Four CBD Programs

Network: Vol. 19, No. 3, Spring 1999

CARE Project Enlists Community Support

PACARA SULLICANI, Peru -- Seasonal rains make their mark quickly on the highlands in southeastern Peru. Streams that are usually of little concern to travelers are swollen and intimidating: their muddy beds and banks suck ferociously at the tires of vehicles fording them. Even with a four-wheel-drive truck, reaching the remote, farming community of Pacara Sullicani from Juli -- the nearest town with basic health services -- takes at least two hours.

When weather conditions are ideal, transportation to or from Pacara Sullicani still is not easy. Nor do most members of this small community of about 200 people wish to travel. Few people in the nearest town will speak their language, Aymara. Meanwhile, time and attention must be devoted to the care of the cattle and sheep grazing in the vast plains of Pacara Sullicani, and the quinoa, beans and purple-flowering potatoes cultivated here.

Crops are not as abundant as they once were. The land tends to be overworked, and there is less land for each person due to repeated divisions among family members over many generations. No longer can it feed many people. Nor are large families now needed to maintain it.

Peru

4,000 CBD workers

Population: 25 million Terrain: coastal, tropical forests and rugged mountains Area: 1.28 million sq km

"The economy of this area makes it very hard for us to raise large families," says Felix Montufa, a farmer and volunteer family planning promoter who lives in the community.

Standing before the dried brown mud and thatch room that he built to provide family planning consultations, Montufa explains how he was enlisted to do family planning work, which occupies about two days each week. "I have been providing other community services since 1987 and I was chosen by the community leaders to be a reproductive health promoter," he says. "I do this now because I know that if couples have six or eight or 10 children, it is not good for my community. I like to know that I'm doing something good for my people."

Montufa is one of 700 community promoters of contraception working in communities near Puno through a project of CARE-Peru and the Peruvian Ministry of Health (MINSA). This eight-year-old project, called the Multisectoral Project of Population and Reproductive Health (PMP), serves approximately 300,000 families throughout the country. Community promoters can distribute condoms, vaginal tablets and oral contraceptives. For longer-acting or permanent methods, they make referrals to a MINSA health post, center or hospital.

The project in the department of Puno is only three years old, but makes family planning available to some 9,000 people in the area. In other locations in Peru where PMP projects began earlier and are more developed, maternal health, adolescent issues and sexually transmitted disease prevention are offered in addition to family planning.

In the past, the project was exclusively financed by major donor agencies -- the U.S. Agency for International Development and the United Kingdom's Department for International Development. But donors and MINSA now share the costs, and MINSA will assume all logistical and financial responsibility by the year 2001.

"The goal has been to get communities involved," says Dr. Irma Ramos of CARE-Peru, PMP project coordinator, "and for CARE-Peru to provide technical support to MINSA to increase access to, and improve, reproductive health services for underserved people living in extreme poverty. Before we began the program, MINSA had reached out as far as its health posts with reproductive health services. It could go no further. We facilitated an expansion of those services into rural communities. And, in turn, MINSA was very helpful in involving the communities and will hopefully be able to provide the ongoing stability to make the program sustainable."

In the first years of the program, CARE-Peru initiated contact with community leaders, and, with MINSA, helped the leaders recruit their own promoters. CARE-Peru also worked to improve a poor contraceptive supply system; trained and supervised community promoters; and designed reporting forms to allow for proper accounting of services and supplies. Reports from promoters provide the health ministry with otherwise unavailable information about contraceptive use and reproductive health among members of remote communities. CARE-Peru staff members also have provided clinical reproductive health, communication, sexuality and gender training for MINSA medical professionals at health centers, and taught them to form, train, supervise and supply networks of promoters.

With CARE-Peru's logistical support, MINSA personnel also continually evaluate the performance, knowledge and practices of promoters through meetings and supervisory visits in the community, refresher courses, and follow-up visits to users. Promoters receive immediate feedback and are classified according to the level of their performance; those receiving poor evaluations often are dismissed.

