Through the Expand Family Planning (ExpandFP) Project, EngenderHealth supported ministries of health in resource-constrained countries to ensure clients’ full, free, and informed choice of family planning (FP), while expanding the availability and use of long-acting reversible contraceptives (LARCs). Funded by The Bill & Melinda Gates Foundation, the project ran from 2013 to 2018 in the Democratic Republic of the Congo (DRC), Uganda, and Tanzania. The project assisted those countries’ health care systems and advanced global learning through research and dissemination of evidence.
EngenderHealth’s work supported the global FP2020 partnership’s goal of providing FP information and contraceptives to an additional 120 million women and girls in the world’s poorest countries by 2020. In collaboration with local governments, ExpandFP focused 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 were the cornerstones of our work. For example, the project supported 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 ensured that a range of contraceptive methods and information were available; that clients’ rights and choices were assured; that medical follow-up care was offered; and that access to implant and intrauterine device (IUD) removal services was in place. Quality assurance and quality improvement initiatives were part of all project activities.
Among many things, ExpandFP supported training for 886 individuals, including FP counselors, supervisors, managers, and support personnel across all three countries. Further, through support to multiple service delivery modalities in each country, the project supported the provision of more than 300,000 modern FP methods and implant and IUD removals to clients.
In 2015, ExpandFP conducted 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. The results underscored that while special FP days and mobile outreach services are important and viable ways to increase women’s access to FP services, notably to LARCs, further attention to improving counseling practices is essential to respecting and fulfilling client rights.
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 United Nation’s World Population Prospects 2017). 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 LARCs such as implants and IUDs. In Kinshasa, 25% of married women of reproductive age have an unmet need for FP. To address this gap and expand access to contraception, EngenderHealth implemented ExpandFP in Kinshasa, a city of more than 10 million people.
Through ExpandFP, EngenderHealth supported the Ministry of Health from 2013 to 2018 to build capacity at nine health facilities in the greater Kinshasa area to offer FP daily and to host special FP events where services are available free of charge. These events included free services one day per month at the nine facilities, as well as mobile outreach services in harder to reach geographies, the latter of which often served more than 2,000 clients across multiple facilities in a single week.
Over the duration of the project, ExpandFP supported training for nearly 200 individual providers, supervisors, and other staff to improve facilities’ capacity to offer quality FP services and supported the provision of nearly 100,000 FP services.
In 2016, ExpandFP launched a research study to explore establishing an internal hospital-based referral system to increase access to FP during the Extended Perinatal Period (from pregnancy to 12 month postpartum) and simultaneously examined the effects of providing free contraceptives to clients on FP uptake and FP counseling. The four-arm study examined the effect of the referral system and postpartum FP training, free contraceptives, or both on FP screening, counseling, referral, and uptake. The group with the combined intervention had the best outcomes on all measures. The study findings suggested that providing FP, including LARCs, in the immediate postpartum period, implementing a systematic screening and referral system, and providing FP methods free of charge are key aspects to improving FP access and uptake in the extended perinatal period.
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 2016, however, these proportions had grown to 27% and nearly 5%, respectively, reflecting widespread demand for and increasing availability of FP. By contrast, 20% of Ugandan women (and 28% of married women) would like to space their next birth by two or more years or do not want a child. Currently, approximately half of all modern contraceptive use in Uganda consists of the injectable. 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 supported two districts (Masaka and Hoima) from 2013 to 2017 to improve access to, quality of, and choice of contraceptive methods. Extensive work was done via seven 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 worked to improve service quality by supporting initiatives such as client-centered counseling, infection prevention, and logistics management. In service delivery, ExpandFP supported special FP days at the clinics as well as mobile outreach services conducted at additional facilities in more rural areas. Community outreach involved using government village health teams to inform the community about the special event days, in addition to providing information on contraception overall. The project also worked with youth peer educators to provide facility- and community-based youth-friendly health services.
ExpandFP Uganda supported the training of more than 400 individual providers, supervisors, and other staff/volunteers (while simultaneously reinforcing their training skills). Through its support to facilities, youth activities, and outreach services to an additional 38 more rural facilities and 49 community sites, ExpandFP supported the provision of nearly 45,000 FP services. At the national level, EngenderHealth support the Uganda Ministry of Health in program planning to improve access to FP and update national training manuals.
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 FP services were provided to clients between January 2014 and September 2015 (on average, approximately 23,000 client services 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 client services 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.