Sponsored by: U.S. Agency for International Development (USAID), World Health Organization (WHO), Action for West Africa Region Project - Reproductive Health (AWARE-RH), Advance Africa, the POLICY Project Repositioning Family Planning in West Africa Repositionnement de la Planification Familiale en Afrique de l’Ouest Community-based Programmes: a Strategy for Improving Access and Quality Ian Askew FRONTIERS in Reproductive Health Population Council

What Have We Learned From 20 Years of CBD in West Africa?

CBD Can Generate Interest in Child Spacing and FP Use CBD agents and key individuals stimulate community and couple discussions Building social acceptance allows couples to practice without stigma Most successful with same sex interactions

CBD Can Increase Use of FP Immediate increase as agents legitimise FP and increase access More methods provided increases overall CPR Increase in use may take time due to building new social norms CBD can augment clinic- based quality improvements

What Types of “CBD” Have Been Tried? Public and Private Sector: –Government programmes –NGO, church-based, employment-based Agent status: –Part-time – voluntary or allowance –Full-time – salaried employees –Male, female –Home visits, depot/post No single model – each developed to fit the situation

Performance of CBD Programs Can Vary by Model

Cost-effectiveness Can Vary by Type of Program

Why Is CBD a Repositioning Strategy for FP? Fertility preferences still high Interest in using FP to space or limit births still low Changing these social norms requires education and discussion at individual, family and community level Clinic-based services cannot easily stimulate or facilitate such social interactions

Why Is CBD a Repositioning Strategy for FP? Providing contraceptives through clinics limits their physical, financial and social access Clinics cannot effectively reach men with FP messages and condoms CBD facilitates continuation of use CBD can offer FP integrated within a range of basic health information and services (malaria, ORT, iron tablets, STI information, etc.)

Challenges – Can CBD Provide More FP Services? Currently offering information, condoms, pills, spermicides, NFP, and referral for clinical methods But: –Can injectables be offered? –Can emergency contraception be offered? –Can IUCD be offered? –Dual protection messages can be communicated – but to what effect?

Challenges – HIV, Safe Motherhood and Child Survival Services? Feasibility of providing basic HIV/STI information proven, but: –Can verbal risk screening and referral be added? –Can STI treatment for males be added? –Can CBD link with VCT, ART and home-based care? Information about pregnancy and child nutrition? Birth planning and support for assisted deliveries?

Major Challenge – Ensuring Sustainability  Transition from pilot project to routine programme critical – but how? Diversification of programme role and income sources (NGOs: Ghana; Zimbabwe) Planned phasing: (MOH: Ghana) –Pilot model, then experiment to test effectiveness (Navrongo) –Sustain, and demonstrate replication (Nkwanta) –Gradual nationwide expansion (CHPS) Revitalise existing government community programmes (Senegal)

Critical Elements in Sustaining Community-based Programmes Commitment to a large-scale, routine CBD programme –Belief in cost-effectiveness of strategy –Willingness to engage community-level cadre as standard staffing component Pilot test model first to identify how it works Plan for going to scale from the beginning: –Immediately sustain successful pilot model in project sites (and expand to district level) –Document successful configuration and pilot its replication in limited additional districts –Develop systems to enable expansion nationwide

Programmatic Recommendations National leadership….with district ownership Reinvigorate (and reconfigure) existing community- level cadres rather than develop new cadre Do not use volunteers in isolation from an employed cadre Offer a range of related and integrated services Include possibility of cost- and profit-sharing for commodities Move from project-funding to line-item budgeting as soon as possible