Consulting room

Montufa is a fairly new promoter, with less than a year's experience, but he takes his volunteer work seriously. Inviting visitors into his tidy consulting room -- painted sky blue and filled with posters, flip charts, brochures and other materials about family planning -- Montufa indicates meticulously detailed notes, written in a firm, steady hand, within a notebook and on individual cards. The notes summarize the use of various contraceptive methods by his clients: 22 users among 60 couples in the community. They also include referrals Montufa has made for longer-acting or permanent methods, such as injectables or intrauterine devices. "At first, I mostly distributed condoms and made referrals for injectables," he concludes, reviewing his records. "But now vaginal tablets are more popular."

In his records, Montufa has also noted the dates, subjects and attendance for various talks that he has delivered in the Aymara language to community members.

"During these community chats," says Dr. Ramos, "promoters generally use pictures rather than text because their clients may be illiterate. They also talk in one of the local dialects on a level that people can understand. They are trained not only to discuss family planning methods, but also self-esteem, responsible parenting, hygiene, how sexual relations and love are related, the importance of prenatal checks, gender issues, men's reproductive health needs, and other related matters. Offering information, education and counseling that takes into account the whole individual is fundamental to removing misconceptions that clients may have held all of their lives.

"Sometimes, people attending these talks are embarrassed by the pictures or information. But, in our experience, curiosity and interest soon conquer this timidity. Although many people do not want others in the community to know how they feel about family planning, their desire not to have many children is often very strong."

"Such promoters greatly help bridge both a geographic and a cultural gap between clients, who are generally Quechua or Aymara Indians, and medical professionals," says Dr. Luis Tam, CARE-Peru health sector director. "Their involvement helps prevent misunderstandings and allows clients to obtain information that is truly meaningful to them."

Two contracepting women from Pacara Sullicani attest to this. Both say they want no more children. Sosana Huayta, one of eight children and the mother of three, says that she is glad that Montufa has given her the means to control her fertility. Maria Valezques, one of six children and the mother of two, says Montufa "has been good for us and our community."

Such expressions of gratitude from community members are powerful incentives for voluntary promoters. In the highlands of Peru, strong traditions and communal bonds prevail. In recognition of their work, communities often bestow special status upon promoters and exempt them from communal labor. After training, promoters receive certificates, identity cards, free uniforms and other materials. CARE-Peru and MINSA are testing other incentives to encourage quality work by community promoters, including free health services for the promoters and their immediate family members, as well as reductions in the cost of medicine.

However, many promoters express indifference to the idea of being paid for their work. Leonardo Chino Aroquipa of the community of Posoconi, sitting on the roan horse that he usually rides to make home family planning visits, explains that he has long attended births in the middle of the night "because I like serving my community. I am 38 and have four children, more than I would have liked, but I did not know about family planning before. I want others to know, and I will keep doing this work even though I do not get paid just because I like it. I now have 18 contraceptive users, all men."

Rosa Quispe Hihuaña, a mother of three and promoter since 1997, proudly says that she has 31 contraceptive users among 73 couples in her sector of the community of Collina Pampa. Is her work difficult? "Yes, because sometimes the people do not want to use contraception and tell me that their personal lives are not my affair. Other people sometimes ask difficult questions. Also, men did not accept me at one time, but many have changed their minds. Because I do not receive any pay, people are not so suspicious of my intentions."

Do older people in the community -- long accustomed to large families -- object to the idea of family planning? "No, because most have suffered very much to raise so many children," says Hihuaña. "And, not infrequently, women see my family planning sign and come to visit with their adolescent daughters."

Although both CARE-Peru and MINSA officials consider this CBD model to be successful, its success was not achieved easily. Nor is its sustainability assured.

"Because this model required that CARE-Peru train MINSA professionals to provide reproductive health services independently and train, supervise and supply CBD workers, it was perhaps slower and more difficult than some other CBD models," says Dr. Ramos, project coordinator.

Beat Rohr, national director of CARE-Peru, emphasizes the importance of government leadership. The community program "has largely prospered because the present government favors health care reform in general, wishes to improve reproductive health, and offers free contraception to every citizen."

