1. Task-Sharing of Implant Insertion to Community Health Workers: The Ethiopia Experience July 14, 2016 Candace Lew MD, MPH

2. THE ETHIOPIAN CONTEXT

3. Ethiopia – 2007 – 73.7 million; 84% rural – 2007 – TFR 5.1 In 2007, the FMOH, Health Extension Program (HEP) established a new cadre of health workers, health extension workers (HEWs). – 10th grade education – 1 year training: 16 element health packages – Community-level (25%) and household-level care (75%) CONTEXT

5. HEW IMPLANON INSERTION: IFHP PILOT

6. Prior to 2009: Implants offered at hospitals and health centers 2009: Program to increase access to LAFP at the community level: Implanon training of HEWs – FMOH mandate to bring LARCs to the community – USAID funded Integrated Family Health Program (now funded through USAID’s E2A), Pathfinder and JSI (IFHP) pilot: 1)Uninterrupted HP services during training 2)Comprehensive method mix at trainings 3)High quality service provision DIRECT PROVISION OF IMPLANTS AT COMMUNITY LEVEL

7. UNINTERRUPTED HEALTH POST SERVICES  Continued services  Demand creation  HEWs  Volunteer community health workers  Community wide announcements  Mobile teams to villages

8. COMPREHENSIVE METHOD MIX AT TRAININGS  Experienced providers able to deliver other methods attended each HEW training  Pre- and post-provision FP counseling was included for all clients, regardless of the method chosen

9.  Small trainer to trainee ratio by training many trainers in TOT  Competency-based training  5 days; 2 theoretical, 3 clinical  Average of 11 insertions before competent  Quality  FMOH, including woreda level providers at trainings  Weekly HP supervisory visits  Regional review meeting  Site review team: 20 insertions TRAININGS: HIGH QUALITY SERVICE PROVISION

10. IFHP PILOT (LEARNING PHASE)  HEWs from 8 woredas from 4 IFHP regions (Amhara, Tigray, Oromia, SNNP)  218 HEWs trained  IFHP awarded the scale-up phase by FMOH

11. HEW IMPLANON INSERTION: IFHP SCALE-UP

12. IFHP SCALE-UP OF HEW IMPLANON INSERTION  Scale-up strategies:  Revised regional management structures  Improved woreda-level training coordination  Reinforcing commodity security  Back up services to HPs from HCs  Supportive supervision  By 2015, approximately 9518 HEWS trained on Implanon insertion (high turnover)  5,320/6380 HPs (83%) in the IFHP areas have an HEW capable of insertion  Gradual transition with continuing technical assistance to the FMOH

13. IMPLANON REMOVAL : IFHP STRATEGIES

14. IMPLANT REMOVAL STRATEGIES: PROVIDERS Capacity building of HC providers to provide quality implant removal services Comprehensive 2 week LAFP competency based trainings Refresher trainings: 6 days competency based trainings (high provider turnover) Training of Trainers: with FMOH to ensure that all TOTs include removal skills Implant removal kits including mosquito forceps, blades supplied to trained providers

15. IMPLANT REMOVAL STRATEGIES: COMMUNITY LEVEL Skilled health providers can now provide quality implant removal services at the community level through several strategies: – Referral services to HCs for removal services – Outreach services to clients outside IFHP service area based on woreda requests – Back- up services by HC providers to their corresponding 5 health posts, removal services offered

16. BACK UP SERVICES: BENEFITS BEYOND

17. SERVICES DELIVERED TO 139 HEALTH POSTS BY BACK-UP SUPPORT PROGRAM: SEPT 2011-SEPT 2015

18. LESSONS FROM ETHIOPIA

19. Full contraceptive commodity audit and service provider questionnaire Context: national strategies to improve access to modern methods Across all methods and cadres, 20% of total CYPs came from HEW/HP implant insertions

20. LESSONS FROM ETHIOPIA  Task-sharing can be an important strategy in increasing access to long-acting contraceptives at the community level  Commitment from all levels of the MOH is essential  Competency-based training and follow-up mentorship/supervision are critical to quality services with task-sharing  Ensuring adequate implant removal services can be accomplished with multi-pronged strategies

21. twitter.com/PathfinderInt facebook.com/PathfinderInternational Youtube/user/PathfinderInt For more information contact : Candace Lew, clew@pathfinder.org