Lessons learned from a public sector community-based distribution program for scaling up DMPA-SC contraceptive services in Nigeria

Overview

UNFPA’s public sector DMPA-SC program was based on the implementation model of a previous, small-scale 2015 pilot project. The 2015 pilot, implemented in two states, Kebbi and Ebonyi used CBD for service provision and leveraged a 2014 government policy shift that expanded the scope of work for Community Health Extension Workers (CHEWs) to allow them to administer injectable contraceptives⁸. The 2015 pilot showed promise⁹, and, as a result, the Nigeria Ministry of Health, in partnership with UNFPA, planned to follow the pilot’s model as they expanded the public sector introduction of DMPA-SC to 10 states in July 2016. Public sector scale-up program states (described in Table 1) were selected based from the following criteria: (a) states with high unmet need and large numbers of estimated public sector contraception clients; (b) states that would represent all Nigeria’s geopolitical zones; (c) areas where the public sector DMPA-SC pilots had already occurred; (d) states where previous public health programs had developed cadres of experienced health volunteers; and (e) not located in the South West, where the private sector DMPA-SC program had been launched⁶.

UNFPA coordinated implementation for three IPs: Action Health Incorporated (AHI), Planned Parenthood Federation of Nigeria (PPFN), and the Association for Reproductive and Family Health (ARFH). UNFPA selected IPs based on their experience with CBD, reproductive health programming history, success reaching marginalized populations, and/or presence in different states. Each IP was responsible for implementation in several states (see Table 1). Program implementation was targeted toward selected urban and peri-urban areas in each state, with participating primary health centers (PHCs) selected based on catchment area size and available health human resources available in local government areas (LGAs).

The program officially launched in July 2016, beginning with a planning, coordination, and preparation phase. This was followed by a provider training phase (November 2016 – February 2017), after which the final phase, program implementation, reached full capacity in March 2017 and continued until September 2017. Thereafter, program coordination was expected to transition to the control of state-level government managers^b.

Operational model

Modeled after the experience of the 2015 two-state pilot, the public sector program was structured around CBD, but IPs were free and encouraged to adapt program features based on their own organizational strengths and experiences and on the context of the local environment (e.g. cultural norms, population density).

IPs used two types of community outreach to raise awareness for contraceptive services and deliver products to users: group mobilizations and individual outreach. Group mobilizations were informational presentations designed to engage large groups of women in community spaces including markets, community centers, churches, and other gathering places. For individual outreach, program workers made household visits, knocking on doors and introducing themselves to potential clients. Outreach workers were primarily community health volunteers (CHVs) and were connected to supervising CHEWs at PHCs in small hub-and-spoke networks.

CHVs and CHEWs were the two types of health workers trained and deployed for community mobilization and service delivery.

CHVs were primarily lay volunteers recruited and trained to conduct community outreach. Across all states, CHVs counseled women on method options and were able to provide nonprescriptive contraception: male condoms, female condoms, contraceptive pills. CHVs working with AHI and ARFH were permitted to administer DMPA-SC for reinjection, but were required to refer first-time potential injection clients or other long-acting reversible contraception (LARC) methods to CHEWs. CHVs working with PPFN’s program were not permitted to administer DMPA-SC.

CHEWs who were employed at PHCs were tasked with counseling new clients interested in contraception and offering informed choice provision. CHEWs also fielded referrals from CHVs for clients, including those reached through group mobilizations, who wished to receive facility-based contraceptive services (e.g. DMPA-IM injections, implants, or IUDs).

Health worker training

UNFPA adapted training curricula and tools from global training resources developed by PATH^10,11. IPs recruited and trained one CHEW per PHC who was recommended by local health managers. As part of the training curriculum, CHEWs received refresher information on general contraception and supplemental training on DMPA-SC.

For CHV candidacy, minimum requirements were proficiency in English and completion of primary school. IPs recruited CHVs from different candidate pools, with a general goal of finding volunteers who had previous health campaign experience. CHVs received training on interacting with users, establishing referral relationships with CHEWs, general information on contraception, and basic reporting practices. Patent and proprietary medicine vendors (PPMVs) were excluded from participating in the program.

