Community-based distribution of injectable contraceptives: introduction strategies in four sub-Saharan African countries.

214 Theresa Hoke is scientist II, Aurélie Brunie is scientist I, Kirsten Krueger is senior technical officer and Crystal Dreisbach was, at the time this article was written, a technical officer, all at FHI 360. Angela Akol is country director at FHI 360/Uganda. Ny Lovaniaina Rabenja was, at the time this article was written, a program officer at FHI 360/Madagascar. Alice Olawo is research associate at FHI 360/Kenya. John Stanback is deputy director, PROGRESS, at FHI 360. Improving access to family planning services and expanding method choice are two fundamental, proven strategies for increasing contraceptive prevalence in resource-poor settings.1–4 Community-based family planning programs are designed to improve access by bringing services to hard-to-reach communities.5,6 Such services are typically delivered by community health workers who are trained in family planning but lack formal clinical credentials. Working outside the health facility, community health workers provide health education to promote family planning, distribute contraceptives and refer clients for clinic-based services. For decades, community-based distribution programs have been credited with expanding access to family planning services in otherwise underserved communities in Africa, Asia and Latin America.5 Despite the important contributions that communitybased distribution programs have made to family planning service delivery in resource-poor settings, their full potential for expanding method choice has not been realized in Sub-Saharan Africa. Most notably, national policies in most countries permit community health workers to provide condoms and oral contraceptives, but not injectable contraceptives. This constraint seriously limits programs’ responsiveness to clients’ needs and preferences, particularly in Sub-Saharan Africa, where injectables are now the most popular modern method.7 Some health officials have been reluctant to approve community-based distribution of injectables because of doubts about lay workers’ ability to maintain safety and quality standards when screening clients for medical eligibility, administering injections, disposing of used needles or delivering timely reinjections. Concerns have also been expressed about community health workers displacing clinicians and providing additional services that are beyond their qualifications. However, global policy developments provide useful, new evidence on the appropriateness of community-based distribution of injectables. The World Health Organization (WHO) and the United States Agency for International Development (USAID) convened a technical consultation in June 2009 to review global scientific results and program experience related to community-based distribution programs. Consultation members reviewed relevant scientific literature, program documents and results from informant interviews pertaining to program experience in nine countries.8 Guided by the evidence, the consultation concluded: “Given appropriate and competency-based training, community health workers can screen clients effectively, provide DMPA (depot medroxyprogesterone acetate) injections safely and counsel on the side effects appropriately, demonstrating competence equivalent to facility-based providers of progestin-only injectables.”9 This statement was subsequently endorsed by international associations representing nurses, midwives and obstetrician-gynecologists, as well as by the International Planned Parenthood Federation, Marie Stopes International, the United Nations Population Fund and the World Bank. Given this increased global support and interest, decision makers now need practical guidance for initiating community-based distribution of injectables. This article documents firsthand observations made during the launch of community-based distribution initiatives in Uganda, Madagascar, Nigeria and Kenya. USAID supported these four programs through grants to FHI 360, an international nongovernmental organization (NGO) specializing in global health and development.