Community Based Distribution of Family Planning Basics of Community-Based Family Planning

Community Based Distribution: Where is the CBD approach useful? i.e. Where does it make sense to use this approach as opposed to a different service delivery approach.

Community Based Distribution: History Significant program experience in Asia, Latin America and Africa over the last decades. Has had demonstrative impact in increased use of FP methods particularly where unmet need is high, where access is low, and where there are social barriers to use of services. CBD strategy has increased the acceptability of modern methods.

Community Based Distribution: CBD Can Increase Use of FP Immediate increase as agents legitimize 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

Community Based Distribution: Why choose this strategy? Effective in early stages of introducing FP services (in areas of large unmet need, low awareness of FP, and poor access). Addresses social and geographical barriers (helps generate more demand for FP, increase use of FP, and sustain use of FP). Potential for addressing the needs and service gaps identified (including responding to other basic health needs).

Community Based Distribution: Why choose this strategy? Can be a strategy to reach men (increase couples communication), and youth. Can be a strategy to increase program coverage to other populations/intervention areas. Community response is positive - services are appreciated, convenient, easy to access, active listening from CBD. It is a strategy that includes a lot of community participation/ownership.

Community Based Distribution: When should this strategy be considered? When use of FP is less than 25%. When there is low knowledge of FP services in the intervention area. When population has limited access to clinics. When there are barriers to use of services. When CBD strategy supports government goals and objectives. When there is organization capacity to include this strategy in FP or health programming.

Community Based Distribution: When should this strategy be considered? When use of FP is less than 25%. When there is low knowledge of FP services in the intervention area. When population has limited access to clinics. When there are barriers to use of services. When CBD strategy supports government goals and objectives. When there is organization capacity to include this strategy in FP or health programming.

Community Based Distribution: Reasons for not choosing this strategy When there is high awareness and knowledge of FP, combined with 45-50% use of modern contraceptives. May not be necessary if there are alternative means of increasing access to services. If CBD use of injectables is not supported by MOH; can’t meet demand for long acting and permanent methods.

Community Based Distribution: Reasons for not choosing this strategy Challenging to assure service quality and continuity of volunteers. Requires significant commitment in time and resources. Success and cost-effectiveness are highly variable. Tend to be small programs with little impact on overall CPR unless it is a national effort.

Community Based Distribution: Program Elements What elements go into CBD programming? (group contribution)

Community Based Distribution: Program Elements Data gathering for decision making (review opportunities and obstacles for CBD). Community participation and volunteer selection (process and criteria are key). Training (traditional, on the job, phased- out, focused on specific groups). Supervision (supportive, selective).

Community Based Distribution: Program Elements Targeting potential users (ELCO, MWRAs). Contraceptive supplies and system for getting supplies. Coordinate with and reinforce existing FP and health services. Integration with other strategies and interventions.

Community Based Distribution: Program Elements CBD Motivation (sustainable and effective incentives). Management Information system (info. users, info. needed, how info. will be used). Monitoring and Evaluation (agent performance, program results).

Community Based Distribution: Program Elements Preparedness for CBD replacement (regular need for training). Preparedness for potential problems.

Community Based Distribution: Planning/Decision making Intervention area (how big), and how many CBD agents to ensure coverage. CBD program model to follow (government, NGO, voluntary, salaried, allowance, commission, male, female, home visits, depot/post). Program staff (existing or new). Expanding existing efforts or initiating new ones.

Community Based Distribution: Planning/Decision Making Assuring ongoing training and supervision. Assuring re-current costs and support. Potential for cost recovery. Donor support (who and for how long). Donor program requirements.

Community Based Distribution: Elements contributing to success What elements contribute to the success of CBD approach? (group contributions)

Community Based Distribution: Elements contributing to success Focusing on social factors as well as technical aspects. Community involvement. Volunteer motivation/incentive plan. Making use of existing networks. Political will and support. Broad service regimen, and evolving program as RH situations evolve.

Community Based Distribution: Elements contributing to success Training is competency-based, incremental and practical. Supervision is supportive. Data and feedback provide motivation and credibility. Integration of evaluation into structure of program so it occurs continuously and at different levels.

Community Based Distribution: Elements which threaten success What elements threaten the success of a CBD approach? (group contributions)

Community Based Distribution: Elements which threaten success Failure to recognize the effort and resources required for CBD program. Failure to capitalize on opportunities and potential for broadening interventions. Pre-mature emphasis on sustainability and cost recovery before demand is adequately established.

Community Based Distribution: Elements which threaten success Failure to address quality of care issues. Lack of support & commitment from MOH at district and facility level. Isolation of CBD (limited contact, support, supervision) CBD job responsibilities may be too broad. (difficult to manage, reduce focus on FP).

Community Based Distribution: Challenges Distribution of injectables in Africa (obstacles). Distribution of emergency contraception (WHO endorsed). Reaching youth and men. Client concern with confidentiality.

Community Based Distribution: Challenges Policies on para-medicals dispensing of medication (such as depo-provera or in the case of broadening CBD role to include treatment of simple, common illness). Lack of evidence of added value of using CBD for other services. Sustainability (community/volunteer motivation, client load, diversification of program role, financial support).

Community Based Distribution: Why is CBD a Repositioning Strategy for FP? Fertility preferences still high. Interest in using FP to space or limit births still low. Access by certain populations is still low (married adolescents, hard to reach groups, people in conflict- affected settings).

Community Based Distribution: Why is CBD a Repositioning Strategy for FP? 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. Kenya example: Reduced support of CBD nationwide - drop in CPR.

Community Based Distribution: Recommendations Pilot test model first to identify what is working/what isn’t. Plan for going to scale from the beginning. Use existing community level workers rather than develop new cadre. Work with service providers.

Community Based Distribution: Group Work Case Studies

Community Based Distribution: Project/Country Group Work: 1.Why or why not CBD? 2.Where are we in the process of implementing community-based family planning programs? 3.What needs to be done to strengthen our CBD and/or other community strategies?