ARFH developed a series of visual guidance materials to facilitate the training of CHVs for all IPs. These “job aids” included information on basic child health, HIV/AIDS, contraception, informed choice strategies, and DMPA-SC.

Volunteer compensation

IPs provided moderate compensation to CHVs in the form of stipends. CHVs were required to attend monthly debriefing meetings and return data collection forms, for which they received reimbursement for transportation costs. AHI and PPFN paid CHVs an additional 2,000N (~$5.50 USD) per month cash stipend. ARFH implemented a small-scale microfinance scheme to support health workers in Ebonyi and had planned to expand the model through all their program states, but was unable to secure support to do so.

Program data reporting

CHEWs and CHVs recorded all user interactions in a standard client register, adapted from the Ministry of Health’s Family Planning Register to include data fields relevant to the dispensing of DMPA-SC (see methods below). CHEWs used the registers to record each client encounter. CHVs used a simplified tally sheet to record methods given out to clients; simplified sheets were used to facilitate data tracking by individuals with low literacy. CHEWs collected tally sheets from CHVs every week, data from which was used as the basis of resupply to CHVs.

The DMPA-SC public sector program used additional data tools for monitoring and supervision. IPs used weekly and monthly supervisor forms to track performance by CHEWs and PHCs. IPs also tracked referral slips used by CHVs and CHEWs to record facility visits. IP program managers collected data tools from CHEWs and CHVs at monthly data validation meetings. IP staff entered the raw data and sent aggregated reports to UNFPA each quarter. Supply chain forms were used by program managers to track commodity levels and request resupplies every two months.

Key performance indicators (KPIs)

During project planning, all participating program partners agreed to a set of KPIs to track during program implementation. To develop these KPIs, each partner outlined monitoring objectives and identified possible metrics for the program given their implementation plans and strategies. KPI focus areas were identified based on common interest across all partners, the feasibility of collecting comparable data across IPs, and their applicability to all implementation strategies. The final set of KPIs included the number of users and services delivered, the number of providers trained, previous use of contraception by program beneficiaries, and the age profile of users. Some KPIs, including percent of new users reached and number of DMPA-SC units administered, had specific targets (20% for new users reached and 325,000 overall DMPA-SC units administered) that were agreed upon by implementing organizations and donors at the outset of the program.

Data sources and analysis

Data inputs for calculating KPIs came from several sources^c:

KPI data were descriptively analyzed for variation across time, states, and IPs. A subset of KPIs were measured against target outputs set at the beginning of the program. In accordance with populations of interest for program reach, we focused on the following categorizations of users:

We cross-referenced variations in KPIs with information from program documents and personnel interviews to understand their associations with operational strategies deployed. By KPI categories of interest, we organized the emerging program features and contextual factors that facilitated or hindered implementation or influenced program achievement.

Ethical approvals

The Institutional Review Boards at the University of California, San Francisco (IRB# 15-18353) and the Nigeria Health Research Ethics Committee (NHREC/01/01/2007-06/01/2016 and NHREC/01/01/2007-16th/02/2017) approved this research. Periodic interviews with program managers focused on organizational operations and did not require informed consent per human subjects research guidelines.

Health worker recruitment and training

IPs recruited and trained providers from November 2016 through February 2017, with most training complete by the end of January 2017. Table 2 shows the number of CHEWs and CHVs trained by IP (see underlying data¹²). In total, the program trained 3,764 providers; 1,649 CHEWs and 2,115 CHVs. ARFH, who had previously managed a program that trained CHEWs to provide injectable contraception, trained approximately 50% more CHEWs than CHVs (940 CHEWs, 600 CHVs). Among the CHEWs recruited and trained by ARFH, a large portion were previously unemployed or under-employed, and thus not formally engaged to staff PHCs; they were able to serve as community-based outreach workers, given the same tasks as most CHVs, with added permission to offer prescriptive contraception to first-time users by virtue of their licensing. In contrast, AHI and PPFN both trained approximately twice as many CHVs as CHEWs (AHI: 375 CHEWs, 740 CHVs; PPFN: 334 CHEWs, 775 CHVs).

