“We’ve had tremendous success with these initial efforts [community-based distribution of injectables] in Africa. Women have been clamoring for it, and there is good evidence that it has really increased the contraceptive prevalence rate in areas where it is now available. We were very careful to collect information about the safety of the practice in Uganda and Madagascar, and so far it seems that the CBD [workers] can do just as good a job, if they are properly trained, as the nurses."
--Dr. John Stanback [Listen to this interview]
Mix of service delivery points emphasizes offering services outside of the clinic setting, to increase access to and acceptability of family planning. This is important particularly in rural areas where health care infrastructure may be weak.
Q. Why have a mix of service delivery points?
A. Having a mix of service delivery points makes family planning services and supplies more accessible. Many programs have focused on clinic-based services. Reaching beyond clinics, however, can reach more people and increase contraceptive use. It also may increase the efficiency of a program. Different service points can play complementary and mutually supportive roles in a service delivery network.
There are many possibilities:
• Community-based distribution (CBD)
• Pharmacies
• Other retail shops
• Primary practitioners
• Primary health care centers
• Community health care centers
• Mobile clinics
Different outlets can offer different methods and services. Some can offer comprehensive family planning services with a wide range of methods, while others may offer only supplies for certain methods.
Q. Who can provide contraceptives at these service delivery points?
A. Anyone with the specific training or experience in providing the methods involved. For example, specifically trained CBD providers safely give contraceptive injections. Pharmacists and chemist’s clerks provide pills. With little or no training, retailers sell condoms.
Q. What are the possible benefits of offering family planning services outside of a clinic?
A. Possible benefits include:
• Provide more people with access to services
• Recruit more people to practice family planning
• Improve continuation rates by making resupply more convenient
• Avoid the cost of establishing and maintaining more clinics
• Protect client confidentiality because they don’t have to go to a clinic
• Directly tap into community opinions and comments
• Increase client motivation through ongoing counseling
• Put clients at ease with discussing their needs, problems, and requirements because they are in their own home
• Avoid waiting time at clinics
• Offer a more familiar and comfortable environment
• Serve people in remote or thinly populated areas
• Improve continuity of care
Q. Why is there a need to provide family planning from a variety of service delivery points?
A. Addressing unmet need.
Many women cannot reach clinics or afford transportation to reach them. The unmet need for family planning is high, and in many places there are not enough health care providers to meet the demand. Family planning programs in many countries have found that training qualified community members to offer services outside the clinic increases access and the acceptability of family planning. This is particularly true in rural areas where health care infrastructure is weak.
Making best use of providers’ skills
Highly trained clinic staff often are overworked, trying to serve more patients than they can manage. Offering routine services, such as re-injection or resupply, outside clinics can allow these staff members to devote more time to the relatively small number of clients who need more skilled care.
Q. What is community-based distribution (CBD)?
A. Community-based distribution involves training people from the community to provide contraceptives from their homes or shops, in health posts, or by visiting clients’ homes. CBD workers have been providing condoms and oral contraceptives in their communities for years. Recently, some programs are offering injectables through CBD as well.
Q. Should every family planning program strive to offer contraceptives outside of the clinic?
A. Yes, especially in situations of high demand, or to improve access to communities that have limited or difficult access to clinic services. Before doing so, however, programs should meet the following requirements:
• Capacity is sufficient- including human resources, program infrastructure, and financial resources
• The quality of services can be kept up, and
• The supply of methods is dependable.
Q. What are some of the quality issues that need to be considered when providing services outside of a clinic?
A. Several areas may need special attention during training and in supervision. CBD staff and other staff outside of a clinic should:
• Be able to screen who can and cannot use the methods they are providing
• Have good counseling skills, particularly to help people learn how to use their method and understand that side effects are not dangerous and may go away. CBD staff should also be encouraged to refer clients who experience side effects that cannot be managed at their level.
• Know what is true and what is myth about contraceptive methods, and be able to correct people’s misperceptions
• If giving injections, give them correctly and dispose of used injection equipment safely
Case Study
With Training, a Range of Providers Can Give Contraceptive Injections
Studies show that many types of health care providers can give injections if they are appropriately trained. Such providers have included pharmacists, auxiliary nurses, midwives, medical assistants, community health workers, and others who have been specifically trained as well as those who have general medical education. Training a wider range of providers to give injections safely can expand access to injectable contraceptives, reduce unsafe, unauthorized injections, and save programs money.
In some cases, particularly when scaling up pilot programs, changes in national policy may be needed to permit new types of providers to give injections. Service delivery guidelines in some countries allow only doctors and nurses to give injections. For example, until 1999 service delivery guidelines in Honduras did not authorize auxiliary nurses to provide the injectable contraceptive depot-medroxy progesterone acetate (DMPA). An auxiliary nurse is often the only provider at a rural health center. Therefore, women in rural areas could not easily obtain injectables. A 1997−98 study showed that auxiliary nurses could provide these services safely and cost-effectively. As a result, the Ministry of Health changed the service delivery guidelines. Within three months use of injectables increased 19% in clinics where auxiliary nurses began offering injectables, and 35% in clinics where the auxiliary nurses offered injectables and also promoted the new services to clients and the community.
Formally training unregulated injection-givers is another way to increase safe access to injectables. A 2003 study in Egypt found that women often seek injections, both contraceptive and therapeutic, from informal providers, or "health barbers." Because the health barbers often charge less than the cost of a new needle and syringe, it is likely that these providers reuse injection equipment—a potentially dangerous practice because they do not have equipment for sterilizing needles and syringes after each use. In this situation changing guidelines to allow such providers to provide injections, training them appropriately, and supplying them with single-use injection equipment could reduce the number of unsafe injections.
Read more about the Case Study
Each of the 10 elements was chosen based on online survey results and was discussed in an online forum hosted by the Implementing Best Practices (IBP) Knowledge Gateway. Read more about the survey, forum and results in the Forum Synopsis. Learn more about IBP Knowledge Gateway, and join their Initiative here.
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