Download - Community-Based Distribution of DMPA in Malawi Margot Fahnestock Futures Group September 30, 2009
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Community-Based Distribution of DMPA in Malawi
Margot FahnestockFutures Group
September 30, 2009
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Presentation Outline
1. Context for CBD of DMPA in Malawi
2. From Debate to Policy Decision
3. Implementation
4. Future Directions
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1. Context for CBD of DMPAin Malawi
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Malawi
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More About Malawi
• Bordered by Mozambique, Tanzania and Zambia
• 14% urban, 86% rural population• Decentralized government, with 28 districts • Predominantly Christian population
(approximately 80%)
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Family Planning in Malawi
• Malawi has been a success story in sub-Saharan Africa• Country enjoys strong policy environment for family
planning; included in:– Reproductive Health Policy– Reproductive Health Strategy– Road Map for Accelerating
Reduction of Maternal Mortality
• According to MICS, CPR has increased but fertility still high. . .
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Making the Case for CBD of DMPA in Malawi
• By 2010, Malawi’s RH strategy aims to:– Reduce TFR to 4.9– Increase modern CPR to 40%
• Fertility rates are still very high• Rural access to health centers is challenging• Health centers are extremely understaffed• Malawi has 20-year history with CBD agents
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"There are so many patients here to
see. The number is about 75 to 100
patients per day. Sometimes people
wait for hours to be attended to.
Yesterday I was alone on duty
without even any medical assistant
to help me. Sometimes I have to do
both day and night shifts in the same
day!
– Loveness Makeyi, 35, Nurse/Midwife, Khonjeni Clinic, Malawi
Source: “Help Wanted: Confronting the healthcare worker crisis to expand access to HIV/AIDS treatment: MSF experience in southern Africa.” Medecins Sans Frontieres. 2007.
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But Who Should Administer?
• Malawi is one of the only countries in Africa with a low-level, paraprofessional, MOH employee – the Health Surveillance Assistant (HSA)– Are they overloaded?
• Malawi’s CBD agents (CBDAs):– Many do not have high
school education– Most are volunteers, with few
or no incentives
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Malawi’s Secret Ingredient: The Health Surveillance Assistant (HSA)
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2. From Debate to Policy Decision
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A Long Debate
• In Malawi, the debate to allow lower-level health workers to administer DMPA was very controversial
• Medical professionals were hesitant to allow “paraprofessionals” to administer injections
• BUT – HSAs already administer immunizations to children under five
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March 2008 – Ministry’s Big Policy Decision
• March 2008, Senior Management team of the MOH decided to allow HSAs to administer DMPA in communities
• Reproductive Health Unit critical to this decision:– Presented literature from other countries
– Argued that CBD approach is safe
– Highlighted large demand for DMPA
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Multiple Factors May Have Contributed tothe Policy Decision
Late 1980sMalawi implements CBD programs
Mid-1990sSeveral districts in Malawi begin to allow HSAs to provide DMPA
1999 – 2003World Bank-funded CBD project using traditional birth attendants
September 2007 SWAp Review
September – December 2007
USAID | Health Policy Initiative stakeholder assessment and focus group discussions
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Current Policy in Malawi on CBD Provision of DMPA
• Current policy:– HSAs can administer DMPA at the community level
(phase-in process)
– Guidelines for HSA administration of DMPA approved late 2008
• Policy challenges:– DMPA and pills still not deregulated
– Districts required to pay 12% handling fee to Central Medical Stores for DMPA (essentially 112%)
– HSAs still not allowed to provide oral contraceptives, resulting in referral issues
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3. Implementation
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USAID-funded CBD Initiatives in Malawi
• USAID | Health Policy Initiative (HPI)– Analysis of feasibility and acceptability of CBD of DMPA– Operational policy barriers analysis to financing and
procurement of contraceptives
• Community-based Family Planning and HIV/AIDS Services Program (CFPHS)– Mission bilateral– MSH is prime contractor– Subcontractors:
• PSI
• Futures Group
– Three-year project with one year option
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Implementation
• Through the MSH-led CFPHS Project• Project includes HSAs and CBDAs:
– CFPHS trained CBDAs in 8 project districts – One HSA has 10 CBDAs reporting– CBDA provides oral contraceptives; female and male
condoms; CycleBeads; counsels on multiple methods– CBDAs refer clients requiring DMPA to the HSA
• Project hired and trained CBDAs from 8 districts in 2008-2009 – more than 1,000
• FP trainers trained HSAs from 9 districts in 2008-2009
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Implementation (Cont.)
• Training– Select HSAs chosen to be training for DMPA provision– HSAs providing DMPA receive 5-day training session
• Supervision– HSA supervisors– Supervision linked to health centers – Nurses-in-charge, environmental health officers, supervise
HSAs at health centers
• Supply – USAID | DELIVER Project assisting
with reporting– HSAs resupply DMPA at health centers– Sharps containers provided
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4. Future Directions
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Future Directions
• Phase-in period– Ends in November 2009– FHI will evaluate HSA provision of DMPA in 9 districts
• Scalability of program– HSAs make scale-up more achievable– National coverage of HSAs
• Plans for scale-up– MOH plans to scale up after evaluation– Pilot-test CBDA provision of DMPA?
• Challenges for scale-up– Public sector supply of DMPA – Future of HSA cadre
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Is the CBDA the Future of CBD of DMPA in Malawi?
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Thank You