Many CHVs engaged by IPs had worked on previous health campaigns (e.g. vaccination campaigns) and had shown a desire to continue working on public health programs. According to personnel interviews, recruiting CHVs with prior volunteer experience not only reduced training and recruitment costs, but also helped to ensure that volunteers were intrinsically motivated to stay engaged throughout the program.

Contraceptive service delivery

From August 2016 through December 2017, the program reached a cumulative 144,505 clients, including 17,022^e men (12% of total clients). Figure 1 displays the trends in cumulative distribution of DMPA-SC over the duration of the project period and delineates the three project phases. From August – November 2016, IPs were primarily engaged in preparatory work, including liaising with state-level government officials and local program managers in the targeted implementation areas. The period of November 2016 – February 2017 was dedicated to recruiting and training CHEWs and CHVs. Although IPs were ready to commence full program activities once trainings were complete, delays in DMPA-SC procurement meant that service delivery did not reach full operational capacity until March 2017.

Figure 1. Cumulative subcutaneous depot medroxyprogesterone acetate (DMPA-SC) distribution over time by state.

¹FCT = Federal Capital Territory (Abuja).

IPs accelerated service delivery following the procurement delay. From March through August 2017, the program reached 120,455 contraceptive clients (83% of total clients); the program reached 65% of all its clients during the three-month period from April through June 2017. By October 2017, the program surpassed its overall clients reached target (100,000^f clients). During the transition period from August to December 2017, as program management was handed over to state reproductive health agencies, an additional 6,674 clients (5% of total) were recorded in the client registry from ad-hoc reporting by IPs.

According to interviews and quarterly field reports, program staff felt that CBD had high utility for reaching contraceptive clients, particularly clients who had not previously been able to connect with reproductive health services. Program staff stressed the importance of both types of community outreach. Public mobilizations, often held in markets, were reported as effective for raising awareness and providing an efficient pathway to reach large numbers of potential users. Staff also reported that visits to individual households were effective for reaching women who may have been underserved by the traditional health system, including those who live in areas with more restrictive cultural norms. Strategies for engaging with women at their homes included framing contraception activities in the general interest of family health and visiting when male partners were not home.

ARFH, which was active in four program states (compared to three states for AHI and PPFN), delivered services to the most clients among IPs (n=80,299; 56% of total clients), followed by AHI (n=35,562; 25%) and PPFN (n=28,644; 20%)^g. Because the size of the catchment area for each state was unknown, we compared the median number of clients reached per state as well as the number of clients reached per trained health worker (CHVs and CHEWs) to assess relative performance. Across all states over the entire program period, the median number of overall clients reached per state and median clients reached per health worker were 15,070 and 44, respectively. On a per-state basis, ARFH also had the highest median numbers of clients reached (19,930), followed by AHI (12,026) and PPFN (10,862). Per provider in each state, ARFH also had the highest median number of clients reached (49), followed by PPFN (42) and AHI (29). In three states (Ebonyi, Gombe, and Kebbi) where ARFH had previously managed reproductive health programs with CHEWs and injectable contraceptives, overall users and per-provider clients reached were all above-median. Programs in these three states represented 43% of overall clients reached and, along with PPFN’s Benue program (62 clients reached per provider), had among the highest number of clients reached per health worker (Ebonyi: 57; Gombe: 66, Kebbi: 60).

Clients reached across sex and age groups

Table 3 describes characteristics of clients reached by UNFPA’s public sector program (see underlying data¹²). Among IPs, AHI’s client base had the highest percentage of women (92% of clients reached; n=32,775/35,562), followed by PPFN (91%; n=25,965/28,587) and ARFH (86%; n=68,575/80,188)^h.

Among clients reached by the program, 104,738 (74%) were older than 25, 28,115 (20%) were between 20 and 25, and 8,198 (6%) were under 20. Among IPs and overall clients reached, AHI reached the highest percentage of under-20 users (10%; n=3,420/35,562), followed by PPFN (5%; n=1,400/28,528) and ARFH (4%; n=3,378/76,961)ⁱ. Percentages of clients reached by age category were similar among DMPA-SC clients. According to field reports and interviews with program staff, AHI credited a series of operational decisions for their higher youth user rates: they conducted focus group discussions with young people to assess potential uptake of contraception and DMPA-SC; they recruited younger CHVs^j; they screened providers for potential age bias; and they targeted group mobilizations to youth-dense locations (e.g. university campuses). Whereas ARFH reported no specific focus on youth-oriented programming, PPFN also reported recruiting younger CHVs from existing youth volunteer networks, but did not have other strategies to tailor strategies toward younger populations.

