Through the Expand Family Planning (ExpandFP) Project, EngenderHealth supports ministries of health in resource-constrained countries to increase access to and use of family planning (FP), with a focus on hormonal implants in a context of full, free, and informed choice. Funded by The Bill & Melinda Gates Foundation, the project began in 2013 and continues to be implemented in the Democratic Republic of the Congo (DRC) and Uganda, and was previously also in Tanzania until activities wrapped up in September 2015 after highly successful implementation. The project assists those countries’ health care systems and advances global learning through research and dissemination of evidence. Results from all three countries will be disseminated by December 2017.
EngenderHealth’s work supports the partnership between the donor community and pharmaceutical companies developed as part of FP2020, a global commitment to providing FP information and contraceptives for an additional 120 million women and girls in the world’s poorest countries by 2020. EngenderHealth works with collaborating partners of The Gates Foundation’s Implants Access Program (IAP)—Jhpiego, John Snow Inc. (JSI), and the Clinton Health Access Initiative (CHAI).
In collaboration with local governments, ExpandFP focuses on building the capacity of public-sector health facilities to offer high-quality FP information and services for women and adolescent girls. Capacity building for providers and supervisors, quality improvement of client counseling and clinic techniques, community information and services, and multiple service delivery approaches are the cornerstones of our work. For example, the project supports ministries of health in scaling up FP services by improving daily service quality at health clinics, sponsoring special FP days, and employing mobile outreach approaches to reach the most remote, vulnerable populations. ExpandFP ensures that a range of contraceptive methods and information are available; that clients’ rights and choices are assured; that medical follow-up care is offered; and that access to implant and intrauterine device (IUD) removal services is in place. Quality assurance and quality improvement initiatives are part of all project activities.
Through this project, EngenderHealth works to:
- Create, expand, and support FP service delivery by increasing the number of trained providers—especially for implants and IUDs—as well as FP counselors, supervisors, managers, and support personnel
- Integrate quality assurance and quality improvement supervision and training into all activities
- Ensure accurate reporting and use of data for decision making, especially for contraceptive security
- Create demand for and awareness of FP services through the use of information and communication materials, client mobilization using community health workers, and engagement of key community members
The Country Programs
Democratic Republic of the Congo (DRC)
By 2017, the DRC will be home to 4.7 million more women of reproductive age than in 2007 (according to EngenderHealth’s Reality Check tool). The total fertility rate is high (6.6 lifetime births per woman), and access to health care is limited, leading to poor health outcomes. Given the long history of conflict in the DRC, preventive health care services such as FP are just beginning to gain momentum, and there is a great need for increased access to contraception, including long-acting reversible contraceptives (LARCs) such as implants and IUDs. In Kinshasa alone, 30% of married women of reproductive age have an unmet need for FP. To address this gap and expand access to contraception, EngenderHealth is implementing ExpandFPin Kinshasa, a city of more than 10 million people.
Through ExpandFP, EngenderHealth supports the Ministry of Health to build capacity at zonal health facilities in nine clinics in the greater Kinshasa area, to offer FP daily, and to host special FP events where services are available free of charge. These events include free services once a month at the nine facilities and mobile outreach services for communities well beyond the clinic walls, which often serve more than 1,000 clients per week.
In the first year of the project, more than 11,600 clients received FP services in Kinshasa, of which approximately 74% voluntarily adopted implants In Year 2, ExpandFP successfully served an additional 23,400 more clients with FP services, of which approximately 89% voluntarily adopted implants as their FP method. Anecdotal evidence points to several reasons for this large uptake of implants, including: substantial latent demand for this highly effective method; the fact that it is a newer option for women in Kinshasa; and recent training and quality improvement activities by multiple donors. In 2015, ExpandFPconducted a client study in the DRC, Tanzania, and Uganda to better understand women’s perceptions of quality and method choice. The study revealed that clients in all service approaches overwhelmingly came to the service with a method in mind, the majority citing hormonal implants. In all three countries, surveyed clients stated that they were satisfied with the quality of services provided and were able to receive their method of choice.
In 2016, ExpandFP launched the Extended Perinatal Period (EPP) research study to examine the potential for integrating FP into wider services in a hospital in Kinshasa. Three additional facilities act as control sites. The four-arm study, which will be completed in 2017, is exploring and will provide evidence for establishing an internal hospital-based FP referral system, especially for postpartum FP, as well as how cost affects clients’ use of all FP services.
Ugandan women have a high unmet need for FP and low contraceptive use. As of 2011, only 21% of women of reproductive age were using modern contraceptive methods, and just 2% were using hormonal implants. By contrast, 34% of Ugandan women would like to space their next birth by two or more years or do not want a child. Currently, more than half of all modern contraceptive use in Uganda consists of the injectable (11%). Offering a broader method mix, with a focus on long-acting reversible contraception, is an important step toward decreasing unmet need and increasing couples’ ability to plan their families.
EngenderHealth’s FP work spans decades of support for capacity building in clinical methods of contraception, quality improvement approaches, and integration of FP with HIV and AIDs prevention and treatment. The ExpandFP project supports two districts (Masaka and Hoima) to improve access to, quality of, and choice of contraceptive methods. Extensive work is done via six health facilities in the two districts to build the capacity of service providers in all methods of FP, including long-acting reversible methods (IUDs and hormonal implants) and permanent methods for women and men. The project works to improve service quality by supporting initiatives such as client-centered counseling, infection prevention, and logistics management. In service delivery, ExpandFP supports special FP days at the clinics as well as mobile outreach services conducted at additional facilities in more rural areas. Community outreach involves using government Village Health Teams to inform the community about the special event days, in addition to providing information on contraception overall.
During the first year of the project, more than 8,432 clients across the two districts received FP services, with 27% of these adopting implants. In the project’s second year, 9,156 more clients received FP services, of whom approximately 33% chose implants. ExpandFP continues to work in creating, expanding, and supporting FP services in Uganda, most recently with the launch of COPE® for Contraceptive Security at all six health facilities. The COPE methodology gives facility staff and their supervisors the means to self-identify—and develop an action plan to address—challenges related to stock management, forecasting, requisitions, and other issues central to decreasing commodity stockouts at the facility level.
The ExpandFP project complemented the national FP program by training providers at 21 facilities across Arusha’s and Iringa’s health zones (inclusive of six regions) who would not have been trained with existing resources. EngenderHealth and the Ministry of Health and Social Welfare worked to increase daily access to and use of FP at these facilities, as well as using special FP days and mobile outreach services to improve access within hard-to-reach communities. The holistic program design also worked to improve the quality of these services, supervision, and the use of data for decision making, particularly for contraceptive security. ExpandFP activities in Tanzania were successfully completed in September 2015.
End-of-project results show that FP service delivery in the six participating districts was significantly expanded over the project period. Notably, a total of 160,378 clients adopted contraception between January 2014 and September 2015 (on average, approximately 23,000 clients per quarter), compared with a total of 25,138 clients in the preintervention baseline period between January and December 2013 (on average, approximately 6,300 clients per quarter).
Mobile outreach services reached 57% of these clients, with the remaining 39% served via routine daily services and 4% during special FP days. The lower percentage of clients served during special FP days was mainly due to the small number of these events (N=60) versus mobile outreach (N=682) during the reporting period.
In a short amount of time, the project demonstrated that when there are trained providers—armed with the supplies they require—and quality counseling and services in place, programs can have a significant impact in reaching women with an expanded contraceptive method mix. Continued support for services, the enabling environment, and demand initiatives will be required to sustain and expand project gains.
ExpandFP is supported by generous contributions from The Bill & Melinda Gates Foundation.