Community-based Distribution of DMPA in Madagascar:

Pilot Introduction and Early Scale-up

Theresa Hatzell Hoke

Family Health International

Major Partners• Ministry of Health and Family Planning,

Madagascar

• USAID

• Family Health International

• SantéNet

• Population Services International

• Adventist Development Relief Agency (ADRA)

• Action Santé Organisation Secours (ASOS)

Pilot Implementation

Scale-up

Pilot Evaluation

Presentation Overview

Pilot Implementation

Scale-up

Pilot Evaluation

Presentation Overview

Contextual Factors Favoring CBD of DMPA in Madagascar

Population:18 M, 74% rural 

Access: 65% of population lives more than 10km from a health center

Service quality: human resource shortages, heavy workloads, waiting times

Unmet need for family planning: 24%

Number of sites with CBD workers : 3422

Growing preference for DMPA

2006 update of National Reproductive Health Norms and Procedures:

Trained community-based workers permitted to provide DMPA services.

Introduced in 13 “communes ” across 4 districts

Added to pre-existing CBD programs

61 CBD agents participated, along with 26 supervisors

Pilot Intervention

Intervention Components

1. Recruitment and selection

2. Training

3. Certification and installation

4. Commodity management

5. Reporting

6. Supervision

3-Day Training

Training ResourcesCBD of DMPA Cartoon Manual

Certification and Installation

Commodity Management

• Initial stock of 15 doses with supplies

• Monthly re-supply at health center

• Single-use syringes

• Sharps container

Supervision and Reporting

DMPA intervention added to pre-existing systems and procedures:

• Monthly contact by clinician and NGO supervisors

Occasional visits by district and central-level supervisors

• Capitalized on pre-existing reporting forms

Pilot Implementation

Scale-up

Pilot Evaluation

Presentation Overview

Measuring Pilot Success1. Did CBD workers provide injection

services in accordance with quality standards?

2. Did use of contraception increase in the communities served?

3. Did the support mechanisms function as intended?

4. Is CBD of DMPA acceptable to CBD agents and their clients and supervisors?

Evaluation Methods

• Data collection 7 months after training

• Structured interviews 61 agents 25 supervisors 303 clients

• Review of service records

Essential Knowledge Score

0%

20%

40%

60%

80%

100%

ADRAMoramanga

(n=19)

ASOSMoramanga

(n=12)

ASOS Sud(n=30)

All Sites (n=61)

Pe

rce

nta

ge

of

CB

D W

ork

ers

18

16

14

CBD Agent Knowledge about DMPA Service Provision

CBD Agent Performance: Client Reports (n=303)

0 20 40 60 80 100

Knows DMPA gives no STI protection

Agent respects confidentiality

Counseled about amenorrhea

Counseled on side effects

Knows duration of pregnancy protection

No problem with injection site

Satisfied with injection technique

% of clients

Impact of Intervention on Contraceptive Use

CBD DMPA acceptors between Jan-June 2007: 1,662 women

Age range: 15 – 49 years

Number of living children: 1-11

Desire a future pregnancy?Yes 63%No 31%Unsure 6%

New FP user, 28%

New DMPA user, 25%

Used DMPA in the past,

47%

Contraceptive History of DMPA Acceptors

(n=303)

3-Month Re-injection (n=199)

No re-injection received,

4%

Other source, 2%

Received from CBD workers,

94%

Impact on Accessibility

• Mean travel time to health center : 136 minutes

• Mean travel time to CBD agent: 27 minutes

• Mean time “saved”:109 minutes

Support Mechanisms: Key Lessons

• Reduce training class size

• Capitalize on supervisors’ strengths

• Ensure consistent DMPA supplies at health centers

• Streamline reporting

• Add DMPA intervention to a well-functioning CBD family planning program

Pilot Implementation

Scale-up

Pilot Evaluation

Presentation Overview

Scale-up Intervention• Training : 3 ½ days

instead of 3 days

• Stronger link with public sector health system

• Expanded collaboration with NGOs

• Prioritized remote, populated areas with committed district health officers

Status Update

• MOHFP collaborating with 16 NGOs

• An additional 406 agents trained

• Of the 61 “pilot” agents, 58 participated in refresher training in June 2008

• By April 2009, 385 agents providing DMPA services in 111 communes across 27 districts