Method choice

Of the 144,505 clients reached by the program, 81% (n=116,614) received DMPA-SC; all DMPA-SC recipients were women and 92% of all women clients (n=116,614/127,315) received DMPA-SC.

For non-DMPA-SC methods, the recipients of which included both male and female clients, 16% (n=23,755) of all clients received male condoms (64% of male condom recipients were male; 36% female), followed by female condoms (3% of all; n=4,298; 11% male; 89% female), pills (2%; n=2,336; 3% male; 97% female), other injectables (<1%; n=986; 100% female) and other LARC methods (<1%; n=136; 100% female). There was minimal variation in uptake of non-DMPA-SC methods across IPs.

The most common multiple method combination received by clients was DMPA-SC with male condoms (n=6,733 clients; 6% of all DMPA-SC recipients and 5% of all clients). There was considerable variation across states in the distribution of clients who received both DMPA-SC and male condoms. Of the 6,733 male condom and DMPA-SC recipients, 68% were in just three states: Cross River (n=950; 14% of total DMPA-SC plus male condom recipients; an AHI state); Abuja (n=2,407; 36%; PPFN); and Gombe (n=1,198; 18%; ARFH). This pattern was also observed across states with minimal DMPA-SC plus male condom combinations: Abia (n=254; 4% of total DMPA-SC plus male condom recipients; AHI); Kaduna (n=10; <1%; PPFN); Ebonyi (112; 2%; ARFH). Over half of all DMPA-SC clients in Abuja received DMPA-SC and male condoms together (62%; 2,407/3,902). In no other state was the percent of DMPA-SC clients who also received male condoms more than 10%. PPFN program managers reported that this finding was due to the practice of encouraging DMPA-SC recipients to use male condoms for the first week following their initial DMPA-SC injection. That explanation is supported by user category data in Abuja, where 86% (n=2,081/2,405) of DMPA-SC plus male condom recipients were new users, compared to 66% (n=2,578/3,898) as new users among all DMPA-SC recipients in the state. However, it was unclear from interviews with program mangers why the provision of multiple methods was so much more prevalent in particular states, even within those managed by the same IP.

New users and switchers

Among women clients reached by the UNFPA program, 80% (n=100,248) were new users of modern contraception, 15% (n=18,785) were repeat users of their previous method, and 5% (n=6,503) had previously used modern contraception but switched to a different method. Among women who switched modern methods, 96% (n=6,285) switched to DMPA-SC.

Limitations

We must note several limitations to the findings presented in this paper. Though the data delivered by UNFPA provided a snapshot of end-user characteristics, some variables were incomplete and had missing observations (2% of age observations were missing; 4% of visit type observations). The short timeline of the program, made even shorter due to the product procurement delay, made it difficult to make inferences about longer trends over time. The user characteristics available were limited in scope; future studies would benefit from expanding user indicators to include information on marital status, parity, education, and wealth. Without data on the providers themselves, we were unable to assess the relationship between provider characteristics and contraceptive uptake. We were unable to conduct analysis on differential delivery by providers because this data was not systematically captured; providers were not universally linked to recorded service interactions. Programmatic activities were reported at the IP level, making it difficult to determine operational differences at the state level. It is important to note that no audit was conducted on informed choice protocols; high rates of DMPA-SC selection could thus be a byproduct of limited options presented by providers.

Underlying data

Harvard Dataverse: Monitoring and evaluation data from the introduction of DMPA-SC in Nigeria's public and private sectors. https://doi.org/10.7910/DVN/XCLNIS¹²

This project contains the following underling data:

Extended data

Harvard Dataverse: Monitoring and evaluation data from the introduction of DMPA-SC in Nigeria's public and private sectors. https://doi.org/10.7910/DVN/XCLNIS¹²

This project contains the following extended data:

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).