Community Based Family Planning and HIV/ AIDS Services Project

1. 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

2. 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.

3. Karonga (11): CFPHS Kasungu (3): BASICS & CFPHS Nkhotakota (6): CFPHS Mangochi (21): BASICS, CFPHS, & TBCAP Salima (9): BASICS & CFPHS Balaka (16): BASICS & CFPHS = Project Head Office Phalombe (26): BASICS & CFPHS Chikwawa (18): BASICS & CFPHS Project Geographic Scope

4. 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

5. DELIVERY OF QUALITY, INTEGRATED SERVICES for FP andPrevention & Treatment of HIV/AIDS/STIs FFSDP MODEL COMMUNITY SUPPORT SYSTEMS Engaged traditional & elected leaders Social marketing & BCC activities Community involvement Local FBOs/NGOs motivated and engaged Community structures involved: women’s & men’s groups, youth associations Local governments involved in all activities FULLY FUNCTIONAL DISTRICTS Technical & Operational Support Trained & motivated staff Sufficient equipment, drugs, & supplies Adequate infrastructure Functional referral system Functional MIS MANAGEMENT& LEADERSHIP SUPPORT at Zonal & National Levels Clear policies & guidelines Adequate norms & protocols Effective strategies & approaches for different groups Planning & mgt tools Human resource mgt Financial mgt systems & tools Supply mgt system Mgt information system Quality assurance system FULLY SUPPORTIVE COMMUNITIES Positive social atmosphere (stigma reduction, reduction of GBV) Attention to underserved & high-risk groups Affordable services Informed choice PROVIDERS (incl. CBDAs /HSAs) RH/FP CLIENTS • Proven FP capacity with performance improvement opportunities • Regular formative supervision • Adapted info. system • Incentives • Respect for clients’ • rights • Understanding of • needs 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 Political Support, Dialogue, & Advocacy Social Support & Local Ownership Sustainable use of quality, integrated FP/RH services Enabling policy and social environment

6. Family Planning Services

7. 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

8. FP Service Provision CFPHS Trained Provider inserting Jadelle DMPA Practicum

9. FP Results • About 90,046 DMPA doses given by HSAs Jan-Dec 09 • 271,799 people counseled on FP and HIV messages

10. Results: New and Old Clients By HSAs and CBDAs Yr 09

11. Results Continued

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

14. HIV TESTING AND COUNSELING SERVICES

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

16. 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

17. People Counseled & Tested for HIV – by Quarter Dec 08

18. HTC Service Delivery Challenges • Proper disposal of hazardous waste • Availability of Test Kits

19. DEMAND CREATION

20. Activities:Increase demand for contraceptives and HIV testing • Message design workshop conducted • Communication strategy document developed • Branded BCC campaign launched

21. 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.

22. 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.

23. 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.

24. 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

25. 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.

26. 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.

27. Demand creation and increasing access: Open Day

28. POLICY AND ADVOCACY

29. Policy Landscape analysis Activities • Consultative meetings • Document review • Disseminated findings at FP sub committee

30. Results • 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

31. CBD of DMPA Activities • 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

32. 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

33. 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

34. 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

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

36. 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

37. Monitoring and evaluation

38. Monitoring and Evaluation • CFPHS Project falls under USAID SO 8 • SO 8 has 4 Intermediate results as follows: • Increased use of improved health behaviours and services • Improvement of quality services • Increased access to services • Strengthening health sector capacity.

39. Monitoring and Evaluation • 3 Indicators chosen to monitor SO8 as follows: • Percentage of under-five children sleeping under insecticide-treated bed nets • Contraceptive prevalence rate • Use of condoms during risky sex • Only last two relate to the CFPHS Project

40. Monitoring and Evaluation • Contribute to Goal Level indicators • Total fertility rate • Prevalence of HIV among 15 to 49 year olds

41. 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.

42. 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

43. Life of Project Outputs • Monthly reports • Quarterly Reports • Bi-annual Reports • Annual Reports

44. Challenges • Staff turnover high • Data collection difficult by design (work in hard to reach areas) • Data management

45. Looking forward • Improve data management • Use of modern communication systems for data reporting – Associated challenges of expenses involved • Staff and Volunteer (CBDA) motivation

46. OVERALL Lessons learnt

47. 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;

48. 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.

49. Capacity gaps in FP and HIV&AIDS issues exist among the Muslim community A sustainable advocacy strategy is important

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