Ensuring Client-Centered Access to Contraceptive Supplies

1. Ensuring Client-Centered Access to Contraceptive Supplies Malawi Story

2. Nabiyeni’s Story • Nabiyeni is a 24 year old woman married with 2 children • Her husband wants another child but - Nabiyeni does not want another child now • She is using FP without his knowledge.

3. Many rivers to cross to get to clinic • Nabiyeni lives in a rural remote village- 20km away from a government clinic where she gets contraceptives. • She has missed her dates for DMPA resupply by one week because one of the rivers she crosses was flooded. • Finally when it subsides she takes the long journey to the clinic with a friend.

4. STOCKOUT • “ Pepani amai, we haven't had Depo for the last three weeks” are the words that greet her just as she sits on the bench. • “Ooh not again, that’s how I got to have this baby, there was no Depo when I came and I don’t want pills because my husband will kill me if he ever finds out I am using contraception” • The nurse asks her to chose another method but she is reluctant to take pills and the nurse has not been trained in IUD or Implant insertion. • The nurse is frustrated; she has never had her orders for Depo fully honored by DHO despite a high demand. • DHO claims they have a tight budget- hence prioritize curative drugs to preventive. “I cannot afford to run out of antibiotics- you want me to run out of a job when politicians storm into this office?” • DHO however reassures the nurse that he will take it up

5. What are the Gaps • Stock outs at service delivery points • Inadequate Financial resources. • SWAp’s and decentralization - greater difficulty mobilizing leaders to fund FP because of competing demands. • District-level decision makers – lack awareness of issues affecting contraceptive security. • Donor dependence • 2 Procurement systems- SWAp and Donor • District Health officers prioritize curative drugs • Unrealistic forecasting due to unreliable data management • Inadequate human capacity • Inaccessibility due to poor roads • Minimal Private sector resources

6. What is being done to help Nabiyeni? Commodity Security • USAID DELIVER supporting SCM improvements • Support by Donor partners (USAID, UNFPA) procurement/distribution • High Level Advocacy: RAPID presentation at US Ambassador’s house; Vice President as Good will Ambassador for RH. • LDP- advocacy paper for removal of handling 5% fees for DMPA • Quantification Exercise using Reality Check • Support to the MOH and DHO in financing and procurement of contraceptives • Expanding delivery of FP services to the private sector through social marketing for those willing and able to pay.

7. Bringing FP Services Closer to the community level • Outreach activities to rural/remote areas far away from health centers through the Tent Outreach Centre Initiative (BLM) • Training CBDs/RHAs based in rural areas • RHAs/HSAs/CBDs providing wide range of services such as Depo (to ensure choice) • TA to MOH and DHO to ensure contraceptive security in decentralized setting • Policy change to allow HSAs to administer DMPA at community level. • Change of scope of work to allow enrolled nurses to insert implants and IUCD at health centre level. • Increased method mix at community level • Outreach services to the community for BTL and vasectomy • Youth FP Programmes at community level

8. Lessons Learned • One approach is not enough- utilizing multiple approaches to ensure the ‘Nabiyenis’ access contraceptives has more impact • Providing capacity building and strengthening local procurement systems can lead to government ownership of contraceptive security

9. Data management to avoid stock- outs MoH- HMIS CMS-pharmacy technician District Level- FP Coordinator FP Monthly summary form HC Level-first & second line supervisors FP monthly summary sheet, stock cards, monthly contraceptive work sheet. Community Level: CBDA; HSAs tally sheets & client registers

10. Thank YOU