1. Advances in Task Sharing: Findings from Uganda & Sierra Leone Julia Byington Programme Advisor, Marie Stopes International

2. Sierra Leone: Task Sharing Depo-Provera to Community Health Workers Marie Stopes International2

3. Sierra Leone: Rationale Advances in Task Sharing Low CPR nationally – 16% (DHS, 2013) Unmet need for FP – Married Women – 25% (DHS,2013) Married Women intending to use FP – 49% (DHS, 2013) Restrictions on access to health services related to: –Distance to health facilities –Poor and pricey travel infrastructure Paucity of health care workers – 1.7 nursing/midwifery personnel per 10,000 people (WHO, 2014) Marie Stopes International3

4. Sierra Leone: Study Objectives Objectives: 1.Determine the feasibility and safety of training CHWs to provide Depo-Provera 2.Determine whether CHWs can provide Depo-Provera safely and providing quality counseling 3.Determine the acceptability of CHWs providing Depo- Provera to clients Location: Six chiefdoms in the Koinadugu District selected because of its high unmet need and being the only District then Ebola free. Marie Stopes International4 Advances in Task Sharing

5. Sierra Leone: Design Advances in Task Sharing 150 CHWs were selected and participated in a competency-based training; 100% pass rate Implementation used a phased approach – each group of CHWs provided Depo for 3 months between July to December 2014 CHWs were placed under the supervision of PHU-in-Charges in their respective communities using monitoring checklist CHWs recorded client data, reported all adverse events, responsible for waste management at the community level Client interviews were conducted by Marie Stopes supervisory staff Marie Stopes International5

6. Sierra Leone: Findings 42.4% of services were provided to first time users of modern FP 53.6% of services were provided to single women Marie Stopes International6 Age of clients CHWs collectively provided 10,810 Depo-Provera injections throughout the pilot intervention period Advances in Task Sharing

7. Sierra Leone: Findings No clinical incidents occurred Supervisors reported satisfaction with FP counseling and Depo-Provera provision 99.1.% of clients reported to have been given clear information instructions for potential problems 99.5% of clients reported that they were given clear understanding of all the various available FP methods 99.5% of clients said they would return to a CHW for Depo-Provera or another service 25% of respondents said that without the CHW they would not continue to use FP and 51.4% said that they would have to travel further to access FP Marie Stopes International7 Advances in Task Sharing

8. Sierra Leone: Challenges Advances in Task Sharing Ebola Virus Disease outbreak Intensive monitoring & supervision requirements Marie Stopes International8

9. Sierra Leone: Conclusion Advances in Task Sharing With specific training and supervision, CHWs can safely and successfully provide Depo-Provera to women in their communities. This intervention was successful in reaching first-time users, as well as young women Scaling up CHW provision of injectable contraceptives nationally could increase FP choice and access to remote and most-in-need communities Awaiting MOHS pilot validation meeting and further policy discussions Marie Stopes International9

10. Uganda: Task Sharing Tubal Ligation by Clinical Officers

11. Uganda: Rationale Advances in Task Sharing Shortage of qualified health providers skilled in LAPM provision National development goal to reduce unmet need for FP (spacers and limiters), especially in rural areas National policy guidelines & service standards for SRH allow clinical officers to provide TL Request to generate evidence on safety and feasibility for Clinical Officers to provide TL in rural settings Marie Stopes International11

12. Uganda: Study Objectives Primary: To assess intra- and post-operative complications associated with Clinical Officer provision of TL in mobile outreach settings Secondary: To evaluate client satisfaction levels associated with Clinical Officer provision of TL Marie Stopes International12 Advances in Task Sharing

13. Uganda: Training for Clinical Officers (CO) Advances in Task Sharing Theoretical training (one week) COs had to pass the theoretical training before moving to practical training Practical training Close supervision from trainer: observed & assessed the trainee’s performance of 50+ procedures Competency assessment: 1.Effective administration of local anaesthesia 2.Effective in surgical steps of the TL procedure 3.Preparedness to manage possible complications Marie Stopes International13

14. Uganda: Design Prospective cohort study (N=518) conducted March – June 2013 in 4 rural regions of Uganda 4 clinical officers, theory training, 50+ TLs under close supervision Audit team included trained COs, supervising physician, 2 data collectors - linked with MSU mobile outreach teams Safety & acceptability outcomes collected at baseline & 3 follow-up visits (days 3,7,45) Safety outcomes – Adverse events data collected intra-operatively & post- operatively; categorized (minor/mod/major) according to MSI guidelines; major adverse events were considered complications Marie Stopes International14 Advances in Task Sharing

15. Uganda: Findings Cohort - 41% of women aged 35-39 years; 49% had 5-7 living children; 60% were using short-term methods (injectables, pills, condoms) Safety - Overall complication rate (major adverse events) - 1.5% (lower than other country studies) Baseline: 2 major adverse events – perforation and failure to mobilize tubes Day 3: 1.9% complications (pain; fever; poor wound healing; infection) Day 7: 0.2% complications (pain) Day 45: no complications Marie Stopes International15

16. Uganda: Findings - Acceptability Advances in Task Sharing 99% of clients were ‘very satisfied’ with the service 97% would recommend the facility where they had the procedure to a friend Marie Stopes International16

17. Uganda: Evidence to Action – Policy Success Advances in Task Sharing The following policies were decided by the Ugandan MoH (Sept 2013): 1. Implement the policy on task sharing for TLs by trained and supervised Clinical Officers 2. Service provider agencies can continue training & employment of Clinical Officers for TL through outreach Marie Stopes International17

18. Any Questions Advances in Task Sharing Marie Stopes International