Learning from Uganda's Experience

CBD of DMPA results impress a delegation from Kenya.

Family Health Research: 2007, Vol. 1, Issue 2

In March 2007, a delegation of seven Kenyan policy-makers and health professionals arrived in Kampala to learn about Uganda's experience with the community-based distribution (CBD) of injectable contraceptives. They were a receptive but skeptical audience.

Could volunteer community health workers be trained to provide injectable contraceptives safely to women in their communities? What kind of support would the volunteers need, and how sustainable is such a program? During the next three days, the Kenyan delegation had an opportunity to discuss these and other questions with those who had been involved in a pilot project to test the CBD of the injectable contraceptive depot-medroxyprogesterone acetate (DMPA) in Uganda.

Representing the Ministry of Health (MOH), various medical associations, and others with a stake in reproductive health care in Kenya, the visitors met with local leaders and health officials, including family planning program managers. They also discussed the CBD of DMPA with staff members from Save the Children USA and FHI, who provide technical assistance to the Ugandan program, and with the CBD workers (called community reproductive health workers, or CRHWs, in Uganda) who implement it.

Perhaps most important, the Kenyan team visited three of the CBD workers at their homes and met staff from the health centers that support them. They learned that many DMPA clients prefer to receive their injections from a CBD worker and that none had experienced serious side effects or complications from their DMPA injections.

At one house, the visitors witnessed the CBD of DMPA firsthand. "We were very impressed with what we saw and the way the CRHW did her work, especially the [client] counseling and recordkeeping," said Dr. William Obwaka of JHPIEGO, an international health organization affiliated with Johns Hopkins University.

When the Kenyan visitors asked about the sustainability of the CBD of DMPA, their Ugandan hosts emphasized the importance of starting with a strong, stable CBD program that is well integrated into the MOH structure. They acknowledged that sustaining a program that relies on unpaid volunteers is challenging, even though the Uganda CBD workers are highly motivated. The support the volunteers receive includes monthly meetings with Save the Children staff to discuss their concerns, work tools such as bicycles and bags for carrying supplies, refresher training, and recognition from their communities.

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MOH Official Champions CBD Approach "It all starts with convincing one key person, who will be the catalyst." That is how Dr. Anthony Mbonye, head of the Ministry of Health's Reproductive Health Division in Uganda, explains describes his role in the process that FHI and its partners used to persuade national decision-makers to advocate for the CBD of DMPA in his country. Once he became convinced of the potential benefits of the approach, Dr. Mbonye was instrument in advancing Uganda's pilot project on CBD of DMPA. And when the results of the project became available, he helped disseminate them. "We found that the acceptance rate was high, the continuation rate was high, and injection safety was good," he said. Photo credit: Benjamin Weil Dr. Anthony Mbonye Dr. Mbonye advises other government officials considering support for the CBD of injectable contraceptives to examine the evidence and consider how the approach could help them achieve their goals. "We have to look at innovative ways of doing things, and involve everybody," he said. "We also need to link the community initiatives to formal health services, including referrals."

The Uganda team cautioned the Kenyan delegates that ensuring a continuous contraceptive supply might pose a challenge. Stock-outs of contraceptive commodities are common in Uganda. When the health centers run out of DMPA, clients have to buy it from the local drug shops.

Members of the Kenyan delegation learned that many national and district health officials initially opposed the CBD of DMPA. Advocacy efforts by MOH supporters of the approach and other local advocates played an important role in persuading those officials to agree to a pilot project.

Many were swayed by the need to expand health care into remote regions. "We don't have enough health workers to give injections," explained Dr. Godfrey Kasibante, district director of health services in Nakasongola, where the pilot project was conducted. "We have to encourage health-seeking behavior, and bring the services to them rather than them coming to us."

The district's MOH trainers taught the CBD workers how to administer injections, which also helped overcome resistance because it increased the local providers' confidence in the project. Many others changed their minds about the CBD of DMPA when they saw the results of the pilot study.

The Kenyans' visit to Nakasongola was part of a broader initiative by FHI and its partners to promote expanded access to injectables contraceptives through CBD programs in sub-Saharan Africa. FHI has worked with partners in Uganda to develop an advocacy strategy and materials and to identify district-level advocates to help raise awareness about the benefits of family planning and the CBD of DMPA. FHI's DMPA checklist, a screening tool, was adapted for use in Uganda, and the MOH is introducing it to CBD workers and other family planning providers through training sessions. And FHI and its partners in Uganda and Madagascar have summarized the practical lessons from their pilot projects into a handbook for family program managers who are interested in starting their own CBD of injectable programs.

At the end of their three-day study tour, the Kenyan delegates concluded that they could give the CBD of DMPA a trial in areas already served by an active CBD program. They recommended starting a pilot project, spearheaded by the MOH, from which Kenya could draw further lessons.

Profile: CBD Worker Faith Mulekhwa   When the Kenyan delegation visited Faith Mulekhwa in March 2007, five clients were waiting for her under a massive tree in her family's compound. A community reproductive health worker in the Nakasongola District of Uganda since 2000, Mulekhwa provides family planning services to women at her home.   Photo credit: Dr. Wesley Tomno, Kenya Clinical Officers Association   Faith Mulekhwa "I prefer giving services at my house for privacy," said Mulekhwa, who added DMPA to the contraceptive methods she provides after attending a three-week training workshop conducted by Save the Children USA in 2004. "Most of the men in this area do not support family planning, so the women hide in order to come for an injection."   Mulekhwa reported that none of her DMPA clients had experienced complications so far. She had recorded 50 DMPA clients in her register and had referred a further 15 women to the local health center for Norplant and tubal ligation.   Mulekhwa is not paid for this work but is motivated by the opportunity to help other women. "When I see the health of a mother has improved, I feel happy," she said.