Ultimately, the success and sustainability of such a program depends upon the people living in the remote communities, says Dr. Ciro Castillo Rojo Salas, director of the MINSA health unit in San Román. "Family planning is not an unknown concept for them," he says. "Many people in the highlands have a long history of trying to control their fertility, and they may very much welcome better ways to help them do so."

-- Kim Best

City Life Isolates Many Clients

JULIACA, Peru -- A volunteer family planning promoter carefully negotiates her way across a puddle covering much of the road on the outskirts of this commercial city. Because she also lives in this neighborhood, the immense puddles and densely populated streets are familiar terrain.

Firmly and confidently, she steps on rocks strategically placed from one side of the puddle to the other. Then, reaching a narrow strip of solid ground, she stops and waits for an obstetric nurse and nurse's aide whom she is accompanying on family planning home visits. They stop at the door of a mother of two who had been given oral contraceptives at a PLANFAMI clinic, but did not return for a scheduled visit.

It is not difficult to understand why. The rainy season has made streets nearly impassable. Also, the mother tells the visiting team, "I decided not to come to the clinic because I was not having problems with the pill."

Nevertheless, the team counsels her about her health, makes sure she knows what to do if she misses a pill, and gives her a new supply of pills for another three months. Finally, they encourage her to discuss reproductive health concerns with her maturing daughters (11 and 14 years old). She agrees, although somewhat reluctantly.

"Women tend to be timid and fear criticism from the community, so it is very important to protect their privacy," says the community promoter, who was selected by people in her neighborhood to serve in the position. "They fear the promoter will gossip, so you have to win their trust."

One of her clients, a 33-year-old mother of two, admits "I did not like it when she approached me at first. But we were neighbors, and she talked to me in my language, Quechua. I was using the rhythm method for two years after the birth of my last child, but then she told me about the vaginal tablets and I decided to try them. I like them. Now I'm thinking about using the condoms she provides in addition to the tablets for extra security."

The need for home services during the rainy season is particularly acute. "People really struggle to get to clinics at this time of year," says Juan de la Riva, executive director of PLANFAMI. "Women are accustomed to staying home, and are scared to travel, even across town to a clinic."

The visiting team is one of several PLANFAMI efforts to reach people, he says. Funded by the U.S. Agency for International Development and receiving technical assistance from Pathfinder International, PLANFAMI operates four clinics within 90 kilometers of its base clinic in Puno. Typically, an obstetric nurse and nurse aide from each clinic make home visits, riding into the countryside on a motorcycle or in a well-equipped van that offers injectables and intrauterine devices, in addition to other methods. PLANFAMI also holds reproductive health discussions and makes video presentations in the countryside, traveling by van with electric generators to supply power.

Volunteer community promoters are given uniforms, backpacks, health materials and contraceptives, an identification card, and transportation to training sessions. Otherwise, they receive no compensation.

PLANFAMI has other innovative efforts. The organization works with a local police station that often feeds impoverished street children to encourage the children's mothers to attend monthly PLANFAMI reproductive health discussions and video presentations, and to receive medical examinations and contraceptives.

PLANFAMI also offers reproductive health services to male and female inmates at a prison, where conjugal visits are allowed. And another effort works with tricycle taxi drivers in Juliaca.

"Not only do taxi drivers know where prostitution takes place in the town, but they themselves are very much at risk for sexually transmitted diseases," notes Mary Vandenbroucke of Pathfinder International, who assists PLANFAMI. "Working directly with these men can be very important."

-- Kim Best

Bangladesh Refines a Successful Program

The Bangladesh family planning program, which operates one of the world's largest, oldest and most successful community-based delivery systems, is beginning to shift its emphasis toward community clinics. The change is designed to improve efficiency and to address changing cultural needs.

Rather than focusing on door-to-door visits to all couples eligible for contraception, a system used for more than 20 years, the program is encouraging many couples to obtain contraceptives from centralized locations, such as village clinics. In addition, the government has begun to integrate family planning at clinics into a broader package of health services that includes antenatal and postnatal care, child immunization and communicable disease prevention.

