Many models for community-based family planning exist. In some, workers are paid; in others, they are volunteers. Some workers live in the village they serve, others do not. Some go door-to-door, while others work from home or another central location. Some programs use mobile clinics or establish small outposts for a variety of health services.
Similar questions tend to arise, in spite of the model used. What is the best way to motivate workers? What is the impact of paying workers or offering other incentives? How much supervision and training are needed? How can the quality of a community program be evaluated?
"The research record generally shows that paid workers perform better than volunteers," says a Population Council review of more than 200 reports and studies on African community-based distribution (CBD) projects. "When agents are paid, supervision can be rigorously exercised, programs can be implemented rapidly, work routines can be standardized and designed to cover populations, and service quality can be maintained." CBD programs that use volunteer workers are more complex to manage, the review says.1
A recent study in Tanzania evaluated the cost effectiveness of different ways of reimbursing workers in three CBD programs. Two of the programs employed part-time volunteers who received in-kind payments while the third program employed full-time workers who were paid salaries. The study measured visits per worker because couple years of protection (CYPs) tend to include factors that are not confined to a worker's efforts. For example, changing a program's policy regarding the number of pill cycles distributed per visit alters CYP costs, even when a worker's efforts remain the same.
The program that paid workers a salary was the most effective in terms of having the highest number of visits per worker. However, this program was not the most cost effective of the three. When considering supervision and training costs, one of the programs using part-time volunteers had the lowest cost per visit.2 "In considering factors that affect the performance of CBD workers, program managers need to consider all costs that motivate performance, not just payments to workers," says Dr. Barbara Janowitz of FHI, a coauthor of the study.
Using number of visits and couple years of contraceptive protection to measure effectiveness, a study in Kenya also concludes that pay may be "a powerful determinant of performance."3 CBD programs in Kenya use various reimbursement schemes, including full-time paid agents, part-time agents with nonmonetary incentives, and part-time agents who receive an allowance for expenses. Paid agents are more motivated than others, says Karugu Ngatia, assistant director of the National Council of Population and Development (NCPD), which coordinates all CBD activities in Kenya.
Supervision
While paid workers may perform better, both the Tanzania and Kenya studies found that other factors also affect worker output and program performance, especially supervision and community involvement. "CBD agents who are supervised more frequently tend to meet with more clients," the Kenya study concluded.
The Kenya study found a statistically significant relationship between the frequency of supervision and the agents' output. Recommendations to strengthen supervision included the use of supervisory checklists, maintaining a firm monthly schedule and using full-time, field-based staff to supervise CBD agents.
To be meaningful, supervision requires more than simply checking records and stocking commodities. "The real question about supervision is not how often to provide it, but what you provide," says Dr. James Foreit of the Population Council, who has conducted CBD studies in Latin America. One study in Brazil, for example, found that reducing supervisor visits from monthly to quarterly resulted in "substantial potential savings in supervisors' salaries and travel at no cost to program performance (new acceptors, revisits, distributor turnover)."4
Community involvement is another important motivator for agents. New CBD programs in Burkina Faso and Togo will allow community leaders to select agents. In Tanzania, agents and supervisors in one program meet quarterly with local leaders to review the program, giving the community a sense of ownership.5
Training
"Most observers agree that the quality and intensity of agent training is the most important single determinant of program quality and impact," concludes the Population Council review of CBD studies. Training generally works better when it is competency-based, incremental and practical.6
In general, CBD workers receive some kind of initial training and then periodic refresher courses. Usually, the refresher training requires the workers to go to a central location for a course lasting several days. "In general, this is expensive and not everybody comes," says Dr. Foreit. An alternative is to take the training to the workers, through a continuous approach that incorporates refresher training into ongoing supervision.
Other types of training approaches have proven difficult to implement. A study in Peru found on-site training through supervisors works in theory, but using it successfully has not been easy. The study compared group training with individual training through supervisors. The individual approach used a checklist to help the supervisor determine what an agent needs to learn, which took less time and was cheaper than group training.7
In Paraguay, a CBD program uses flowcharts in a small handbook with tabs to train agents. A worker follows the flowcharts, flipping to a particular page depending on each client's answers to specific questions. For example, a person is asked if she wants to use contraception. If the answer is yes, the book tells the agent to go to a page that illustrates basic information on a variety of method choices. One study concluded that this method of training agents achieved the largest gain in quality and was the least expensive approach over other training options.8
Offering a variety of methods is an important aspect of quality family planning services. CBD workers, however, can only offer certain methods and may emphasize those over methods that require a referral. A study in Kenya found that community-based distributors tended to emphasize oral contraceptives more and explore medical contraindications less thoroughly than did clinic providers.9 CBD training should include clinical and nonclinical methods, so agents are able to discuss a range of choices. Agents should be encouraged to refer clients to clinics when appropriate.
-- William R. Finger
References
- Phillips JF, Greene WL, Jackson EF. Lessons from Community-based Distribution of Family Planning in Africa. New York: Population Council, 1999.
- Chege J, Rutenberg N, Janowitz B, et al. Factors Affecting the Outputs and Costs of a Community-based Distribution of Family Planning Services in Tanzania. New York: Population Council, 1998.
- Chege JN, Askew I. An Assessment of Community-based Family Planning Programmes in Kenya. Nairobi: Population Council, 1997.
- Foreit JR, Foreit KG. Quarterly versus monthly supervision of CBD family planning programs: an experimental study in northeast Brazil. Stud Fam Plann 1984;15(3):112-20.
- Chege, Rutenberg, 29-30.
- Phillips.
- Leon F, Foreit J, Monge R, et al. An Experiment to Improve the Quality of Care in a Peruvian CBD Program. New York: Population Council and INPPARES, 1989.
- Carron JM, Melian MM, Leon FR. Developing Tools of Low-cost Use to Improve the Quality of Care of Rural CBD in Paraguay. New York: Population Council, 1994.
- Kim YM, Kols A, Mucheke S. Informed choice and decision-making in family planning counseling in Kenya. Int Fam Plann Perspect 1998;24(1):4-11.
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