HSAs already supervising CBDAs

HSAs with JC and MSCE

No limiting factor on gender (have equal percentage of the male and female)

HSAs who are in areas where there are no CBDA programs

HSAs who are not committed to other programs already running in the community

  1. Curriculum adjustments
  1. Existing curriculum is already comprehensive
  2. From the 8-10 week training, add six days for DMPA
  3. RHU should design training
  4. There are overlaps with current modules of HAS training therefore integrate all activities to have one package of the RH
  1. FP in-service training on ICs

Add 6 days to usual training for more in-depth FP-ICs provision

  1. Three specific next steps
  2. Task force to put together selection criteria (learn from IMCI)
  3. Develop ICs module
  4. Pre-test the module through training

Comments to Group B