"A lot has changed with women in Bangladesh over the last 20 years," says Nancy Piet-Pelon, who followed the Bangladesh shifts closely in her former position as Asia regional director for AVSC International. "A major reason this program began was that women were not allowed to leave their homes alone, and that has changed. Their status has changed. Now, women want to use family planning and can leave their home to get supplies."

Small community clinics are beginning to offer both family planning and other health services. Health assistants and family welfare assistants with more training than door-to-door village workers will provide most of these needs, explains Dr. Mohammad Alauddin, country representative for Pathfinder International, a U.S.-based service delivery organization that works in rural areas of Bangladesh.

Sustainability

Door-to-door distribution throughout Bangladesh, using workers called family welfare assistants, has been among the factors in rising contraceptive use. Demographic surveys show about half of all married women of reproductive age are using contraception, up from 7 percent in 1975 when community-based distribution began.

In recent years, however, a series of studies raised concerns about the current system. With the maturity of the program, the demand for services has increased as more and more women enter their reproductive years. Meeting the growing demand requires efficient use of clinical facilities and of home service delivery workers. A 1996 study by the Bangladesh Ministry of Planning, with assistance from FHI and Associates for Community and Population Research, found that family welfare assistants typically spent only a few minutes with each client.¹ "Visits that take only about four minutes may not be adequate. For example, the client may not learn very much about how to handle side effects," says Dr. Barbara Janowitz, an FHI economist who coauthored the study.

Bangladesh

30,500 CBD workers

population: 125 million Terrain: alluvial plain and hills Area: 144,000 sq km

Under a long-standing system, family welfare assistants were supposed to visit all couples eligible for contraception every two months, regardless of whether the couple was interested in family planning or was already obtaining services elsewhere. Targeting clients who are more likely to need services is one strategy that can improve effectiveness.² An analysis by John Snow, Inc., a U.S.-based organization that specializes in contraceptive logistics management, questioned an emphasis on methods that require routine visits and supplies, such as oral contraceptives.³

Lower fees charged at clinics than for services provided in home visits can be used to encourage clients to visit clinics. Also, long-term methods (intrauterine devices and sterilization) can be offered free, as a way to promote the use of those methods.⁴

However, studies also suggest caution about strategies that could weaken or eliminate door-to-door distribution. Without the household program, contraceptive prevalence in 1993 would have been about 25 percent in Bangladesh, instead of 40 percent, according to a Population Council study.⁵ Home visits also reduce travel costs for clients, and waiting time. "In the case of contraceptive continuation, timely workers' visits may enable women to manage side effects" by offering counseling or an alternative method, concludes Dr. Mary Arends-Kuenning of the Population Council.⁶

-- William R. Finger

References

1. Janowitz B, Jamil K, Chowdhury J, et al. Productivity and Costs for Family Planning Service Delivery in Bangladesh: The Government Program. (Research Triangle Park, NC: Family Health International, 1996)35.
2. Janowitz B, Holtman M, Hubacher D, et al. Can the Bangladeshi family planning program meet rising needs without raising costs? Int Fam Plann Perspect 1997;23(3):116-21.
3. Fiedler JL, Day LM. A cost analysis of family planning in Bangladesh. Int J Health Plann Mgmt 1997;12:251-77.
4. Kane TT, Khuda, B, Levin A, et al. Achieving sustainability of health and family planning services. In Khuda B, Kane TT, Phillips JF. Improving the Bangladesh Health and Family Planning Programme: Lessons Learned through Operations Research. Dhaka, Bangladesh: International Centre for Diarrhoeal Disease Research, Bangladesh, 1997.
5. Phillips JF, Hossain MB, Arends-Kuenning M. The long-term demographic role of community-based family planning in rural Bangladesh. Stud Fam Plann 1996;27(4):212.
6. Arends-Kuenning M. How Do Family Planning Workers' Visits Affect Women's Contraceptive Behavior in Bangladesh? Working Papers No. 99. (New York: Population Council, 1997)52.

Zimbabwe's "Clinics under Trees" Increase Access

HARARE, Zimbabwe -- Sibonindaba Moyo rides her bicycle along the red dirt roads, traveling from village to village in the Goromonzi farming area near Harare. In her waterproof satchel she carries oral contraceptives and condoms, which she will sell to the women and men she meets along the way.

