1. Ensuring Client-Centered Access to Contraceptive Supplies Malawi Story

2. Nabiyeni’s Story Nabiyeni is a 24 year old woman married with 2 children Her husband wants another child but - Nabiyeni does not want another child now She is using FP without his knowledge.

3. Many rivers to cross to get to clinic Nabiyeni lives in a rural remote village- 20km away from a government clinic where she gets contraceptives. She has missed her dates for DMPA resupply by one week because one of the rivers she crosses was flooded. Finally when it subsides she takes the long journey to the clinic with a friend.

4. STOCKOUT “ Pepani amai, we haven't had Depo for the last three weeks” are the words that greet her just as she sits on the bench. “Ooh not again, that’s how I got to have this baby, there was no Depo when I came and I don’t want pills because my husband will kill me if he ever finds out I am using contraception” The nurse asks her to chose another method but she is reluctant to take pills and the nurse has not been trained in IUD or Implant insertion. The nurse is frustrated; she has never had her orders for Depo fully honored by DHO despite a high demand. DHO claims they have a tight budget- hence prioritize curative drugs to preventive. “I cannot afford to run out of antibiotics- you want me to run out of a job when politicians storm into this office?” DHO however reassures the nurse that he will take it up

5. What are the Gaps Stock outs at service delivery points Inadequate Financial resources. SWAp’s and decentralization - greater difficulty mobilizing leaders to fund FP because of competing demands. District-level decision makers – lack awareness of issues affecting contraceptive security. Donor dependence 2 Procurement systems- SWAp and Donor District Health officers prioritize curative drugs Unrealistic forecasting due to unreliable data management Inadequate human capacity Inaccessibility due to poor roads Minimal Private sector resources

6. What is being done to help Nabiyeni? Commodity Security USAID DELIVER supporting SCM improvements Support by Donor partners (USAID, UNFPA) procurement/distribution High Level Advocacy: RAPID presentation at US Ambassador’s house; Vice President as Good will Ambassador for RH. LDP- advocacy paper for removal of handling 5% fees for DMPA Quantification Exercise using Reality Check Support to the MOH and DHO in financing and procurement of contraceptives Expanding delivery of FP services to the private sector through social marketing for those willing and able to pay.

7. Bringing FP Services Closer to the community level Outreach activities to rural/remote areas far away from health centers through the Tent Outreach Centre Initiative (BLM) Training CBDs/RHAs based in rural areas RHAs/HSAs/CBDs providing wide range of services such as Depo (to ensure choice) TA to MOH and DHO to ensure contraceptive security in decentralized setting Policy change to allow HSAs to administer DMPA at community level. Change of scope of work to allow enrolled nurses to insert implants and IUCD at health centre level. Increased method mix at community level Outreach services to the community for BTL and vasectomy Youth FP Programmes at community level

8. Lessons Learned One approach is not enough- utilizing multiple approaches to ensure the ‘Nabiyenis’ access contraceptives has more impact Providing capacity building and strengthening local procurement systems can lead to government ownership of contraceptive security

9. Data management to avoid stock- outs

10. Thank YOU