Moyo is one of more than 700 community-based distributors of contraceptives employed by the Zimbabwe National Family Planning Council (ZNFPC). While making her rounds, she will discuss the benefits of family planning with people who have never used contraception. She will bring new supplies of pills and condoms to women and men who have already begun family planning, and will refer clients seeking other methods to health clinics. This is her routine as she conducts "clinics under the trees."

In Zimbabwe, community-based distribution (CBD) workers are an integral part of their community, which officials believe has encouraged the use of family planning. "People feel comfortable with one of their own," says Thandy Nhliziyo, ZNFPC assistant director of service delivery.

The family planning program in Zimbabwe, considered one of the most successful in Africa, began nearly a half century ago. Initially, services were clinic-based, but by the mid-1970s, the first CBD workers, known as "pill agents," began working to increase access to contraception.

Zimbabwe's fertility rate has fallen from 6.6 births per woman in the late 1970s to 4.3 in 1994, and its contraceptive prevalence rate is one of the highest in Africa -- 48 percent of married women of reproductive age are using a modern method. High levels of contraceptive use are due in large measure to the CBD program, which serves nearly a fourth of the country's family planning clients. However, in spite of its successes in reaching clients, fertility levels are considerably higher in rural areas than in cities (4.9 versus 3.1 births, respectively). The pill is the most widely used method (33 percent of all married women).¹

Most CBD workers are women. They are selected by community leaders who nominate three candidates. After initial training in Harare, the finalist continues training under a supervisor in the community, and eventually must pass a written exam. ZNFPC encourages CBD workers to participate in local activities, such as club meetings or even simply doing laundry at the river with other women. Their presence shows they are interested in the community's welfare and is also a reminder that family planning is readily available, since workers often attend with their satchel of pills, condoms and family planning information.

"We tell them your working hours are from 8 a.m. to 4:30 p.m., but if someone comes at 8 in the evening and needs condoms, or they are going out of town and need more pills, you cannot say 'I closed at 4:30,'" says Hope Monica Sibindi, a ZNFPC provincial manager.

Zimbabwe

800 CBD workers

population: 125 million Terrain: alluvial plain and hills Area: 144,000 sq km

Very often, a CBD worker is the first, if not the only link, to any type of health care for families in her community. In addition to family planning information, CBD workers can dispense analgesics for headaches. They can provide information on HIV/AIDS -- what it is and how it is transmitted. They discuss breastfeeding with new mothers, explain the importance of hand washing as a means of disease prevention, talk about the immunization schedule for infants, and discuss purification of water.

Zimbabwe's CBD program is highly organized and structured. Supervisors, typically experienced CBD workers with additional training, are responsible for monitoring the work of 10 to 12 workers. In turn, nurses manage supervisors.

For three weeks each month, a worker typically travels throughout her territory. The fourth week of the month is devoted to administrative tasks, including ordering contraceptive supplies, training and record-keeping. During group training, workers practice counseling skills by role-playing.

A pilot program funded by the Rockefeller Foundation seeks to expand services to younger adults. Traditional midwives and teachers serve as CBD workers or "family friends" and visit young people in their homes to discuss contraception and reproductive health. Parents were skeptical at first, but "but now they are calling CBD workers for assistance," says Sithokozile Simba, ZNFPC service delivery manager.

Sibindi says a popular view is that discussing contraception encourages adolescent sexual activity, although many studies indicate that sexual education delays the initiation of sexual activity. "We need to consider ways to meet the needs of young people without offending the community," she says. "Even talking with youth about sex is discouraged. We need to strengthen CBD workers' skills in how to deal with this."

-- Barbara Barnett

References

1. Zimbabwe Central Statistical Office, Macro International Inc. Zimbabwe Demographic and Health Survey 1994. Calverton, MD: Zimbabwe Central Statistical Office and Macro International Inc., 1995; Miller K, Miller R, Askew I, et al., eds. Clinic-based Family Planning and Reproductive Health Services in Africa: Findings from Situation Analysis Studies. New York: The Population Council and U.S. Agency for International Development, 1998.

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